NURS379
Leadership in Nursing Practice
Leading the Team: Nursing Care Delivery Systems

 

Models of Care

What is a model of care?  

 "A model of care is a configuration of nursing practice or pattern of delivery" (Ritter-Teitel, 2002, p. 35). 

Models of care are developed to support or enhance professional practice.  Models might also be called nursing or patient care delivery systems.

Why is it important to discuss something as mundane as models of nursing care? This slide highlights those reasons:

Basically nurses need to understand the positive and negative consequences of each model in order to plan and propose to decision-makers the most efficient and effective way to deliver care. Let me explain:

  • When we discuss models of care we are essentially talking about staffing issues: types of staff, the numbers of staff, when they are needed, for what hours, etc.

  • When you consider that 60% of the total operating costs of any organization are salaries and benefits. . . and that the nursing personnel budget is easily 60-70% of that. . .it makes sense that nursing personnel budgets are the one of the first places that budget barons look to cut operating costs.

  • Thus we need to understand the different models of care so that we can make a good case for one model or the other, or a hybrid of several.

The take-away message for this week is that there is no one right or wrong model. The model we choose should be based on the patient population, the environment in which the care is being delivered, and the staff we have available to deliver it.

History Explains the Present

It is helpful to take a quick look at how social changes have dictated the way you and I organize our nursing care. This is another example of how the external environment has significantly influenced health care and, more specifically, nursing practice. We will start our review by looking at the four traditional models:

 

Total patient care/Case Method

In this model, the RN is responsible for all of the care provided to a patient for a shift. It is the oldest nursing care delivery model. This is the way most nursing students were taught – take one patient and care for all of their needs. The consequences of teaching nursing this way was that reality shock hit upon graduation when the new graduate hit the floors and had to care for more than one patient.  Even in the case of the student nurse, the students frequently do not provide all of the care as they may not be qualified to do the work.  We may still see this model used in critical care areas, labor and delivery, or any area where one nurse cares for one patient’s total needs.  It is interesting to note that nurses were self-employed when the case method came into being, because we were primarily practicing in homes.  Home health agencies use a form of this model when nurses are assigned patients and provide all home care.  Even this has been adapted; as the RN may delegate or coordinate some of the care to a home care aide or other service such as physical therapy or dietician for example.

Advantages:
RNs were self-employed
Patient needs were quickly met
Close relationship between the RN and the patient
Disadvantages:
Cost! RNs are expensive! :-)

Functional Nursing

This model is also referred to as the Task Method, and for good reason! Functional nursing evolved during the Depression when RNs went from being private practitioners (see above) to becoming employees for the purposes of job security. Once WWII broke out, however, nurses left to care for the soldiers which left the hospitals short-staffed. To accommodate this shortage, hospitals increased their use of ancillary personnel (sound familiar?). For efficiency, nursing was essentially divided into tasks, a model that proved very beneficial when staffing was poor. The key idea was for nurses to be assigned to TASKS, not to patients. For example, one nurse would be responsible for all the treatments, another nurse for all the medications, and so on.

Advantages:
A very efficient way to delivery care. Could accomplish a lot of tasks in a small amount of time
Staff did what only they were capable to do: no extraneous work was added that could be done by assistive personnel.
Disadvantages:
Care of persons became fragmented
Patients did not have one identifiable nurse and the nurse had no accountability.
Very narrow scope of practice for RNs
Lead to patient and nurse dissatisfaction

 

Team Nursing

This is the most commonly used model and is still in use today. It was developed in the 1950’s after WWII when there was a severe nursing shortage and major changes in technology (replaced functional nursing) and to somewhat ameliorate the fragmentation that was inherent in the functional model (see above). In the past, approaches to team nursing was thought to use the decentralized decision making with decisions made closer to the patient, there actually was limited team member collaboration. These teams tended to communicate only among themselves and not as well with physicians. Today, the goal of the Team method is for a team to work democratically. In the ideal team, an RN is assigned as a Team Leader for a group of patients. The Team Leader has a cadre of staff reporting to her and together they work to disseminate the care activities. The team member possessing the skill needed by the individual patient is assigned to that patient, but the Team Leader still has accountability for all of the care. Team conferences occur in which the expertise of every staff member is used to plan the care; a hallmark is that each member’s input (RN, LPN, NA, etc) is considered essential for the process to work. As is obvious, the Team Leader must be both a skilled clinician and an effective group leader.

Advantages:
Each member’s capabilities are maximized so job satisfaction should be high
Patients have one nurse (the Team Leader) with access to other providers
Disadvantages:
Requires a team spirit and commitment to succeed
RN may be the Team Leader one day and a team member the next, thus continuity of patient care may suffer.
Care is still fragmented with only 8 or 12 hour accountability.

 

Primary Nursing

Primary nursing was developed in the 1980’s by Marie Manthey and the hallmark of this model is that one nurse cares for one group of patients with 24 hour accountability for planning their care. In other words, a Primary Nurse (PN) cares for her primary patients every time she works and for as long as the patient remains on her unit. An Associate Nurse cares for the patient in the PN’s absence and follows the PN’s individualized plan of care. This is a decentralized delivery model: more responsibility and authority is placed with each staff nurse. It has been debated whether PN is a cost-effective model. Some say it is because the RN has all the skills necessary to move the patient through the health care system quickly. Others say it is not cost effective because RNs spend time doing things that other, less expensive employees can do.

Advantages:
Increased satisfaction for patients and nurses
More professional system: RN plans and communicates with all disciplines. RNs are seen as more knowledgeable and responsible.
RNs more satisfied because they continue to learn as a function of the in-depth care they are required to deliver.
Disadvantages:
Intimidating for new graduates who are less skilled and knowledgeable
Where do we get all these RNS during times of shortage?

 

Nursing Case Management

We will end this week’s discussion with a look at Nursing Case Management, a model of care that came of age in the 1990’s as managed care changed our conceptualization of nursing practice from one of quality of care to one of quality of care PLUS cost. This model of care was adopted from social workers, but had also been widely used in outpatient psychiatry. A couple of your colleagues this semester are Case Managers or are members of Care Management Teams – interdisciplinary groups that meet regularly to monitor patient’s progress through the health care system. It will be interesting to hear them describe their practice on the upcoming discussion board.

The key variables of case management are outcomes, resources, and time. Simply put:

Nursing case managers are empowered to identify the best patient outcomes and for mobilizing the resources to achieve those outcomes in a preset time frame.

The tool used by Case Managers, of course, is called a Care Map, or a Critical Path. I’m sure you all have experience in using these. The hallmark of case management plans, whatever you label them, is that they allow for mobilization of resources over the course of an illness; in addition they provide automatic reassessment at prescribed intervals. It becomes evident to the team when a patient “falls off” the Care Map; consequently steps are immediately taken to identify why, and what needs to be done to get the patient back on an expected trajectory to wellness.  

Not unlike the skills necessary in Team Nursing and Primary Nursing, a Case Manager requires the skill of both a good clinician and a good manager who can effectively coordinate the care delivered by others.

Some of the results reported since Case Management has become more popular for inpatient nursing care:

  • Length of stay has decreased
  • RNS and MDS like it
  • Provides a new marketing potential for hospitals
  • It increases the chance that agencies can recruit and retain the best and the brightest

Case Management, then, is a lot of things as this slide indicates:

At this point you should take a look at the other models discussed in your textbook.

Summary Discussion for Models of Care

We need to be aware of the nuances of each nursing model so that we can choose a model that best fits the organization, the unique patient needs, and the talents/education of the available staff. There are many variations of each of the models discussed this week. In fact, I would imagine that hybrids are more common than not.

It is at this point that you should read/review the readings and then go to the Learning Activity to do the analysis of the model of care in use in your agency, or on your nursing unit. For some of you this will be a simple exercise. But others are in very unique roles and may have more difficulty categorizing your delivery system.

 

 

Acknowledgment for content development and items within this module: Dr. Betty Woodard