Nursing Model of Care

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Delivery of Care Nursing Models Context to Nursing Practice and Profession:
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delivery systems have undergone continuous and significant changes Various nursing delivery systems have been tried and critiqued *Importance of NURSING -LED INNOVATION in care delivery models and outcomes *understanding how policy and economic forces intersect with nursing models of care
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Traditional Models of Care: (3)
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functional nursing team nursing primary nursing
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Functional nursing, also called ___________, began in hospitals in the mid 1940s in response to a ***national nursing shortage***
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task nursing
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In functional nursing, the needs of a group of pts are broken down into tasks that are assigned to RNs, LPNs, or UAPs so that the skill and licensure of each caregiver is used to his or her best
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advantage
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Under the functional model, an RN assesses pts whereas others:
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give baths, make beds, take vital signs, administer treatments, and so forth. As a result, the staff become very efficient and effective at performing their regular assigned tasks
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Disadvantages of functional nursing (3)
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uneven continuity lack of HOLISTIC understanding of the patient Problems with FOLLOW UP Bc of these problems, functional nursing care is used infrequently in acute care facilities and only occasionally in long term care facilities
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Picture functional nursing
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charge nurse –> med nurse, treatment nurse, UAP with bath duty, UAP responsible for vital signs, UAP responsible for transportation –> pts
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Team nursing Team nursing evolved from functional nursing and has remained popular since the middle to late 1940s. Sometimes called :
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modular nursing (pod structure)
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Team nursing components
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a team of nursing personnel provides total pt care to a group of pts a team may be assigned a certain # of pts OR the assigned pts may be GROUPED BY DIAGNOSES OR PROVIDER SERVICES. The size of the team varies according to physical layout of the unit, pt acuity, and nursing skill mix. ***the team is led by an RN and my include other RNs, LPS, and UAPs*** Team members provide patient care under direction of the team leader The team, acting as a unified whole, has a HOLISTIC PERSPECTIVE OF THE NEEDS OF EACH PATIENT
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Team nursing contd
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Team leader activities: indirect* pt care activities Developing or updating nursing care plans Resolving problems encountered by team members Conducting nursing care conferences Communicating with physicians and other health care personnel Unit nurse manager consults with team leaders, supervises pt care teams, and may make rounds with all physicians
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Key aspect of team nursing:
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nursing care conferences, where the team leader reviews with all team members each pt’s plan of care and progress
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Advantages team nursing (3)
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It allows the use of LPNs and UPAs to carry out some functions (making beds, transporting pts, collecting some data) that do not require the expertise of an RN It allows pt care needs requiring more than one staff member, such as pt transfers from bed to chair, to be easily coordinated The geographical boundaries of team nursing help save STEPS and TIME
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Disadvantages of team nursing (6)
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A great deal of time needed for team leader to communicate, supervise, and coordinate team members Continuity of care may suffer due to changes in team members, leaders, and pt assignments NO ONE PERSON CONSIDERS THE TOTAL PT ther may be role confusion and resentment against the team leader, who staff may view as more focused on paperwork and less directed at the physical or real needs of the patient Nurses have LESS control over their assignments due to the geographical boundaries of the unit Assignments may not be equal if they are based on pt acuity or may be monotonous if nurses continuously care for patients with similar conditions
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Additional considerations: team nursing (2)
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skills in delegating, communicating, and problem solving are essential for a team leader to be effective OPEN COMMUNICATION between team leaders and the nurse manager is also important to avoid duplication of effort, overriding of delegated assignment, or competition for control or power
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Problems in ________ and __________ are the most common reasons why team nursing is LESS effective than it theoretically could be
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delegation and communication
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team nursing/modular nursing picture
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charge nurse –> team/module leader –> RN, LPN, UAP –> pts (x3)
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Total patient care The goal of this delivery system is to have ONE nurse give ALL care the the same patient(s) for the ENTIRE SHIFT Total patient care delivery systems are typically used in areas requiring a
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high level of nursing expertise, e.g., critical care units or post anesthesia recovery areas
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Advantages of total patient care (3)
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Continuous, holistic, expert nursing care TOTAL accountability for the nursing care for the assigned patient(s) for that shift Continuity of communication with the patient, family, physician(s), and staff from other departments charge
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total pt care picture
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charge nurse –> RN –> patients
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Disadvantages total pt care
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RNs spend some time doing tasks that could be done more cost effectively by less skilled persons
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Primary Nursing Designed to place the RN back at the patient’s bedside Conceptualized in 1960s as response to team nursing DECENTRALIZED DECISION MAKING BY STAFF NURSES is the core principle of primary nursing
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Responsibility and authority for nursing care allocated to staff nurses at the bedside
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Core principle of primary nursing
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decentralized decision making by staff nurses
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How primary nursing works:
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the RN maintains a patient load of primary patients A primary nurse designs, implements and is accountable for the nursing care of patients in the patient load for the duration of the patient’s stay on the unit Actual care is given by the primary nurse and/or associate nurses (other RNs) Blend of total care and team nursing
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Primary nursing contd This model is seen as advancing the professional practice of nursing because:
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A knowledge based practice model DECENTRALIZATION of nursing care decisions, authority, and responsibility to the staff nurse 24 hour accountability for nursing care activities by ONE nurse Improved continuity and coordination of care Increased nurse, patient, and physician satisfaction
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Primary nursing disadvantages and trends
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It requires excellent communication between the primary nurse and associate nurses Primary nurses must be able to hold associate nurses accountable for implementing the nursing care as prescribed Bc of transfers to different units, critically ill patients may have several primary care nurses, disrupting the continuity of care inherent in the model Staff nurses are neither compensated nor legally responsible for patient care outside their hours of work Associates may be unwilling to take direction from primary nurse Fallacy of 24 hour accountability Expensive with all RN staff Many hospitals discontinued
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Integrated models of care Practice Partnerships
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RN and an assistant -UAP, LPN, or less experienced RN – agree to be PRACTICE PARTNERS The partners work together with the SAME schedule and the SAME group of patients Senor and junior partners Can be applied to primary nursing and other nursing care delivery systems such as team nursing and total patient care
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Disadvantages practice partnerships
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Organizations tend to increase the # of UAPs and decrease the ratio of professional nurses to nonprofessional staff Potential for inappropriate delegation to junior partners
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Practice partnerships pic
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RN, partner –> pts
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primary nursing pic
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other HCPs, primary nurse, charge nurse –> patient –> associate nurse, associate nurse
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Integrated models of care Case management
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Adopted form community and psychiatric settings for acute inpatient care Involves identifying, coordinating, and monitoring the implementation of services needed to achieve desired patient care outcomes within a specified period of tie Nursing case management organizes patient care by major diagnoses or diagnosis related groups (DRGs) Focuses on attaining predetermined patient outcomes within specific time frames and resources Collaboration of all members of the health care team Identification of expected patient outcomes within specific time frames Use of principles of continuous quality improvement (CQI) and variance analysis Promotion of professional practice
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Successful nursing case management elements 5 elements needed for successful case management: SACAE
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Support by key members of the organization (administrators, physicians, nurses) A qualified nurse case manager Collaborative practice teams A quality management system Established critical pathways
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Critical pathways (sometimes referred to as a care map) The EXPECTED OUTCOMES and care strategies developed by the collaborative practice team variance –> case managers identify modifications
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Interdisciplinary/interprofessional consensus Specific and measurable outcomes determined Managing the care of a specific patient during a specified time period They accommodate the unique characteristics of the patient and the patient’s condition Critical paths use resources appropriate to the care needed and reduce costs and length of stay Critical paths are used in every setting where health care is delivered*** Nursing diagnoses identify outcomes needed
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Critical pathways contd
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altering time frames or interventions is categorized as a VARIANCE, and the case manger tracks all variances Collaborative practice teams analyze the variances, not trends, and decide how to mange them The critical pathway may need to be revised or additional data may be needed before changes are made ***Features are included on all critical paths***, such as specific medical diagnosis, the expected length of stay, patient identification data, appropriate time frames (in days, hours, minutes, or visits) for interventions, and patient outcomes
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Evolving Models of Care Patient centered care
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The role of the nurse is BROADENED TO COORDINATE a team of multifunctional unit based caregivers In acute care setting: the # of caregivers at the bedside is reduced**, but their responsibilities are increased** so that service time and waiting time are decreased Success using a patient centered care model continues to be reported in the literature Lower mortality rates in selected patient populations
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Evolving models of care SYNERGY MODEL OF CARE Developed by the American Association of Critical Nurses (AACN)
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Patient’s characteristics MATCHED WITH NURSE COMPETENCIES Patient characteristics, for ex: complexity, predictability Nursing competencies, for ex: clinical judgement, systems thinking Looking for fluidity: matching nurses to acuity of pts – looking at characteristics of nurses
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Evolving models of care CLINICAL MICROSYSTEMS MODEL Decision making is BEST given to those involved in the SMALLEST unit of care
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Small unit of care that maintains itself over time Elements: core team of careigvers, defined population to receive care, informational system for both patients and caregivers, support staff, equipment and facilitative environment
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The clinical microsystem model has been shown to be effective in
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neonatal ICUs
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Literature demonstrating that clinical microsystems increases effectiveness of
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quality improvement initiatives
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Chronic care model The goal of the chronic care model is not to manage a disease but to
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change how daily care is delivered by clinical teams Instead of reacting to changes in the patient’s condition, the team provides proactive interventions
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6 components of chronic care model
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Self management support decision support deliver system design clinical information systems health care organization community resources
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Transitions of care model – features
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INTERPROFESSIONAL COMMUNICATION, collaboration, coordination from admission throug htransition Clinical SHARED ACCOUTABILITY during all points of transition Comprehenive planning and risk assessment throughout hospital stay Standardized transition plans, procedures, forms STANDARDIZED TRAINING is an organizational priority (nursing, physicians in risk assessment and planning) Timely follow up, support, coordination post care setting Understanding causes of readmissions within 30 days of discharge, when these occur Evaluation of transitions of care measures
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http://www.jointcommission.org/assets/1/18/hot_topics_transitions_of_care.pdf
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