Staffing and Nursing Care Delivery Models

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Definition of Staffing?
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Activities required to ensure an adequate number and mix of health care team members to meet patient needs and provide safe, quality care (activities that give you the right mix & # of staff for the pt’s needs, safety and quality care)
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What considerations should be made when staffing?
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patient needs staff satisfaction organizational needs
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According to research, why are RN’s important in healthcare? What contribution do they make?
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improved patient outcomes prevention of premature mortality
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***What are the 5 primary considerations for staffing?
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1. number of patients 2. intensity of care required 3. staff experience and preparation 4. geography of the environment (ER v. Medsurg) 5. available resources (computer charting v. paper)
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What is an Acuity level?
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It is a patient classification system that categorizing patients according to care needs (Ex. some one with circulatory deficiencies v. abdominal pain)
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What needs to occur with higher acuity levels?
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nursing care needs are more intense
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***The ANA recommends that classification systems should consider patients….?
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– Age and functional ability – Communication skills – Cultural and linguistic diversity – Severity and urgency of the admitting condition – Scheduled procedures – Ability to meet health care requisites – Availability of social support – Other specific needs identified by patient and RN (In class: Family dynamics, are they demanding)
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What should a staff member have in order to meet patient’s care needs? who needs to be informed if this does not happen?
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– educational preparation, skills, experience necessary to meet patient care needs (Ex. if you get floated to L&D, you should have some skills and knowledge in order to provide adequate care) – executive level manager
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What are the benefits of having satisfied nurses?
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provide higher quality of care and more cost-effective care
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What are KEY to staff satisfaction?
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gain staff input about staffing and enhance autonomy
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What are some organizational needs that are affected by staffing?
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financial resources licensing regulations and accreditation standards customer satisfaction
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Efficient staff management ensures the organization’s ….?
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financial solvency (organization is able to pay off debts as they become due and stay in business)
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For what budgetary guidelines are nurse manager accountable for?
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Number of staff working at any given time Staff mix
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Who is the most expensive staff?
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RNs
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What is critical to an organizations success?
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Customer satisfaction
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What is KEY to customer satisfaction?
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Customer’s personal interaction with employees
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Since mandatory staffing ratios are not imposed by licensing and accreditation agencies what do they look for in a health care organization?
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evidence that patients are adequately cared for
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Nurse Manager’s Number one challenge?
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Appropriate staffing within budget constraints with well-trained, professional staff members who are committed to providing safe, high-quality care
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What is a Nursing Care Delivery Model?
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details how task assignments, responsibilities, and authority are structured to accomplish patient care – describes which healthcare worker is going to perform what task, who is responsible, and who has the authority to make decisions – Premises NUMBER and TYPE of caregiver are closely MATCHED TO PATIENT CARE NEEDS in a COST-EFFECTIVE manner
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What are the CLASSIC nursing care delivery models?
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– Total patient care – Functional nursing – Primary care nursing – Team nursing
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What is Total Patient Care?
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Nurse is responsible for planning, organizing, and performing ALL patient care during the assigned shift Ex. used in ICU and PACU (seen in higher acuity cases)
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What is another name for total patient care?
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Case nursing
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What Nursing care delivery model does a nursing student typically perform?
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Total patient care
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What are advantages of Total patient care?
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– RN maintains a high degree of practice autonomy – Lines of responsibility and accountability are clear – Patient receives holistic, unfragmented care – Communication at shift change is simple and direct
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What are disadvantages of Total patient care?
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– Number of RNs required is very costly – Some task could be accomplished by a caregiver with less training and at a lower cost – Nursing shortage will affect RN availability
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What is Functional nursing?
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staff members are assigned to complete certain tasks for a group of patients rather than care for a specific patient Ex. Operating room and ER (everyone does an assigned task)
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What are the lines of responsibility and accountability in Functional nursing model?
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– RN nurse manager assigns responsibility for completing of tasks to a group of health care workers – RN is responsible for planning care and supervising workers – RN retains accountability for the patient care provided – this is true for all Nursing care delivery models
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What are the advantages of Functional nursing?
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– provided economically and efficiently – minimum number of RNs required for patient care – tasks completed quickly, little confusion about responsibilities
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What are the disadvantages of Functional nursing?
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– May be fragmented; possibility of overlooking priority patient needs – Patient may feel confused because of many different care providers – Caregivers may feel unchallenged when performing repetitive functions
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What is Team Nursing?
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RN functions as a tea leader and coordinates care for a small group of patients Ex. Medsurg, inpatient and outpatient health care settings
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What are advantages of Team nursing?
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– High-quality, comprehensive care can be provided with a relative high proportion of ancillary staff – Each member participates in decision making, problem solving – Each member contributes his/her own special expertise or skills
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What are disadvantages of Team nursing?
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– Continuity of care may suffer with daily learn assignments – Team leader may not have the leadership skills required to effectively direct the team – Insufficient time for care planning and communication leads to unclear goals and fragmented care
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What are the lines of responsibility and accountability in Team nursing?
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– RN team leader is responsible for the following (planning, assigning duties, directing, supervising and assisting team members, giving direct care) – RN retains accountability for all patient care – RN team leader is responsible for encouraging a cooperative environment and maintaining clear communication
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What is the name of the modified Team Nursing care delivery system?
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Modular Nursing
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What is Modular nursing?
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– Patient unit divided into modules; same team of caregivers assigned consistently to same geographic location – Each location or module has RN as team leader – Each module should contain all the supplies needed by the staff to maximize efficiency – GOAL is to increase the involvement of RN in planning and coordinating
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What is Primary nursing?
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RN “primary” nurse assumes 24-hour responsibility for planning, directing, and evaluating the patient’s care form admission through discharge -provides total patient care while on duty – while off duty, an associate nurse provides care, who follows the care plan established by the primary nurse Ex. home health, hospice, long-term care
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What are advantages of Primary Nursing?
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– Direct patient care provided by a small number of nurses allows for high-quality, holistic patient care – Patient able to establish a rapport with the primary nurse, and patient satisfaction is enhanced – job satisfaction high because nurses are able to practice with a high degree of autonomy and feel challenged and rewarded
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What are disadvantages of Primary nursing?
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– Implementation may be difficult because primary nurse is required to practice with high degree of responsibility and autonomy – Inadequately prepared primary nurse may not be able to make the necessary clinical decisions or to communicate effectively with the health care team – RN may not be willing to accept 24-hour responsibility as required – Number of RNs required for this method of care may not be cost effective and may be difficult to recruit and train
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What are the lines of responsibility and accountability in Primary nursing model?
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– RN primary nurse has 24-hour responsibility and accountability for patient care – Associate nurse are responsible for following the plan of care – RN primary nurse is responsible for maintaining clear communication among all members of the health care team
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What is another name for Partnership Model?
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Co-primary Nursing
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What is the Partnership Model?
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– RN is partnered with an LPN/LVN or a nursing assistant, pair work together consistently
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The Partnership Model is a modification of what classic nursing care delivery model…? and why?
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Its a modification of the primary nursing model To ensure more efficient use of RN
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What are advantages of Partnership Model?
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– More cost-effective than the primary care system – RN can encourage training and growth of partner
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What are disadvantages of Partnership Model?
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– RN may have difficulty delegating to the partner – Consistent partnerships are difficult to maintain on the basis of varied staff schedule
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Lines of responsibility and accountability in the Partnership Model?
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– RN responsible for planning care, assigning duties, coordinating care and supervising the partner – RN is accountable for patient care for all assigned patients
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Patient-Centered Cared is considered ___________, Not a typical nursing care delivery model.
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A philosophy of care (this should be incorporated as an essential component of any nursing care delivery model)
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IOM’s definition of Patient-Centered care?
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Providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions
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Methods to engage patients, families, and significant others as partners in care?
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– include then in developing care plans and discharge plans – include them in change-of-shift or hand-off reports – Provide them with the information and education needed to make informed decisions – Establish “family advisory councils” to engage patients and families in decision making
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Other names for Telehealth nursing?
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TELEPHONE TRIAGE, telephone nursing, or telehealth
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What types of clients are helped with Telehealth nursing?
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clients in ambulatory setting, since 1970s, by use of e-mails, internet, fax, and telephone Ex. Integral part of an outpatient clinic practice, centralized call center
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Nurses’ roles in telehealth nursing?
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– Triage – interventions – Consultations – Surveillance and follow-up
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Practice Standards published by the American Academy of Ambulatory Care Nursing?
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– Using Protocols, Algorithms, or Guidelines to assess and address patient needs – Prioritizing the urgency of patient needs – Developing a collaborative plan of care – Evaluating outcome of practice and care
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Who introduced case managers to healthcare and why?
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– Introduced in 1970s by insurance companies – A method to monitor and control expensive health insurance claims
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Why did Hospitals recognize the need for case management?
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– to manage patients’ treatment plan and length of stay because of the diagnosis-related group (DRG) payment method
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What does a case manager do?
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coordinates the patient’s care throughout the course of an illness, as an employee of the payer or as an employee of the healthcare facility
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Goal of case management?
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is to focus attention on quality, outcomes and cost of care and to assist the patient to move through the continuum of care (highest level of care with least amount of cost)
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What does a case manager “manage”?
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a “case load” of patients from preadmission (onset of illness) to discharge (resolution of illness)
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What is case management?
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Collaborative approach to providing and coordinating health care services, identifying and facilitating options and services for meeting health needs, decreasing fragmentation and duplication of care and enhancing quality, cost-effective clinical outcomes
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What role do case managers assume in patient care?
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planning and evaluating NOT responsible for DIRECT patient care
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Who is appointed a case manager?
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Reserved for chronically ill, the seriously ill or injured and long-term, high cost cases Ex. someone with multiple trauma, Stroke, need for long-term care
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Other names for Clinical Pathways?
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critical paths, practice protocols, care maps
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***What is a Critical Pathway?
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delineates a predetermine written plan of care for a particular health problem – Specifies desired outcomes and the interdisciplinary intervention required within a specified period for a particular diagnosis or health problem – written to address common diagnoses such as Heart Failure, Pneumonia
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Clinical Pathway V. Clinical Practice Guidelines
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Clinical Pathway: Key processes and patient goals in the day-to-day management of care Ex. Based on evidence analyzed all data on pneumonia, it says you should do this for the patient and expect pt to go home at a certain time Clinical Practice Guidelines: guide broader decision making and focus on decisions made in performing a procedure or service
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Variance in a clinical pathway?
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Any event that may alter the patient’s progress though the clinical pathway Ex. Patient falls and breaks hip on the 3rd day postop, this will later the patients recovery and the flow of the pathway
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Trigger
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Alerts caregivers that an unexpected event has occurred and identifies potential and actual variations in patient’s response to a planned intervention
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Interdisciplinary Intervention
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collaborative effort by all disciplines, along with the patient and family to reach desired health outcomes
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Patient outcomes
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results of interventions by the health care team
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***Essential Components of Clinical Pathways
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– consults – Laboratory and diagnostic test – Treatments and diagnostic test – Safety and self-care activities – Nutrition – Patient and family education needs – Discharge planning – May address triggers
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Development of Clinical Pathways
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– Based on accepted standards of practice – Developed for the health care organizations MOST COMMON and COSTLY DIAGNOSES – A Team supported by management (with representatives from various disciplines such as nursing, medicine, therapy, pharmacy and dietary) develops clinical pathways
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What influences the type of nursing care delivery model used by a health care organization?
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– Health care setting (acute care, long-term care, ambulatory care, home care and hospice) – Organizational structure and resources (management structure, staffing resources, supply resources, physical layout of the facility) – Patient needs (acute or long-term/chronic) – Staff availability, skills and competencies
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What Questions are important in evaluating the nursing care delivery model in place?
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Are the patient outcomes achieved in a timely, cost-effective manner? Are patients and families happy with care? Are physicians and other health team members satisfied with care? Does the system allow for implementation of the nursing process? Does the system facilitate communication among all members of the health care team?
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Factors influencing Changes in Nursing Care Delivery?
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– Rapid technological advances – Fast-paced patient turnover in acute care settings – RN’s value in patient safety and quality care – Ongoing shortages of nurses and other health professionals – Strong focus on outcomes of care (because there is better healing and pt. outcomes with outpatient procedures, more are being done) – Consumer demand for instant access to care and information – Need to focus on the underlying determinants of health that are affected by lifestyle and personal choice
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Nurses in Outpatient and Community settings are challenged to address the following…?
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Patient demands for instant access to care and information Patients need for support and education to address lifestyle and personal choices that may affect their health
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What kind of care should be considered in high-tech fast-paced environments?
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Relationship-based care (Where care must be consistent with nursing values of compassion, caring and healing)
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What are the future challenges for nursing leaders when picking a nursing model?
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Identify new models that are cost-effective, will improve quality and safety of care, and facilitate relationship-based nursing
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Nurses of the future must ___________ and __________ before the patient is quickly transitioned to another level of care
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conduct focused assessments set priorities to resolve
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What do traditional models of nursing care focus on? and how is it different in the future?
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Focus on comprehensive knowledge of patient needs and care provided over an extended period Now nurses may be assigned an entirely new group of patients to care for every shift or even more than once during a shift (patient rapid turnover)
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***List three indications that the nursing care model in use on a particular unit is effective
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– Patient outcomes are consistently good, as measured by quality indicators such as low complication rates – Patient and family satisfaction ratings are high for care received – Physicians and other health team members express satisfaction with the quality of care and the quality of communication
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Monitors the treatment plan and length of stay for long-term, high-cost cases
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Case Manager
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Categorizing patients according to care needs
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Acuity Level
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Assignments are to complete certain tasks rather than to care for specific patients.
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Functional
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Contributes to higher-quality, more cost-effective care
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Satisfaction
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Patient classification systems help nurse managers to _________ the amount and level of care needed.
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Quantify
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A measure of the efficient use of staff
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Productivity
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A primary nursing role in telehealth nursing
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Triage
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Modification of primary nursing designed to make more efficient use of the RN
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Partnership model
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May have a significant effect on the nursing unit’s budget
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Staff Mix
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Identifies potential variations in progress along a clinical pathway
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Trigger
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Responsible for promoting a cooperative environment and maintaining clear communication
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Team Leader
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Stage in the case management process during which research is appraised as the basis for clinical treatment decisions
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Assessment
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Knowing only the number of patients who require care is an ________ way to plan staffing.
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Ineffective
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The higher the acuity level, the more __________ the patient care needs are.
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Intense
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More recent development in nursing care delivery models
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Patient centered care
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Practice standards for telehealth nursing dictate that nurses _________ the urgency of patient care needs.
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Prioritize
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Event that may alter the patient’s progress along a clinical pathway
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Variance
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Stage in the case management process during which the patient’s progress toward goal accomplishment is monitored.
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Interacion
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Management function designed to ensure an adequate number and mix of health care team members to provide safe, quality care
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staffing
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Nurse assumes 24-hour responsibility for planning, directing, and evaluating the patient’s care.
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Primary nursing

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