Nursing Care Delivery Systems Issues and Trends Module 6

Five Major Types of Nursing Care Delivery Systems Total Patient Care Functional Nursing Team or Modular Nursing Primary Nursing Case Management Marquis and Huston 2012

Total Patient Care Registered Nurse assumes responsibility for a group of patients for a shift – provides all care to the patient. Advantages – continuity for the shift, responsibility is clear, generally satisfying for nurses. Disadvantages – can be very expensive, may not utilize RN time wisely and may not be possible with staffing shortages.

Functional Nursing Staff Members are assigned to a specific task or group of tasks for patients – example Medication Nurse, IV Nurse, Vital Signs --- RN assumes overall direction of care. Advantages – incorporates the use of LPNs and UAPs and maximizes their skills, can be cost effective. Disadvantages – Can lead to fragmentation and gaps in patient care – not holistic.

Team Nursing/Modular Nursing RN Team Leader coordinates care for a group of patients working with other team members (RNs, LPNs and UAPs) utilizing their skills. Advantages – if done well can be very satisfying to staff and patients as well as cost effective. Disadvantages – requires high level leadership skills from RN – harder to do with high patient acuity and inconsistent team members.

Primary Nursing Registered Nurses assume 24/7 accountability for their Primary Patients – establish plan of care and coordinate care even in their absence. Advantages – can result in high job satisfaction and excellent holistic care for patients. Disadvantages – requires high RN mix, difficult to do with today’s flexible scheduling, some staff don’t want the accountability and responsibility.

Case Management RN Case Manager supervises the care of the patient and use of resources across the continuum – focus is on individual patients. Advantages – can be very cost effective and satisfying for patients who are high risk/problem prone. Disadvantages – Case Management is not a true inpatient delivery system but rather the management of patient care.

Leadership Responsibilities in Selecting a Model Determine whether the patient acuity and patient needs in the setting fits the model being recommended. Assess whether your staff is ready and trained to utilize a new model. Ensure that your staff understand scope of practice issues. Ensure that the model will allow your nursing staff to do their best work. Determine the economic feasibility. Assess the adequacy of your nursing resources to support the model.

Hot Issues with Nursing Care Delivery Systems Movement of Nursing back to a Team or Modular Approach Increasing Numbers of Associate Degree Nurses with no Leadership Training who are assigned as Team Leaders. Confusion about Scope of Practice particularly with LPNs in Acute Care has led to reduction of LPN use but an increase in PCA or PCT Use.

What Every Nursing Leader needs to know about the Florida Nurse Practice Act before introducing a New Nursing Care Delivery System

Supervision - Definition “Supervision is the provision of guidance by a qualified nurse and periodic inspection by the nurse for the accomplishment of a nursing task or activity” Florida Nurse Practice Act

Delegation - Definition “Transferring to a competent individual the authority to perform a selected nursing task in a selected situation.” National Council of State Boards of Nursing

Practice of Professional Nursing Observation, Assessment, Nursing Diagnosis, Planning, Intervention, Evaluation of Care and Health Teaching. Administration of Medications and Treatments as prescribed by a duly authorized licensed practitioner in the state. Supervision and Teaching of other personnel in the performance of the above acts. Florida Nurse Practice Statute 464

Practice of Practical Nursing Performance of selected acts including administration of treatments and medications in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health and prevention of illness of others. Works under the direction of a Registered Nurse, a Licensed Physician, a Licensed Osteopath, a Licensed Podiatric Physician or a Dentist. Florida Nurse Practice Statute 464

Unlicensed Assistive Personnel - UAPs Certified Nursing Assistants Personnel Care Assistants Student Nurses Patient Care Technicians None of the above are licensed

Registered Nurses Cannot Delegate the Following Assessment or Reassessment of Patients Planning of Care Evaluation of Care Decisions about whether to contact a Physician about Changes in a Patient’s Condition

Registered Nurses can Delegate Tasks involving Activities of Daily Living Data Collection such as Intake/Output, Weights, Vital Signs, Glucose Finger Sticks Administration of Medications or Performance of Treatments

Supervision of Care Supervision of Care in an Acute Care Setting is ALWAYS the responsibility of a Registered Nurse. Licensed Practical Nurses in Nursing Home Setting can supervise care given by other LPNs or UAPs providing that have 6 months experience and a 30 hour supervisory course. Florida Nurse Practice Statute 464

Questions to ask before you change your skill mix? What is the acuity mix of your patients and will RNs be able to safely assign patients to other levels of staff and provide the level of follow-up needed? Do your RNs clearly understand that LPNs can never assume full responsibility for acute care patients? Do your RNs and LPNs understand that patient assessments and reassessments must be done by Registered Nurses?

More Questions to ask before you change your skill mix? Do your LPNs who have worked in Nursing Homes understand that their scope of practice is different in acute care settings. Do your Registered Nurses have the leadership capabilities to delegate and provide the level of supervisory follow-up that acute care patients require?

Key Information Sites For Nurse Practice Guidance https://www.ncsbn.org/index.htm The National Council of State Boards of Nursing http://www.doh.state.fl.us/mqa/nursing/index.html The Florida Board of Nursing