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Topic: Types of Nursing Care Delivery System
Central Objective: At the end of 1 hour creative presentation, the learners shall gain knowledge, develop skills and acquire positive attitudes and values
Time allotment: 1hour
Teaching-learning Activity: Creative presentation with scenarios and caselets Evaluation: Oral evaluation and active participation after the presentation
At the end of 1 hour creative presentation, the learners shall:
Discuss comprehensively the function of organizing and it’s application
Analyze critically the different types of nursing care delivery systems in terms of its positive and negative aspects.
A hospital experiencing shortage nurses decided to try various types of nursing care delivery systems to provide nursing care to patients with varying needs of intensity of care. Over the years this hospital critiqued different types of nursing care delivery system. They see to it that they give effective, cost-efficient, and quality nursing care to the patients.
Types of Nursing Care Delivery Systems
The purpose of a nursing care delivery system is to provide a structure that enables nurses to deliver nursing care to as specified group of patients. The delivery of the care includes assessing care needs, formulating a plan of care, implementing the plan, and evaluating the patient’s responses to interventions. No delivery system is perfect. Most organizations use a combination or modification of various nursing care delivery systems to meet the unique demands of different patient care units. Before adopting any nursing care delivery system, the nursing organization must consider its goals, characteristics, and needs; the demands placed on it; and the cost of the nursing care delivery system (Sullivan, 2005).
1. Functional Nursing
Functional nursing, also called task nursing, began in hospitals in the mid-1940s in response to a national nursing shortage. The number of registered nurses (RNs) serving in the armed forces during World War II depleted the supply of nurses at home. In functional nursing, the needs of a group of patients are broken down into tasks. Tasks are assigned to RNs, LPNs (Licensed Practical Nurses), UAPs (Unlicensed Assistive Personnel) so that the skill and licensure of each caregiver is used to the best advantage.
a. Client care is provided in an economic and efficient manner b. Minimum number of RNs are required for client care
c. Tasks are completed quickly and there is little confusion about job responsibilities d. Cost effective and less staffing
a. Uneven continuity of care,
b. Absence of a holistic view of the patient,
c. Time-consuming communications, and
d. Problems with follow-up.
2. Team Nursing
Team nursing remains the most common nursing care delivery system in the United States in acute as well as long-term-care settings. Historically, team nursing evolved from functional nursing and has remained popular since the middle to late 1940s. Under this system, a team of nursing personnel provides total patient care to a group of patients. Modular nursing is a modification of team nursing that tries to enhance the effectiveness of a team concept by assigning a module that is confined to a limited geographic area. This size of the module varies according to a physical layout of the unit, the patient acuity, and nursing skill mix.
a. It allows the use of less prepared staff members (LPNs and UAPs) to carry out some functions that do not require the expertise of an RN. b. It allows patient care needs requiring more than one staff member, such as a patient transfers from bed to chair, to be easily coordinated.
a. A large amount of time is required for the team leader to maintain effective communication for team planning, supervising, and coordinating the care provided by all team members. b. Continuity of care may be diminished because of day-to-day changes in team members and leaders, as well as the group of patient assigned to the team. c. Each member of the team is assigned specific tasks for the patient and no one considers the total patient, team or modular nursing does not allow for a holistic view of the patient.
3. Total Patient Care
The original model of nursing care delivery was total patient care, also called case method, in which a registered nurse was responsible for all aspects of the care of one or more patients. During the 1920s, total patient care was the typical nursing care delivery system. Student nurses often staff hospitals, whereas RN provided total care to the patient at home. In total patient care, RN work directly with the patient, family, physician, and other health care staff in implementation a plan of care. The goal of this delivery system is to have one nurse give all care to the same patient(s) for the entire shift.
a. Continuous, holistic, expert nursing care;
b. Total accountability for the nursing care for the assigned patient(s) for the shift; and c. Continuity of communication with the patient, family, physician(s), and staff from other department.
a. Continuity of care may suffer because each nurse has the right to modify
the care plan and client may get different approaches to care b. costly
4. Primary Nursing
Conceptualized by Marie Manthey and implemented during the late 1960s after two decades of team nursing, primary nursing was designed to place the registered nurse back at the patient’s bedside (Manthey, 1980). Decentralized decision making by staff nurses is the core principle of primary nursing, with responsibility and authority for nursing care allocated to staff nurses at the bedside. Primary nursing recognized that nursing was a knowledge-based profession practice, not just task-focused activity.
a. A knowledge-based practice model;
b. Decentralization of nursing care decisions, authority, and responsibility to the staff nurse; c. 24-hour accountability for nursing care activities by one nurse; d. Improved continuity and coordination of care; and
e. Increased nurse, patient, and physician satisfaction.
a. Expensive, needs large number of RNs
b. May be difficulty to recruit and train large number of RNs c. Inadequately prepared nursed may not make necessary clinical decisions or communicate effectively with the health care team d. The RN may no be willing to accept 24 hour responsibility – RN “emotional burn out”
5. Practice Partnership
This is a more recent concept also introduced by Marie Manthey. It can be applied to a primary nursing and used in other nursing care delivery system, such as team nursing, modular nursing, and total patient care. It offers an efficient way of using the skills of a mix of professional and nonprofessional staff with differing levels of expertise.
In the practice partnership model, an 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. The senior RN partner directs the work of the junior partner within the limits of each partner’s skills set and the limits in the state’s nurse practice act.
The relationship between the senior and the junior partner is designed to create synergistic energy as the two work in concert with the patients. The senior partner performs selected patient care activities but delegates less specialized activities to the junior partner.
Advantage(s): When compared to team or modular nursing, practice partnership offer more continuity of care and accountability for patient care. When compared to total patient care or primary nursing, partnerships are less expensive for the organization and more satisfying professionally for the partners.
a. It tends to increase the number of UAPs and decrease the ratio of professional nurses to nonprofessional staff. b. Another is the potential for the junior member of the team to assume more responsibility than appropriate
6. Case Management
Following the introduction and impact of prospective payment, nursing case management, used for decades in community and psychiatric settings, was adopted for acute inpatient care. It is a model used for identifying, coordinating and monitoring the implementation of services needed to achieve desired patient care outcomes within a specified period of time. It organizes patient care by major diagnoses or diagnosis-related groups and focuses on attaining predetermined patient outcomes within specific time frames and resources
The case manager, who may be called a care coordinator, usually does not provide direct patent care but rather supervises the care provided by licensed and unlicensed nursing personnel. Patient involvement and participation is key to successful case management. Ideally, nursing case managers have advanced degrees and considerable experience in nursing.
a. For the patient:
– Establishing and achieving a set of “expected” or standardized patient care outcomes for each patient. – Facilitating early patient discharge or discharge within an appropriate length of stay.
– Using the fewest possible appropriate health care resources to meet expected patient care outcomes.
– Facilitating the continuity of patient care through collaborative practice of diverse health professionals. b. For the nurse:
– Enhancing nurse’s professional development and job satisfaction.
– Facilitating the transfer of knowledge of expert clinical staff of novice staff.
a. The nurse may have a large case load
b. Monitoring of health expenses may be more important than quality of care
7. Critical Pathways
Successful case management relies on critical pathways to guide care. The term critical path refers to the expected outcomes and care strategies developed by the collaborative practice team. Again, interdisciplinary consensus must be reached and specific, measurable outcomes determined.
A critical path quickly orients the staff to the outcomes that should be achieved for the patient for that day. Nursing diagnoses identify the outcomes needed. If patient outcomes are not achieved, the case manager is notified and the situation analyzed to determine how to modify the critical path.
Altering time frames or interventions is categorized as a variance, and the case manager tracks all variances. After a time, the appropriate collaborative practice term analyze the variances, note trends, and decide how to manage them. The critical pathway may need to be revised or additional data may be needed before changes are made.
Some features are included on all critical paths, such as specific medical diagnosis, the expected length of stay, patient identification data, appropriate time frames for interventions, and the patient outcomes. Interventions are presented in modality groups. The critical path must be included a means to identify variances easily and to determine whether the outcome has been met.
A recent evolution of critical paths is the incorporation of actual and potential nursing diagnoses with specific time frames into the critical pathway. Education paths are also excellent tools for planning patient and family education. A copy of this form is given to the patient and the family, and the nurse reviews the information with them. Thus, both the patient and the family know what to expect during an anticipated, uncomplicated hospitalization.
a. It provides direction of managing the care of a specific patient during a specified time period. b. It accommodates the unique characteristics of the patient and the patient’s condition. c. It use resources appropriate to the care needed and, thus reduce cost and length of stay. d. It is used in every setting where health care is delivered.
a. Some physicians perceive pathways to be cookbook medicine and are reluctant to participate in their development. b. Development requires a significant amount of work to gain consensus from the various disciplines on the expected plan of care. c. Pathways are less effective for patient populations that are nonstandard, since they are constantly being modified to reflect individual patient needs.
8. Differentiated Practice
Differentiated practice is a method that maximizes nursing resources by focusing on the structure of roles and functions of nurses according to their education, experience, and competence. It is designed to identify distinct levels of nursing practice based on defined abilities that are incorporated into job descriptions.
In differentiated practice, the responsibilities of RNs differ according to the competence and training associated with the two education levels as well as the nurses’ experience and preference. The scope of nursing practice and level of responsibility are specifically defined for each level.
Differentiated practice models have been used in a variety of inpatient, acute care settings as well as in home care and clinics.
a. improves patient care and contributes to patient safety,
b. allows for the most effective and efficient use of scarce resources, c. Offers increased satisfaction for nurses, and provides opportunity to compensate nurses fairly based on their expertise, contributions, and productivity. Differentiated practice is especially important to maintain quality of care, ensure patient outcomes, and address personnel budget concerns.
a. Nurses who have experience, knowledge, and capability to function beyond their original education may not be recognized. b. Organizations that have determined minimal educational requirements for RN positions may have difficulty in recruiting staff with the requisite credentials.
9. Patient Centered Care
Patient-centered care is a model of nursing care delivery in which the role of the nurse is broadened to coordinate a team of multifunctional unit-based caregivers. In patient-centered care, all patient care services are unit-based, including admission and discharge, diagnostic and treatment services, and supportive services, such as environmental and nutrition services and medical records. It focuses on decentralization, the promotion of efficiency and quality, and cost control.
It consists of patient care coordinators, patient care associates, unit support assistants, administrative support personnel, and a nurse manager.
a. Patient comes into contact with fewer workers
b. Workers are unit based and spend more time in direct-care activities c. Team is supervised by an RN
d. RN is accountable for a wide range of services and functions at a higher level e. Cost-effective. It may be used in outpatient and home care setting.
a. Major change in organizational structure is required
b. Departments and nursing may have difficulty accepting shared tasks c. Nurse Manager supervises many types of workers; staff stress.
JOURNAL READINGS: Integration Mechanisms and Hospital Efficiency in Integrated Health Care Delivery Systems SUMMARY:
This study analyzes integration mechanisms that affect system performances measured by indicators of efficiency in integrated delivery systems (IDSs) in the United States. The research question is, do integration mechanisms improve IDSs” efficiency in hospital care? American Hospital Association”s Annual Survey (1998) and Dorenfest”s Survey on Information Systems in Integrated Healthcare Delivery Systems (1998) were used to conduct the study, using IDS as the unit of analysis. A covariance structure equation model of the effects of system integration mechanisms on IDS performance was formulated and validated by an empirical examination of IDSs.
The study sample includes 973 hospital-based integrated health care delivery systems operating in the United States, carried in the list of Dorenfest”s Survey on Information Systems in Integrated Health care Delivery Systems. The measurement indicators of system integration mechanisms are categorized into six related domains: informatic integration, case management, hybrid physician–hospital integration, forward integration, backward integration, and high tech medical services. The multivariate analysis reveals that integration mechanisms in system operation are positively correlated and positively affect IDSs” efficiency. The six domains of integration mechanisms account for 58.9% of the total variance in hospital performance.
The service differentiation strategy such as having more high tech medical services have much stronger influences on efficiency than other integration mechanisms do. The beneficial effects of integration mechanisms have been realized in IDS performance. High efficiency in hospital care can be achieved by employing proper integration strategies in operations.
JOURNAL READINGS: Creating Workplace Environments that Support Moral Courage
Nurses practicing in today’s healthcare environment are confronted with increasingly complex moral and ethical dilemmas. Nurses encounter these dilemmas in situations where their ability to do the right thing is frequently hindered by conflicting values and beliefs of other healthcare providers. In these circumstances, upholding their commitment to patients requires significant moral courage. Nurses who possess moral courage and advocate in the best interest of the patient may at times find themselves experiencing adverse outcomes.
These issues underscore the need for all nurses in all roles across all settings to commit to working toward creating work environments that support moral courage. In this manuscript the authors describe moral courage in nursing; and explore personal characteristics that promote moral courage, including moral reasoning, the ethic of care, and nursing competence. They also discuss organizational structures that support moral courage, specifically the organization’s mission, vision, and values; models of care; structural empowerment; shared governance; communication; a just culture; and leadership that promotes moral courage.
Challenges in the care environment are myriad. All professional nurses assume the responsibility for serving as patient advocates and role models. This duty exists whether nursing practice occurs at the bedside, in the classroom, in the board room, or in the research setting. Quite simply, the accountability and responsibility for creating environments that promote moral courage in practice and transform the workplace is an obligation shared by all nurses, in every role, in every specialty, in every setting.
JOURNAL READINGS: Value-Added Care: A Paradigm Shift in Patient Care Delivery
Extrinsic and intrinsic forces brought to bear on hospitals have placed them in a constant state of transition. One major driving force in health care is spiraling costs as a direct result of scientific advances, technology, increased diversity, informed consumer partnering for safe care and decision making, and intensive illnesses with an increase in the aging population. An additional force is the higher demand by both providers and consumers for issues of quality care and satisfaction. Since nurses are the most important factor in the overall operation of each hospital, their practice remains in a constant state of change.
Identifying methods of providing care that combine humanistic and scientific perspective in a single model is of utmost importance. Thus, this gives meaning to the old adage: “If we cannot change the direction of the wind, we must learn how to sail.” In an effort to address quality, efficiency, and safety outcomes, many health care organizations have ex pended much energy in developing structural work role redesigns.
Nursing is a synergistic and dynamic profession, one that integrates art and science in a unique way. Just as unique are the consumers of health care (patients). Regardless of the type of care delivered, adhering to a set of numbers alone would miss the overall picture of this distinct aspect that differentiates nursing from other health professions. To provide a stronger basis for practice, one that can be integral in improving efficiency, quality, and reducing cost, the quantification of front-line staff should be replaced by a more systematic approach to the delivery of patient care. Through the understanding and acknowledgment of value-added care, nursing functions can be measured in terms of quality. Thus, a systematic intervention can enhance value-added care and reduce waste in the health care system.
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