Ch.

20 Notes
Staffing

Activities required to ensure an adequate number and mix of health

care team members to meet patient needs and provide safe, quality
care
Considerations are patient needs, staff satisfaction, and organizational
needs
Staffing and Patient Needs

Research validates contribution of RNs to improved patient outcomes

and prevention of premature mortality
Primary considerations for staffing a nursing unit
o Number of patients
o Intensity of care required
o Staff experience and preparation
o Geography of the environment
o Available technology
Patient classification systems
o Categorize patients according to care needs (acuity level)
o Higher acuity levels mean that nursing care needs are more
intense
ANA recommends that classification systems should consider patients:
o Age and functional ability
o Communication skills
o Cultural and linguistic diversities
o Severity and urgency of the admitting condition
o Scheduled procedures
o Ability to meet health care requisites
o Availability of social supports
o Other specific needs identified by patient and RN
Staff members must have the educational preparation, skill, and
experience necessary to meet patient care needs
Concerns about inadequate numbers of appropriately skilled and
experienced staff should be addressed with executive level managers

Staffing and Staff Satisfaction

Satisfied nurses generally provide higher quality, more cost-effective
care
24 hours/day, 365 days/year staffing needs make meeting the nurses
personal needs difficult
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Ch. 20 Notes
Creative staffing options are available to meet varied needs of staff
members
Methods to gain staff input about staffing and to enhance autonomy
are the key to staff satisfaction
Staffing and Organizational Needs

Organizational needs affected by staffing include:

o Financial resources
o Licensing regulations and accreditation standards
o Customer satisfaction
Efficient staff management ensures the organizations financial
solvency
Nurse manager accountable for budgetary guidelines for:
o Numbers of staff working at any given time
o Staff mix
RNs the most expensive staff; thus ratios for RNs to other types of care
providers may be established
o Licensing and accreditation agencies do not impose mandatory
staffing ratio but do look for evidence that patients are
adequately cared for
o Customer satisfaction is critical to an organizations success
o A customers personal interaction with employees is key to
satisfaction
Nurse managers number one challenge:
o Appropriate staffing within budget constraints with well-trained,
competent, professional staff members who are committed to
providing safe, high-quality care
Nursing Care Delivery Models

Detail how task assignments, responsibility, and authority are

structured to accomplish patient care
Describe which health care worker is going to perform what tasks, who
is responsible, and who has the authority to make decisions
Basic premise is that the number and type of caregivers are closely
matched to patient care needs in a cost-effective manner
Classic Nursing Care Delivery Models

Total patient care

Functional nursing
Team nursing
Primary nursing

Ch. 20 Notes

Variations of these classics have been adopted to improve quality and

cost-effectiveness of patient care
Total Patient Care

Nurse is responsible for planning, organizing, and performing all

patient care during the assigned shift
Background
o Oldest method of organizing patient care, sometimes referred to
as case nursing
o Nursing student typically performs total patient care for assigned
patients
o Advantages
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
o Disadvantage
Number of RNs required is very costly
Some tasks could be accomplished by a caregiver with less
training and at a lower cost
o Common use areas: intensive care units, postanesthesia care
units
Functional Nursing

Staff members are assigned to complete certain tasks for a group of

patients rather than care for specific patients
Lines of responsibility and accountability
o RN nurse manager assigns responsibility for completion of tasks
to a group of health care workers
o RN is responsible for planning care and supervising workers
o RN retains accountability for the patient care provided
Advantages of patient care
o Provided economically and efficiently
o Minimum number of RNs required for patient care
o Tasks completed quickly; little confusion about responsibilities
Disadvantages of patient care
o May be fragmented; possibility of overlooking priority patient
needs
o Patient may feel confused because of many different care
providers
o Caregivers may feel unchallenged when performing repetitive
functions
Common use areas: operating room
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Ch. 20 Notes
Team Nursing
RN functions as a team leader and coordinates care for a small group
of patients
Lines of responsibility and accountability
o RN team leader is responsible for the following:
Planning care
Assigning duties
Directing, supervising, and assisting team members
Giving direct care
o RN retains accountability for all patient care
o RN team leader is responsible for encouraging a cooperative
environment and maintaining clear communication
Advantages
o High-quality, comprehensive care can be provided with a
relatively high proportion of ancillary staff
o Each member participates in decision making, problem solving
o Each member contributes his/her own special expertise or skills
Disadvantages
o Continuity of care may suffer with daily team assignments
o Team leader may not have the leadership skills required to
effectively direct the team
o Insufficient time for care planning and communication leads to
unclear goals and fragmented care
Common use areas: effective, efficient method of patient care delivery
that has been used in most inpatient and outpatient health care
settings
Modular Nursing
Modification of team nursing
o Patient unit divided into modules; same team of caregivers
assigned consistently to same geographic location
o Each location or module has RN as team leader
o Goal is to increase the involvement of the RN in planning and
coordinating care
o Designated modules should contain all the supplies needed by
the staff to maximize efficiency
Primary Nursing
RN primary nurse assumes 24-hour responsibility for planning,
directing, and evaluating the patients care from admission through
discharge
o Provides total patient care while on duty
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Ch. 20 Notes
o While off duty, care is provided by an associate nurse, who
follows the care plan established by the primary nurse
Lines of responsibility and accountability
o RN primary nurse has 24-hour responsibility and accountability
for patient care
o Associate nurses are responsible for following the plan care
o RN primary nurse is responsible for maintaining clear
communication among all members of the health care team
Advantages
o Direct patient care provided by a small number of nurses allows
for high-quality, holistic patient care
o Patient able to establish a rapport with the primary nurse, and
patient satisfaction is enhanced
o Job satisfaction high because nurses are able to practice with a
high degree of autonomy and feel challenged and rewarded
Disadvantages
o Implementing may be difficult because primary nurse is required
to practice with a high degree of responsibility and autonomy
o Inadequately prepared primary nurse may not be able to make
the necessary clinical decisions or to communicate effectively
with the health care team
o RN may not be willing to accept 24-hour responsibility as
required
o Number of RNs required for this method of care may not be costeffective and may be difficult to recruit and train
Common use areas: home health, hospice, long-term care
Partnership Model (or Co-primary Nursing)
RN is partnered with an LPN/LVN or a nursing assistant; pair work
together consistently
Modification of primary nursing designed to ensure more efficient use
of RN
Lines of responsibility and accountability
o RN responsible for planning care, assigning duties, coordinating
care, and supervising the partner
o RN is accountable for patient care for all assigned patients
Advantages
o More cost-effective than the primary care system
o RN can encourage training and growth of partner
Disadvantages
o RN may have difficulty delegating to the partner
o Consistent partnerships are difficult to maintain on the basis of
varied staff schedules
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Ch. 20 Notes
Patient-centered Care
Definition by IOM (2001)
o Providing care that is respectful of and responsive to individual
patient preferences, needs, and values and ensuring that patient
values guide all clinical decisions
o Nurses, physicians, and other health professionals partner with
patients and families to ensure that health care decisions respect
patients wants, needs, and preferences
Philosophy of care
o Not a typical nursing care delivery model but more a philosophy
of care
o Should be incorporated as an essential component of any nursing
care delivery model
Methods to engage patients families, and significant others as
partners in care
o Include them in developing care plans and discharge plans
o Include them in change-of-shift or hands-off reports
o Provide them with the information and education needed to
make informed decisions
o Establish family advisory councils to engage patients and
families in decision making
Telehealth Nursing
Characteristics
Important method of providing nursing care to clients in ambulatory
settings
Formally used to interact with patients, beginning in the early 1970s
Also called telephone triage, telephone nursing, or telehealth
Encompasses all telecommunication methods- e-mail, internet, fax,
and telephone
Nurses Roles in Telehealth Nursing
Triage
Interventions
Consultation
Surveillance and follow-up
Practice Standards
(Published by the American Academy of
Ambulatory Care Nursing)
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Ch. 20 Notes
Using protocols, algorithms, or guidelines to assess and address
patient needs
Prioritizing the urgency of patient needs
Developing a collaborative plan of care
Evaluating outcomes of practice and care
Structure
Integral part of an outpatient clinic practice
Function of a centralized call center
Future of Telehealth Nursing
Ever-increasing opportunities for nurses in telehealth to influence the
quality of care
Case Management
Evolution
Introduced in 1970s by insurance companies as a method to monitor
and control expensive health insurance claims
Today, most health insurance companies have a case management
program
By mid-1980s, hospitals recognized need for case management to
manage patients treatment plan and length of stay because of the
diagnosis-related group (DRG) payment method
The RN case manager coordinates the patients care throughout the
course of an illness, as an employee of the payer or as an employee of
the health care facility
Goal of case management is to focus attention on quality, outcomes,
and cost of care, and to assist the patient to move through the
continuum of care
Studies have demonstrated the value of case management in
improving patient outcomes and reducing costs
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
Nurse case manager manages a case load of patients from
preadmission (onset of illness) to discharge (resolution of illness)
Case Management in Health Care
Other disciplines, most notably social work, have been involved in
developing case management programs
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Ch. 20 Notes
When clinical knowledge is required, the RN is most effective in the
case management role
Variations in case management are found in almost all health care
organizations
Case Management and Other Nursing Care Delivery Models
Supplemental form of nursing care that does not replace the nursing
care delivery model already in place to provide direct patient care
RN case manager assumes a planning and evaluative role and usually
is not responsible for direct care duties
Case management is generally reserved for the chronically ill; the
seriously ill or injured; and long-term, high-cost cases
Clinical Pathways
(Critical Paths, Practice Protocols,
Care Maps)
Defining Features
Delineates a predetermined 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 medical diagnoses such as heart failure
and pneumonia, common nursing care needs such as immobility, and
medical complications such as weaning from mechanical ventilation
Differ from clinical practice guidelines
o Clinical pathways define key processes and patient goals in the
day-to-day management of care
o Clinical practice guidelines guide broader decision making and
focus on decisions made in performing a procedure or service
Background
Developed to identify quality, cost-effective care plans to reduce the
patients length of stay in the hospital
Dictate the type and amount of care given and thus have financial
implications for the health care facility

Terminology
Patient outcomes: result of intervention by the health care team
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Ch. 20 Notes
Interdisciplinary intervention: collaborative effort by all disciplines,
along with the patient and family, to reach desired health outcomes
Variance: any event that may alter the patients progress through the
clinical pathway
Trigger: alerts caregiver that an unexpected event has occurred and
identifies potential and actual variations in patients response to a
planned intervention
Essential Components of Clinical Pathways
Consults
Laboratory and diagnostic tests
Treatments and medications
Safety and self-care activities
Nutrition
Patient and family education needs
Discharge planning
May address triggers
Development of Clinical Pathways
Based on accepted standards of practice
Medical specialty boards developed clinical practice guidelines
The Agency for Healthcare Research and Quality (AHRQ), in
conjunction with medical specialty associations, professional societies,
and other health care organizations, has developed a series of clinical
practice guidelines
Developed for the health care organizations most common or costly
diagnoses
A team supported by management, with representatives from various
disciplines such as nursing, medicine, therapy, pharmacy, and dietary,
develops clinical pathways

Choosing a Nursing Care Delivery Model

Examples of Different Health Care
Settings Requiring Different Models
Emergency departments use financial nursing because emphasis is on
efficient assessment and immediate treatment
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Ch. 20 Notes
Team nursing frequently used in medical-surgical units
Total patient care is common in critical care units
Home health agencies may use primary nursing
A study found that more than 50% of staff from 26 hospitals reported
using two or three nursing care delivery models, sometimes over the
course of a single shift
Influences on the Type of Nursing Care Delivery Model Used
Health care Setting
o Acute care
o Long-term care
o Ambulatory care
o Home care and hospice
Organizational structure and resources
o Management structure
o Staffing resources
o Supply resources
o Physical layout of the facility
Patient needs
o Acute
o Long-term/chronic
Staff availability, skills, and competencies
Evaluation of Nursing Care Delivery Models
Are 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 of members of
the health care team?

Future Nursing Care Delivery Models

Factors Influencing Changes in Nursing Care Delivery
Rapid technological advances
Fast-paced patient turnover in acute care settings
RNs value in patient safety and quality care
Ongoing shortages of nurses and other health professionals
Strong focus on outcomes of care
Consumer demand for instant access to care and information
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Ch. 20 Notes
Need to focus on the underlying determinants of health that are
affected by lifestyle and personal choice
Nursing Now and in the Future
Traditional models of nursing care focused 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
Nurses of the future must conduct focused assessments and set
priorities to resolve before the patient is quickly transitioned to another
level of care
Nurses in outpatient and community-based settings are challenged to
address the following:
o Patients demands for instant access to care and information
o Patients need for support and education to address lifestyle and
personal choices that may affect their health
Relationship-based care must be considered in high-tech fast-paced
environments where care must be consistent with nursing values of
compassion, caring, and healing
Nurse leaders will be challenged to identify new models that are costeffective, will improve quality and safety of care, and facilitate
relationship-based nursing

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