STAFFING

AND NURSING
CARE DELIVERY
MODELS

Nursing care delivery

models

Nursing care delivery

models, also called care
delivery systems or patient
care delivery models, detail
the way task assignments,
responsibility, and
authority are structured to
accomplish patient care.

Nursing care
delivery models

The nursing care delivery

model describes
1. which health care worker is
going to perform what tasks,
2. who is responsible, and
3. who has the authority to
make decisions.

Nursing care
delivery
models
The basic premise of nursing

care delivery models is that

the number and type of
caregivers are closely matched
to patient care needs to
provide quality care in the
most cost-effective manner
possible.

Nursing care
delivery
models
The four classic nursing care
delivery models used during
the past five decades are
(1) total patient care,
(2) functional nursing,
(3) team nursing, and
(4) primary nursing.

Total Patient Care

The oldest method of organizing
patient care is total patient care,
sometimes referred to as case
nursing. In total patient care nurses
are responsible for planning,
organizing, and performing all care,
including personal hygiene,
medications, treatments, emotional
support, and education required for
their assigned group of patients
during the assigned shift.

Total Patient Care

Registered
Registered
Registered
nurse 8-hour
nurse8-hour
nurse8hour
shift
shift
shift

Patient care

The registered nurse

plans, organizes,

and performs all care.

The total patient care (case method) delivery

model.

Functional Nursing
In the functional nursing method of
patient care delivery, staff members are
assigned to complete certain tasks for a
group of patients rather than care for
specific patients. For example, the RN
performs all assessments and administers
all intravenous medications; the LVN/LPN
gives all oral medications; and the
assistant performs hygiene tasks and
takes vital signs. A charge nurse makes
the assignments and coordinates the care.

Functional Nursing

Nurse Manager

LVN/LPN
RN
Nurse aide
Nurse
aide
PO Meds
Assessments
Vital signs
Hygiene
Treatments Care plans
Hygiene
Stocking

Assignet Patient Group

The functional nursing care delivery model

Team Nursing
In team nursing the RN functions as
a team leader and coordinates a
small group (no more than four or
five) of ancillary personnel to provide
care to a small group of patients. " As
coordinator of the team, the registered
nurse is responsible for knowing the
condition and needs of all the patients
assigned to the team, and for planning
the care of each patient" (Marquis and
Huston, 2000).

Team Nursing
The team leader is responsible for
encouraging a cooperative
environment and maintaining clear
communication between all team
members.
The team leader's duties include
planning care, assigning duties,
directing and assisting team members,
giving direct patient care, teaching,
and coordinating patient activities.

Team Nursing

Nurse Manage

RN Team Leader

RN
LVNs/LPNs
Nursing assistants
assistants
Assigned patient
patient

group

RN Team Leader
RN
LVNs/LPNs
Nursing

Team nursing model

Assigned
group

Advantages of the Team

Nursing Model

1. High-quality, comprehensive care

can be provided with a relatively high
proportion of ancillary staff.
2. Each member of the team is able
to participate in decision making and
problem solving.
3. Each team member is able to
contribute his or her own special
expertise or skills in caring for the
patient. (Marquis and Huston, 2000).

Disadvantages
of
the
Team
1. Continuity of care may suffer if the daily
Nursing
team assignments
varyModel
and the patient is
confronted with many different
caregivers.
2. The team leader may not have the
leadership skills required to effectively
direct the team and create a "team spirit."
3. Insufficient time for care planning and
communication leads to unclear goals.
Therefore responsibilities and care may
become fragmented.

TEAM NURSING
Team nursing is an effective, efficient
method of patient care delivery and
has been used in most inpatient and
outpatient health care settings.
The team leader must have strong
clinical skills, good communication
skills, delegation ability, decisionmaking ability, and the ability to
create a cooperative working
environment.

Modular Nursing

Modular nursing is a modification of team

nursing and focuses on the patient's
geographic location for staff assignments.
The patient unit is divided into modules
or districts, and the same team of
caregivers is assigned consistently to the
same geographic location.
Each location, or module, has an RN
assigned as the team leader, and the
other team members may include
LVNs/LPNs and UAP (Yoder Wise, 1999).

Modular Nursing
The concept of modular nursing calls for a
smaller group of staff providing care for a
smaller group of patients.
The goal is to increase the involvement of
the RN in planning and coordinating care.
Communication is more efficient among a
smaller group of team members (Marquis and
Huston, 2000).

To maximize efficiency, each designated

module should contain all the supplies
needed by the staff to perform patient care.

Partnership Model
The partnership model, sometimes
referred to as co-primary nursing, is
a modification of primary nursing
and was designed to make more
efficient use of the RN.
In the partnership model the RN is
partnered with an LVN/LPN or UAP,
and the pair work together
consistently to care for an assigned
group of patients.

CASE MANAGEMENT

Evolution of Case Management

Case management is a model of care
delivery in which an RN case manager
coordinates the patient's care throughout
the course of an illness.
The concept of case management was
first introduced in the 1970s by insurance
companies as a method to monitor and
control expensive health insurance
claims, usually created by a catastrophic
accident or illness (More and Mandell, 1997).

CASE MANAGEMENT
Today, virtually every major health
insurance company has a case
management program to direct and
manage the use of health care
services for their clients.
Case management by payer
organizations (e.g., health insurance
companies, health maintenance
organizations [HMOs]) is known as
external case management.

CASE MANAGEMENT
The ANA has defined nursing case management
as "a dynamic and systematic collaborative
approach to providing and coordinating health
care services to a defined population. It is a
participative process to identify and facilitate
options and services for meeting individuals'
health needs, while decreasing fragmentation
and duplication of care and enhancing quality,
cost-effective clinical outcomes. The framework
for nursing care management includes five
components: assessment, planning,
implementation, evaluation, and interaction" (ANCC,
2001, p. 1).

Components of Case
Assessment.Management
Review the client's history and current
status
Perform comprehensive health
assessment
Identify available resources and support
system (e.g., individual, family, financial,
health insurance, community)
Identify barriers to accessing necessary
treatment (e.g., lack of health insurance
coverage; no family support)

Components of Case
Management
Assessment.
Identify health promotion and disease
prevention opportunities
Identify adherence patterns,
educational needs, and ability to learn
Determine potential for overuse or
under use of resources
Find, appraise, and use research
findings as the basis for treatment
decisions (evidence-based practice)

Components of Case
Management
Planning.
Prioritize needs and set realistic, measurable
goals and outcomes
Identify realistic treatment options
Coordinate various providers involved in the
plan of care (e.g., physician, physical
therapist, dietitian)
Determine appropriate levels of care and
realistic treatment settings (e.g., home, longterm care, rehabilitation facility)
Identify and address gaps in care
Ensure continuity of care
Negotiate and manage financial aspects of
care

Components of Case
Management

Implementation

Ensure implementation of the care plan in

a safe, timely and cost-effective manner
Coordinate services and referrals to
providers or agencies
Ensure compliance with federal, state,
and local regulations and standards
Use appropriate community resources
Document progress toward achieving
goals and outcomes
Accept accountability for implementation
of the care plan

Components of Case
EvaluationManagement

Measure clinical goals, functional

improvement, satisfaction with services and
cost-benefit of treatment plan
Is/was the plan of care realistic,
collaborative, and mutually beneficial to all
involved?
Are/were the established time frames
realistic?
Are/were the best possible and most costeffective treatments used?
Are/were individual educational
opportunities maximized?

Components of Case
Management
Interaction
Interact on a daily basis with diverse groups
of people: client, family members, and
significant others; health care team members;
payer representatives; representatives from
other health care agencies and community
organizations
Motivate diverse groups to cooperate,
collaborate, and work in the best interest of
the client
Use good communication, negotiation,
facilitation, and documentation skills.

CASE MANAGEMENT
Nursing case management in a health
care facility is a supplemental form of
nursing care delivery and does not take
the place of the nursing care delivery
model in place to provide direct patient
care.
Case management is not needed for
every patient in a health care facility and
generally is reserved for the chronically
ill, seriously ill or injured, and long-term,
high-cost cases.