Nursing care delivery

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  • 1. Staffing and Nursing Care Delivery Models
  • 2. Key Concepts Staffing for health care organizations Patient classification systems Nursing care delivery models Critical pathways Nursing case management
  • 3. Staffing  Activities to ensure an adequate number and mix of team members  Staffing considerations  Patient needs  Staff satisfaction  Organizational needs
  • 4. Meeting Patient Needs  Primary considerations  Number of patients  Intensity of care required  Staff experience and preparation  Patient classification systems/acuity level  Categorize patients according to care needs
  • 5. Classification System Considerations Age and functional ability Communication skills Cultural and linguistic diversities Severity/urgency of the admitting condition Scheduled procedures Ability to meet health care requisites Availability of social supports Other specific needs (Recommended by the American Nurses Association)
  • 6. Meeting Staff Needs  Satisfied nurses provide higher quality, more cost-effective care  24 hour/day, 365 day/year staffing needs create staffing challenges  Creative staffing options  Staff input about staffing
  • 7. Meeting Organizational Needs  Budget and financial management  Number of staff  Staff mix  Licensing and accreditation  Customer satisfaction  Quality care
  • 8. The Number One Challenge  Appropriate staffing within budget constraints with well-trained, competent, professional staff members who are committed to providing safe, high-quality care
  • 9. Nursing Care Delivery Models  Detail assignments, responsibility, and authority to accomplish patient care  Determine who is going to perform what tasks, who is responsible, and who makes decisions  Match number and type of caregivers to patient care needs
  • 10. Classic Nursing Care Models Total patient care Functional nursing Team nursing Primary nursing Variations have been adopted to improve care
  • 11. Total Patient Care  Nurse is responsible for planning, organizing, and performing all care  Oldest method of organizing patient care  Typically performed by nursing students  Common use areas—intensive care unit (ICU) and postanesthetic care unit (PACU)
  • 12. Total Patient Care—cont’d Advantages  High degree of autonomy  Lines of responsibility and accountability are clear  Patient receives holistic, unfragmented care Disadvantages  Each RN may have a different approach to care  Not cost-effective  Lack of RN availability
  • 13. Registered Registered Registered Nurse Nurse Nurse8-hour shift 8-hour shift 8-hour shift Patient Care The registered nurse plans, organizes, and performs all careTotal Patient Care (Case Method) Delivery
  • 14. Functional Nursing  Staff members assigned to complete specific tasks for a group of patients  Evolved during World War II as a result of a nursing shortage  Unskilled workers trained to perform routine, simple tasks  Common use area—operating room
  • 15. Functional Nursing—cont’d Advantages  Care is provided economically and efficiently  Minimum number of RNs required  Tasks are completed quickly Disadvantages  Care may be fragmented  Patient may be confused with many care providers  Caregivers feel unchallenged
  • 16. Nurse ManagerLPN RN Nurse Aide Nurse Aide PO Meds Assessments Vital signs HygieneTreatments Care Plans Hygiene Stocking Assigned Patient Group Functional Nursing Care Delivery Model
  • 17. Team Nursing RN as team leader coordinates care for a group of patients Evolved in the 1950s to improve patient satisfaction Goal was to reduce fragmented care Common use areas—most inpatient and outpatient areas
  • 18. Team Nursing—cont’d Advantages  High-quality, comprehensive care with a high proportion of ancillary staff  Team members participate in decision making and contribute their own expertise Disadvantages  Continuity suffers if daily team assignments vary  Team leader must have good leadership skills  Insufficient time for planning and communication
  • 19. Nurse Manager RN Team Leader RN Team Leader RN RN LPNs/LVNs LPNs/LVNs Nursing Assistants Nursing AssistantsAssigned Patient Group Assigned Patient Group Team Nursing Model
  • 20. Modular Nursing Modification of team nursing Patient unit is divided into modules or units with an RN as team leader The same team of caregivers is assigned consistently to the same geographic area Concept evolved to increase RN involvement in care
  • 21. Modular Nursing—cont’d Advantages  Continuity of care is improved  RN more involved in planning and coordinating care  Geographic closeness and efficient communication Disadvantages  Increased costs to stock each module  Long corridors not conducive to modular nursing
  • 22. Nurse ManagerGeographic Geographic Geographic Patient Unit Patient Unit Patient Unit Patient Care Patient Care Patient Care Team: Team: Team: RNs RNs RNs LPNs/LVNs LPNs/LVNs LPNs/LVNs Nurse Aides Nurse Aides Nurse Aides Meds Meds Meds Supplies Supplies Supplies Linens Linens Linens Modular Nursing Model
  • 23. Primary Nursing RN “primary nurse” assumes 24-hour responsibility for planning, directing, and evaluating care Evolved in the 1970s to improve RN autonomy Common use areas—hospice, home health, and long-term care settings
  • 24. Primary Nursing—cont’d Advantages  High-quality, holistic patient care  Establish rapport with patient  RN feels challenged and rewarded Disadvantages  Primary nurse must be able to practice with a high degree of responsibility and autonomy  RN must accept 24-hour responsibility  More RNs needed; not cost-effective
  • 25. Primary Nurse 24-hour responsibility for planning, directing & Associate Nurses Physician and other members evaluating patient care Provide careof the health care when primary team nurse is off duty Patient Primary Nursing Model
  • 26. Partnership Model(Co-Primary Nursing) RN is partnered with an licensed practical nurse/licensed vocational nurse (LPN/LVN) or nursing assistant to work together consistently Modification of primary nursing to make more efficient use of the RN
  • 27. Partnership Model(Co-Primary Nursing)—cont’d Advantages  More cost-effective than primary nursing  RN can encourage training and growth of partner Disadvantages  RN may have difficulty delegating to partner  Consistent partnerships difficult to maintain due to varied schedules
  • 28. Patient-Centered Care(Patient-Focused Care) Cross-functional teams of professionals and assistive personnel work together as a unit- based team Recent development in nursing care delivery models More patient oriented than department oriented Models vary considerably among facilities
  • 29. Patient-Centered Care(Patient-Focused Care)—cont’d Advantages  Patient comes into contact with fewer workers  Workers are unit based and spend more time in direct-care activities  Team is supervised by an RN  RN is accountable for a wide range of services and functions at a higher level  Cost-effective
  • 30. Patient-Centered Care(Patient-Focused Care)—cont’d Disadvantages  Major change in organizational structure is required  Departments other than nursing must be willing to accept nursing leadership  Nurse manager supervises many types of workers
  • 31. Nurse ManagerPatient Care Respiratory Services Patient TransportationHousekeeping ECG Admission/Discharge PhlebotomyPhysical/Occupational/Speech Therapy Dietary ServicesFinancial Counseling Supply Management Patient Patient-Centered Care Model
  • 32. Case Management First introduced in the 1970s by insurance companies Hospitals adopted the model in the 1980s Value demonstrated through research Components include:  Assessment, planning, implementation, evaluation, and interaction
  • 33. Case Management—cont’d Variations are found in most health care organizations Reserved for chronically ill patients, seriously ill patients, or long-term, expensive cases RN assumes a planning and evaluative role; usually not responsible for direct-care duties Supplemental form of care delivery; does not replace direct-care model
  • 34. RN Case Manager Coordinates the patient’s care throughout the course of an illness from a payer or facility perspective  Employee of the payer (external case management)  Employee of the health care facility (internal case management)
  • 35. Collaborates With Patient and Family NURSE CASE MANAGEROnset of Resolution of Assesses, plans, implements, coordinates, Illness Illness monitors, and evaluates patient care options and services to meet health needs Collaborates with Nursing, Coordinates Services: Physicians, Physical/Speech/ Home Care, Hospice, Occupational Therapists, Dietary, Extended /Long-term Care and Ancillary Services Ambulatory Care Services Nursing Case Management Model
  • 36. Clinical Pathways Delineate a predetermined written plan of care for a particular health problem Specify desired outcomes and transdisciplinary intervention Address a common medical diagnosis Dictate the type and amount of care given and thus have financial implications
  • 37. Clinical PathwaysTerminology Patient outcomes Transdisciplinary intervention Variance Trigger
  • 38. Clinical PathwaysEssential Components Consults  Self-care activities Laboratory and  Nutrition diagnostic tests  Patient and family Treatments education Medications  Discharge planning Safety  Triggers
  • 39. Choosing a Nursing Care DeliveryModel What staff mix is required? Who should make work assignments? Work assigned by task? By patient? How will communication be handled? Who will make decisions? Who will be responsible and accountable? Fit with unit/facility/organization management?
  • 40. Influences on Nursing CareDelivery Model Selection Health care setting  Acute care, long-term care, ambulatory care, home care, and hospice Organizational structure and resources  Management, staffing, supplies, and physical layout Patient needs  Acute, long-term, and chronic
  • 41. Evaluation of Nursing CareDelivery Models  Timely, cost-effective outcomes achieved?  Patient and families happy with care?  Team members satisfied with care?  Good communication among all team members?  RNs utilized and challenged appropriately?