Care Delivery Models In Nursing Traditional Non Traditional and Cotemporary Models

The Care Delivery Models In Nursing Traditional Non Traditional and Cotemporary Models. Decision-making is centralized, with minimal patient involvement. Work is task-oriented, and staff rotate between roles. Staff learn tasks that anyone in the NF could perform. The services provided are impersonal.

What are Care Delivery Models In Nursing Traditional Non Traditional and Cotemporary Models

Care models have evolved from traditional to modern approaches, each with its own focus and structure. Traditional models, such as integrated care and team-based care, prioritize efficient task allocation, while modern models prioritize patient-centered care, inter-professional collaboration, and the use of technology to improve outcomes.

Organizing Patient Care

Organizing patient care is a critical role for nursing leaders and managers, whether in a hospital, a skilled nursing facility, home care, or other health-care settings. The primary goal when organizing patient care is delivering safe and quality nursing care using available resources effectively.

In this topic, the major components of organizing patient care are covered, including identifying, implementing, and monitoring a care delivery model; deter mining staffing needs for safe and quality care; developing and implementing a staffing plan; monitoring productivity; and evaluating staffing effectiveness. Knowledge, skills, and attitudes related to the following core competencies are included: patient-centered care, teamwork and collaboration, quality improvement, informatics, and safety.

Care Delivery Models

Care delivery models are used to organize and deliver nursing care and focus on structure, process, and outcomes (Duffield, Roche, Diers, Catling-Paull, Blay, 2010; Neisner & Raymond, 2002; Wolf & Greenhouse, 2007). Additionally, care delivery models serve to drive assessments, decisions, planning, organization, and evaluation of structures, processes, and outcomes (Wolf & Greenhouse, 2007). These models have evolved over the past century in response to issues such as war, politics, economics, social environment, technology, and advances in health care.

The care delivery model used in an organization is usually determined by nurse leaders and managers at the executive level, with the model chosen reflective of the organizational mission, philosophy, and goals. Nurse leaders and managers at the unit level should have input regarding the model chosen to ensure that it is appropriate for the unit, skill mix, number of nursing personnel available, and the acuity of the patients.

Unit level leaders and managers are also responsible for implementing, monitoring, and evaluating the effectiveness, efficiency, and outcomes of the selected care delivery model. Frontline nurses should assist in monitoring and evaluating outcomes of the process. Nursing care delivery models address five questions (Neisner & Raymond, 2002, p. 8):

1. Who is responsible for making decisions about patient care?
2. How long do that person’s decisions remain in effect?
3. How is work distributed among staff members: by task or by patient?
4. How is patient care communication handled? 5. How is the whole unit managed?

Care delivery models must foster effective communication and also balance the needs of the patients with the competencies and availability of the nursing staff. Models of care provide for continuity of care across the continuum and give nurses the authority and responsibility for the provision of nursing care (Kaplow & Reed, 2008). To be effective, care delivery models should be aligned with the organization, sustainable over time, and replicable (Wolf & Greenhouse, 2007).

Regardless of the care delivery model employed, nurse leaders and managers have a responsibility to ensure that safe and quality patient care is provided by competent nursing staff. The American Organization of Nurse Executives (AONE, 2010) contends that nurse leaders and managers will need to participate in redesigning nursing

care delivery in the future by focusing on patient- and family-centered care, ensuring that frontline nurses participate in the decision-making process, and optimizing nursing roles and care across the continuum. In addition, the AONE includes effective use of delivery models as a component of the knowledge of the health care environment competency (AONE, 2015, p. 6) in the following ways:

• Demonstrate current knowledge of patient care delivery systems across the continuum.
• Describe various delivery systems and patient care models and the advantages/ disadvantages of each.
• Assess the effectiveness of new care delivery models.
• Align care delivery models and staff performance with key safety and economic drivers.

There are many care delivery models in use today, classified as traditional, nontraditional, and contemporary models.

Traditional Models

Traditional care models are rooted in nursing’s historical beginnings. The best-known traditional models of care delivery are total patient care, functional nursing, team nursing, primary nursing, and nursing case management. Many of these models are still in use today, with many newer models incorporating aspects of traditional models.

Total Patient Care

Total patient care, also known as the case method, is the oldest model of care delivery. At the turn of the 20th century, nursing care took place in the patient’s home. The nurse was responsible for complete nursing care of the patient as well as other duties, such as cooking and cleaning. As nursing care transitioned into the hospital in the 1930s, total patient care remained the principal care delivery model (Tiedeman & Lookin land, 2004).

In the total patient care method, often used in settings such as critical care and hospice care, the nurse provides holistic care. When used in a hospital setting, total patient care is provided by one nurse during a shift; communication is hierarchical, and the charge nurse is responsible for making assignments, interfacing with physicians, and shift reports. Some variations of this method are in use today.

Functional Nursing

During World War II, nursing shortage developed in response to increase demands for nurses abroad, resulting in a need to reorganize nursing care in hospitals stateside. Functional nursing was implemented to accomplish patient care with the assistance of ancillary personnel. In this model, staff members work side by side and are assigned to complete specific tasks, such as passing medications, taking vital signs, and providing hygiene, for all or many patients on a unit (Tiedeman & Lookinland, 2004).

Although it was intended to be used as a temporary mode of care delivery until nurses returned from the war, with the increase in population after World War II functional nursing continued in popularity because of efficient management of time, tasks, and resources. Because this model allows care to be provided by a limited number of registered nurses (RNs), it is often used today in long-term care and ambulatory care facilities.

Although the functional model is viewed as efficient and cost effective, it can also result in fragmented care because nurses focus on physician’s orders and necessary tasks. This model does not promote autonomy or professional development (Tiedeman & Lookinland, 2004). Communication is hierarchical, and the charge nurse is primarily responsible for assigning shifts, supervising tasks, interfacing physicians, and writing shift reports.

Team Nursing

In response to criticism of functional nursing, team nursing was designed. In team nursing, licensed and unlicensed personnel collaborate to deliver total care for a group of patients under the direction of a team leader. Typically, the team leader is an RN and is responsible for the following: assigning duties to team members, based on licensure, education, ability, and competence; supervising care provided; and providing more complex care.

In this model, the team leader must have effective communication skills and the necessary experience to provide strong leadership for his or her team (Tiedeman & Lookinland, 2004). Typically, the team leader is responsible for interfacing with physicians and providing shift reports to the oncoming team leader. In some modifications, communication can be hierarchical, and the charge nurse is responsible for related tasks directly. Some adapted versions of team nursing are still in use today on medical-surgical units.

Primary Nursing

Developed in 1968, primary nursing brought the RN back to the bedside. Initially, this model was developed for inpatient units on which an RN managed care for a group of patients for 24 hours a day, 7 days a week throughout their hospital stay (Manthey, 2009). When the primary nurse is not available, an associate nurse cares for the same group of patients and follows the plan of care developed by the primary nurse. The primary nursing model fosters a strong relationship between the nurse and the patient and his or her family because much of the decision making occurs at the bedside (Tiedeman & Lookinland, 2004).

Primary nursing is popular in situations in which one nurse manages care for an extended number of hours or on a long term basis, such as in ambulatory care units and home health-care settings (Manthey, 2009). In this model, communication is lateral, with the primary nurse being responsible for direct care, interfacing with physicians and other members of the health care team, and providing shift reports.

Nursing Case Management

In an attempt to improve the cost effectiveness of patient care, nursing case management emerged in the late 1980s (Neisner & Raymond, 2002). Nursing case management was borrowed from social work, psychiatric settings, and community health. The goal of nursing case management is to organize patient care according to major diagnostic-related groups to achieve measurable quality outcomes while meeting predetermined time frames and costs.

Case management focuses on decreasing fragmented care, improving patient self-care and quality of life, and optimizing use of resources and decreasing costs (Neisner & Raymond, 2002, p. 11). The RN functions as a case manager and is assigned to coordinate care for high-risk populations, such as patients with congestive heart failure, and manage care from admission through discharge.

Historically, case management was used primarily in the hospital setting, but it now extends to community settings. The RN case manager typically has earned an advanced degree and rarely provides direct care. Case management improves communication among health-care professionals and is identified as an approach to improve patient safety while transitioning patients among levels of care.

Nontraditional Models

During the 1980s and into the 1990s, the health-care system experienced many challenges, including pressure to cut health-care expenses. In an effort to reduce costs, hospitals examined strategies to change how patient care was delivered. The result consisted of nontraditional models of nursing care that borrowed from team nursing and included the incorporation of unlicensed assistive personnel (UAPs). The most popular models of nontraditional care delivery are patient-focused care, partnership models, nonclinical models, and integrated models (Lookinland, Tiedeman, & Crosson, 2005; Neisner & Raymond, 2002).

Regardless of the care delivery model used, nurse leaders and managers must ensure that nurses deliver culturally competent, safe, effective, and quality care. In addition, nurse leaders and managers must support nursing control of nursing practice, respect nurses’ rights and responsibilities, and respect patients’ rights and preferences (American Nurses Association [ANA], 2015c).

Patient-Focused Care

Patient-focused care revolves around a multiskilled team approach to nursing care. In this model, the RN functions as the patient care manager and coordinates all patient-related activities. Goals of patient-focused care are to make nursing care more patient centered rather than caregiver centered, reduce the number of care givers a patient sees during a hospital stay, and increase direct patient care time for RNs (Jones, DeBaca, & Yarbrough, 1997).

In the most extreme forms of patient focused care, all patient care services are brought to the patient. In some cases, entire units are decentralized, meaning that all staff members from housekeeping, dietary, physical therapy, and nursing are employees of that specific unit. Ultimately, patient-focused care decreases the cost of providing health care while improving the quality of services (Myers, 1998). In this model, communication is lateral, and the team interfaces with the health-care providers.

Partnership Models

Partnership models emerged in the late 1980s with the goal of decreasing the cost of nursing care while increasing productivity. Examples include Partnership in Practice (PIP), Partnership to Improve Patient Care (PIPC), and nurse extender models. In the PIP model, the RN hires the UAP, and they work as clinical partners on the same schedule; UAPs may be cross-trained to perform skills such as phlebotomy and dressing changes, thus allowing them to work with the RN to provide direct patient care (Manthey, 1989).

The PIPC and nurse extender models are similar to the PIP model in that the UAPs are cross-trained to perform additional skills and typically work the same schedules as their RN partners; how ever, the RN is not involved in hiring (Lookinland, Tiedeman, & Crosson, 2005). Partnership models offer more continuity of care than team nursing and are more cost effective than primary nursing. In partnership models, communication is lateral, and RNs coordinate the care, provide direct patient care, and remain accountable for all patients

Nonclinical Models

In nonclinical models, UAPs may or may not be partnered with the RN and do not provide direct patient care. In this model, the UAP’s role is supportive and includes nonclinical tasks such as assisting patients with hygiene needs, feeding patients, answering call lights, ordering supplies, and transporting patients (Lookinland, Tiedeman, & Crosson, 2005). In the nonclinical model, RNs are responsible for coordinating care, and communication is lateral.

Integrated Models

In integrated models, UAPs provide both direct care and indirect care. In some cases, the UAP is responsible for combined duties, such as housekeeping and food service (Lookinland, Tiedeman, & Crosson, 2005). RNs may work with only a UAP or with a licensed practical nurse (LPN)/licensed vocational nurse (LVN) and a UAP. The goal of integrated models is to relieve RNs of non-nursing tasks to im prove the quality of patient care. In this model, the RN coordinates all nursing care, and communication is lateral.

Contemporary Models

Contemporary models of care, also called innovative models, are the newest approaches to organizing patient care to foster patient safety and quality outcomes. Contemporary models include the Professional Nursing Practice Model, the Differentiated Nursing Practice Model, the Clinical Nurse Leader Model, the Synergy Model for Patient Care, Transforming Care at the Bedside, and the Patient and Family-Centered Care Model.

Professional Nursing Practice Model

The Professional Nursing Practice Model provides “a framework for guiding and aligning clinical practice, education, administration, and research in order to achieve positive patient and nurse staff outcomes” (Lineweaver, 2013, p. 14.) This model is identified as a core feature of Magnet hospitals (Neisner & Raymond, 2002) because magnet hospitals typically have higher RN-to-patient ratios, and many of these hospitals are moving to all-RN staffs.

In this model, RNs have greater autonomy and control over practice, and there are higher rates of patient satisfaction, lower rates of nurse burnout, and safer work environments (Neisner & Raymond, 2002). This model supports the RN’s control over the delivery of nursing care as well as effective interprofessional and intraprofessional communication.

Differentiated Nursing Practice Model

The Differentiated Nursing Practice Model resulted from a meeting between the American Association of Colleges of Nursing (AACN) and the AONE in 1993, when members of a joint Task Force sat down together to develop a set of formal goals and recommendations regarding differentiated nursing practice (AACN-AONE Task Force, 1995).

Care in this model is differentiated based on the level of education, competence, and clinical expertise of RNs: nurses with an associate degree function as technical nurses and provide the majority of bedside care; baccalaureate-prepared nurses function on a broader scale, collaborating and facilitating patient care from admission through discharge; and advanced practice nurses function within the broad health care system and provide care across all settings throughout wellness and death. The goals of this model include the following (Neisner & Raymond, 2002, p. 11):

• Optimal nursing care matching patients’ needs with the nurse’s competencies
• Effective and efficient use of scarce nursing resources
• Equitable compensation
• Increased career satisfaction among nurses
• Greater loyalty to the employer
• Enhanced prestige of the nursing profession

In the differentiated nursing practice environment, nurses must be clinically competent and flexible in providing nursing care, and they must value the differing roles. Nurse leaders and managers must match the unique capabilities of nurses with patient care requirements. Differentiated nursing practice recognizes that all nurses, regardless of education, are needed to provide high-quality, comprehensive care to all patients in all settings (AACN-AONE Task Force, 1995).

Clinical Nurse Leader Model

The Clinical Nurse Leader (CNL) Model was developed with the goal to improve the quality of patient care across the continuum and as a way to engage highly skilled clinicians in outcome-based practice and quality improvement (AACN, 2013). The graduate of a Master’s degree program, the CNL has responsibilities including de signing, implementing, and evaluating patient care by coordinating, delegating, and supervising the care provided by an inter-professional team.

The nurse in this role is the leader in the health-care delivery system and is not in an administrative or managerial role. “The CNL assumes accountability for patient-care outcomes through assimilation and application of evidence-based information to design, implement, and evaluate patient-care processes and models of care delivery” (AACN, 2013, para. 4).

The CNL is a provider and coordinator of care and fosters inter-professional and intra-professional communication. The CNL graduate is eligible to sit for the CNL certification offered by the Commission on Nurse Certification.

Synergy Model for Patient Care

The American Association of Critical-Care Nurses developed the Synergy Model for Patient Care with the core concepts that the needs of patients and families influence and drive the competencies of nurses and that synergy occurs when the needs and characteristics of the patient, clinical unit, or system are matched with the nurse’s competencies (American Association of Critical-Care Nurses, n.d.). It is a framework that can be used to organize patient care in various settings.

Because each patient and family is unique, has characteristics that span the health-illness continuum, and has varying capacity for health and vulnerability to illness, the model includes eight patient characteristics and eight nursing characteristics derived from patients’ needs (American Association of Critical-Care Nurses, n.d.). Assessment data collected based on the patient characteristics can assist nurses in the development of individualized plans of nursing care.

This model fosters effective communication and collaboration in achieving optimal, realistic patient and family goals. Although the model was originally developed for critical care units, it has been used in a variety of clinical settings.

Transforming Care at the Bedside

A national initiative launched by the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement in 2003, Transforming Care at the Bedside (TCAB) is a care model that empowers frontline nurses and nurse leaders and managers to (Lee, Shannon, Rutherford, & Peck, 2008; Rutherford, Moen, & Taylor, 2009):

• Improve the safety and quality of patient care on medical-surgical units
• Increase the vitality and retention of nurses
• Engage and improve patients’ and their family’s experiences of care
• Improve the effectiveness of the entire health-care team

The goal of TCAB is to empower nurses and other health-care team members to redesign work processes to improve the quality of patient care and decrease turnover. The initiative brings the health-care team together to collaborate on im proving the quality of care. The framework includes “optimizing communication among clinicians and staff” as one of the four essential building blocks for improving staff vitality and enhancing patient safety (Lee, Shannon, Rutherford, & Peck, 2008, p. 4). Five themes comprise the TCAB model of care (Rutherford, Moen, & Taylor, 2009):

1. Transformational leadership: Leadership and management practices empower frontline staff, and this empowerment is critical to ensuring that innovations are sustained. The success of TCAB depends on the commitment of leaders and managers across the health-care system.
2. Safe and reliable care: Health-care teams can respond immediately to changes in a patient’s condition. Processes are in place to prevent medication errors, injuries from falls, pressure ulcers, and harm from adverse events. Additionally, the care delivered is effective and equitable.
3. Vitality and teamwork: When the health-care team functions in a joyful and sup portive environment, teamwork is effective and communication is optimized. Health-care teams strive for excellence.
4. Patient-centered care: Care is focused on the “whole person and family, respects individual values and choices and ensures continuity of care” (p. 13).
5. Value-added care processes: Patient care is free of waste, promotes continuous flow of work, and decreases redundancy. Nurses can spend more time on activities that have value for the patient and family.

Since the initiative was launched in 2007, many health-care agencies in the United States and internationally have applied improvement strategies used in TCAB for engaging frontline nurses in deciding on and implementing changes to improve patient outcomes. The TCAB model has the potential to transform care delivery and the work environment for nurses and to support inter-professional teamwork and communication at the bedside (Rutherford, Moen, & Taylor, 2009).

Patient- and Family-Centered Care Model

Health care is plagued with many problems that require system wide solutions and partnerships with health-care professionals, administrators, planners, policy makers, and patients and their families (Conway et al., 2006). For health-care professionals to provide safe and quality care effectively, a shift is required from provider centered care to patient-centered care. Additionally, as patients are becoming more knowledgeable and informed, and taking care into their own hands, nurses must be prepared to advocate strongly for patients and their families as they navigate the health-care system.

The Institute for Patient- and Family-Centered Care (IPFCC) is a nonprofit organization whose mission is to advance the understanding and practices of patient- and family-centered care and to integrate the core concepts of dignity and respect, information sharing, participation, and collaboration into all aspects of health care (IPFCC, 2011). The IPFCC defines patient- and family-centered care as:

An approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families. … an approach to health care that shapes policies, programs, facility design, and staff day-to-day interactions. It leads to better health outcomes and wiser allocation of resources and greater patient and family satisfaction. (IPFCC, 2010, para. 1).

Patient- and family-centered care places an emphasis on collaborating and plan ning care with patients (and their families) of all ages, at all levels of care, and in all health-care settings (Conway et al., 2006). In the patient-focused care model, the RN is the coordinator and planner of care who brings as many care services to the patient as possible; in patient- and family-centered care, the patient has control over his or her care, and all health-care decisions are made with the RN as a collaborator in his or her care.

The model of patient- and family-centered care is based on four foundational concepts (Conway et al., 2006):

1. Dignity and respect: Health-care professionals listen to and respect the values and choices of the patient and family, and the values, beliefs, and cultural backgrounds of the patient and family are integrated into the planning and delivery of care.
2. Information sharing: Health-care professionals communicate and share all information with patients and families in a timely manner. Patients and families receive comprehensive and accurate information to participate in care and decision making effectively.
3. Participation: Patients and families are encouraged and supported in participating in care and decision making at the level they choose.
4. Collaboration: Patients and families as well as health-care professionals and leaders collaborate in policy and program development, implementation, and evaluation; health-care facility design; professional education; and delivery of care (Conway et al., 2006).

Nurses are strategically positioned to be the catalysts for integrating this model into practice. The nurse-patient relationship is inherently built on mutual trust, respect, and communication. In patient- and family-centered care, nurses initiate and promote a safe healing environment, respond to individual patients’ choices, recognize patients as the source of control, effectively communicate with patients and their families, and provide all necessary information for patients to make an informed health-care decision. The model of patient- and family-centered care can transform the experience of care for patients and families and of caregiving for all health-care professionals.

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