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Adapting to the new workplace reality: maximizing the role of RNs within a collaborative nursing practice model.

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Editor's note: This is the third of six articles looking at how registered nurses can best adapt to changes in the mix of nursing care providers in the health care system. The topics in the series are: "Professional Nursing Practice: Requisite Capacities," "Professional Nursing Practice: Rule of Three," "Organizing Patient Care," "Directing Care," "Working Together" and "Professional Nursing Practice: Continuing Competence."

It is the hope of the Practice Department that each article will provide information to registered nurses on how to interpret professional nursing practice from a registered nurse point of view and to assist the registered nurse in understanding their professional role and responsibilities in the context of a collaborative practice setting which includes other nursing care providers.

Organizing Patient Care

The ongoing changes to skill mix and service delivery models create new working relationships between registered nurses (RNs) and other nursing care providers. RNs need a clear understanding of how these changes affect their professional practice as they are increasingly required to work through others to achieve patient outcomes.

Collaborating and working with others requires an understanding of the role and accountability of all nursing care providers. The working relationship between nursing care providers is one of colleagues who collaborate and communicate to determine the care needs of the patients. Trust is the key.

Professional nursing practice does not happen by chance. We need to look at:

* How we organize work

* Systems/supports for expanding knowledge and skills

* Clarifying roles and functions

* Defining leadership, authority, accountability and decision-making

* Strengthening the decision making role of nurses in direct care positions

* How we communicate

Professional nursing practice is about the structures and processes that help nurses achieve the mission and vision of nursing. For example standards of care (evidence-based processes used to achieve specific outcomes). Therefore, it is important to take a close look at our structures and processes to make sure that they facilitate/enhance professional nursing practice rather than the opposite.

Employer's support professional nursing practice by creating and maintaining quality practice environments which include the following structures:

i) a nursing care delivery model;

ii) appropriate staffing ratios and staffing mix;

iii) standards of care including policies and procedures;

iv) accountability structures (performance management); and continuous quality improvement measures.

For professional nursing practice to occur we need to pay attention to how work is organized. Organizational structures influence the capacity and ability of nurses to perform and develop at the expert level and to the full extent of their scope of practice. Clinical leaders establish organizational structures including care delivery models that organize how patients are assigned.

A major managerial function for the nurse manager is staffing a unit in order to accomplish the goals of the organization. One part of the staffing role is for the nurse manager to select a care delivery model that is right for the unit. There are many ways of organizing patient assignment at the unit level.

The selection of a care delivery model that supports professional practice is a significant undertaking. The nurse manager must be informed about the various patient care delivery models or assignment systems, their underlying assumptions, and their advantages and disadvantages. Nursing management texts outline the staffing role of the nurse manager in more detail.

Care Delivery Models

Functional Nursing

Functional or task-centered nursing began in the 1950s and involves assigning each staff member to perform one or two tasks (functions) for all patients in the unit. For instance, a typical division of labor for RNs would be medication nurse or treatment nurse and so on. Decision making in this model is usually done by the head nurse or charge nurse. Caregivers think in time frames associated with the tasks of their shift. Functional nursing de-skills nurses who have been educated to function in a professional manner.

The disadvantage of functional assignment is that each patient's care is fragmented and it does not support the RN's professional practice responsibilities.

Team Nursing

Team nursing was another response to the nursing shortage in the 1950s.

Team nursing is a model where an RN, as team leader, and one or more nursing personnel work as a team where they provide total care for a defined group of patients. The leader supervises and coordinates all the care provided by those in the team. The care is divided into the simplest components and then assigned to the appropriate care provider in the team. One of the main features of team nursing is the nursing care conference. Its primary purpose is the development and revision of nursing care plans by providing the team members the opportunities to identify problems and to adjust the care plan accordingly. Team nursing contributes to patient and staff satisfaction. Each patient is treated as a unique individual. All team members are used to their full scope and when time is built in for ongoing communication between the team members, this model supports professional practice. With workload demands, the key features of team nursing, ongoing communication throughout the shift and up to date nursing care plans, may receive inadequate attention, resulting in care that is routinized.

Primary Nursing

Primary nursing was a response in the early 1970s to the increased acuity of hospitalized patients and the demand for more registered nurses in acute care hospitals.

In this model, patients have a primary nurse who is responsible for the patient's total nursing care throughout the patient's stay including the coordination of care. The primary nurse is responsible for developing a plan of care that is followed by nurses and other care providers caring for the patient. The primary nurse does the admission interview and develops the nursing care plan, including teaching and discharge planning, which is shared via the written care plan.

Primary nursing, unlike functional and team nursing, provides the primary nurse with autonomy and authority for the care of her patients. The nurse can identify the patient outcomes as a result of her planning. A misconception about primary nursing is that it is only RNs who can provide care.

Case Management

Case management was an approach to care originated in community mental health. Case management is built on a foundation of managed care, a method of matching the care for a group of patients with the same diagnostic group to a plan of care called the care map or critical path. It specifies, for each day of the hospital stay, the outcomes to be reached. Patients with atypical responses to the course of treatment show up as variances on the critical path. Variances are flagged and then individual approaches are developed to get the patient back on track. In the typical model of case management, an RN is assigned to a specific patient population or service, such as postoperative hip replacement patients or a specific nursing department and coordinated the nursing care. The case manager has the responsibility to work with all health discipline to facilitate care. For example, if a postsurgical hospitalized patient has not met recovery goals (eg: ambulation, eating, pain control) according to the care plan, the case manager would work with the physician and other nurses to determine what is preventing the patient from achieving these goals.

Variations on the Models

Variations to functional, team, and primary nursing have developed as a result of shortened length of stay, twelve hour shifts, and nursing shortages. Total patient care is a variation on primary nursing that commits nurses to the central tenets but not the structure of primary nursing. The nurse is responsible for the total care of the patients assigned for that shift only. Some support may be given by other nursing care providers who are not assigned to the nurse or the specific patients. Modular nursing is a variation on team and primary nursing. It may involve a pairing of an RN and another care provider to a group of patients. This pairing results in a division of work through assignment of tasks to the appropriate care provider. The model can be reduced to functional nursing although that is not the intent of the design.

Conclusion

When considering a model for the delivery of nursing care, patient risk must be considered at all times and balanced against cost containment. A delivery model should provide administrative efficiency, patient needs satisfaction, and staff needs satisfaction and economy. Regardless of the model selected, all nursing care providers must be included in the selection process. Ongoing day-to-day support is imperative during the implementation of any change to the care delivery model to help staff adjust to the change without reverting to the previous model.

In many care delivery models, the RN is not the only health care worker offering nursing services to the patients. Many models are based on collaborative work and the nursing care can be provided by registered nurses (RNs), licensed practical nurses (LPNs) and other nursing service personnel such as unregulated care providers (UCPs). In any nursing care delivery model, the RN has the responsibility for the overall direction of the nursing care.

References:

Kelly-Heidenthal, P., (2003). Nursing Leadership and Management. Thomson Delmar Learning. ISBN 0-7668-2508-6

Nurses Association of New Brunswick (2005). Position Statement: Framework for a Quality Professional Practice Environment for Registered Nurses. Fredericton: Author.

Potter and Perry (2006). Canadian Fundamentals of Nursing. 3rd edition. Elsevier Mosby. ISNB 13-978-0-7796-9961-2

Tomey, A-M., (2004). Guide to Nursing Management and Leadership. 7th Edition. Mosby. ISBN 0-323-02864-0

Principles for Selecting a Care Delivery Model

The care delivery model should:

* Facilitate meeting the organization's goals

* Be cost effective

* Contribute to meeting patients outcomes

* Provide role satisfaction for nurses

* Allow implementation of the nursing process

* Provide adequate communication among all healthcare providers

* Support the RNs responsibility for the overall direction of nursing care

* Be designed to give the RN the responsibility, authority and accountability for planning, organizing, and evaluating nursing care

* Ensure the skills and knowledge of each care provider is used for the best patient outcomes

* Ensure communication can occur

* Ensure that the model advances professional nursing practice

* Provide for care which is perceived by the patient as a coherent whole (unity of action by a team of RNs/LPNs/others if applicable)

* Should provide for the combination/groupings of RNs, LPNs, other workers if applicable with the appropriate knowledge required to meet the nursing care needs of the patient

Care Delivery Models

* Functional nursing

* Primary nursing

* Team nursing

* Case Management

* Variations on the models-total patient care, modular

Practice Capsule

Selecting a care delivery model:

Recognizing and understanding the assumptions underlying each delivery model is an important first step.

Three questions to consider when proceeding with a change in the care delivery system are:

1) What is good for the patients? Does the model support continuity of care? Highlight patient outcomes?

2) What is good for nursing? Does the model maximize professional practice? Minimize nonnursing tasks? Promote job satisfaction?

3) What is good for the organization? Does it promote collaborative practice? Maintain or improve the quality of care?

References

Lendrum, B.L. Organization of Patient Care in Hibberd, J.M. & Kyle, M.E. (Eds.) Nursing Management in Canada (1994). Toronto: Saunders.

BY THE STAFF OF THE PRACTICE DEPARTMENT
COPYRIGHT 2008 Nurses Association of New Brunswick
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2008 Gale, Cengage Learning. All rights reserved.

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Publication:Info Nursing
Geographic Code:1CANA
Date:Mar 22, 2008
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