Nursing Care Models Order Description Nursing Care Models Paper: Guidelines PURP

Nursing Care Models
Order Description
Nursing Care Models Paper:
Guidelines
PURPOSE
The purpose of this assignment is to identify nursing care models utilized in todays various health care settings and enhance your knowledge of how models impact the management of care and may
influence delegation. You will assess the effectiveness of models and determine how you would collaborate with a nurse leader to identify opportunities for improvement to ensure quality safety and
staff satisfaction.
COURSE OUTCOMES
Completion of this assignment enables the student to meet the following course outcomes.
CO#1: Apply leadership concepts skills and decision making in the provision of high quality nursing care healthcare team management and the oversight and accountability for care delivery in a
variety of settings. (PO #2)
CO#2: Implement patient safety and quality improvement initiatives within the context of the interprofessional team through communication and relationship building. (PO #3)
CO#3: Participate in the development and implementation of imaginative and creative strategies to enable systems to change. (PO #7)
CO#6: Develop a personal awareness of complex organizational systems and integrate values and beliefs with organizational mission. (PO #7)
CO#7: Apply leadership concepts in the development and initiation of effective plans for the microsystems and/or system-wide practice improvements that will improve the quality of healthcare
delivery. (PO #2 and #3)
CO#8: Apply concepts of quality and safety using structure process and outcome measures to identify clinical questions as the beginning process of changing current practice. (PO#8)
DUE DATES
This assignment is to be submitted to the Dropbox by Sunday 11:59 p.m. MT end of Week 4.
POINTS
This assignment is worth 200 points.
DIRECTIONS
1. Read your text Finkelman (2012) pp- 118- 127.
2. Observe staff in delivery of nursing care provided. Practice settings may vary depending on availability.
3. Identify the model of nursing care that you observed. Be specific about what you observed who was doing what when how and what led you to identify the particular model.
4. Write a 5-7 page paper that includes the following:
5. Review and summarize two scholarly resources (not including your text) related to the nursing care model you observed in the practice setting.
6. Review and summarize two scholarly resources (not including your text) related to a nursing care model that is different from the one you observed in the practice setting.
7. Discuss your observations about how the current nursing care model is being implemented. Be specific.
8. Recommend a different nursing care model that could be implemented to improve quality of nursing care safety and staff satisfaction. Be specific.
9. Provide a summary/conclusion about this experience/assignment and what you learned about nursing care models.
10. Write your paper using APA format. Submit to the Dropbox.
GRADING CRITERIA: NURSING CARE MODELS PAPER
Category Points % Description
Identify Nursing Care Model in practice including specifics about who what when where etc. 60 30% Identifies Nursing Care Model for delivery of nursing care. Provides specifics.
Besides Finkelman locate scholarly resources related to Nursing Care Models 40 20% In addition to Finkelman locates four scholarly resources related to Nursing Care Models. Summarizes all
resources in body of paper.
Implementation and Recommendations 60 30% Describe implementation of current Nursing Care Model and recommend a different model that could be utilized to improve quality of nursing care safety and
staff satisfaction.
Conclusion/ summary 20 10% Summarize what you learned about this experience including new knowledge about nursing care models.
Clarity of writing 20 10% Content is organized logical and with correct grammar punctuation spelling and sentence structure are correct. APA formatting is apparent and CCN template is
utilized. References are properly cited within the paper; reference page includes all citations; proper title page and introduction are present and evidence of spell and grammar check is obvious.
GRADING RUBRIC
Assignment Criteria Outstanding or Highest Level of Performance
A Very Good or High Level of Performance
B Competent or Satisfactory Level of Performance
C Poor Failing or Unsatisfactory Level of Performance
F
After an introduction paragraph identifies Nursing Care Model in practice including specifics about who what when where etc.
60 points After an introduction paragraph thoroughly identifies Nursing Care Model in practice including specifics about who what when where etc.
55-60 points After an introduction paragraph clearly identifies Nursing Care Model in practice including specifics about who what when where etc.
50-54 points After an introduction paragraph briefly identifies Nursing Care Model in practice including minimum specifics about who what when where etc.
46-49 points Does not provide an introduction paragraph but identifies Nursing Care Model in practice in first or subsequent paragraphs including minimum specifics about who what when where etc.
0-49 points
Besides Finkelman locate scholarly resources related to Nursing Care Models
40 points Thoroughly reviews and summarizes two scholarly resources (not including your text) related to the nursing care model you observed in the practice setting; then reviews and summarizes
two scholarly resources (not including your text) related to a nursing care model that is different from the one you observed.
37-40 points Clearly reviews and summarizes two scholarly resources (not including your text) related to the nursing care model you observed in the practice setting; then reviews and summarizes
two scholarly resources (not including your text) related to a nursing care model that is different from the one you observed.
34-36 points Briefly reviews only one resource (besides text) related to nursing care model observed in practice setting and only one resource (besides text) related to a nursing care model that is
different from the one you observed.
30-33 points Briefly reviews only one resource (besides text) related to nursing care model observed in practice setting OR only one resource (besides text) related to a nursing care model that is
different from the one you observed.
0-29 points
Implementation and Recommendations
60 points Thoroughly describes implementation of current Nursing Care Model and recommends a different model that could be utilized to improve quality of nursing care safety and staff
satisfaction.
55-60 points Clearly describes implementation of current Nursing Care Model and recommends a different model that could be utilized but omits quality or safety or staff satisfaction.
50-54 points Briefly describes implementation of current Nursing Care Model and recommends a different model that could be utilized but omits two of the following (quality/safety/staff
satisfaction).
46-49 points Briefly describes implementation of current Nursing Care Model or recommends a different model that could be utilized. Various elements are missing related to improving quality of
nursing care safety and staff satisfaction.
0-45 points
Conclusion/ summary
20 points Includes conclusion paragraph and thoroughly summarizes what you learned about this experience including new knowledge about nursing care models.
18-20 points Includes conclusion paragraph and clearly summarizes what you learned about this experience including new knowledge about nursing care models.
16-17 points Includes conclusion paragraph but briefly summarizes what you learned about this experience or includes new knowledge about nursing care models but not both.
14-15 points Does not Include a conclusion paragraph or conclusion/summary is present but difficult to find in closing paragraphs of paper.
0-13 points
Clarity of writing
20 points Content is organized logical and with correct grammar punctuation spelling and sentence structure are correct. APA formatting is apparent utilizing CCN template. References are
properly cited within the paper; reference page includes all citations; proper title page and introduction are present and evidence of spell and grammar check is obvious. Less than three errors
noted.
1820 points Content is mostly organized logical and with correct grammar punctuation spelling and sentence structure are correct. APA formatting is apparent utilizing CCN template. References
are properly cited within the paper; reference page includes all citations; proper title page and introduction are present and evidence of spell check and grammar check is obvious. Four to six
errors noted.
1617 points Content is somewhat organized logical and with correct grammar punctuation spelling and sentence structure are correct. APA formatting is somewhat apparent but CCN template was not
utilized. References are properly cited within the paper; reference page includes all citations; proper title page and introduction are present and evidence of spell check and grammar check are not
obvious. Seven to 10 errors noted.
1415 points Content is disorganized and writing has numerous grammar spelling or syntax errors and APA formatting errors are obvious. Spell check and grammar check are not obvious. More than 11
errors noted.
013 points
Total Points Possible= 225 Points Earned = A quality assignment will meet or exceed all of the above requirements.
Finkelman text reading Pages 118-127
PROFESSIONAL NURSING PRACTICE WITHIN NURSING CARE MODELS
The American Nurses Association (2004) defines nursing as the protection promotion and optimization of health and abilities prevention of illness and injury alleviation of suffering through
the diagnosis and treatment of human response and advocacy in the care of individuals families communities and populations (p. 7). The American Organization of Nurse Executives (AONE)
emphasizes the following with patient population as the central core (2005).
The core of nursing is knowledge and caring. (evidence-based practice and patient-centered care)
Care is user-based. (patient-centered care)
Knowledge is access-based. (evidence-based practice)
Knowledge is synthesized. (evidence-based practice; informatics; quality improvement)
Relationships of care presence-virtual. (patient-centered care)
Managing the journey (interprofessional teams)
The items in italic describe how each of the AONE elements relate to the five IOM core competencies. These are all interrelated. Also all of these elements have been discussed in earlier chapters
or will be discussed in later chapters as they are critical aspects of leadership and management. Intertwined within these critical elements is the recognition of the importance of autonomy
responsibility delegation and accountability.
Autonomy in clinical decision making occurs whenever a nurse makes an independent judgment about the presence of a clinical issue and then provides the resolution to nursing care (Ritter-Teitel
2002 p. 32). Autonomy requires competence and skills that focus on the nursepatient relationship. It also means that there needs to be an organized assessment method to determine patient care
needs and reassigning staff. Nurses also have the right to consult with others as professionals when they provide or manage care. Autonomy control and decision making are related. Professional
practice implies control over the terms of the work but also control over its content and regulation of its standards (Ritter-Teitel 2002 p. 33). Nurses who feel that they have autonomy know
that they have the right to make decisions in their daily practice and also actively participate in developing organizational policy and change. Staff autonomy however does not work in
organizations in which leaders are authoritarian and when centralized decision making and control are key characteristics of the organization. This situation will quickly lead to conflict. In
addition the work environment must be conducive to collaboration with physicians and all relevant staff as is discussed in Chapter 12. Responsibility refers to being entrusted with a particular
function (Ritter-Teitel 2002 p. 34). A nursing practice model that does not address responsibility will not be effective. Along with this is the need to clearly recognize the importance of
delegation. Delegation involves transferring responsibility for the performance of the task from one person to another (Ritter-Teitel 2002 p. 34). Delegation is discussed in more detail in
Chapter 14. Accountability is a term that is typically found in job descriptions and descriptions of organizational structure. In nursing it is particularly important to recognize that
accountability is the acceptance of responsibility for the outcomes of care (Ritter-Teitel 2002 p. 34). Nurses need to know that when they provide patient care their work has relevanceit must
reach outcomes. Magnet hospitals are discussed in Chapter 6 as examples of organizations that exemplify these characteristics.
The AONE elements and these characteristics such as accountability need to be considered when nursing practice models are assessed. Models of care are developed to support or enhance professional
practice and by considering these elements and characteristics the models will be more effective. Within a health care organization how do nurses provide nursing care? What is a model of care?
Are these elements found in the model? A model of care is a configuration of nursing practice or pattern of delivery (Ritter-Teitel 2002 p. 35). Models might also be called nursing or patient
care delivery systems. These models have undergone major changes over the last several decades. Nursing practice models have been used to implement resource-intensive strategies with the goal of
decreasing expenses and using staff more effectively. These practice models establish organizational frameworks that provide nursing staff opportunities to become more committed to their practice
and to be more involved in decision making (Upenieks 2000 p. 330). A review of multiple nursing care models (Beattle 2009) indicates that many models have common themes:
Elevating the role of nurses and transitioning from caregivers to care integrators
Taking a team approach to interprofessional care
Bridging the continuum of care outside of the primary care facility
Defining the home as a setting of care
Targeting high users of health care especially older adults
Sharpening focus on the patient including an active engagement of the patient and his or her family in care planning and delivery and a greater responsiveness to patient wants and needs
Leveraging technology
Improving satisfaction quality and coast
Others have identified the following elements that are still relevant today (Brennan Anthony Jones & Kahana 1998): continuity of care participation in management collaboration leadership
learning environment nurses role staffing communication specialization orientation of temporary staff and team commitment. ORourke (2006) believes that building the professional role is
important and describes a professional practice model with a professional role development emphasizing self-direction and decision making evidence-based practice role-based transfer of knowledge
and role-based provision of care. See Chapter Media Links for access to website describing the ORourke model.
Nursing modelsprovide an infrastructure that decreases variation among nurses the interventions they will choose and ultimately patient outcomes. Conceptual frameworks also differentiate
forward thinking organizations from those where nursing has less of a voice (Kerfoot et al. 2006 p. 20). Models help to identify and describe nursing care. The IOM emphasis on the five core
competencies could be used for a model and as newer models are discussed later it is easy to see how these five competencies are the key elements of health care delivery. Kimball and Joynt (2007)
identify key factors driving innovation in health care delivery. These factors are described in Figure 4-2.
HISTORICAL PERSPECTIVE ON NURSING MODELS
The following is a description of common models some of which have undergone many changes over the years or are not used anymore but they have had an impact on newer models. In addition how
models are implemented in an organization can be highly variable.
TOTAL PATIENT CARE/CASE METHOD
In this model which is the oldest the registered nurse is responsible for all of the care provided to a patient for a shift. A major disadvantage of this model is the lack of consistency and
coordinated care when care is provided in 8-hour segments. This type of care is rarely provided today except among student nurses who are assigned to
FIGURE 4-2 WHAT IS DRIVING INNOVATION?
Source: Kimball B. & Joynt J. (2007). The quest for new innovative care delivery models. JONA 37(9) 392398. Reprinted with permission.
provide all of the care for a patient during the hours that they are in clinical. Even in this case the students frequently do not provide all of the care as they may not be qualified to do this
and a staff nurse maintains overall responsibility for the care. Home health agencies use a form of this model when nurses are assigned patients and provide all the required home care; however
even this has been adapted as more home care is provided by a team. An RN may coordinate the care and provide professional nursing services but a home care aide may provide most of the direct care
and other providers such as a physical therapist dietician and social worker may be required for specialty care.
FUNCTIONAL NURSING
The model of functional nursing is a task-oriented approach focusing on jobs to be done. When it was more commonly used it was thought to be more efficient. The nurse in charge assigned the tasks
(e.g. one nurse may administer medications for all patients on a unit; an aide may take vital signs for all patients). A disadvantage of this model is the risk of fragmented care. In addition
this type of model also leads to greater staff dissatisfaction with staff feeling they are just grinding out tasks. Individualized care may also be compromised when patient care is provided by
different staff members who may or may not be aware of other needs and the care provided by others. This model is not used much now. It can be found in some long-term care facilities and in some
behavioral/psychiatric inpatient services although in a modified form. In the latter situation a registered nurse may be assigned the task of medication administration for the unit and
psychiatric support staff may be assigned such tasks as vital signs and checks of all patients. In this situation RNs would still be assigned to individual patients to coordinate their care.
TEAM NURSING
Team nursing developed after World War II when there was a severe nursing shortage as well as major changes in medical technology replaced functional nursing. A nursing team consists of an RN
licensed practical nurses (LPNs) and nurse aides. This team of two or three staff provides total care for a group of patients during an 8- or 12-hour shift. The RN team leader coordinates this
care. In this model the RN has a high level of autonomy and assumes the centralized decision-making authority. Although the past approach to team nursing was thought to use decentralized decision
making with decisions made closer to the patient there actually was limited team member collaboration. In addition these teams tended to communicate only among themselves and not as well with
physicians. The team concept or model also focused on tasks rather than patient care as a whole. More current versions of the team model are different from this earlier type. Currently the team
model has been changed to meet changes in organizations and leadership corresponding to the needs for better consistency and continuity of care as well as collaboration and coordination.
PRIMARY NURSING
In the late 1970s care became more complex and nurses were dissatisfied with team nursing. In the primary nursing model the primary nurse who can only be an RN provides direct care for the
patient and the family; an associate nurse provides care following the care plan developed by the primary nurse when the primary nurse is not working and assists when the primary nurse is working.
The primary nurse needs to be knowledgeable about assigned patients and must maintain a high level of clinical autonomy. When primary nursing was first used and well-accepted it was easier to
substitute RNs for other health care providers as cost was not as much of a focus as it is today. When the nursing shortage began to reoccur and salaries increased implementing primary nursing
became more difficult and health care cost moved to the top of the concerns. There was however no research data to support that primary nursing was more expensive than team nursing but many
hospitals nonetheless felt it was (Gardner 1991; Gardner & Tilbury 1991; Glandon Colbert & Thomason 1989; Shukla 1983). Primary nursing is often viewed as a model in which the primary nurse
has to do everything limiting collaborative or team effort although it does not have to be implemented in this way.
Second-generation primary nursing clarifies some of the issues about this practice model. One of the critical problems with primary nursing was whether or not it required an all-RN staff which was
thought to increase staff costs. The second-generation view of primary nursing noted that the mix of staff is more important than having an all-RN staff. Another concern with primary nursing was a
need to develop a clear definition of 24-hour accountability which was interpreted by some as 24-hour availability. This of course is not a reasonable approach and it really does not apply to
primary nursing. When the primary nurse is not working the associate nurse provides the care. Primary nursing is a responsibility relationship between the nurse and the patient. The primary nurse
is not the only caregiver but does have responsibility for planning the care and ensuring that care outcomes are met. Only registered nurses can be primary nurses. This role and the model require
RNs who are competent and possess leadership skills. Primary nursing is not used as much today.
CARE AND SERVICE TEAM MODELS
In the 1980s care and service team models began to replace primary nursing. These models are implemented differently in different hospitals as is true of most of the models. Key elements of these
models are empowered staff interprofessional collaboration skilled workers and a case management approach to patient careall elements related to the more current views of leadership and
management (Finkelman 2011). Care and service teams introduced the different categories of assistive personnel (for example multiskilled workers nurse extenders and UAP). There has been some
disagreement as to whether these new staff member roles were complementary or involved substitution of professional nursing care.
COMPLEMENTARY MODELS
Complementary modelsbegan in 1988 by using nurse extenders such as a unit assistant who would be responsible for environmental functions. The nurse would then have more time for direct patient
care. Does this reduce costs? Certainly when nurse positions are changed to nurse extender positions there is some cost reduction; however some hospitals found that overtime sick time and on-
call costs rose particularly with nurse extender staff (Powers Dickey & Ford 1990). Another example is Mantheys (1989) partners-in-practice. Technical assistants signed a partnership agreement
to work with an experienced RN. Reduction in costs was initially seen with this model because each partnership could care for the same number of patients as two RNs. Staffing costs however
continued to increase. Complementary models are not used as much today and have been replaced by substitution models in health care organizations. Substitution models tend to use multiskilled
technicians to perform select nursing activities. The RNs supervise these activities.
Another approach is cross-training. This involves training staff to work in different specialty areas or to perform different tasks. For example a respiratory therapist may be trained not only to
perform typical respiratory therapist tasks but also phlebotomy and basic nursing care. This offers much more flexibility in that staff can fulfill many different needs. They can then be used as
staffing adjustments are needed for changes in patient census or acuity. It is critical that this cross-training meet patient needs so that staff will be able to deliver quality safe care and not
feel undue stress while delivering the care. It is also important that state practice act requirements are met and this is not always easy to accomplish. It requires education staff to provide
support ongoing educational training and documentation of competencies as well as management staff who understands which staff members are qualified to move from area to area. Hospitals and
other health care organizations are trying to find the best methods for using substitution without compromising quality and safety and yet control costs. As demands change different models will be
required and nursing leadership to develop these models will be critical.
As with earlier team models the RN must spend time coordinating care and the work. The focus of the team is on patient-centered care as opposed to the nursepatient relationship. The Case
Management Society of America (CMSA) defines case management as a collaborative process of assessment planning facilitation and advocacy for options and services to meet an individuals health
needs through communication and available resources to promote quality cost-effective outcomes (2002 p. 1). Case management is based on the assumption that patients with complex health problems
catastrophic health situations and high cost medical conditions need assistance in using the health care system effectively and a case manager can help patients with these needs (Finkelman 2011).
Case managers may also work with the teams to achieve outcomes which increases shared accountability. Case management can be viewed as a nursing model when the case manager is a nurse; however in
some organizations nurses are not used as case managers but rather other health care professionals such as social workers are the case managers. Case management is not a profession but rather a
collaborative and trans-disciplinary practice (Commission for Case Management Certification 2009 p. 1). Several health care professional organizations and experts have defined case management;
however there clearly is no universally accepted definition for case management. Case management is used in many different types of settings and the setting also affects the definition
(Finkelman 2010).
CARE MANAGEMENT MODEL
The care management model focuses on the needs of the integrated delivery system. It has many similarities to case management in that it includes planning assessment and coordination of health
services. The patient focus however is population-based instead of based on an individual patient. The population might be people who live in a specific geographic area members of a health
insurance plan or could be a specific group with similarities such as patients with diabetes. The goal is to integrate a continuum of clinical services. Care management is not only concerned with
medical care but also health promotion and disease prevention costs and use of resources. Case management is often used within the care management model. Typical tools used to facilitate care
management are clinical pathways disease management programs and benchmarking.
NEWER NURSING MODELS
INTERDISCIPLINARY PRACTICE MODEL
The interdisciplinary or interprofessional practice model is emphasized in the IOM reports on quality improvement by identifying the importance of all health professions meeting the
interdisciplinary or interprofessional competency emphasizing the need to work in interprofessional teams to cooperate collaborate communicate and integrate care in teams to ensure that care is
continuous and reliable (2003 p. 4). These teams include providers from different health care professions and occupations designed to meet the required patient needs. With increasing complex
patient care needs this model is better able to address needs and to effectively use a mix of expertise and knowledge to reach patient outcomes. Patient-centered care is the focus. The advantages
of using interprofessional teams are as follows (Finkelman & Kenner 2010 p. 337):
Decreased fragmentation in a complex care system
Effective use of multiple expertise (e.g. medicine nursing pharmacy allied health social work and so on)
Decreased utilization of repetitive or duplicate services
Increased creative or innovative solutions to complex problems
Increased learning for team members about different roles and responsibilities communication and coordination and how to better plan care
Provides motivation and increased self-esteem in team and individual performance
Greater sharing of responsibility
Empowers members to speak up
SYNERGY MODEL OF PATIENT CARE
This model of care was developed by the American Association of Critical Care Nurses but it has been applied in all types of nursing units. Synergy results when the needs and characteristics of a
patient clinical unit or system are matched with a nurses competencies (American Association of Critical Care Nurses 2009). Patient characteristics incorporated into this model are as follows
(American Association of Critical Care Nurses 2009):
Resiliency: the capacity to return to a restorative level of functioning using compensatory/coping mechanisms; the ability to bounce back quickly after an insult
Vulnerability: susceptibility to actual or potential stressors that may adversely affect patient outcomes
Stability: the ability to maintain a steady-state equilibrium
Complexity: the intricate entanglement of two or more systems (e.g. body family therapies)
Resource availability: extent of resources (e.g. technical fiscal personal psychological and social) the patient/family/community brings to the situation
Participation in care: extent to which patient/family engages in aspects of care
Participation in decision making: extent to which patient/family engages in decision making
Predictability: a characteristic that allows one to expect a certain course of events or course of illness
The Synergy model ties the above patient characteristics with the following nurse competencies (American Association of Critical Care Nurses 2009).
Clinical judgment: clinical reasoning which includes clinical decision making critical thinking and a global grasp of the situation coupled with nursing skills acquired through a process of
integrating formal and informal experiential knowledge and evidence-based guidelines.
Advocacy and moral agency: working on anothers behalf and representing the concerns of the patient/family and nursing staff; serving as a moral agent in identifying and helping to resolve
ethical and clinical concerns within and outside the clinical setting.
Caring practices: nursing activities that create a compassionate supportive and therapeutic environment for patients and staff with the aim of promoting comfort and healing and preventing
unnecessary suffering. Includes but is not limited to vigilance engagement and responsiveness of caregivers including family and health care personnel.
Collaboration: working with others (e.g. patients families health care providers) in a way that promotes/encourages each persons contributions toward achieving optimal/realistic
patient/family goals. Involves intra- and interprofessional work with colleagues and community.
Systems thinking: body of knowledge and tools that allow the nurse to manage whatever environmental and system resources exist for the patient/family and staff within or across health care and
nonhealth care systems.
Response to diversity: the sensitivity to recognize appreciate and incorporate differences into the provision of care. Differences may include but are not limited to cultural differences
spiritual beliefs gender race ethnicity lifestyle socioeconomic status age and values.
Facilitation of learning: the ability to facilitate learning for patients/families nursing staff other members of the health care team and community. Includes both formal and informal
facilitation of learning.
Clinical inquiry (innovator/evaluator): the ongoing process of questioning and evaluating practice and providing informed practice. Creating practice changes through research utilization and
experiential learning.
PRIMARY CARE TEAM
The Primary Care Team (PCT) is a model that emphasizes differentiated nursing practice from a team perspective (Kimball & Joynt 2007). The team includes an RN care manager RN or LPN/LVN provider
and clinical assistant. The patient is actively involved in the care process. The team principles are as follows (Kimball & Joynt 2007. p. 394):
Every patient deserves an experienced RN.
Every novice nurse deserves mentoring from an experienced RN.
Every patient deserves the opportunity to participate in planning of his or her care.
Every team member is committed to meet the needs of every patient assigned to the team.
Each PCT member functions within his or her defined scope of practice/experience.
Work intensity decreases with improved work distribution processes and team support.
The model of nursing care delivery is an important element in patient safety and patient staff and physician satisfaction.
COLLABORATIVE PATIENT CARE MANAGEMENT MODEL
The Collaborative Patient Care Management Model is an interprofessional population-based case management model (Kimball & Joynt 2007). The model focuses on high risk high volume and high cost
populations. The team is co-coordinated by a physician and an RN patient care coordinator. The RN leads rounds and there is an interprofessional plan. This model has been used in acute care and
outpatient settings across the continuum of care services.
TRANSITIONAL CARE MODEL
This model focuses on providing comprehensive in-hospital planning care coordination and home follow-up for high-risk elders (Kimball & Joynt 2007 p. 395). Nurse practitioners lead this model
to ensure that the elders receive the care that they need including post-hospitalization. The model has had a positive impact on decreasing time between readmissions number of readmissions and
total health care costs. With the increasing number of elders this type of model will become more important.
PATIENT NAVIGATION
Patient Navigation is a model that has primarily focused on patients with cancer who are at risk for poor cancer outcomes though other types of patients populations have also benefited from patient
navigation (Wells et al. 2008). Clinical nurse leaders often hold the position of nurse navigator. Patient navigation focuses on decreasing barriers to better ensure that patients get the care
they need when they need it (Finkelman 2011). This mode is an intervention designed to reduce health disparities by addressing specific barriers to obtaining timely quality health care (Wells
et al. 2008 p. 2010).
TRANSFORMATIONAL MODEL FOR PROFESSIONAL PRACTICE
This model integrates patient care services (Beckman Institute for Innovation in Patient Care 1998 as cited in Wolf Hayden & Bradle 2004). The model has four components: (1) professional
practice: assessment and activation of professional practice relationships and support with emphasis on transformational leadership care delivery system professional growth and collaborative
practice; (2) the process component: engagement in purposeful and deliberate critical thinking negotiation and decision-making; (3) the primary outcome component: reach targeted outcomes (quality
improvement patient satisfaction caregiver satisfaction); and (4) the strategic outcome component: consumer organizational professional health).
THE QUALITY-CARING MODEL
This model emphasizes caring and evidence-based practice with an emphasis on structure-process-outcomes as dimensions of quality care (Duffy & Hoskins 2003). It addresses concerns about the need
to build relationships with patients and familiescooperative collaborative relationships. This is described as nursings work rather than a focus on a task oriented biomedical model.
Nursing care delivery models have changed over the years due to economic factors staffing shortages or excesses philosophy and goals nursing research tasks that need to be accomplished
technology information management scientific advancements and new leadership and organization theories and styles. Some models have disappeared (for example functional nursing). Another example
of a model that is used less often is primary nursing which was popular in many areas of the country but is not used as much now primarily due to costs and the RN shortage. The total patient
care or case method although rarely used may still be used in critical care settings and home care although even here there is a movement toward interprofessional care. Why have the changes
occurred? Some nursing care can be done by others more cost effectively and still be safe quality care and staff are available to do these tasks such as LPNs/LVNs or UAP. Typically a hospital
will use a combination of models.
CASE STUDY DOES A NURSING MODEL MAKE A DIFFERENCE?
As Director of Staff Development in a large university hospital the Chief Nurse Executive (CNE) has met with you to discuss orientation for student nurses and faculty. The CNE is concerned that
students and faculty do not understand the hospitals new nursing model Synergy model of patient care. She tells you it is your job to correct this problem. You leave the meeting overwhelmed.
This seems like a big responsibility to you. The hospital has many nursing students from three schools of nursing that use its services for practicum. All have to attend a 4-hour orientation to the
hospital which is already overburdened with content. The units have also been struggling with applying the model since it was initiated 6 months ago.
QUESTIONS
1. Why is it important for the students and faculty to understand the model?
2. How does the nursing model relate to the organizations theory or approach?
3. How would you describe this model? Consider methods and examples.
4. Develop a plan that you will submit to the CNE explaining how you will address this problem. Who might you include in developing the plan and in implementing it?
SHARED GOVERNANCE
Governance or self-regulation has long been recognized as a privilege given to professions that earn the public trust by demonstrating accountability for their specialized practices (Maas &
Specht 2001 p. 318). How does this relate to shared governance? As a nursing management form shared governance emphasizes nurses roles and responsibilities in decision making (Anthony 2004;
Hess 2004). It thus increases each nurses influence over the organization empowering staff and is based on six dimensions of governance.
1. Control over professional practice
2. Influence over organizational resources that support practice
3. Formal authority granted by the organization
4. Committee structures that allow participation in decision making
5. Access to information about the organization
6. Ability to set goals and negotiate conflict
Shared governance can be viewed as a management philosophy a professional practice model and an accountability model that focuses on staff involvement in decision making particularly in
decisions that affect their practice. In doing this the model provides staff with autonomy and control over implementation of their practicelegitimizing control over their own practice. Nurses in
these organizations usually feel less powerless and are more efficient and accountable.
A critical factor in shared governance is that accountability and responsibility are found in the same person. Accountability should rest in the person who is most likely to be the most effective
person to complete the function. For individual staff to be accountable and responsible for a function or task staff must also have the authority to make sure that the right decisions are made.
Within the professional context then the statement that the professional is accountable for his or her practice has meaning only when the necessary authority which is part of that
accountability is transferred to the individual who assures compliance and who is capable of taking corrective action in the absence of compliance (Porter-OGrady & Finnigan 1984 p. 80).
Shared governance is also a surrogate term for collaboration. It is an organizational arrangement with a highly participatory staff empowered to function cooperatively with both management and
colleagues and leadership that empowers staff. The organization can be referred to as a learning organization (Sullivan 1998 p. 471). Transformational Leadership enhances shared governance. As
was discussed in Chapter 1 an important element of leadership is self-awareness and it is important in shared governance. In this type of organizational arrangement staff members feel committed
to the organization and consider themselves to be partners in meeting the goals of the organization. Staff members should not feel that they are working alone but rather working in teams to meet
specific goals (Hess 2004).
In shared governance nurse managers typically are not directly involved in daily direct patient care although there are some managers who are still involved in direct care. The typical
responsibilities of the nurse manager are staffing program evaluation personnel evaluation coordination allocation of resources financial activities and long-range planning discussed in
Chapter 1. If patient care outcomes are not met it is the responsibility of the nurse providing the care to address this issue. The nurse manager may become involved but it is the direct care
provider who should take the lead. Clinical practice is the responsibility of the practitioners. When clinical problems occur the nurse who provides direct care must be the one to solve these
problems working with the care team. The main factor in shared governance is that decision making is spread over a larger number of staff and is decentralized. Nurses are accountable for their
practice. Health care organizations that use shared governance must have clear communication processes or the organization will encounter problems and confusion in the decision-making process.
Typically this model leads to greater staff satisfaction with the job and the organizationstaff feels empowered (Caramanica 2004). The key components of shared governance are practice quality
education and peer process/governance. How are these accomplished? As with any such change some organizations change for real and others appear to change to this model but in the latter
situation very little has really changed in the decision-making process or in actual practice. Shared governance is associated with collaboration horizontal relationships and investment and need
to be demonstrated in the organization. The change has to be real.
Organizations that use this model have some type of structure that relates to the shared accountability such as councils cabinets committees or a combination of these groups or teams that make
the decisions. The chain of command is not the same as in traditional organizations. In the shared governance model these groups make decisions about policies procedures and other aspects of
getting the work done. How might shared governance be implemented?
Health care organizations have been working for several years to create leaner and more effective organizations. It is important to recognize that to move toward a shared governance model the
organization must take a comprehensive change approach and not an incremental approach. All parts of the organization and all staff must be expected to change. This is very difficult to accomplish
but if shared governance is the goal it is necessary.
Decentralized decision making is now found in many health care organizations and it is frequently associated with participative management strategies such as a shared government model. This
approach to organizational structure and process is associated with the economy job satisfaction and retention. For decentralization to be effective staff must have autonomy to make decisions.
All of this is intimately connected with shared governance. It requires staff members who are committed to the organizations values and goals and demonstrate this by working to meet the goals.
Magnet hospitals also share these common shared governance characteristics (see Chapter 6). Whatever the process of changing structure locus of control decision processes and team-based
initiatives are called they are essential to the future of doing health services business. From shared governance to shared leadership shared decision making empowerment point-of-service
accountability or whatever other name might be attached to the dynamic shared decision making is an essential element of work of reconceptualizing and configuring health care for the future
(Porter-OGrady 2001 p. 473).
Finkelman A. (2012). Leadership and management for nurses: Core competencies for quality care (2nd ed.). Boston MA: Pearson.