Models of Nursing Care Delivery
Nursing care can be carried out through a variety of organiza-tional methods. The model of nursing care used varies greatly from one facility to another and from one set of patient circum-stances to another. A review of past and current models provides a background for understanding the nursing models and meth-ods needed for today’s changing health care delivery system.
Team nursing, which had its origins in the 1950s and 1960s, in-volved use of a team leader and team members to provide various aspects of nursing care to a group of patients. In team nursing, medications might be given by one nurse while baths and physi-cal care are given by a nursing assistant under the supervision of a nurse team leader. Skill mixes include registered nurses (RNs), often as team leaders; licensed practical nurses; and nursing assis-tants or unlicensed assistive personnel (UAP). With the current emphasis on cost containment in health care agencies, variations of team nursing are being used, and UAPs are increasingly being included as team members. There has been little substantiation, however, that team nursing is cost-effective. The quality of pa-tient care with this system is questionable, and fragmentation of care is of concern.
Primary nursing (not to be confused with primary health care, which pertains to first-contact general health care) refers to com-prehensive, individualized care provided by the same nurse throughout the period of care. This type of nursing care allows the nurse to give direct patient care rather than manage and su-pervise the functions of others who provide direct care for the pa-tient. This care method is rejected by many institutions as too costly; the patient–nurse ratio is small, and a larger professional staff is needed, because the primary nurse is usually an RN. How-ever, primary nursing may provide a foundation for transition to case management in some institutions.
The primary nurse accepts total 24-hour responsibility for a patient’s nursing care. Nursing care is directed toward meeting all of the individualized patient needs. The primary nurse is re-sponsible and accountable for involving the patient and family directly in all facets of care and has autonomy in making decisions in this regard. The primary nurse communicates with other mem-bers of the health care team regarding the patient’s health care. This process promotes continuity of care and collaborative efforts directed toward quality patient care.
During times when the primary nurse is not scheduled to work, an associate nurse or co-nurse assists in overseeing the de-livery of care. The associate nurse implements the nursing plan of care and provides feedback to the primary nurse for evaluating the plan of care. The primary nurse assumes responsibility for making appropriate referrals and for ensuring that all relevant in-formation is provided to those who will be involved in the pa-tient’s continuing care, including the family.
The long-term survival of primary nursing as it is currently de-signed is uncertain. As cost-containment measures continue and patient acuity increases, staffing ratios of patients to nurses are in-creasing. Many nursing service departments and agencies are meeting the increased workload demands by making modifica-tions in their approach to primary nursing or by reverting to team or functional systems for delivering care. Others are changing their staffing mix and redesigning their models of practice to ac-commodate nurse-extender roles. Still others are changing to more innovative systems such as case management.
Community-based care and community health–public health (CH-PH) nursing are not new concepts for nursing. Nursing has played a vital role in the community since the middle to late 1800s, as visiting nurses provided care to the sick and poor in their homes and communities and educated patients and family mem-bers. Although community health (CH) nursing, public health (PH) nursing, community-based nursing, and home health nurs-ing may be discussed together and aspects of care in each type do overlap, there are distinctions among these terms. Confusion ex-ists regarding the differences, and the similar settings may blur these distinctions (Hunt, 2000; Kovner, 2001). The central idea of CH-PH nursing is that nursing intervention can promote well-ness, reduce the spread of illness, and improve the health status of groups of citizens. CH-PH nursing practice is concerned with the general and comprehensive care of the community at large, with emphasis on primary, secondary, and tertiary prevention. Nurses in these settings have traditionally focused on health promotion, maternal and child health, and chronic care.
Community-based nursing occurs in a variety of settings within the community and is directed toward individuals and families (Hunt, 2000). It includes home health care nursing. Most community-based and home health care is directed toward specific patient groups with identified needs; these needs usually relate to illness, injury, or disability resulting most often from advanced age or chronic illness. However, both community-based and CH-PH nurses are now expanding to meet the needs of many groups of pa-tients with a variety of problems and needs. Home health care will be a major aspect of community-based care discussed throughout this text. Home health care services are provided by community-based programs and agencies for specific populations (eg, the elderly, ventilator-dependent patients), as well as by hospital-based home health care agencies, hospices, independent professional nurs-ing practices, and freestanding health care agencies.
As trends continue toward shortened hospital stays and in-creased use of outpatient health care services, the need for nurs-ing care in the home and community setting has increased dramatically. Because nursing services are being provided outside as well as within the hospital, nurses have a choice of practicing in a variety of health care delivery settings. These settings include acute care medical centers, ambulatory care settings, clinics, ur-gent care centers, outpatient departments, neighborhood health centers, home health care agencies, independent or group nurs-ing centers, and managed care agencies.
Community nursing centers, which have emerged over the past two decades with the advent of NPs, are nurse managed and provide primary care services that include ambulatory and out-patient care, immunizations, health assessment and screening ser-vices, and patient and family education and counseling. The populations that these centers serve are varied, but most typically they include a high proportion of patients who are rural, very young, very old, poor, or members of racial minorities—groups that are generally underserved.
The numbers and kinds of agencies that provide care in the home and community have expanded because of the expanding needs of patients requiring care. Home health care nurses are challenged because patients are discharged from acute care insti-tutions to their homes and communities early in the recovery process and with more complex needs. Many are elderly, and many have multiple medical and nursing diagnoses and multi-system health problems that require acute and intensive nursing care. Medical technologies such as ventilatory support and intra-venous or parenteral nutrition therapy, once limited to acute care settings, have been adapted to the home care setting.
As a result, the community-based care setting is becoming one of the largest practice areas for nursing. Home care nursing is now a specialty area that requires advanced knowledge and skills in general nursing practice, with emphasis on community health and acute medical-surgical nursing. Also required are high-level assessment skills, critical thinking, and decision-making skills in a setting where other health care professionals are not available to validate observations, conclusions, and decisions.
Home care nurses often function as acute care nurses in the home, providing “high-tech, high-touch” services to patients with acute health care needs. In addition, they are responsible for patient and family teaching and for contacting community re-sources and coordinating the continuing care of the patient. For these reasons, the scope of medical-surgical nursing encompasses not only the acute care setting within the hospital but also the acute care setting as it expands into the community and the home.