Chapter 13 Care Delivery Strategies

Case method negatives

Expensive, not enough resources, not enough nurses

Nurse manager's role of case Method

Has to decide what type of care patients need/receive, must consider expense of system

Eight patient characteristics of the energy model

Resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making and predictability

ANS: A The primary nursing model assumes that the primary nurse is accountable for patient care, even while off duty. The primary nurse is responsible for establishing the patient plan of care and therefore for altering it with the input of an associate. The associate is responsible for implementation of the established care plan when the primary nurse is off duty.

A conflict develops between an associate nurse and a primary nurse over the assessment of a patient with pulmonary edema. Based on her assessment of the patient, the associate nurse insists that it is her role to change the care plan because she is the one who has made the assessment. As the nurse manager, you clarify that: a. It is the role of the primary nurse to make alterations based on assessment data and input. b. The associate nurse is accountable and responsible while the primary nurse is off duty and therefore is able to alter the care plan. c. Neither the primary nor the associate should make changes without first consulting you as the manager. d. It really does not matter who alters the nursing care plan as it depends on situation and time to do so.

Team nursing

A modification of functional nursing, was devised to improve patient satisfaction. care through others became the Hallmark

ANS: C Significant overlap can be seen between primary nursing and total patient care in terms of breadth of assessment and knowledge required to provide holistic care. A primary difference is that nurses in the total care model assume accountability while on shift, whereas primary nurses assume responsibility from time of admission to discharge and 24 hours a day.

A nurse manager questions the true difference between primary nursing and total patient care. After careful consideration of both models, the nurse manager concludes that primary nursing differs significantly from total patient care in: a. Breadth of nursing knowledge and expertise required. b. Intention to provide holistic nursing. c. Degree of task orientation. d. Levels and types of assessment.

ANS: C Functional team nursing involves licensed and unlicensed personnel who perform specific tasks for a large number of patients. A disadvantage of functional team nursing is the fragmentation of care. The physical and technical aspects of care may be met, but the psychological and spiritual needs may be overlooked. Patients become confused with so many different care providers per shift. These different staff members may be so busy with their assigned tasks that they may not have time to communicate with each other about the patient's progress.

A patient complains to you that she has no idea who "her nurse" is on any given day. "I ask one nurse for my pills and she says, 'That's not my job.' I ask the pill nurse about my lab tests and she says that I should ask another nurse." The nursing care delivery model most likely employed in this situation is: a. Differentiated practice. b. Team nursing. c. Functional nursing. d. Case management.

ANS: D An advantage of functional nursing is that both unskilled assistive personnel and skilled staff are involved in performance of specific tasks, and the repeated performance of tasks enables staff to become very efficient in specific functions. Disadvantages of the model include difficulty in being able to assess the patient's nonphysical needs effectively and the potential for ineffective communication because of the focus on specific tasks.

A patient complains to you that she has no idea who "her nurse" is on any given day. "I ask one nurse for my pills and she says, 'That's not my job.' I ask the pill nurse about my lab tests and she says that I should ask another nurse." This nursing care delivery model employed in this situation might be particularly effective in: a. Promoting communication among diverse team members. b. Facilitating multiple perspectives on the total care of a patient. c. Avoiding patient-provider conflict. d. Developing competence and confidence in unskilled workers.

ANS: A Because of the breadth of nursing knowledge required, baccalaureate education is preferred for primary nurses.

A patient is admitted to a medical unit with pulmonary edema. His primary nurse admits him and then provides a written plan of care. What type of educational preparation best fits the role of primary nurse? a. Baccalaureate b. Associate c. Diploma d. LPN/LVN

Clinical pathways

A tool that case managers use Trixie patient outcomes that use patient focused documents to describe the clinical standards necessary interventions and expected outcomes for the patient at each stage throughout the treatment process or hospital stay

ANS: A Case managed care is not revenue generating but rather revenue protecting in that better coordination of care enables efficient achievement of patient outcomes, can result in shorter length of stay, and can prevent readmission.

Case managed care may enhance profit in a for-profit health organization by: a. Minimizing costs in high resource consumption areas. b. Combining licensed and non-licensed care providers in delivering patient care. c. Increasing reimbursement from third-party payers. d. Reducing the amount of technology used to support clinical decision making.

The eight nurse competencies of synergy model

Clinical judgment, advocacy, caring practices, facilitation of learning, collaboration, systems thinking, response to diversity, and clinical requirement

ANS: D Differentiated nursing practice models are models of clinical nursing practice that are defined or differentiated by level of education, expected clinical skills or competencies, job descriptions, pay scales, and participation in decision making.

Complex care of acutely ill patients is required on a surgical unit, which utilizes differentiated nursing practice as its model of care delivery. The concept of differentiated nursing practice is based on: a. Licensure status. b. Experience in the agency. c. Leadership capabilities. d. Education and expertise.

Disadvantages of primary nursing

Costly for the agency, registered nurse may not want 24 hour responsibility, registered nurse maybe inexperience and lack autonomy

Differentiated nursing practice

Defined by level of education, expected clinical skills or competencies, job descriptions, payscales, and participation and decision-making

Magnet recognition program

Designed for hospitals to achieve recognition of excellent nursing care through a self nominating, self appraisal process to achieve

ANS: A The case method may involve total patient care provided by a registered nurse, which, in today's costly healthcare economy, is very expensive. In times of nursing shortages, there may not be enough resources or nurses to use this model.

During times of nursing shortages and increased nursing costs in health care, which of the following nursing care delivery models might come under greatest scrutiny? a. Case method b. Team nursing c. Functional nursing d. Nurse case management

Functional nursing positives

Each person becomes efficient at specific task, and much work can be done in a short time. Unskilled workers can be trained to perform one or two specific task very well. The organization benefit financially from this model because care can be delivered to a large number of patients by mixing staff with a fixed number of our ends in a larger number of UAPs

Disadvantages case management nursing

Financial barriers, lack of administrative support, human resource inequalities, turf battles, and the lack of information support systems have been identified as obstacles in the implementation

ANS: A Although repetition of tasks increases confidence and competence, it can also lead to boredom. Rotation of tasks can assist specifically in this model to reduce the boredom that is a potential disadvantage of this model.

For a nurse manager in the functional nursing model, an approach that will assist in maintaining staff satisfaction in this specific model is: a. Rotation of task assignments. b. Frequent opportunities for in-service education. c. Orientation to job responsibilities and performance expectations. d. Team social events in off hours.

Functional Nursing negatives

Fragmentation of care, physical and technical aspects of care may be met, but the psychological and spiritual needs may be overlooked. Patients become confused with so many different care providers per shift Staff members might become busy and forget to communicate with other staff

Synergy model

Identifies patient characteristics as drivers of the necessary competencies for nurses

Transforming care of the bedside

Implemented to redesign the work environment of nurses. Reliability, teamwork, patient centered care, value added care processes. Brainstorm innovations, plan/do/study

Advantages of nursing case management

Improve care outcome, decreased the length of stay in the hospital, service efficient

Advantages of team nursing

Improved patient satisfaction, organizational decision-making occurring at lower levels, and cost-effectiveness for the agency

ANS: C The partnership care delivery model is a variation of primary nursing in which an RN works with a consistent assistant, who performs basic nursing functions consistent with state delegation rules.

In a small rural nursing home, a director of nursing decides, because of a shortage of nurses, to implement a partnership model to help with basic tasks that comply with state rules regarding delegation. What type of design constitutes a partnership care delivery model? a. RN and LPN/LVN b. RN and RN c. RN and medication assistants d. RN and certified nurses' aides

ANS: D In a functional nursing model, where other team members are focused on performing specific tasks, the nurse manager assumes primary responsibility for patient outcomes.

In an acute care unit, the nurse manager utilizes the functional nursing method as the care delivery model. The nurse manager's main responsibility is the needs of the: a. Department. b. Unit. c. Staff. d. Patient.

ANS: A Team nursing delivers care to a small group of patients, using a mix of licensed and unlicensed personnel. Team nursing uses the strengths of each caregiver.

In comparing team and functional models of care, a nurse manager favors the team model. In particular, she finds that the team model: a. Can be effective in recognizing individual strengths and backgrounds of staff. b. Promotes autonomy and independence for the RN. c. Avoids conflict because of role clarity. d. Is efficient in delivering care to a large group of patients, utilizing a staffing mix.

ANS: C Magnet™ hospitals exemplify hospitals whose focus processes attract and retain nurses who value and promote quality care and excellence in nursing environments.

In considering whether or not to accept a job offer as a nurse manager at a Magnet™ hospital, you look at an environment that you might encounter as a head nurse at the hospital. You determine that you could expect to: a. Find it difficult to recruit new staff. b. See rapid turnover of staff on your unit. c. Find nurses who exemplify interest in quality care. d. Find limited interest in excellence in the nursing environment.

Case method positives

Patient received consistent care, builds a trusting relationships works towards goals

ANS: B Nurses who have less than 2 or 3 years' experience in primary nursing and/or less than 2 or 3 years of nursing experience will likely require more assistance than other nurses, which will put a greater demand on the unit during a time of transition.

In hiring nurses during the transition from team nursing to a primary nursing model, Benner's work would suggest that you give priority to nurses who are at least at which level of competency? a. Advanced beginner b. Competent c. Proficient d. Novice

ANS: B The nurse manager who is considering movement to primary nursing needs to consider how the role of the manager changes, as well as the roles of the staff. The role of decision making at the patient care level is relinquished to the primary nurse, and the role of manager becomes that of facilitator, coach, mentor, role model, and clinical resource.

In transitioning to a primary nursing model, it is important for a nurse manager who enjoys a high level of control over patient care to understand that his or her decision making at the patient care level: a. Is increased. b. Is decreased. c. Is relinquished. d. Remains the same.

Advantages for primary nursing

Increase communication, increase patient rapport, autonomy,motivation, holistic care

Team nursing manager

Management skills, provide support, plans care, follow up with members to evaluate the quality of care

Primary nursing

Method for organizing patient care delivery in which one registered nurse functions autonomously as the patient's primary nurse throughout the hospital stay

Functional nursing role of manager

Must be sensitive to the quality of patient care delivered and institutions budgetary constraints. Patient outcomes becomes the nurse managers responsibility

The chief nursing officer (CNO) of a large metropolitan hospital is preparing to defend her request for more staffing in certain units during budget development. Research has illustrated that a number of outcomes are improved when there is sufficient staffing on the unit. To make her case for more nursing staff, the CNO should gather data on which outcomes associated with staffing patterns and highlighted in the research?

Number of errors in patient care identified over time on a unit. Inadequate staffing has been linked to an increase in the number of patient care errors.

Case method(total patient care)

One nurse provides total care for one patient during the entire work period

A rural, critical access hospital has used a total patient care model to deliver nursing care to patients because of the hospital's commitment to individualized care to patients in the community. Environmental factors such as a nursing shortage in the area and limited profitability of the hospital have forced the nursing administration to consider another, less expensive model of nursing care delivery. They want to continue their commitment to individualized care to the extent possible. Which model of care would be most appropriate in this situation?

Patient-centered care The patient-centered care model of care maintains the commitment to individualized care; however, it uses less expensive unlicensed assistive personnel to extend the practice of the registered nurse.

Nursing case management

Process of coordinating healthcare by planning, facilitating, and evaluating interventions across levels of care to achieve measurable cost and quality outcomes

Registered nurse role of case method

Provide holistic care, physical, emotional, and technical aspects of care

Functional nursing

Providing patient care by which each licensed and unlicensed staff member perform specific tasks for a large group of patients

The most important role of the nurse case manager is to:

Serve as a communication link between all providers of care. The primary role of the case manager, according to the Case Management Society of America, is to increase the involvement of individual and caregivers in the decision-making process.

Disadvantages of team nursing

Team leader has poor leadership skills causing a potential for fragmentation of care

ANS: C This model is especially useful in the care of complex patients who need active symptom management provided by an RN, such as the care of the patient in a hospice setting or an intensive care unit. This method would be justifiable delivery in the pediatric intensive care unit, where the status of patients can change rapidly and where complex functions of care involve both patients and families.

The case method of care delivery could be best justified in which of the following scenarios? a. Stable patient population with long-term care and family needs b. Acute care surgical unit with predictable postsurgical outcomes and many technical procedures c. Pediatric intensive care unit that heavily involves families as well as patients d. Home healthcare environment with patients at varying levels of acuity

Disease management

The focus of this model of care is the concept of wellness, living well with a chronic disease. Determining the barriers to self-care is an essential element of successful disease management programs

A hospital in a large metropolitan area hopes to obtain magnet status. The following are characteristics of the nursing service in this hospital. Select the areas that must be addressed in order to become a magnet hospital. (Select all that apply.)

The hospital has a nurse vacancy rate of 20%. Correct The chief nursing officer holds a MSN, with a specialty in nursing administration. NO 50% of the nurse managers hold a BSN. Correct Transforming Care at the Bedside has been implemented in all units. NO Cost reduction at the hospital has resulted in a 50% decrease in the number of staff in the Education Department. Correct Magnet status highlights hospitals that provide a positive work environment for nurses and other staff. A high vacancy rate suggests that nurses are leaving the hospital, in some cases, because the environment does not "hold" them to their job. Similarly, cost reduction in the area of staff development suggests a lack of support for ongoing professional development. Finally, effective January 2014, all nurse managers must hold a BSN.

ANS: D The goals and outcomes established in a critical pathway are designed to support the aims of case management, which are shortened hospital stays and prevention of hospital readmissions.

The nurse case manager is working with a client admitted for end-stage renal disease. The case manager's major goal during this hospitalization is to: a. Implement the care pathway on admission. b. Provide direct nursing care throughout the hospitalization. c. Supervise the nursing staff members who implement the care map. d. Prevent additional hospitalizations resulting from complications of the client's disease.

ANS: B Team nursing, functional nursing, and case management are all considered efficient, cost-effective methods of care delivery because they enable utilization of various types of healthcare providers (rather than baccalaureate nurses in direct care, which is the primary nursing method). Case management is considered particularly cost-effective in patient care settings because it maintains quality care while streamlining costs for high-risk, high-volume, high-cost patient populations and seeks the active involvement of the patient, the family, and diverse healthcare professionals.

The nurse manager at a cardiac rehabilitation unit was asked to select a care delivery model. Which of the following methods would be the most cost-effective? a. Functional method b. Case management method c. Primary care method d. Team method

ANS: A Because the basic education of baccalaureate-prepared RNs emphasizes critical-thinking, clinical reasoning, and leadership concepts, they are likely candidates for such roles. Benner (2001), however, identified five stages of clinical competence for nurses: novice, advanced beginner, competent, proficient, and expert. She suggests that competence is typified by a nurse who has been on the job in the same or similar situation 2 to 3 years. Nurses who are at the novice or advanced beginner stage would be less likely than their more experienced counterparts to implement any type of delivery model effectively and thus, this assignment overlooks the nurse's level of clinical expertise and leadership experience.

The relief charge nurse has assigned a newly licensed baccalaureate-prepared nurse to be one of the team leaders for the 3-11 shift. In making this decision, the charge nurse has overlooked this nurse's: a. Clinical expertise. b. Leadership ability. c. Communication style. d. Conflict-resolution skills.

Functional nursing role of registered nurse

The staff RN become skilled at the task that are usually assigned by the charge nurse. Clearly defined policies and procedures are used to complete the physical aspects of care in an efficient and economical manner

ANS: C A particular challenge in team nursing is that staff mixes and staff may change daily because of individual schedules and shortages.

To effectively delegate in a team nursing environment, the RN team leader must be familiar with the legal and organizational roles of each group of personnel and must: a. Be able to effectively communicate with patients. b. Build relationships with physicians. c. Be able to adapt to daily changes in staffing. d. Adapt in communicating information to her supervisor.

Registered nurse team nursing

Uses the strength of each caregiver example if you're good at an IV you do the IV every time

ANS: D Although some studies suggest there is little difference between functional nursing and primary nursing, primary nursing tends to be more satisfying for RNs, who enjoy a high level of accountability and autonomy in decision making. Patient satisfaction is also high, as patients form close therapeutic relationships with the nurse because of the continuity of the relationship. Functional nursing is criticized for low patient satisfaction and potential staff dissatisfaction related to boredom and an autocratic approach to management.

When comparing functional nursing and primary nursing, a nurse manager, after evaluating particular models of nursing care for potential adoption, determines that patient and nurse satisfaction in primary nursing are: a. Similar to those in functional nursing. b. Not of significance in either model. c. Low by comparison with functional nursing. d. High when compared with functional nursing.

ANS: D Case managers can come from a variety of disciplines but should have advanced preparation with the particular at-risk population being served, be comfortable in an advocate role, and be outcome and patient focused.

When hiring a case manager for a rehabilitation setting, you would most likely consider a: a. Registered nurse with a master's degree. b. Physiotherapist with a background in stroke rehabilitation. c. Social worker with a background in counseling. d. Health professional with advanced background who is client and outcome focused.

ANS: B The functional model of nursing is a method of providing patient care by which each licensed and unlicensed staff member performs specific tasks for a large group of patients.

When interviewing an applicant for a position, the nurse manager describes the unit's care delivery system as one in which each nursing assistant is cross-trained to perform specific tasks, and the RNs do all treatment, medication administration, and discharge teaching. The nurse applicant knows this nursing care delivery strategy to be: a. The case method. b. Functional nursing. c. Primary nursing. d. Nurse case management.

ANS: B This particular model includes a focus on patient care that includes multidisciplinary teams and assistants at the bedside. Services, including laboratories and pharmacies, are decentralized to bring them closer to where care is delivered.

You are considering putting forward a proposal to move the model of care from team nursing to a primary nursing hybrid: patient-focused care model. In considering this proposal, you recognize that significant costs specific to operationalizing this model are related to: a. Implementation of an all-RN staff complement. b. Significant changes in the physical structure of units. c. Orientation of staff to new roles and responsibilities. d. Testing and piloting technology at the bedside.

ANS: C A critical pathway outlines outcomes, clinical standards, and interventions for a patient in each phase of treatment. The goal of critical pathways is effective coordination of care across various staff and levels of care.

You are the nurse manager of a nursing service organization that provides around-the-clock care to clients in their homes. To achieve maximum reimbursement for a client who is recovering from a hip replacement, the nursing staff most likely will follow the nursing care guidelines presented in the: a. Nursing care plan. b. Physician's orders. c. Critical pathway. d. Clinical practice guidelines.

ANS: A, B, E Transforming care at the bedside (TCAB) relies on active involvement of staff in the generation of innovative ideas to improve patient care. Staff are actively engaged in selecting innovation, planning, and evaluation of the innovations. Critical to practice changes, rapid cycle change is a process that encourages testing creative change on a small scale while determining potential impact.

Your organization has made a decision to implement TCAB in your hospital. As a manager, what strategies would you use to implement TCAB? (Select all that apply.) a. Encourage recognition among staff of their knowledge of the patient-care environment. b. With staff, select small changes for consideration. c. Select only projects that have widespread impact. d. Secure external advisors to evaluate innovation. e. Present ideas based on best practices and ask staff for advice on implementation.

A patient's family asks the nurse why a clinical pathway is being used to determine her care. The best answer is "Clinical pathways:

help everyone caring for you to provide effective care based on research findings. Clinical pathways are designed to integrate research and best practices into the care.