RUC1 Nursing as an Evolving Discipline chp. 20 & 26

Nursing roles

(1) Traditional duties and responsibilities of the professional nurse, regardless of practice area or setting, such as the roles of care provider, educator, counselor, client advocate, change agent, leader and manager, researcher, and coordinator of the interprofessional health care team. (2) Duties and responsibilities of the professional nurse that are guided by specific professional standards of practice and usually are carried out in a distinct practice area (e.g., flight nurse, forensic nurse, and occupational nurse).

The four classic nursing care delivery models used during the past five decades are:

(1) total patient care, (2) functional nursing, (3) team nursing, and (4) primary nursing. As the health care system continues to evolve in the twenty-first century with a focus on rapid patient turnover in acute care settings, extensive use of outpatient and community-based settings, and evidence of the RN's valuable role in patient safety and improved outcomes, the need for new models of nursing care delivery is emerging. Thus considerations for future care delivery models also are presented.

CHAPTER 20 Staffing and Nursing Care Delivery Models

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Helpful Staffing Websites

ANA's Safe Staffing www.safestaffingsaveslives.org Institute of Medicine Report: Keeping Patients Safe: Transforming the Work Environment of Nurses www.nap.edu/books/0309090679/html National Database of Nursing Quality Indicators www.nursingquality.org/Default.aspx

CHAPTER 26 Contemporary Nursing Roles and Career Opportunities

After studying this chapter, the reader will be able to: 1 Evaluate the effect of the current health care environment on the future role of nurses. 2 Analyze the influence of current demographic characteristics of RNs in the United States on contemporary nursing roles. 3 Differentiate among various innovative nursing practice roles today. 4 Differentiate between the roles of advanced practice nurses and other RNs in various settings. 5 Describe the role of the CNL.

Nursing care delivery model

Also called care delivery system or patient care delivery model; details the way work assignments, responsibility, and authority are structured to accomplish patient care; depicts which health care worker is going to perform what tasks, who is responsible, and who has the authority to make decisions.

Specific Client Services

An almost endless list of specific client services can be found in hospitals, depending on the hospital's size and function within the community. Some nursing positions might be self-evident, such as the intravenous team on which the nurse provides support and interventions with the insertion and maintenance of intravenous therapies. Other services might relate to ostomy care, counseling, support groups, or health education related to a specialty area.

Telephone Triage Nurse

Another career option is that of telephone triage nurse. In this practice, nurses interact with clients on the telephone to assess needs, intervene, and evaluate. This position requires excellent communication and assessment skills, in addition to problem-solving skills. Telephone triage is used in a variety of settings, including emergency departments and physician practices.

Informatics Nurse Specialist

As health care systems face the inevitable need for data management for decision making, another nursing role has emerged—the informatics nurse specialist. Nursing informatics (NI) focuses on management and processing of health care information. The Joint Commission (TJC) recognized the increased need for information management in the clinical client care settings. The 1994 Joint Commission standards define information management as critical to organizational success. Nurses are well positioned to assume these roles because they best understand client care processes. The American Nurses Credentialing Center (ANCC) has developed a certification examination for nurses who demonstrate beginning levels of competency to become certified as informatics nurses. The ANA Scope and Standards of Nursing Informatics Practice states, "Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.

Hospice Nurse

As more clients with terminal illness choose to stop aggressive treatment, hospice nursing has flourished. More than 4100 hospice programs exist in the United States. The growth of hospice was seen by the 1.45 million clients receiving these services in 2008. According to the National Hospice and Palliative Care Organization (NHPCO), 38.5% of all Americans who died in 2008 with cancer received hospice care. Hospice and palliative care nurses treat the symptoms of those with progressive terminal disease. These nurses work holistically with clients and families to maximize quality of life rather than focus on the quantity of life remaining. To learn more about the hospice concept, visit the NHPCO website at: www.nhpco.org/templates/1/homepage.cfm (Box 26-3).

In essence the clinical pathway can be viewed as a road map the patient and health care team should follow to guide the patient's care management and recovery.

As the patient progresses along the path, specified goals should be accomplished. If a patient's progress deviates or leaves the planned path, a variance has occurred. A positive variance means that the patient has progressed ahead of schedule, and a negative variance means that the identified goals are 437438 not accomplished as planned. The RN generally identifies that a variance has occurred and mobilizes the interprofessional team members to create an action plan to address the problem or issue.

Advanced practice nursing

Based on knowledge and skills acquired through basic nursing education, with licensure as a registered nurse (RN) and graduate education and experience that includes advanced nursing theory, physical assessment, and psychosocial assessment and treatment of illness. Includes nurse practitioners (NPs), certified nurse-midwives (CNMs), certified registered nurse anesthetists (CRNAs), and clinical nurse specialists (CNSs).

Professional Nursing Roles

Care provider Educator and counselor Client advocate Change agent Leader and manager Researcher Coordinator of the interprofessional health care team

Evolution of Case Management

Case management is a model of care delivery in which an RN case manager coordinates the patient's care throughout the course of an illness. The concept of case management was first introduced in the 1970s by insurance companies as a method to monitor and control expensive health insurance claims, usually created by a catastrophic accident or illness. Today virtually every major health insurance company has a case management program to direct and manage the use of health care services for their clients. Case management by payer organizations (e.g., health insurance companies, health maintenance organizations [HMOs]) is known as external case management. To keep costs lower than the diagnosis-related payment, the hospitals had to efficiently manage the treatment provided to a patient and reduce the patient's length of stay. Thus internal case management, or case management "within the walls" of the health care facility, was created to maintain quality care while streamlining costs.

Variations on Traditional Roles in Nursing

Clients can be monitored through home visits by RNs, expanded technology, radiographs, or telemetry at home. Uterine monitoring for high-risk obstetric clients is common as vital signs of the mother and baby are observed by telephone modem. All these changes increase the need for home-care nurses who are expert clinicians and client educators.

Clinical pathway

Clinical management plans that specify the optimal timing and sequencing of major patient care activities and interventions by the interprofessional team for a particular diagnosis, procedure, or health condition and are designed to standardize care delivery (Coffey et al, 2005); clinical pathways may also be called critical paths, practice protocols, or care maps; clinical pathways support the implementation of clinical practice guidelines.

Developing Clinical Pathways

Clinical pathways most often are developed for the health care facility's most common or costly diagnoses. For example, a general hospital may develop pathways for the treatment of congestive heart failure from admission in the emergency department, to care in the coronary care unit, to care on the general floor, to discharge home. It is important that the clinical pathway be individualized to meet unique patient needs. Clinical pathways should also be based on accepted standards of practice as recommended by specialty nursing organizations.

CLINICAL PATHWAYS

Clinical pathways, also called critical paths, practice protocols, patient care protocols, or care maps, are clinical management plans that specify major patient care activities and interprofessional interventions and desired outcomes within a specified time period for a particular diagnosis or health condition. The advantage of the clinical pathway is that it provides a means of standardizing care for patients with similar diagnoses. Clinical pathways differ from clinical practice guidelines in that clinical pathways define key processes and patient goals in the day-to-day management of care, whereas clinical practice guidelines guide broader decision making and focus on the decisions to perform a procedure or service. Clinical pathways are usually developed within the health care facility and are based on broader clinical practice guidelines. Because clinical pathways dictate the type and amount of care given, they have financial implications for the health care facility.

Staff mix

Combination of categories of workers employed to provide patient care (e.g., RNs, LPNs, or licensed vocational nurses [LVNs], nursing assistants, multiskilled workers, or nursing assistive personnel [NAP]).

Components of Clinical Pathways

Components of a clinical pathway include physical assessment guidelines, laboratory and diagnostic tests, medications and procedures, safety and self-care activities, nutrition requirements, patient and family education, discharge planning, and milestones the patient should achieve through the progression of care. Many clinical pathways also address triggers, which are events that identify potential or actual variations in the patient's response to the planned interventions. The most commonly used clinical paths in acute care settings are for treatment of community-acquired pneumonia, total hip or knee replacement, and stroke or transient ischemic attack

Researcher

During the past decades, nursing has taken its place among other disciplines in the production and use of research specific to its profession. Although the majority of researchers in nursing are prepared at the doctoral and postdoctoral levels, an increasing number of clinicians with master's degrees are participating in research as part of their advanced practice role. Nurses prepared at the baccalaureate and associate degree levels are also participating in research. These nurses may be assisting with data collection, critiquing research findings, and using these findings in practice. More nursing interventions are based on nursing research than in the past.

Staffing

Ensuring that an adequate number and mix of health care team members (e.g., RNs, LPNs or LVNs, NAP, clerical support) are available to provide safe, quality patient care; usually a primary responsibility of the nurse manager.

Flight Nurse

Flight nursing is a specialty for nurses who desire autonomous practice and the opportunity to use advanced clinical skills. Practice is diverse because clients are all ages and from all backgrounds with different health problems. Critical care experience, with certification in advanced cardiac life support, is necessary. Most programs prefer experienced nurses in critical care and/or emergency department nursing. The two types of flight practice available are military, such as in the Air Force Reserves or active duty, and civilian flight nursing. To learn more, visit the website "So, you wanna be a flight nurse?" (see Box 26-3). Nurses who enjoy a fast-paced diverse practice in an unstructured setting may find this role a good fit. For more information, call the Air and Surface Transport Nurses Association, formerly known as the National Flight Nurse Association, at 1-800-897-NFNA or visit their website (see Box 26-3).

Travel Nurse

For the person who wants to travel and still work as a nurse, travel nursing may be an answer. This role is expanding as the demand for nurses grows nationwide. Benefits and company programs vary, but many include travel reimbursement allowance for assignments, in addition to free housing, free insurance, travel money, free phone card use, and other benefits. Sign-on bonuses may also be offered. If these benefits are not important to the nurse, higher wages may be available. Some companies allow nurses' pets to travel with them. Assignments are usually for a minimum time, such as 12 weeks, but others may last as long as a year. For more information, visit the travel nurse website (see Box 26-3).

Forensic Nurse

Forensic nursing may well be one of the fastest-growing nursing specialties in the twenty-first century. This is likely due to the epidemic increase in violence and resulting trauma in this country. The ANA's Scope and Standards of Forensic Nursing Practice, published by American Nurses Publishing, serves as a professional guide for nurses working in or entering this evolving specialty. Forensic nursing applies nursing science to public or legal proceedings in the scientific investigation and treatment of trauma and/or death of victims of violence, abuse, criminal activity, and traumatic accidents. The forensic nurse may provide direct services to individual clients and consult with and/or be an expert witness for medical and law enforcement. To learn more about this exciting practice, visit the International Association of Forensic Nurses (IAFN) website (see Box 26-3). The American Forensic Nurses' Organization offers distance-learning programs through the Internet (see Box 26-3).

Licensing Regulations and Accreditation

Health care facility licensing agencies, such as a state health department, and accreditation agencies, such as TJC, address minimum staffing levels. However, TJC and state licensing agencies do not impose mandatory staffing ratios (with the exception of California, which enacted legislation mandating specific nurse-patient ratios). Licensing regulations for long-term care facilities stipulate minimum RN coverage for the unit, but do not mandate specific nurse-to-patient ratios. However, these agencies do look for evidence that patients receive adequate care, which can only occur with adequate staffing. They also require documentation of staff training and competency to care for the organization's specific patient population.

Interprofessional team

Health care team composed of professionals from different disciplines including chaplains, nurses, dietitians, pharmacists, physical therapists, physicians, respiratory therapists, social workers, and speech language pathologists who cooperate, collaborate, communicate, and integrate care to ensure that care is continuous and reliable.

This topic highlights the following objectives:

Identify factors that are changing the roles of nurses in healthcare. Distinguish among common traditional nursing careers. Explain the responsibilities and education requirements of newer, specialized nursing roles (e.g., informatics, hospice, forensics, quality manager). Explain the characteristics of licensure and practice unique to advanced practice nurses. Analyze the impact of various specialized nursing roles on the perception of nursing by other professions and the public. Analyze the impact of advanced practice nurses on interprofessional practice and patient care outcomes.

Primary Nursing

In primary nursing, the RN, or "primary" nurse, assumes 24-hour responsibility for planning, directing, and evaluating the patient's care from admission through discharge. This model differs significantly from the total patient care model in that the "primary nurse" assumes 24-hour responsibility for directing the patient's plan of care. While on duty the primary nurse may provide total patient care or delegate some patient care tasks to LPNs or LVNs or NAP. When the primary nurse is off duty, care is provided by an associate nurse who follows the care plan established by the primary nurse. The primary nurse, who has 24-hour responsibility, is notified if any problems or complications develop and directs alterations in the plan of care. A fundamental responsibility for the nurse in the primary nursing model is to maintain clear communication among all members of the health care team, including the patient, family, physician, associate nurses, and any other members of the health care team.

Team Nursing

In team nursing, the RN functions as a team leader and coordinates a small group (no more than four or five) of ancillary personnel to provide care to a small group of patients. As coordinator of the team, the RN must know the condition and needs of all the patients assigned to the team and plan for individualized care for each patient. The team leader also is responsible for encouraging a cooperative environment and maintaining clear communication among all team members.

Functional Nursing

In the functional nursing method of patient care delivery, staff members are assigned to complete certain tasks for a group of patients rather than care for specific patients. For example, the RN performs all assessments and care planning, and administers all intravenous medications; the LVN or LPN gives all oral medications; and the assistant performs hygiene tasks and takes vital signs.

Patient acuity

Indication of the amount and complexity of care required for any particular patient; high acuity indicates a need for more intense, complex nursing care as compared with lower acuity, which indicates a need for moderate, less complex nursing care.

Coordinator of the Interprofessional Health Care Team

Interprofessional teams consist of collaborative practice relationships among several disciplines of health care professionals. These disciplines may include nursing, medicine, pharmacy, nutrition, social work, case management, and other allied health professionals, such as physical therapists, respiratory therapists, occupational therapists, and speech therapists. Chaplains or pastoral care representatives also serve a valuable role on the interprofessional health care team. These teams are found in all health care delivery settings and function most effectively when their focus revolves around the needs of the client. Interprofessional teams are valuable because professional members bring in-depth and specialized knowledge and skills to the interaction process. In an age of exploding information, the roles of interprofessional team members complement one another. Through the formal and informal communication of ideas and opinions of team members, health care plans are determined. A plan of care developed by the interprofessional team is considered a valuable health management tool.

Patient classification system

Method used to group or categorize patients according to specific criteria and care requirements and thus help quantify the amount and level of nursing care needed.

Modular Nursing

Modular nursing is a modification of team nursing and focuses on a smaller team assigned to a geographic location in the nursing unit. The nursing unit is divided into modules or districts, and the same team of caregivers is assigned consistently to the same geographic location. The concept of modular nursing calls for a smaller group of staff providing care for a smaller group of patients. The goal is to increase the involvement of the RN in planning and coordinating care. To maximize efficiency, each designated module should contain all the supplies needed by the staff to perform patient care.

School Nurse

Most registered professional nurses employed in school health are generalists prepared at the baccalaureate level who function as consultants or coordinators. The newer role for school nurses is school health manager or coordinator and includes functions, such as policymaking, case management and program management activities, and health promotion and protection activities. The National Association of School Nurses defines the role as "a specialized practice of professional nursing that advances the well-being, academic success, and life-long achievement of students. To that end, school nurses facilitate positive student responses to normal development; promote health and safety; intervene with actual and potential health problems; provide case management services; and actively collaborate with others to build student and family capacity for adaptation, self-management, self-advocacy, and learning" (NASN, 2009; see Box 26-3).

Educator and Counselor

Multiple factors increase the need for nurses to serve as educators. Today the emphasis is on health promotion and health maintenance, in addition to management of disease conditions. The role of nurse counselor has been elevated to new heights. More than ever, nurses encourage clients to look at alternatives, recognize their choices, and develop a sense of control in a rapidly changing health care environment.

Clinical Nurse Specialist (CNS)

NSs are educated in graduate nursing programs. Their expertise is acquired from combining graduate study with clinical experience. The educational program for CNSs features an intense study of nursing theories and knowledge from other disciplines. Programs emphasize advanced scientific concepts, research methodologies, and supervised clinical practice. With the advent of the CNL (Clinical nurse leaderCertified Registered Nurse Anesthetist (CRNA)), there has been some confusion with the role of the CNS. However, the AACN (2006) supports both the CNL and the CNS as distinct and complementary roles with their differences summarized as follows: ♦CNLs are educated as generalists, whereas CNSs are prepared for specialty practice. ♦CNLs operate primarily on the clinical level involving small, frontline nursing units; CNSs are engaged at the clinical frontline level and organizational systems levels. ♦CNLs coordinate and implement client care; CNSs design and evaluate patient-specific and population-based programs. ♦CNLs evaluate and implement evidence-based practice; CNSs have the added responsibility of generating new evidence.

NURSING CARE DELIVERY MODELS

Nursing care delivery models, also called care delivery systems or patient care delivery models, detail the way task assignments, responsibility, and authority are structured to accomplish patient care. The nursing care delivery model describes which health care worker is going to perform 429430 what tasks, who is responsible, and who has the authority to make decisions. The basic premise of nursing care delivery models is that the number and type of caregivers are closely matched to patient care needs to provide safe, quality care in the most cost-effective manner possible.

Definition of Case Management

Nursing case management is defined as a "dynamic and systematic collaborative approach to provide and coordinate health care services to a defined population. Nurse case managers actively participate with their clients to identify and facilitate options and services, providing and coordinating comprehensive care to meet patient-client health needs, with the goal of decreasing fragmentation and duplication of care, and enhancing quality cost-effective clinical outcomes. Nurse case managers continually evaluate each individual's health plan and specific challenges and then seek to overcome obstacles that affect outcomes" (American Nurses Credentialing Center). The framework for nursing case management includes five components: assessment, planning, implementation, evaluation, and interaction.

Occupational Health Opportunities

Nursing within the framework of specific occupational groups (e.g., automobile manufacturing, textile plants, etc.) has long been a career option for nurses. Within these settings the nurse designs and implements a program of health promotion and disease prevention for employees and assists with immediate health needs as necessary. In this primary care milieu, the nurse assesses the need for programs about specific topics of importance to the health of the employees. Some examples of these might be breast-screening programs for female employees and information on early identification of prostate cancer for male employees. Other programs might revolve around the management of developmental events, such as empty nest syndrome, menopause, care for aging parents, or retirement.In addition to services related to maintaining the health of employees, the occupational nurse is responsible for the assessment of the work environment to ensure the safety of the employees.

Patient Classification Systems

Patient classification systems group or categorize patients according to specific criteria and care needs and thus help quantify the amount and level of care needed. This may be referred to as the acuity level. The higher the acuity level, the more intense the patient's nursing care needs.

Customer Satisfaction

Perhaps most critical to an organization's success in a competitive health care environment is customer (patient) satisfaction. The key to customer satisfaction is the patient's personal interaction with the organization's employees. According to Kenagy and associates (1999), "Interactions with patients and their families have remarkably strong effects on clinical outcomes, functional status and even physiologic measures of health". Appropriate staffing within budget constraints with well-trained, competent, professional staff members who are committed to providing safe, high-quality care is the nurse manager's number-one challenge.

Nursing Educator

Preparation for nurse educators occurs at the graduate level. Nursing educators should be competent in clinical practice either at the advanced generalist or specialist level (Southern Region Education Board, 2002). They should be prepared in the specialty area in which they teach and match the needs of the institution that hires them. Nursing educators assume leadership in curriculum development, instruction, and evaluation. Knowledge of the learning process and classroom and clinical teaching methods that include engagement and "virtual teaching" is essential. The role of faculty or nursing educator can be very rewarding for those nurses who enjoy lifelong learning and mentoring. Individuals who assume these roles usually are expected to have not only teaching responsibilities, but evidence of scholarship and service to the community.

Client Advocate

Professional nurses find that the role of client advocate is essential in various situations with a multitude of client populations. Promoting what is best for the client, ensuring that the client's needs are met, and protecting the client's rights remain important responsibilities of the professional nurse.

Clinical practice guidelines

Recommendations for appropriate treatment and care for specific clinical circumstances; guidelines are developed though a systematic process to integrate the best evidence for treating specific medical conditions and assist health care providers to make decisions about appropriate treatment (Institute of Medicine [IOM], 1990).

Coordinator Positions

Some hospitals have various coordinator positions, such as trauma nurse coordinator. The nurse in this position is responsible for the coordination and integration of the clinical and administrative requirements of the trauma victim. Consisting of equal parts of program and case management, the trauma nurse coordinator role involves overseeing the care of the client from the point of injury through acute care to rehabilitation and back to society. Maintenance of a comprehensive database on the management of trauma victims is an important part of this position. Another example of a coordinator position for a highly specialized area is the organ donor coordinator, who procures organs and oversees the transplantation program. Coordinators require considerable experience in the specialty in which they practice.

TELEHEALTH NURSING

The American Academy of Ambulatory Care Nursing (AAACN) defines the practice of telehealth nursing as "using the nursing process to provide nursing care and access to health care for individual patients or patient populations over the telephone" Nurses' roles in telehealth nursing include triage, interventions, consultation, surveillance, and follow-up. Challenges for telehealth nursing include multistate licensure that opens doors for nurses to provide care for clients across state lines, regulation of telehealth for nursing and medicine, legal issues, and Medicare reimbursement.

Clinical Nurse Leader (CNL)

The CNL is a master's degree-prepared generalist who oversees the care coordination of a distinct group of patients in any setting. The CNL actively provides direct patient care in complex situations, evaluates patient outcomes, and has the decision-making authority to change care plans when necessary. This clinician puts evidence-based practice into action to ensure that patients benefit from the latest innovations in care delivery and is envisioned as a frontline leader in the health care delivery system.

Clinical nurse leader (CNL)

The CNL is a master's degree-prepared generalist who oversees the care coordination of a distinct group of patients in any setting. The CNL actively provides direct patient care in complex situations, evaluates patient outcomes, and has the decision-making authority to change care plans when necessary. This clinician puts evidence-based practice into action to ensure that patients benefit from the latest innovations in care delivery and is envisioned as a leader in the health care delivery system.

Doctor of nursing practice (DNP)

The DNP is an expert in advanced nursing practice who has an earned clinically focused doctorate degree in nursing.

Doctor of Nursing Practice (DNP)

The DNP is an expert in advanced nursing practice who has an earned clinically focused doctorate degree in nursing. DNPs include advanced practice nurses, such as CRNAs, NPs, CNSs, and CNMs, in addition to nurse administrators whose expertise is in advanced systems of care. This is a professional doctorate as opposed to the academic doctorate, which is the doctor of philosophy (PhD) that prepares individuals for a research career.

Patient-Centered Care

The IOM (2001) defines patient-centered care as "providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions" (p. 40). Delivering patient-centered care means that nurses, physicians, and other health professionals partner with patients and families to ensure that health care decisions respect patients' wants, needs, and preferences and patients have the education and support they need to make decisions and participate in their own care

Certified Registered Nurse Anesthetist (CRNA)

The educational preparation of CRNAs occurs at the graduate level or in association with traditional institutions of higher education, most commonly in schools of nursing or health sciences. The educational curriculum in the anesthesia specialty ranges from 24 to 36 months in an integrated program of academic and clinical study. The academic curriculum consists of a minimum of 30 credit-hours of formalized graduate study in courses such as advanced anatomy, physiology, pathophysiology, advanced pharmacology, principles of anesthesia practice, and research methodology and statistical analysis. All programs require approximately 1000 hours of hands-on clinical experience. Students gain experience with clients of all ages who require medical, obstetric, dental, and pediatric interventions. Admission requirements to a nurse anesthesia educational program include a bachelor of science degree in nursing, licensure as an RN, and a minimum of 1 year of acute care nursing experience. Nurse anesthetists are required to successfully complete a written examination for certification as a CRNA.Recertification, which includes practice and continuing education requirements, must be met every 2 years. CRNAs are qualified to make independent judgments relative to all aspects of anesthesia care based on their education, licensure, and certification. CRNAs provide anesthesia and anesthesia-related care on request, assignment, or referral by a client's physician, most often to facilitate diagnostic, therapeutic, or surgical procedures. In other instances, CRNAs perform consultation or assistance for management of pain associated with obstetric labor and delivery, management of acute or chronic ventilatory problems, or management of acute or chronic pain through the performance of selected diagnostic or therapeutic blocks.

Infection Control

The infection control nurse assesses the total incidence of infections within the hospital. Clients who suffer an infection while in the hospital are comprehensively reviewed to ensure prompt and accurate treatment and timely containment of the client's infection so that it is not passed to other clients or staff. The infection control nurse must also conduct a thorough analysis to determine the source of the infection and its onset. If the infection is determined to have been contracted during hospitalization, an investigation is initiated to assess the sequence of events leading up to the infection, and an action plan is developed to prevent future occurrences. A position such as this enables the nurse to have hospital-wide interactions and functioning. Knowledge of epidemiology and outstanding interpersonal skills foster full participation in the infection assessment process. Infection control nurses may work in community settings and hospitals.

Leader and Manager

The leadership role of the professional nurse is paramount to the health care system. Nursing leadership varies according to the level of application and includes: ♦Improving the health status and potential of individuals or families ♦Ensuring that safe, high-quality care is provided across all health care settings ♦Increasing the effectiveness and level of satisfaction among professional colleagues providing care ♦Managing multiple resources in a health care facility ♦Raising citizens' and legislators' attitudes toward and expectations of the nursing profession and the health care system There is little doubt that the management role of the nurse has become more important. Nursing management includes planning, giving direction, and monitoring and evaluating nursing care of individuals, groups, families, and communities.

Financial Resources

The nurse manager is accountable for appropriately managing staffing to stay within budgetary guidelines for the following: ♦Numbers of staff working at any given time to provide care to a given number of patients ♦Staff mix, the combination of types of workers present to provide patient care (e.g., RNs, LVNs or LPNs, nursing assistants, multiskilled workers, or NAP)

Level of Staff Preparation and Experience

The nurse who is responsible for making staffing decisions must be aware of each individual staff member's educational level, competencies, experience, skill, and training. Ideally, clinical support from experienced RNs should be available to support and advance the skills of those RNs and other staff members with less experience. Unfortunately, this is not always possible in times of nursing shortages. If the nurse manager does not believe that adequate numbers of appropriately skilled and experienced staff members are available to provide safe patient care, the nurse should immediately address those concerns with his or her supervisor.

Total Patient Care

The oldest method of organizing patient care is total patient care, sometimes referred to as case nursing. In total patient care, nurses are responsible for planning, organizing, and performing all care, including personal hygiene, medications, treatments, emotional support, and education required for their assigned group of patients during the assigned shift. Advantages of the total patient care model are: ♦The patient receives holistic, unfragmented care by only one nurse per shift. ♦At shift change, the RN who has provided care and the RN assuming care can easily communicate about the patient's condition and collaborate about the plan of care to ensure continuity because so few caregivers are involved. ♦The nurse maintains a high degree of practice autonomy. ♦Lines of responsibility and accountability are clear. Disadvantages of the total patient care model are: ♦The number of RNs required to provide total patient care may simply not be available because of the nursing shortage or financial constraints. ♦The RN performs many tasks that could be performed by a caregiver with less training at a lower cost. Today the total patient care method is commonly used in the hospital's critical care areas, such as intensive care units and postanesthesia care units, where continuous assessment and a high degree of clinical expertise are required at all times.

Partnership Model

The partnership model, sometimes referred to as coprimary nursing, is a modification of primary nursing. This model was designed to make more efficient use of the RN, who delegates nonprofessional tasks to the partner, thus providing more time for the RN to address professional demands, such as assessment and patient education (Lookinland, Tiedman, and Crosson, 2005). In the partnership model, the RN is partnered with an LVN, LPN, or NAP, and the pair work together consistently to care for an assigned group of patients.

Staffing and Patient Needs

The primary considerations for staffing a specific nursing unit are the number of patients; the level of intensity of care required by those patients (commonly referred to as patient acuity); contextual issues, such as architecture, geography of the environment, and available technology; and the level of preparation and experience of the staff members providing the care. To account for the diverse care needs and quantify the intensity of care required by a group of patients, nurse managers responsible for staffing use various patient classification systems.

Care Provider

The role of care provider is basic to the nursing profession. As the provider of care the nurse assesses client resources, strengths and weaknesses, coping behaviors, and the environment to optimize the problem-solving and self-care abilities of the client and family. The nurse plans therapeutic interventions in collaboration with the client, physician, and other health care providers. In addition, the nurse takes responsibility for coordination of care that involves other health professionals or resources, providing continuity and helping the client deal effectively with the health care system. As part of this role, caring is always central to nursing interventions and is an essential attribute of the expert nurse.

Parish Nurse

The role of parish nurse has become a recognized specialty in a growing professional practice. In 1998 the ANA, in collaboration with the Health Ministries Association, established the scope and standards of this professional practice. This role focuses on health promotion within the beliefs, values, and practices of various faith communities. In these contexts, health is seen as a sense of physical, psychologic, social, and spiritual well-being. Health is further viewed as being in harmony with self, others, the environment, and God. The parish nurse functions as counselor, teacher, referral agent, volunteer coordinator, and integrator of spiritual care and health. Although all communities do not have a hospital or clinic, most have a faith community, providing an exciting setting in which to teach disease prevention and health promotion.

Staffing and Organizational Needs

The three basic organizational needs that are significantly affected by staffing are: (1) financial resources, (2) licensing regulations and The Joint Commission (TJC) standards, and (3) customer satisfaction.

Quality Manager

This reflects the need for health care providers to assess opportunities for process improvement, implement changes, measure outcomes, and then start the improvement process over again. Quality management nurses research and describe findings and look for opportunities to improve care. The result of quality assessment studies may produce critical pathways or algorithms defining care and expected client outcomes. Basic and advanced knowledge of quality management tools is essential, although practice may vary from setting to setting. For instance in the inpatient setting, the quality management nurse needs strong clinical skills, such as those that might be acquired in medical-surgical practice, intensive care units, or the operating room. The role of quality manager is one that promotes improved care for health care recipients in a variety of settings. For more information, visit the quality management websites listed in Box 26-3 and see Chapter 20.

Case Manager

This role has had a rich tradition in community and public health nursing and now has gained more prominence in acute care. Case managers coordinate resources to achieve health care outcomes based on quality, access, and cost. The complexity of case management practice is obvious in the era of chaotic systems caused by recent changes in the health care market, in which providers, services, and coverage details are constantly changing. Case managers identify the best resources at the lowest cost to achieve the optimal health outcome for the client. Case managers are often nurses, but can also be other professionals, such as medical social workers.

Multiskilled worker

Unlicensed caregiver trained to perform multiple tasks, such as phlebotomy, vital signs, housekeeping, and assisting patients with hygiene and ambulation.

Nursing assistive personnel (NAP)

Unlicensed individuals who are trained to function in an assistive role to the RN by performing patient care activities as delegated by the nurse (American Nurses Association [ANA], 2005).

Change Agent

When nurses first adopted the role of "change agent," few individuals anticipated to what extent nurses would fulfill this role. However, nurses have expanded their role as change agents in many ways. The profession continues to identify client, patient safety, and health care delivery problems; to assess individual and organizational motivation and capacity for change; to determine alternatives; to explore possible outcomes of the alternatives; and to assess cost-effective resources in infinite health-related situations.

STAFFING

While appreciating the overall value of the RN in providing patient care, several specific considerations regarding staffing are reviewed related to (1) patient needs, (2) staff satisfaction, and (3) organizational needs

Quality Management

the basic premise is to ensure that outcomes in client care services are consistent with established standards. Benchmarking activities to establish such standards have been under way on a national level for the past few decades. Quality management nurses assess the compliance of the agency or institution with established standards and explore variations from these established standards. Chart reviews and ongoing interaction with the staff of the agency are integral components of a quality management position. Chapter 20 provides a more in-depth overview of the quality management process.

ANA (2009b) has recommended that the following physical and psychosocial factors be considered when determining the intensity of care required for any group of patients:

♦Age and functional ability ♦Communication skills ♦Cultural and linguistic diversities ♦Severity and urgency of the admitting condition ♦Scheduled procedures ♦Ability to meet health care requisites ♦Availability of social supports ♦Other specific needs identified by the patient and by the RN

Disadvantages of the functional nursing model are:

♦Care may be fragmented, and the possibility of overlooking priority patient needs exists because several different workers focus only on performing specific patient care tasks. ♦The patient may feel confused because of the many different individuals providing different aspects of care. ♦Caregivers may feel unchallenged and unmotivated when performing repetitive functions. Although the functional nursing model is considered efficient and economical, the patient is treated by many caregivers who are not able to give personalized care because they are focused on performing a task, not on meeting patient needs. This model may not fit well in the new health care system, which focuses on customer service. However, functional nursing care delivery is still appropriate in some care settings and may be used in the operating room.

Disadvantages of the team nursing model are:

♦Continuity of care may suffer if the daily team assignments vary and the patient is confronted with many different caregivers. ♦The team leader may not have the leadership skills required to effectively direct the team and create a "team spirit." ♦Insufficient time for care planning and communication may lead to unclear goals. Therefore, responsibilities and care may become fragmented. In an attempt to overcome some of its disadvantages, the team nursing design has been modified many times since its original inception, and variations of the model are evident in other methods of nursing care delivery, such as modular nursing.

Advantages of the primary nursing model are

♦Direct patient care provided by a few nurses allows for a one-to-one relationship to be established between nurse and patient. ♦Nurses are able to practice with a high degree of autonomy and feel challenged and rewarded.

Advantages of the team nursing model are:

♦High-quality comprehensive care can be provided with a relatively high proportion of ancillary staff. ♦Each member of the team is able to participate in decision making and problem solving. ♦Each team member is able to contribute his or her own special expertise or skills in caring for patients.

Disadvantages of the primary nursing model are

♦Implementation may be difficult because the primary nurse is required to practice with a high degree of responsibility and autonomy. ♦An inadequately prepared primary nurse may not be able to make the necessary clinical decisions or communicate effectively with the health care team. ♦The RN may not be willing to accept the 24-hour responsibility required in primary nursing. ♦The number of nurses required for this method of care may be difficult to recruit and train. The primary care nursing model lends itself well to home health nursing, hospice nursing, and long-term care settings in which the patient requires nursing care for an extended period.

In every care setting a nurse manager must carefully evaluate the nursing care delivery model to ensure safe, efficient, and effective patient care. When evaluating nursing care delivery models, the following questions should be asked:

♦Is patient safety ensured while achieving optimal patient outcomes in a timely, cost-effective manner? ♦Are patients and families happy with the care they are receiving? ♦Are nurses, physicians, and other health team members satisfied with the safety and quality of care they are able to provide? ♦Does the system allow for implementation of the nursing process in a timely and efficient manner? ♦Does the system facilitate communication among all members of the health care team?

Advantages of the functional nursing model are:

♦Patient care is provided in an economic and efficient manner because less-skilled, lower-cost workers are used in areas where task completion is the focus. ♦A minimum number of RNs is required to supervise and to perform strictly nursing duties. ♦Tasks are completed quickly, and there is little confusion about job responsibilities.

Clinical Pathway Terminology

♦Patient outcomes are the end result of intervention by the health care team. ♦Interprofessional intervention is the collaborative effort by all disciplines (e.g., nursing, physician, dietitian, physical therapy, occupational therapy, pharmacy), along with the patient and the family, to help the patient reach the desired health outcomes. ♦Variance is any event that may alter the patient's progress through the clinical pathway. ♦Triggers alert the caregiver that an unexpected event has occurred and identify potential and actual variations in the patient's response to the planned intervention (Birdsall and Sperry, 1997).

Following are some practical methods for ensuring that patients and families are actively engaged as partners and decision makers in their health care:

♦Patients, families and significant others are included in developing care plans and discharge plans. ♦Patients, families, and significant others are included in change of shift or other hand-off reports. ♦Patients, families, and significant others are provided with the information and education they need to make informed decisions. ♦"Family advisory councils" are established to engage patients and families in decision making (Ponte et al, 2003)

Without a doubt, the ways in which nursing care is delivered over the next 20 years will change dramatically as a result of the following factors:

♦Rapid technologic advances in medical care with less invasive procedures for disease treatments ♦Fast-paced patient turnover in acute care settings; the rapid discharge and admission cycle is now referred to as "churning" and is estimated to range from 25% to 70% on a typical medical-surgical unit (Spader, 2008) ♦Evidence of the RN's value in promoting patient safety and quality of care ♦Ongoing shortages of nurses and other health professionals ♦Strong focus on safety and outcomes of care ♦Consumers' demands for instant access to care and information ♦Need to engage people to focus on the underlying determinants of their individual health that are affected by lifestyle and personal choice

Disadvantages of the partnership model are:

♦The RN may have difficulty delegating to the partner. ♦Consistent partnerships are difficult to maintain based on varied staff schedules.

Advantages of the partnership model are:

♦The model is more cost-effective than the true primary care nursing system because fewer RNs are needed. ♦The RN can encourage the training and growth of his or her partner. ♦The RN can perform the nursing duties and the partner can perform the nonnursing tasks.

The AAACN has defined the following criteria for telehealth nursing practice

♦Using protocols, algorithms, or guidelines to systematically assess and address patient needs ♦Prioritizing the urgency of patient needs ♦Developing a collaborative plan of care with the patient and his or her support systems, which may include wellness promotion, prevention education, care counseling, disease state management, and care coordination ♦Evaluating outcomes of practice and care