NCM 119A Nursing Leadership and Management

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Chapter II
PATIENT CARE DELIVERY SYSTEM
A Nursing Care Delivery System defines the way we use our nursing values to
care for our patients, families, colleagues, and selves.

The care delivery system is actually a subsystem of the professional practice model
that describes our approach to delivering patient care by:
 Detailing assignments, responsibilities and authority to accomplish patient care;
 Determining who is going to perform what tasks, who is responsible, and who
makes decisions; and
 Matching number and type of caregivers to patient care needs.
Learning Outcome:
After the discussions, the learners must have:
 Knowledge on Nursing Process in the delivery of care services
 Information of patients classification system,
 Knows the different health care modalities.

A. Nursing Process in the Delivery of Nursing Care Services

The nursing process provides that individual-centered care is given in
accordance to a plan and that time is used in a more effective way while promoting
communication between team members and increasing the quality of nursing care
by providing written resources and evidence for nursing education and research.
The nursing process, like nursing models, was not without its critics.
Increasingly, it was questioned whether the proposed linear problem-solving
approach to care delivery was a valid reflection of the nature of clinical decision-
making, particularly for experienced nurses (Walsh, 1998).
The arrival of nursing models and the nursing process in the UK can be seen
from around the mid 1970s with the publication of influential texts on the nursing
process and models (MacFarlane and Castledine, 1982; Aggleton and Chalmers,
1986). The introduction in the 1970s of the idea of the nursing process as a four
stage problem solving method to enhance the delivery of care to the individual was
an important vehicle in the application of nursing models to clinical practice
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(Aggleton and Chalmers, 1986). The values, beliefs and theories for care within a
given model of nursing could be used to guide the assessment, planning,
implementation and evaluation of nursing care.

B. Patient Classification System

The Patient Classification System (PCS), also known as patient acuity system,
is a tool used for managing and planning the allocation of nursing staff in accordance
with the nursing care needs. Is used to assist nurse leaders determine workload
requirements and staffing needs.
Originally used to determine the workload of the nursing team and, thus,
support staff allocation and the calculation of staffing requirements, the range of
applications of PCS’s gradually expanded during the following decades, marked by
the proliferation of innovative systems, mainly in United States and Canada.

Why utilize Patient Classification tools?

The utilization of PC tools enables the construction of a database favoring decision
making and supplying information to healthcare managers on the:

 Characterisation of the institution’s customer care profile such as minimum care,

intermediate care, etc;
 Identification of the amount of nursing care provided thereby allowing planning
of care and of patient discharge;
 Nursing workload and hence support staff allocation and nursing staff
requirements; measurement of the workload, i.e. the amount of nursing care
provided, constitutes the basis on which staffing needs and nursing costs are
calculated. The main purpose of classification tools is to achieve optimal
resource utilization in relation to patient care needs.
 Productivity and hence nursing service costs.

Additionally, other benefits of using PC tools may be identified, such as

assisting in providing quality nursing care by the individualisation of patient care
needs, thus backing arguments in the process of negotiation and supporting
managerial decisions regarding service organisation.
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Below are the three most common kinds of PCS used are:
1. Descriptive - this is a purely subjective system wherein the nurse selects which
category the patient is best suited.
2. Checklist - a subjective system, wherein the patient is assigned to a numerical
value based on the level of activity in specific categories. The numerical value is
added up to give the nurse an overall rating.
3. Time Standards - this is another method where the nurse assigns a time value
based on the various activities needed to be completed for the patient. This time
value is sum up and converted to an acuity level.
Among these three, the most commonly used is descriptive kind of Patient
Classification System and are subdivided into four classifications, namely:
A. Self-care / Minimal Care - the first classification of patients who are recovering
and normally requires only diagnostic studies, minimal therapy, less frequent
observations, and daily care for minor conditions and are awaiting elective surgery.
B. Moderate Care - the patient int this category is moderately ill or under the
recovery from a serious illness or operation. They require nursing supervision or
assistance that is related to ambulating and caring for their own hygiene.
C. Maximum Care - patient needs close attention and complete care all through the
shift. The nurses initiate, supervise and perform most of the patient’s activities.
D. Intensive Care - this category, wherein the patients are acutely ill and high level of
nurse dependency is required. Intensive therapy care or intensive nursing care is
needed because of the unstable condition of the patient. Patients in these levels
include those in critical conditions or in life and death situations that needs frequent
evaluations, observations, monitoring and adjustment of therapy is required.

* But whatever PCS is used, this will be applied to forecast staffing needs within each
department. Nurses should be informed of the patient care ratios that are relevant
to each department and should understand how to predict the staffing needs.
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C. Modalities of Care

First- and middle- level managers generally have their greatest influence on
the organizing phase of the management process at the unit or department level. It
is here that managers organize how work is to be done, shape the organizational
climate, and determine how patient care delivery is organized.
This lesson introduces nursing care delivery models used in healthcare
agencies to organize care. The historical development and structure of the case
method; functional nursing; team nursing; primary nursing, including hybrid forms of
this approach; and nursing case management are presented. The discussion
summarizes the benefits and disadvantages of each model with an explanation of
the nurse manager’s and staff nurse’s role.
Each nursing care delivery model has advantages and disadvantages, and
none is ideal. Some methods are conducive to large institutions, whereas other
systems may work better in smaller community settings. Managers in any
organization must examine the organizational goals, the unit objectives, patient
population, staff availability, and the budget when selecting a care delivery model.
This historical overview of the common care models is designed to convey the
complexity of how care is delivered. This perspective is important because each of
these approaches is still used within the broad range of healthcare organizations. In
addition, these models often serve as the foundation for new innovative care
delivery models.
Learning Objectives :
After the discussions, the learners will be able:
 Differentiate the characteristics of nursing care delivery models used in health
care.
 Determine the role of the nurse manager and the staff nurse in each model.
 Summarized the differentiated nursing practice model and related methods to
determine competencies of nurses who deliver care.

A. Modalities of Delivering Care

1. Case Method (Total Patient Care)
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The case method, or total patient care method, of nursing care delivery is the
oldest method of providing care to a patient. This model should not be confused
with nursing case management, which is introduced later in the chapter.

The premise of the case method is that one nurse provides total care for one
patient during the entire work period. This method was used in the era of Florence
Nightingale when patients received total care in the home. Today, total patient care
is used in critical care settings where one nurse provides total care to one or two
critically ill patients. Nurse educators often select this method of care when students
are caring for patients. Variations of the case method exist, and it is possible to
identify similarities after reviewing other methods of patient care delivery described
later in this chapter.

Figure 1: Case Method of Patient care for an 8-hour shift.

In today’s costly healthcare economy, total patient care provided by a
registered nurse (RN) is very expensive. Is it realistic to use the highly skilled and
extremely knowledgeable professional nurse to provide all the care required in a unit
that may have 20 to 30 patients? Who oversees the care coordination in a 24-hour
period (Tiedeman & Lookinland, 2004)? In times of nursing shortages, there may not
be enough resources or nurses to use this model.
2. Primary Nursing
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Primary nursing, also known as relationship-based nursing, developed in the
early 1970’2, uses some of the concepts of total patient care, and brings the RN back
to the bedside to provide clinical care. This is one type of patient care delivery that
requires a one-to-one relationship between and RN and a patient, with responsibility
for planning and managing care clearly established.
 As originally designed, primary nursing requires a nursing staff made up only of
RNs. The RN primary nurse assumes 24-hour responsibility for planning the care
of one more patients from admission or the start of treatment to discharge or
the treatment’s end. During work hours, the primary nurse provides total direct
care of the patient.
When the primary nurse is not on duty, associate nurses, who follow the care
plan established by the primary nurse, provide care. Although designed for use in
hospitals, this structure lends itself well to home health nursing, hospice nursing,
and other health care delivery enterprises. An integral responsibility of a primary
nurse is to establish clear communication among the patient, the physician, the
associate nurses, and other team members.

Figure: Primary Nursing Model.

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Figure 2 : Advantages and Disadvantages of Primary Nursing.

Disadvantages : as in team nursing, lie primarily in improper implementations. An

inadequately prepared or incompetent primary nurse may be incapable of
coordinating a multidisciplinary team or identifying complex patient needs and
condition changes. Many nurses may be uncomfortable in this role or initially lack
the experience and skills necessary for the role.
3. Team Nursing
- was developed in the 1950s in an effort to decrease the problems
associated with the functional organization of patient care.
- Team nursing was developed because of social and technological changes
in World War II drew many nurses away from hospitals, learning haps, services,
procedures and equipment became more expensive and complicated, requiring
specialization at every turn. It is an attempt to meet increased demands of nursing
services and better use of knowledge and skills of professional nurses.
- believed that despite a continued shortage of professional nursing staff, a
patient care system had to be developed that reduced the fragmented care that
accompanied functional nursing.
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Figure 4. Structure of the Team Nursing.

In team nursing, ancillary personnel collaborate in providing care to a group
of patients under the direction of a professional nurse. As the team leader, the nurse
is responsible for knowing the condition and needs of all the patients assigned to the
team and for planning individual care.
The team leader’s duties vary depending on the patient’s needs and the
workload. These duties may include assisting team members, giving direct personal
care to patients, teaching and coordinating patient activities. ,
The team leader should be an experienced critical care nurse with clinical and
organizational knowledge. This person must be a critical thinker not only about
patient care, but also about patient assignments. Excellent interpersonal skills are a
must for effective delegation and conflict management.
Through extensive team communication, comprehensive care can be
provided for patients despite a relatively high proportion of ancillary staff. This
communication occurs informally between the team leader and the individual team
members and formally through regular team planning conferences. A team should
consist of not more than five people, or it will revert to more functional lines of
organization.
Team nursing usually associated with democratic leadership. Group members
are given as much autonomy as possible when performing assigned tasks, although
the team shares responsibility and accountability collectively.
Team nursing allows members to contribute their own special expertise or
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skills. Team leaders, then, should use their knowledge about each member’s abilities
when making patient assignments.
Disadvantages : are associated primarily with improper implementation
rather than with the philosophy itself. Frequently, insufficient time is allowed for
team care planning and communication. This can lead to blurred lines of
responsibility, errors, and fragmented patient care. For team nursing to be effective,
the leader must be an excellent practitioner and have a good communication,
organizational, management, and leadership skills.

4. Modular Nursing
Mini-team (two or three members) approach. Members of the modular
nursing team are sometimes called care pairs. Keeping the team small and
attempting to assign personnel to the same team as often as possible should allow
the professional nurse more time for planning and coordinating team members.
Additionally, a small team requires less communication members better use of their
time for direct patient care activities.
Modular nursing is a modification of team nursing and focuses on the
patient's geographic location for staff assignments. The patient unit is divided into
modules or districts, and the same team of caregivers is assigned consistently to the
same geographic location.
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Figure 4: Modular Nursing Model

The modular nursing model has the potential to provide advantages for both
patients and nursing staff and may be a particularly good fit for value-based care.

 Geographic proximity and a smaller team can make for more efficient
communication between team members and between team members and patients
and families—this might be especially noticeable on larger units.
 The model allows for RNs to be more involved in the planning and
coordination of patient care, which can result in better continuity of care and make
transitions of care more seamless. Continuity of patient care is improved as the
team of caregivers grows more familiar with their patients and their unit.
 Modular nursing models also make it easier to assign teams based on
patient acuity, and the skills and or experience of the providers can more easily be
matched to patient care needs.
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 The smaller, more focused patient care teams can result in higher levels of
accountability for individual team members—an important element of team
member job satisfaction.

Modular Nursing – Managing Weaknesses

While advantages appear to outweigh disadvantages, there can be some challenges as
well:

 Modular nursing requires a high level of nursing leadership. Education,

particularly around the specifics of the model and in nursing leadership and
management skills, can help support nurses in this model.
 Modular nursing can be difficult to execute with inconsistent team
members. The model depends on assigning a consistent group of caregivers to a
specific set of patients within a specific area of a nursing unit. High levels of staff
turnover or a high percentage of travelers might make this difficult to implement.
Fortunately, higher levels of staff satisfaction with the model may make it easier to
attract and retain a consistent staff.
 It may complicate staff assignments. Creating a team that has all of the
competencies needed for patients on their module can be a challenge –
particularly on units where acuity is high. The educational needs of team members
may be easier to identify when using this model which may make it easier for nurse
leaders to assign the most relevant and necessary education as it is needed.

5. Functional Nursing

The functional method of delivering nursing care evolved as a result of World

War II. Because nurses were in great demand overseas and at home, a nursing
shortage developed and ancillary personnel were needed to assist in patient care.
These relatively unskilled workers were trained to do simple tasks and gained
proficiency by repetition. Personnel were assigned to complete certain tasks rather
than care for specific patients. Example : checking blood pressures, administering
medication, changing linens, and bathing patients.
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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. These tasks are in part determined by the scope of practice
defined for each type of caregiver. For example, the RN must be responsible for all
assessments, although the LPN/LVN and UAPs may collect data that can be used in
the assessment. Regarding treatments, an RN may administer all intravenous (IV)
medications and do admissions, one LPN/LVN may provide treatments, another
LPN/LVN may give all oral medications, one assistant may do all hygiene tasks, and
another assistant may take all vital signs (Figure 13-2). This division of aspects of care
is similar to the assembly line system used by manufacturing industries. Just as an
auto worker becomes an expert in attaching fenders to a new vehicle, the staff nurse
becomes expert in the tasks expected in functional nursing. A charge
nurse coordinates care and assignments and may ultimately be the only person
familiar with all the needs of any individual patient.
RNs became managers of f care rather than direct care providers, and “care
through others” became the phrase used to refer to this method of nursing care.
Most hospitals continue to use CNAs in functional roles, such ass bathing and bed
making (Weitzel, Robinson, Henderson, & Anderson, 2004).

Figure 5: Functional Nursing structure.

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This form of organizing patient care was thought to be temporary, as it was

assumed that when the war ended, hospitals would not need ancillary workers.
However, the baby boom and resulting population growth immediately following
World War II left the country short of nurses. Thus, employment of personnel with
various levels off skill and education proliferated as new categories of health care
workers were created. Currently, most health care organizations have continued this
practice of employing health care workers of many educational backgrounds and skill
levels.

Figure 5.1: Advantages and Disadvantages of Functional Nursing.

6. Nursing Case Management
Case Management is the latest work design proposed to meet patient needs.
There is much confusion regarding the term because it has had several different
meanings since it first came into use. The ANA (1991, p. 191) defines case
management as “. . . a healthcare delivery process whose goals are to provide
healthcare, decrease fragmentation, enhance the client’s quality of life and contain
costs”.
Case management nurses are registered nurses who coordinate all aspects of
the care of individual patients. They ensure proper utilization of services and
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resources as well. Case managers provide assistance within, between, and outside of
facilities. Nurses working in case management facilitate outstanding patient care
using fiscally responsible strategies. They are experts at obtaining resources. Case
managers work with patients, families and other professionals. Case managers need
to be savvy communicators, well organized, and creative.
Case management nurses provide care in hospitals and in communities. Many
work closely with social workers, obtaining services for people who need long term
care or home care after hospitalization.
Case management is a collaborative process. They work closely with
physicians, nurses, social workers and a wide range of medical and non medical
professionals. Case managers work to meet complex patient needs. They make
provisions for current and future needs of patients. Case management nurses
promote quality care which encourages appropriate use of available resources.

Case managers ensure that ethical and legal issues are addressed. They also
ensure that patients receive medically appropriate services. They need to be experts
regarding public and private insurance reimbursement policies regarding
healthcare. Case managers review charts and meet with other health care
professionals to ensure that patients receive appropriate levels of care. They
facilitate admission and discharge processes.

Case managers work holistically, ensuring that care and discharge plans meet the
physical, social, and emotional needs of patients.

Lyon (1993) makes an effort to clarify and define case management, starting
it is not a nursing care delivery model such as team nursing and primary nursing care
or total patient care. Instead, case management is a role that was developed and
enlarged as a result of the managed care concept developed by HMOs.
Zander (1988) lists four essential components of case management: (1)
achievement of clinical outcomes within a prescribed time frame, (2) the caregiver
acting as the case manager, (3) episodic nurse-physician group practice that
transcends unity or departments, (4) active participation of the patient and family in
setting goals and evaluation. However, it differs from primary nursing in two ways.
First, although the case manager uses nursing process, the primary focus is on
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planning, coordinating, and evaluating care. There is less control of the patient care
and more collaboration (Zander, 1994). the case associates assigned to the care deal
more directly with assessment and intervention. Second, unlike primary nursing, in
case management it is recognized that not every patient needs a case manager
(Marquis & Huston, 1998).
Case management began in outpatient organizations and was an expansion
of the old total patient care system. However, community health nurses coordinated
many needs of their patient, not just nursing care, and frequently did not all of the
care personally but planned, evaluated, and coordinated the care.
According to the Commission for Case Manager Certification, case
management is defined as a “collaborative process that assesses, plans, implements,
coordinates, monitors, and evaluates the options and services required to meet a
client’s health and human service needs.” Basically, case management companies
focus on the client’s well being, wellness, and full functional capability.
When it comes to case management in workers’ compensation, case
management specialists not only coordinate with injured workers and employers but
also the clinicians who will evaluate the cause of the injured worker’s claim and
develop a treatment plan. The main goal of medical case management is to ensure
that the injured worker gets the right treatment at the right time so that the patient
can return to work either in a full or light duty capacity.

7. Innovative / Contemporary Method

There are new health care providers—midlevel practitioners (advance

practice nurses, certified nurse midwives, physician assistants, and medical
technologists)—and new modes of diagnosis such as genetic testing. Furthermore,
the rise of managed care, the explosion of biotechnology, and the availability of
information on the Internet have dramatically changed how health care is delivered.

Some health care industry observers suggest the speed at which these changes have
occurred has further harmed an already complicated and uncoordinated health care
system. There is concern that the present health care system cannot keep pace with
scientific and technological advances. Many worry that the health care system is
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already unable to deliver quality care to all Americans and that it is so disorganized
that it will be unable to meet the needs of the growing population of older
Americans or to respond to the threat of a pandemic or bioterrorism.

Widespread use of innovations in health care delivery should be

recommended only after objective analysis has demonstrated that the innovation
will measurably benefit the safety, effectiveness, efficiency, or timeliness of health
service delivery. Innovations should also be considered if they have the potential to
reduce waste of equipment, supplies, or personnel time or if they have the capacity
to allocate or distribute health care more equitably. Equitable distribution refers to
access to care that does not vary in quality based on the characteristics, such as race,
gender, ethnicity, or socioeconomic status, of the population served.

8. Emerging Trends
Rising costs, a higher proportion of elderly in the population, proliferation of
high technology and increased knowledge about efficient and effective service
provision have all led to increased cost-consciousness in the health system.
Historically, regulatory approaches have provided equity of access and funding, but
for controlling costs they have now become inappropriate because they leave the
mix of services untouched. In the future, regulatory approaches may make more use
of guidelines and algorithms for care (the “soft” regulatory route), or they may
directly control the supply of providers and other resources in the health system (the
“hard” regulatory route). An alternative is the competition approach which allows
choices by consumers on where to obtain health care based on the efficiency with
which those services are provided. The danger in this approach is the potential for
equity to be compromised; this may be addressed by combining the regulatory and
competitive approaches.
The healthcare industry needs to adapt to a growing, ageing population, an
increasing prevalence of chronic diseases, workforce shortages, and rising
expectations of patients and workers. Financial challenges plague both public and
private healthcare systems. To face these issues, healthcare providers are applying
“smart”, cloud-based solutions in various areas.
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A. Accuracy and effectiveness of treatment

Healthcare’s focus needs to shift from treatment to prevention, using early

intervention to address the rising prevalence of chronic diseases. To do so, care
providers are going to need more data, better automation, and a customer-centric
approach that will allow them to build better treatment plans. Better data collection
and processing can allow healthcare providers to introduce predictive care models
and use a more proactive approach.

B. Real-time health monitoring, conducted remotely and continuously with the use
of wearable devices, IoT sensors and smartphones, offers opportunities for gathering
crucial data. Doing so could vastly improve reaction times to changes in patients’
condition, and allow for a shift towards preventive treatment.

Digital therapeutics, for example, uses software to prevent, manage, and treat
medical disorders. This category consists of a broad group of products: from virtual
reality simulations used in the treatment of anxiety or social disorders, to
personalised mobile apps, which can offer assistance to diabetics who need to
monitor their insulin intake.

C. Care experience

New digital solutions introduce easier, faster, and more user-friendly ways
of delivering healthcare services. They make new patient engagement strategies
possible, improving interactions between patients and care providers through a
patient-centric approach. Remote appointments and follow-ups are examples of
such strategies.

Patients are becoming active decision-makers rather than passive participants. They
expect more transparency, convenience, easier access to care services, and
personalisation. To meet these demands, care providers might choose to focus on
digital innovation, rather than on expanding their physical presence.

D. Management
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Currently, many care providers are shifting to digital models for handling patient
data. These systems streamline communication and allow for instant information
sharing thanks to electronic health records (EHRs). Improved diagnostics and a
shorter response time are some of the benefits of EHRs.

In the future, digital patient data storage can evolve and bring additional
opportunities to the market. Insights could be monetised and used to support areas
such as population health management or value-based care.
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