Professional Practice Models
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The goals of safe and successful patient care delivery include high-quality and low-cost care with the achievement of patient and family outcomes and satisfaction levels. The ability to reach these objectives depends on the organization's approach to the matching of human and material resources with patient characteristics and health care needs via a model of professional practice for care delivery.
Both assignment and delegation are methods used by managers to deliver patient care within the structure of the health care system. The determination of the structure and method by which assignments are made is a managerial responsibility. Although this is part of a process of developing a model of nursing care delivery, pure nursing care delivery models, mainly reflecting the care of the patient by registered nurses on a discrete hospital unit (Minnick et al., 2007), are characteristic of the “siloed” approaches of the industrial age. These approaches are seen as not well matched to organizational effectiveness in an era of primary care–based service delivery such as in Patient-Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs).
Nursing leaders are the primary designers and stewards of systems for the provision of client care and the betterment of the organization (Morjikian et al., 2007). Nurses, as the major providers of care, develop and implement patient plans of care in collaboration with the multidisciplinary health care team within the framework of the care delivery model. The model of care delivery has a direct relationship to the allocation of control over decisions about client care. It is the means through which nurse managers delegate effectively and thereby free up and manage time as a scarce resource. The type of care delivery system or care model is seen as determining whether professional practice exists among the nursing staff on a particular unit because delivery systems constrain nursing decision making. This means that autonomy over practice decisions is determined largely by the care model and the resultant nurse decision-making latitude. The type of care delivery system used has implications for job satisfaction, the character of professional practice, and the amount of authority that is actually transferred to the staff.
The determination of a nursing care model or system of care delivery depends on the identification of organizational structures, patient care processes, and health care provider roles that are necessary to achieve care goals. Examples of structure and process criteria are found in Box 15-1. Trends in the health care environment strongly influence organizational structure.
DEFINITIONS
There is confusion over the differences between the terms professional practice models and models of care delivery (Wolf & Greenhouse, 2007). These concepts are often used interchangeably, yet their meanings are quite different. Professional practice models (PPMs) refer to the conceptual framework and philosophy under which the method of delivery of nursing care is a component. PPMs describe the environment and serve as a framework to align the elements of care delivery. The professional practice model can be thought of as a link between the problems presented by client populations, the purposes of professional occupations, and the purposes of health care organizations. For any practice model, the degree of integration of the nursing care given to a client, the degree of continuity in assignment of nursing personnel caring for a client, and the type of coordination used to plan and organize the client's care need to be consistent with general client characteristics, available nursing resources, and the organizational support available to nursing (Mark, 1992). The five subsystems of a PPM are: professional values, professional relationships, care delivery model, governance, and professional recognition and rewards (Shirey, 2008).
Examples of professional practice models include Relationship-Based Care (Koloroutis, 2004), the Synergy Model (Hardin & Kaplow, 2005), and Watson's Caring Model (Watson & Foster, 2003). Hoffart and Woods (1996) described five subsystems in a professional nursing practice model:
Models of care delivery are the operational mechanisms by which care is actually provided to patients and families (Person, 2004). A care delivery model is defined as a method of organizing and delivering care to patients and families to achieve desired outcomes. It organizes the work. The basic elements of any care delivery systems are identified as nurse/patient relationship and clinical decision making, work allocation and patient assignments, interdisciplinary communication, and the leadership or management of the environment of care (Manthey, 1991; Person, 2004). Coordination is a critical component that must be considered to manage task interdependencies upon which process and clinical outcomes rely. Relational coordination (Gittell et al., 2000) is described as the management of the multiple dimensions of communications and relationships between and among health care providers that are necessary to provide quality and efficient care.
Care delivery models must address both direct patient care functions (hands-on or delivery of health care services) and indirect patient care functions (management of providers and the environment) (Deutschendorf, 2003) (see Box 15-1). Direct patient care functions are facilitated by and depend on management, or indirect functions. For example, the client care assignment system is an aspect of operations included in indirect patient care functions. It is how the work is distributed. Using human resource decisions such as staffing and skill mix, a framework for the deployment of nursing staff and other interdisciplinary providers and their assignment to client care can be determined. Although the nurse manager is ultimately accountable for the achievement of direct and indirect patient care functions, the scope of responsibility necessitates appropriate delegation and assignment to competent unit staff. Delegation and assignment of management functions are vital to developing and maintaining professional nursing practice.
BACKGROUND
Executive leadership is responsible for making decisions about and designing strategies to create a climate and environmental context around the provision of nursing and health care services. Organizational environments exert a strong influence over patient care delivery, either positive or negative. Nursing care delivery can be seen as the dynamic balance between routine resource management and the structure, process, and outcomes of practice. One feature is that the system for distribution of nursing personnel must ensure that staff members of the right skill mix and numbers are promptly deployed so that clients are cared for in an appropriate and timely manner. Studies have demonstrated the impact of skill mix and nurse staffing on patient outcomes (Aiken et al., 2002; Kane et al., 2007; Needleman et al., 2001), further clarifying the need for appropriate role and resource deployment. The four strategic decisions to make are a philosophy of resource utilization, a choice of delivery system, common and individual practice expectations, and a development of the role of the registered nurse (RN) (Manthey, 1991). These four strategic decisions may be made at different levels in any organization. If these decisions are made only by the chief nurse executive, then shared governance and decentralization do not exist.
Professional Practice Models
A PPM is a framework and a structure that glues together elements of the work environment, management and governance, and the needs of patients and families to ultimately achieve outcomes, including care coordination and integration. The nursing practice environment contains those organizational or unit attributes that facilitate/constrain professional nursing practice (Arford & Zone-Smith, 2005). The concept of “magnetism” arising from the Magnet Recognition Program® addresses organizational attributes necessary for attracting and retaining nurses. Nurses want a work environment that allows them to feel productive, have control over work, exhibits respect for employees, and gives feedback on job accomplishment (Arford & Zone-Smith, 2005). The Exemplary Professional Nursing Practice component of the Magnet model measures aspects of the PPM and model of care and their outcomes (Wolf et al., 2008). In one example of a PPM (Erickson & Ditomassi, 2011), the nine components were: (1) vision and values, (2) standards of practice, (3) innovation and entrepreneurial teamwork, (4) clinical recognition and advancement, (5) research, (6) patient care delivery model, (7) collaborative decision making, (8) narrative culture, and (9) professional development. Traditional aspects of the PPM, which are often also incorporated into strategic planning, are organizational mission statements such as mission, vision, values, and philosophy. Organizational structural elements that are the foundation of a PPM are policies and procedures.
Mission Statements
Within an organization there is an established framework for management. For each organization, a characteristic collective of power and authority is vested in the managerial hierarchy. This legitimate authority, given by position, is used with the management process, management skills, and whatever resources are available to meet the organization's goals. The elements of management and the resources available combine to form the basic framework for the management and functioning of an organization. Organizations have a mission—to produce a product or service. This goal will be expressed in mission statements and carried through into policies and procedures, all documents that form the basis for guiding standard operations. These documents are generally gathered into an overall strategic plan.
As a service industry, health care has a product. The basic product of health care is client care service, such as disease treatment or health promotion. Health may be the ultimate outcome to be achieved. An interesting question is whether the product of nursing is the same as the product of health care. Quality care is one ideal product of health care. Kramer and Schmalenberg (1988a, b) said that the product of a hospital is a quality, accessible, cost-effective service called client care. In hospitals, 90% of client care is delivered by nurses. If the product is “quality care,” valid and reliable measurement is needed to ensure that quality care is delivered and received. The idea has been presented that nursing is not a service composed of tasks but, rather, a business with a product of enhanced client outcomes and contained costs (Zander, 1992). This idea takes Drucker's (1973) conceptualization and merges ideas about a service industry with ideas about traditional for-profit businesses. For nursing, the product is derived from the use of expertise to solve problems for clients. Similarly, the product of nursing administration relates to the use of expertise to solve problems for nurses within systems of care.
Mission, values, and vision are the glue that holds an organization together. They describe what the organization is trying to do, how to go about it, and where it is headed. This helps keep an organization on track and provides yardsticks for measuring present performance. Groups can be brought to crisis by conflicts over basic issues of mission, values, and vision. Without these agreements in place, no organization is truly viable (Adams, 2004).
Mission, vision, and values statements can be mere words on a page, or they can be “living documents” that unify an organization around a purpose. The process of development of these statements needs to begin with bringing members into basic agreement and alignment around the statements.
Using a goals-based strategic planning method, the first step is to develop a mission statement. The mission of any organization is its purpose, function, and reason it exists. Organizations exist to do something such as produce a product or deliver a service. The founders' intentions for what they wanted to achieve by starting this organization need to be reexamined and refreshed periodically to keep the organization dynamic (Adams, 2004). For a health care organization, the mission relates to health care services—for example, client care, teaching, and research. For a nursing department's purpose, constraints include the organization's purpose, the state nurse practice act and other legal parameters, the context of the local community, and the directives of regulating agencies. The mission statement should be short, concise, and clear. The mission of the nursing department should mesh with the mission of the institution.
In developing a mission statement, factors such as the organization's products, services, markets, values, public image, and activities for survival need to be considered (McNamara, 2008). In addition, the intent of the organization's founders and its history are useful to review. Often employees are unaware of historical background. Because the mission statement needs to describe the overall purpose of the organization, the wording should be carefully crafted. It needs to be derived by a process that respects the organization's culture. The statement needs to have sufficient description to clearly identify the purpose and scope and suggest some order of priorities (McNamara, 2008).
Vision Statements
Vision statements are designed to address the preferred future of the organization. They draw on the mission, beliefs, and environment of the organization and are positive and inspiring. Vision statements are crafted to describe the most desirable state at some future point in time. Often, one step in planning is a gap analysis of the difference between the current state and the vision (Drenkard, 2001). The advantage of vision statements are that they transcend bounded thinking; identify direction; challenge and motivate; promote loyalty, focus, and commitment; and encourage creativity. Vision statements are designed to rise above fatigue, tradition, routine, and complacency. Visioning is setting a high-level direction through turbulent times and creating a compelling picture of a desirable future state. Imagery and stories may be used to sustain the vision. Vision statements need to be vivid enough to keep the organization moving forward.
Values Statements
Core values are strongly held beliefs and priorities that guide organizational decision making. Core values are things that do not change. They are anchors or fundamentals that relate to mission and purpose and hold constant, whereas operations and business strategies change. Values drive how people truly act in organizations. They are the bridge to align how people actually behave with preferred behaviors (McNamara, 2008). Adams (2004, p. 2) stated, “Articulating values provides everyone with guiding lights, ways of choosing among competing priorities, and guidelines about how people will work together.”
One way that core values are expressed are through lists or values statements as part of a strategic plan. Another way to express values as statements is to compose a statement of philosophy. Some organizations have philosophy statements, and others use a mix of mission, vision, and values statements as a proxy for their philosophy. Both individuals and organizations can compose a statement of philosophy. For an individual, this would be an expression of personal and professional values, vision, and mission. Although difficult to do, writing a personal professional statement of philosophy is an exercise in clarity and communication.
A statement of philosophy is defined as an explanation of the systems of beliefs that determine how a mission or a purpose is to be achieved. An organization's philosophy states the beliefs, concepts, and principles of an organization. It serves as a guide for and an explanation of actions (Poteet & Hill, 1988). The philosophy is abstract: it describes an ideal state and gives direction to achieving the purpose. It may begin with “We believe that…” For example, the system of beliefs, or philosophy, might be stated in any of the following ways:
• We believe that everyone has a right to the highest quality of client care.
• We believe that we have an obligation to render quality client care at a cost-effective price.
• We believe that any person who walks through the door should receive care, regardless of his or her ability to pay.
The philosophy has implications for a nurse's practice role. If an organization's stated mission includes client care, teaching, and research, then all employees will be expected to be involved in all three aspects of the mission. Part of the nurse's job will be to teach students and be involved in research. The nursing department's philosophy should be congruent with the organization's philosophy. The three vital components that form the core of a nursing department philosophy are the client, the nurse, and nursing practice (Poteet & Hill, 1988).
The organization's philosophy is important to assess as it relates to one's personal philosophy. For example, a potential employee on a job search might compare his or her own philosophy, both of nursing practice and of management, with the philosophy of an organization in which he or she might secure employment. Is there a match? For example, hospitals owned by religious organizations may prefer to hire people who share this same religious faith. If the nurse is not of that religious faith or if he or she has a prejudice or a lack of knowledge about that religious faith, it is advisable to assess personal fit with that particular organization. If some part of the philosophy is personally distasteful, it can have implications for functioning within the practice environment. For example, a specific religious tradition may still be pervasive within the organizational culture, even though the stated philosophy may say that the organization provides care to people of all faiths. That may be bothersome. One example occurs when an organization that is owned and run by a religious group opens each administrative meeting with a prayer. Another example occurs when a nurse believes in providing the total scope of public health services to clients but the organization is run by for-profit principles that dictate the provision of only those services that make a profit. Taking a job in an organization suggests an implicit agreement to cooperate with the organization's values while at work.
Policies and Procedures
Policies and procedures are two functional elements of an organization that are extensions of the mission statements. Both are written rules derived from the mission statement. Together they determine the nursing systems of the work unit and the department of nursing. The purpose of policies and procedures is to provide some order and stability so that the unit functions in a coordinated manner within the larger structure of nursing and the institution. Organizations need to integrate the behaviors of employees to prevent random chaos and maintain some order, function, and structure. These plans are often referred to as standard operating policies and procedures. They guide personnel in decision making.
Policies
A policy is a guideline that has been formalized. It directs the action for thinking about and solving recurring problems related to the objectives of the organization.
There will be specific times when it is not clear who is supposed to do something, under what circumstances it should be done, or what should be done about unusual circumstances. For example, often there are controversies about the dress code because of disagreements about the definition of what is appropriate. This occurs, for example, when the dress code says, “Nurses will come to work dressed in appropriate attire.”
Policies direct decision making and serve as guides to increase the likelihood of consistency in decisions and actions. Policies should be written, understandable, and general in nature to cover all employees. If written, they should be readily available in the same form to all employees. Policies should be reviewed during employee orientation because they indicate the organization's intentions for goal achievement.
After institutional approval, policies need to be collected in a manual or computerized database that is indexed, classified, and easily retrievable. Policies so organized can be easily replaced with revised ones, which often become necessary in light of new environmental circumstances. Policy formulation in any organization is an ongoing core process. Hospitals will have a standing committee for the review of policies as a part of the organizational structure. Policies establish broad limits on and provide direction to decision making; yet they permit some initiative and individuality for unique circumstances.
Policies can be implied, or unwritten, if they are essentially established by patterns of decisions that have been made. In this situation, the informal policies represent an interpretation of observed behavior. For example, the organization may expect caring treatment for all clients. This expectation may not be written as a policy of the organization. However, by the decisions and disciplinary actions that occur, an employee can infer that there is a policy that will be enforced even though it is not written. However, the vast majority of policies are and should be written. Informal and unwritten policies are less desirable because they can lead to systematic bias or unfairness in their application and enforcement (Box 15-2).
Some general areas in nursing require policy formulation. These are areas in which there is confusion about the locus of responsibility and in which lack of guidance might result in the neglect, malpractice, or “malperformance” of an act necessary to the client's welfare. For example, clear policies need to be in place about medication error reporting and follow-up. In those areas in which it is important that all persons adhere to the same pattern of decision making given a certain circumstance, a policy is necessary so that it can be used as a guideline. Also, areas pertaining to the protection of clients' or families' rights should have written policies. For example, the use of restraints to manage difficult clients came under scrutiny as the Omnibus Budget Reconciliation Act of 1987 (OBRA) pushed restraint-reduction strategies and created policy revisions. Other examples are policies related to “do not resuscitate” and end-of-life care. Areas involving matters of personnel management and welfare, such as vacation leave, should have written policies. In such cases, the lack of a uniform policy would be considered unfair. Many conflicts arise about the scheduling of vacations. How many people can be off at any one time? How long in advance must a vacation request be made? How is the priority for granting requests to be determined (e.g., by seniority or order of request)? The policy is the guideline for determining specific decisions.
Procedures
Procedures are step-by-step directions and methods for actions to follow in common situations. Procedures are descriptions of how to carry out an activity. They are usually written in sufficient detail to provide the information required by all persons engaging in the activity. This means that procedures should include a statement of purpose and identify who is to perform the activity. Procedures should include the steps necessary and the list of supplies and equipment needed. A procedure is a more specific guide to action than a policy statement. Procedures usually are departmentally or divisionally specific, so they will vary across an institution. They may be very detailed as to how to perform a specific procedure on a specific unit. They help achieve regularity. They are a ready reference for all personnel (Box 15-3).
The similarities between policies and procedures are that both are a means for accomplishing goals and objectives. Both are necessary for the smooth functioning of any work group or organization. The difference between a policy and a procedure is that a policy is a general guideline for decision making about actions, whereas a procedure gives directions for actions. For example, policies about the use of restraints to manage difficult clients would indicate when such restraint use is appropriate. Procedures would cover how to apply specific devices.
A policy is a more general guide for decision making; a procedure is more like a cookbook recipe or a how-to guide giving specific directions about how to perform a certain act or function. There are legal implications to the application of policies and procedures. For example, the nurse may be held liable for failing to follow written policies and procedures. Thus it is important for nurses to be informed about the policies and procedures governing practice in an institution. In addition, both policies and procedures need regular, periodic reviews.
Healthy Work Environment
Nurse leaders and managers can create and maintain an environment that facilitates the practice of the professional nurse. Leadership is required to bring about a good environment. Three elements form the basis for the creation of a positive professional work environment: fun, hope, and trouble. Nurses can use these elements to support each other, stimulate creativity, and work together successfully (McCloskey, 1991). Another aspect of leadership and management in times of change is the creation of a healthy work environment as a nursing core value. Striving for a healthy work environment is a conscious choice. Respect is a hallmark criterion. Elements for constructing such an environment include acknowledgment of the reality of the present environment, clear behavioral expectations and standards, systems and structures to ensure that organizational changes are enduring, and a means to continually assess the health of the work environment. Bylone (2011) noted that nurses still struggle to create a healthy work environment. The six standards of a healthy work environment (American Association of Critical Care Nurses, 2005) are: skilled communication, true collaboration, effective decision making, meaningful recognition, appropriate staffing, and authentic leadership. They have direct relevance to PPMs.
Both older and newer systems and models of patient care delivery are in use. The complexity of the health care environment strongly influences organizational decisions regarding patient care. Fiscal responsibility, accountability to the consumer, and quality and safety outcomes are priorities in an environment of increasing health care costs and health care errors. The development of new models is characterized by changes in the health care climate, including costs, consumer expectations, patient characteristics, and new medical information and technology (Wolf & Greenhouse, 2007). Although all models have their advantages and disadvantages, there is no one right way to structure patient care. The appropriate care delivery model is the one that maximizes existing resources while meeting the objectives of direct and indirect patient care functions (Deutschendorf, 2003). In addition, pieces of older systems often are incorporated into new delivery models as they are developed. Therefore it is important to understand the variety of models available, both old and new. Pure nursing models (effective in less complex times) have yielded to collaborative practice and interdisciplinary approaches with the proliferation of health care provider roles, expedited care processes, and increased severity of illness.
TRADITIONAL NURSING CARE DELIVERY MODELS
Historians mark the emergence of modern nursing from the time of Florence Nightingale's work in the Crimea. Nightingale believed that nursing care of patients included spiritual well-being as well as the environment. The evolution of nursing models of care has resulted from the impact of economic, social, and political agendas over the past century (Tiedeman & Lookinland, 2004). There are five traditional nursing models of care: (1) private duty, (2) functional, (3) team, (4) primary, and (5) case management. Of these, functional, team, primary, and case management were and are currently associated with hospital nursing practice. Private duty and case management were associated with public health, home health care, and community health but have been adapted to the inpatient setting. Private duty, later called case or case management, was the original way nursing care was delivered; it later became the foundation for public health nursing and community service delivery.
Private Duty Nursing
Private duty nursing, sometimes called case nursing, is the oldest care model in the United States. Private duty nursing is defined as one nurse caring for one client. In this model, complete and total care is provided by one nurse, but the nurse carries only one client assignment. Originally, when the nurse went into the home, the nurse did the cooking, cleaning, bathing of wounds, and organizing of the household functions, basically functioning as a home manager. In American nursing practice, private duty was the original way that graduate nurses found employment, although some had administrative positions in hospitals and some worked in public health (Reverby, 1987). A form of hospital case nursing evolved between 1900 and the 1930s. When the Great Depression hit, most families were too poor to afford private duty nurses and so nurses were without jobs. Hospitals then began to employ graduate nurses.
Reverby (1987) noted that during the depression years, a great transformation from private duty to hospital staffing took place in nursing. As the graduate nurses who had been doing private duty moved into the hospital, they wanted to retain the type of care model to which they had become accustomed. Private duty, the idea that one nurse does the total care of one client, was transplanted into hospital settings for as long as nurses were paid by clients. When nurses became employees of hospitals, the kind of client care that private duty allowed was not possible within the organizational structure of hospital staff nursing. The organization of work in hospitals was task-focused, not client-focused (Reverby, 1987).
The advantage of private duty nursing was that the nurse's focus was entirely on one client's needs. This fostered closeness in the nurse-client relationship and increased RN and client satisfaction with care delivery. The disadvantage was that private duty is a costly model because of its low efficiency. Furthermore, job security was tenuous and irregular (Lee, 1993; Reverby, 1987). Other disadvantages were that nurses had little job mobility and were relatively isolated from colleagues.
Two main variations to the basic pattern of private duty nursing developed: group nursing and total patient care. Group nursing was an early alternative model that combined private duty concepts with hospital staff nursing. Total patient care was a hospital care model characterized by 8-hour shift accountability.
Group nursing was a care model proposed in the 1930s by Janet Geister, then the executive director of the American Nurses Association (ANA). Defined as nursing group practice, the idea of group nursing in hospitals was similar to divisional private duty in which several clients shared a private nurse. The plan was to reorganize private duty from individual to group practice, both inside and outside the hospital. Thus the registry of private duty nurses would be transformed into a group practice and linked to a community's public health nursing service. Facing political pressure, the plan died. Hospitals also experimented with a group nursing care modality, described as being halfway between a private duty arrangement and graduate nurse hospital staff nursing. Under this plan, clients were grouped together in a special unit in which several clients shared a private nurse. Thus three nurses could do 8-hour shifts for two clients instead of four nurses being needed for 12-hour shifts. The hospital paid the nurses' wages but charged the clients directly as a surcharge on the hospital bill. The advantages included shorter hours for nurses, order and regularity in hospital staffing, steady employment for nurses, slightly cheaper rates for clients, and responsibility for the total care of several clients for the nurse. Nurses obtained the autonomy and care delivery method of private duty without its isolation and uncertainty. Nurses were members of the hospital's staff, yet their time was specifically allocated only to a set number of clients who paid for this service directly. However, economic and political pressures for more efficiency, productivity, and service cut off the adoption of this system in hospitals (Reverby, 1987). It is interesting to note the parallels between group nursing and what eventually came to be the way physicians organized themselves.
Total patient care has been defined as a case method for organizing nursing care in which nurses are responsible for total care of a client for the hours in which that specific nurse is present (Glandon et al., 1989). Examples initially occurred in intensive care, hospice care, and home health care. The term total patient care has come to mean the assignment of each client to a nurse who plans and delivers care during a work shift (McCloskey et al., 1991; Minnick et al., 2007). Total patient care reemerged in the mid-1990s as a prevalent care delivery system after reengineering and restructuring occurred. The term has become confused with team or primary nursing care delivery systems. Total patient care has been described as a “form of primary nursing” (Reverby, 1987); however, the accountability for patient care coordination throughout the acute episode does not happen. The advantages are the intensity of focus with shift-only responsibility. Significant disadvantages are lack of communication and continuity of care for the client over time. Models of total patient care have contributed to task- and shift-based care that diverts attention from achievement of future patient goals (Bower, 2004). Total patient care has been called the oldest model of nursing care delivery (Shirey, 2008).
Functional Nursing
Functional nursing emerged as a care model in the 1940s. In this model, the division of labor is assigned according to specific tasks and technical aspects of the job. It has been defined as work allocation by functions or tasks, such as passing medicine, changing dressings, giving baths, or taking vital signs (McCloskey et al., 1991). Under functional nursing, the nurse identifies the tasks to be done for a shift. The work is divided and assigned to personnel, who focus on completing the assigned task. Tasks are divided based on the complexity of judgment and technical knowledge and a variety of workers other than RNs to complete the assignment. Functional nursing has the advantage of being efficient for taking care of the tasks related to handling a large number of clients and using workers with varying skill levels (Tiedeman & Lookinland, 2004). Because the division of labor is clearly delineated, administrative efficiency is maximized.
Functional nursing was the norm in U.S. hospitals from the late 1800s through the end of World War II. Factors such as increases in client acuity, greater complexity of care delivery, and expansion of the number of paying clients increased demand for hospital nursing services. As hospitals searched for ways to improve efficiency and service yet control labor costs, the functional division of tasks was instituted to get the work done. Cyclical shortages of nursing labor, exacerbated during times of war, accelerated staffing shortages and the demands of work. This organization of work, combined with frequent understaffing, forced nurses to be task oriented rather than client oriented. It was a major reason why graduate nurses disliked staff nursing as compared with private duty (Reverby, 1987).
In the early 1900s, business and industry concepts of “scientific management” emphasized efficiency. The efficiency was gained by breaking down a work process into its component task steps and then analyzing and timing the steps, establishing standards, and determining the best way to perform each task. Thus managerial control over the planning and execution of work could be established. Assembly lines in factories were one result. Functional nursing was developed as a result of this concern for task analysis and proper division of the nursing workload. Under this model, there might be a “temperature nurse,” a “medication nurse,” a nurse for the right side of the hall, and a nurse for the left side of the hall (Reverby, 1987). Functional nursing was not oriented to individualized and holistic client care but, rather, facilitated a fragmented approach to patient care. One advantage was that there was little confusion about roles and duties. When applied to nursing, this method was efficient and inexpensive but nurses and clients hated it. Client satisfaction dropped under this kind of care delivery system. Clients felt that they could not identify who was their nurse caregiver.
Team Nursing
Team nursing is a care model that uses a group of people led by a knowledgeable nurse. It is a delivery approach that provides care to a group of clients by coordinating a team of RNs, licensed practical nurses/licensed vocational nurses (LPNs/LVNs), and aides under the supervision of one nurse, called the team leader (Glandon et al., 1989). Team nursing has been defined as the assignment of a group of clients to a small group of workers under the direction of a team leader. Each team member provides most of the care to his or her assigned clients, although some tasks (e.g., medications) may be assigned separately (McCloskey et al., 1991).
Team nursing is designed to make use of each member's capabilities to meet the nursing needs of his or her group of clients. It is a delegation of care to a designated team of staff members. The staff members have various levels of expertise, but they are formed into a team. The nurse leader takes into account the level of expertise and then divides the assignments accordingly so that the clients who are assigned to a team of caregivers have their needs appropriately met. Team nursing developed in the early 1950s in response to a shortage of RNs and in reaction to the dissatisfaction with functional nursing.
The advantages of team nursing are that each member's particular capabilities can be used to the maximum. This model supports group productivity and the growth of team members. Communication is vital. A sense of contribution via the team can be fostered. Oversight for novice nurses and temporary personnel can be facilitated. However, it takes a skilled RN to be a team leader. Furthermore, an RN team member may not be functioning up to his or her full potential because of being assigned an ancillary role, which creates some underutilization of the RN personnel.
One variation of team nursing is modular nursing. Modular nursing is based on the existence of specific facilities and on actual structural and spatial changes to enable hospital nurses to stay near the bedside. Structural modules based on client acuity are clustered in larger districts based on geography. Nurses are stationed near their clients, and a wider range of responsibility is delegated to them. Open design and convenient access architecture provide for decentralization of care delivery based on the spatial arrangement of the unit and enhanced communication (Magargal, 1987). The development of an innovative new care delivery system needs to be in synchrony with the philosophy of care (Guild et al., 1994). The essential features of modular nursing are as follows (Anderson & Hughes, 1993):
• A module consists of a group of nurses and a group of clients.
• Clients are grouped by spatial or floor-plan clustering.
• Nurse/client assignment is standardized.
In one facility, decentralizing nursing activity to three modular substations for a 50-bed unit allowed for a reduction in RN skill mix from 63% to 46% (Abts et al., 1994).
Functional nursing was a precursor of team nursing. Both models emphasized efficiency and care delivery with a limited number of RNs. However, team nursing corrected some deficiencies in care fragmentation and regimentation that were a problem with functional nursing.
Primary Nursing
Primary nursing began in the 1970s as a way to overcome the discontent with functional and team nursing's emphasis on tasks and discrete functions that directed nurses' attention away from holistic care of the client. This matched a societal trend toward accountability, as well as nursing's rising level of professionalism. Primary nursing is an approach in which a nurse has responsibility and accountability for the continuous guidance of specific clients from hospital admission through discharge. Thus the primary nurse provides for the total nursing process for the client during a period of hospitalization (Glandon et al., 1989). Primary nursing has been defined as the assignment in a hospital of each client to a primary nurse who plans, delivers, and monitors care under a 24-hour responsibility from admission to discharge (McCloskey et al., 1991). The hallmark of the primary nursing concept is the 24-hour accountability element. Autonomy, authority, and accountability in the primary nurse's role are basic to primary nursing. When the nurse is not actually taking care of clients, an associate delivers the care. However, the primary nurse makes the care and treatment coordination decisions, supervising the entire stay, 24 hours per day, for the length of the hospital stay. This increases continuity of care and consistency in assignments. Primary nursing does not mean that the primary nurse takes care of clients 24 hours a day. Rather, the 24-hour accountability is for the supervision and delegation of client care. Primary nursing has been called the first formal professional model in hospital nursing (Zander, 1992).
The advantages of primary nursing include a focus on the client's needs, greater nurse autonomy, and greater continuity of care. Primary nursing eventually came to be associated with all-RN staffing but has moved away from that position. Problems in the implementation of primary nursing have included the wide variation in its operationalization and implementation. The result has been confusion and lack of a structure to enable primary nurse autonomy. Under cost-containment pressure, an all-RN staff is difficult to justify. Total accountability may create burnout, and a poorly prepared RN may feel threatened by primary nursing.
Research conducted to compare team nursing with primary nursing care models found higher quality of nursing care, higher levels of nurse satisfaction, increased continuity of care, improved nurse retention, and positive client outcomes with primary nursing. Levels of client satisfaction were equal and cost comparisons were inconclusive between the two models (Gardner, 1991; Lee, 1993).
Private duty was a precursor of primary nursing emphasized the closeness of the nurse-client relationship, but primary nursing was more cost-effective. Primary nursing was a care model that evolved in reaction to the desire of RNs to return to more direct and active care instead of supervision of ancillary workers as in the team nursing care model. This approach promoted greater RN professional authority, accountability, autonomy, and continuity of care. Initially, an all-RN staff was thought to be needed. Compatible support systems were needed for a primary nursing care model to be effective. Primary nursing is highly sensitive to human resource distribution, skill mix, staff competency levels, and client care needs. However, as budget constraints, shortened lengths of stay, increased client severity, and pressures for cost containment in hospitals grew in the late 1980s and early 1990s, it was difficult to maintain primary nursing care models (Cohen & Cesta, 2005).
Case Management
Case management as a nursing model of care evolved in the late 1980s. It has been defined as both a process (it is a provider intervention) and a care delivery model. Case management has developed as a method to manage care. Managed care is care coordination that is organized to achieve specific client outcomes, given fiscal and other resource constraints. Managed care has been described as “the systematic integration and coordination of the financing and delivery of health care” (Grimaldi, 1996, p. 6).
The Case Management Society of America (CMSA) is the professional organization representing case managers in practice. It is a multidisciplinary organization. The CMSA definition of case management is “Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes” (CMSA, 2012, p. 1). Thus there is a major professional organization that defines case management as a multidisciplinary provider intervention and promotes the knowledge base for practice.
In nursing, the ANA first defined nursing case management as a system of health assessment, planning, service procurement, service delivery, service coordination, and monitoring through which the multiple service needs of clients are met (ANA, 1988; Zander, 1990). Hospital acute care nursing case management is an attempt to reconfigure the delivery of hospital care away from previous care models. Case management and care coordination have been the care delivery models used for years by public health and community health nurses (Mikulencak, 1993). In these settings, case management has been centered on client needs, rather than the shift, unit, or system. Case management can occur inside or outside the hospital only, extend across the health care continuum, or be linked to a population focus (Lee, 1993; Lyon, 1993).
Case management is a system of client care delivery that focuses on the achievement of client outcomes within effective and appropriate time frames and resources. Case management has components of health services delivery, coordination, and monitoring through which multiple service needs of clients are met. Hospital-based acute care nursing case management was focused on an entire episode of illness, crossing all settings in which the client receives care. Care is directed by a case manager, who is not always a nurse, and can be unit- or population-focused.
Case management is frequently associated with the use of structured care methodologies (SCMs). SCMs are streamlined interdisciplinary tools used to “identify best practices, facilitate standardization of care, and provide a mechanism for variance tracking, quality enhancement, outcomes measurement, and outcomes research” (Cole & Houston, 1999, p. 53). Examples of SCMs are critical pathways, evidenced-based algorithms, protocols, standards of care, order sets, and clinical practice guidelines. The use of best evidence is considered the gold standard to reduce practice variation in an environment focused on patient outcomes. Critical paths outline time and the sequence of events for an episode-of-care delivery. Resources appropriate in amount and sequence to a specific case type and individual client are managed for length of stay, critical events and timing, and anticipated outcomes. A critical path is a written plan that identifies key, critical, or predictable incidents that must occur at set times to achieve client outcomes within an appropriate length of stay in a hospital setting. As a pathway, it is a tracking system for the timing of treatments and interventions, health outcomes, complications, activity, and teaching/learning.
In the face of strong economic external forces, acute care hospitals turned to case management to help reduce provider practice variation and to ensure the appropriateness of care. Case management was seen as a way to incorporate and build on the strengths of earlier care models yet provide a professional practice model for nurses through autonomous decision making and collaborative practice. The risk with case management models is that communication and coordination infrastructures may not be available or integrated for effectiveness. Converting case managers from a service-based approach to a unit-based model may not only improve efficiencies but also enhance integration into the patient care delivery model, improving communication and collaboration with the multidisciplinary health care team (Zander & Warren, 2005).
EVOLVING MODELS
Nursing shortages and health care reform will continue to have a strong impact on the creation of current and evolving types of patient care delivery models. Nurse staffing models were retooled in the late 1980s as a result of a severe nursing shortage and in an attempt to complement the work of the professional nurse with the use of nursing extenders (Eastaugh & Regan-Donavan, 1990; Lookinland et al., 2005). When managed care became predominant, fiscal restraint became a driver for restructuring, reengineering, and redesign. Nurses were perceived as more “costly than cost-effective” as a result of their 24-hour responsibility for patient care and contribution to the overall labor budget (Hall, 1997). Many of the resulting structures for patient care were staff mix models, in which nurses were partnered with a variety of “extenders” or multiskilled workers. Outcome studies have clearly demonstrated the negative impact of “substitution models” in which extenders have not been used to complement nurses but, rather, served as replacements, thereby increasing RN/patient ratios (Aiken et al., 2002; Needleman et al., 2001). Unruh (2003) found that it was not the ratio of skilled to unskilled workers that influenced patient outcomes but, rather, the RNs' hours of care. It has not been determined which models are the most effective to fully utilize professional nursing skills in patient care while optimizing tasks that can be safely delegated (Duffy et al., 2007; Jennings, 2008; Lookinland et al., 2005).
Many of the models that evolved in the 1990s are identified in the literature as mixed models, or some form of second-generation primary nursing or professional practice models that emphasize outcomes management, collaboration, the use of a variety of caregivers with variable competency and preparation, and integrated practice (Jones-Schenk & Hartley, 1993; Lengacher et al., 1993; Wolf et al., 1994; Zander, 1992). Concepts of accountability, cost containment, effectiveness, seamless continuum of care, integration, multidisciplinary collaboration, new roles, alteration in skill mix, and new assignment systems are key components. All sought to reconfigure nursing's work within resource constraints, care needs, and current ideas about professional nursing practice.
Patient- and Family-Centered Care
Patient-focused or patient- and family-centered care emerged as one method of patient care delivery to meet the needs of organizations that were reengineered to be more competitive and cost-effective. Pioneered by the Picker Institute in 1978 (Planetree, 2008), patient-centered care is defined as “the redesign of patient care in the acute care setting so that hospital resources and personnel are organized around the patient's health care needs” (Maehling, 1995, p. 62). It was part of a redesign effort to realign the structure and processes involved in delivering care to center around the patient to improve efficiency and resource use. Patients are aggregated according to care requirements or similar service demands (as opposed to similar diagnoses). Protocols or pathways (SCMs) form a central point of focus. With a patient and family-focused approach, there is an ongoing process to seek out and determine what is important to the person receiving care. This approach adopts the perspective of the person receiving care and strives to establish mutual goals between patient and provider to meet unique needs. To reach this complexity challenge, horizontal structures with an emphasis on relationships and effective working partnerships are built (Comack et al., 1999). The model is recommended by the Institute of Medicine (IOM) (2001) and has been expanded to include the aspect of the family as well as the patient.
The advantage of patient-focused care redesigns is that they center systems and services closer to the patient. This strong customer focus may increase quality, safety and patient satisfaction and conserve resources. However, implicit in these redesign efforts is a series of significant work group and culture changes affecting the financial operations and cost structure of hospitals. It also requires a commitment for initial allocation of resources to achieve ultimate financial and clinical outcomes. There are also concerns related to appropriate delegation, acceptance of assignments, and follow-up accountability (Duffy et al., 2007). The use of case managers addresses care coordination (Shirey, 2008).
INNOVATIVE AND FUTURE MODELS
Because the acute care environment is multifaceted around multiple levels and sites of care, patient types, diseases, and providers, a single organizational model for patient care delivery may be unrealistic. Deutschendorf (2003) proposed the development of unit-based models that incorporate an evaluation of structure and process criteria that influence direct and indirect patient care functions to determine an appropriate model.
The increase of health care errors noted in the IOM's report, To Err Is Human: Building a Safer Health System (Kohn et al., 2000), is a symptom of care delivery process and structures that have become dysfunctional, disorganized, and inappropriate as the health care environment has become increasingly complex. The IOM's 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century described the need for sweeping change and redesign of patient care delivery systems to foster innovation and improve the delivery of care. It called for a comprehensive strategy and action plan that included high-functioning interdisciplinary teams that delivered safe, effective, patient-centered, timely, efficient, and equitable health care.
Affordable Care Act of 2010
Despite the dramatic activity from the public and private sectors and regulatory agencies demanding the demonstration of safety and quality outcomes, most hospitals and health systems made only incremental changes toward the kind of patient care redesign called for by the IOM (Kimball et al., 2007). Previous practice models that were either “nursing” or “medical” are single discipline–focused in an environment in which there are many structures of rationality and points of view. The focus on the hospital as the hub of all health care activity must be shifted to encompass the primary care environment as well (Vlasses & Smeltzer, 2007). Emphasis on continuity of care through transitions of care with seamless communication and care coordination is a theme that must be addressed with future models to ensure quality and safety outcomes. This is the new imperative under the rapid changes in health care induced by the Patient Protection and Affordable Care Act (PPACA) of 2010.
Before the ACA, models that incorporated the principles of care coordination and integration began to emerge. In 2005, Partners HealthCare in Boston collaborated with Health Workforce Solutions to identify innovative models of patient care delivery that met the following criteria (Kimball et al., 2007):
• Primarily adult patients were served.
• Nurses served as primary caregivers.
• Acute care hospitals were involved.
• Technology, support systems, and new roles were integrated.
• Quality, efficiency, and financial outcomes were improved.
Their research identified 10 models meeting the stated criteria. All of them had common elements, which included an empowered RN role, heightened concentration on the patient and family, methods for smoothing patient transitions and handoffs across levels of care, optimizing technology, and outcomes management through performance measurement (Kimball et al., 2007).
The 12-bed hospital is designed to improve communication and continuity through the development of 12- to 16-bed units, creating a feeling of a small hospital within a large one. A registered nurse functions as the patient care facilitator (PCF) for each unit and assumes 24/7 accountability for individualized patient care. The PCF is the primary point of contact for the interdisciplinary team, as well as the patient and family. The PCF mentors and educates new staff members and is responsible for achieving performance measures identified through a dashboard of quality, financial, and efficiency indicators. Initial outcome studies have suggested that patient satisfaction is improved, length of stay is shortened, and patient safety measures have reduced the number of falls with injury and the number of pressure ulcers (Kimball et al., 2007; Smith & Dabbs, 2007).
The Partnership Care Delivery Model is conceived as a multidisciplinary model of care that is patient- and family-centered, with all of the disciplines participating in collaborative practice. The term partnership implies that all disciplines are equally accountable for patient outcomes of care. The key components of this model include daily multidisciplinary rounds, partnerships with patients and families, education and support, and a systems approach to care delivery (Wiggins, 2006).
The Transitional Care Model incorporates the role of advanced practice nurses (APNs) to provide comprehensive care coordination and home follow-up of high-risk elders (Kimball et al., 2007). The APN, in collaboration with physicians and other members of the health care team, coordinates care during the patient's hospitalization, including discharge planning and the alignment of resources to facilitate post-discharge outcomes such as the reduction of readmissions and emergency department use. The APN not only provides a comprehensive assessment of the patient's health care status and development of plan of care in the acute care setting but also follows the patient into the home setting to ensure the continuation of the patient care plan. Outcomes achieved as a result of the implementation of the Transitional Care Model include decreases in time to discharge and total hospital readmissions, decreased total health care costs, and increased patient and physician satisfaction. Improving transitions of care is a focus of the National Transitions of Care Coalition (NTOCC, 2010) and is important because of the costs and poor outcomes associated with lack of care continuity (Naylor et al., 2011).
The Patient-Centered Medical Home Model (PCMH) was originally conceived by the American Academy of Pediatrics as a method to care for children with chronic diseases. The current model has been developed as a collaborative effort among several professional physician organizations to provide patient-centered care that is focused on prevention, health promotion, and coordinated care across the life span (Vlasses & Smeltzer, 2007). This model refocuses patient care from the hospital to the primary care setting. The interdisciplinary team is responsible for coordinating care across all levels of care and includes the provision of comprehensive health care services. Continuity and coordination across specialties, access to services, and patient responsibility for decision making are key components of this model. These models are being testing for efficacy and efficiency (Vlasses & Smeltzer, 2007).
“The Affordable Care Act is altering the way healthcare is delivered” (Katz & Frank, 2010, p. 82). The IOM's vision for the future, with a key feature being new models of care, has been carried forward in the ACA. The themes of integration and coordination of care, addressing needs in a comprehensive manner, with patients as key partners, and providing services efficiently are consistently present. Provisions of the ACA promote new models that will address these themes, such as ACOs. Care coordination is the linchpin. Propelled by the evidence-based recommendations of the IOM, the ACA is triggering a radical shift in the delivery of health care toward primary care–based and health promotion–focused systems. The focus has turned to how to prevent disease or chronic condition deterioration and unneeded ED visits and hospital admissions. Reimbursement structures and incentives to physicians are changing to incentivize new models. Meaningful changes in the workforce are a major implication. Evidence-based care delivery models, such as population health management programs (Rust et al., 2011), are likely to be the future models of care delivery.
LEADERSHIP AND MANAGEMENT IMPLICATIONS
Fundamentally, a care delivery system is the way clients' needs are matched to health care resources to achieve positive clinical outcomes. Through many complex relationships, the care delivery model influences the quality of nursing care provided and its cost. A number of nursing care models have been developed, and there is evidence of evolutionary changes yet repeating cycles. Traditionally, care delivery was provided within a pure nursing framework. Over time, nursing care delivery methods were changed and adapted to better fit external forces and the balance of the needs of clients and the needs of employing organizations. With these changes came variations in assignment systems, skill mix, and the role of the nurse. Nursing care delivery has become more complex as integration with other provider disciplines is essential to meet the client's needs through the entire continuum of care. Future trends point to greater integration and multidisciplinary team collaboration models for service delivery as health care reform drives changes in the organizations within the health care industry.
The current health care environment is dynamic and continues to change at a rapid pace. Health care costs continue to rise, and safety outcomes have not dramatically improved since the initial IOM report, To Err Is Human (Leape & Berwick, 2005). For nursing to ensure its status in health care, nursing leaders and managers must have a broad vision to facilitate the design of care delivery models that meet the objectives of cost containment, patient satisfaction, quality, and safety outcomes over the course of the care cycle (Vlasses & Smeltzer, 2007). Nursing leaders are in the perfect position to lead the changes essential in care delivery redesign.
Nursing, as a major percentage of the health care labor force, must be able to demonstrate its effectiveness in producing financial as well as clinical outcomes. Nurse leaders are responsible for creating the formal business plan, which includes quantitative analysis of costs and benefits with revenue and expense calculations (Morjikian et al., 2007). It is critical that caregiver costs, roles, and activities be clearly understood. The challenge to prove “value” will continue. Although outcome studies in recent years have clearly linked professional staffing ratios to clinical outcomes (Unruh, 2008), including patient morbidity and mortality, the focus on nursing recruitment and retention to alleviate the most recent nursing shortage has resulted in increased costs. Multiple studies have demonstrated the relationship of nursing satisfaction to work environment, leadership, and perceptions of autonomy, which include the method in which care is delivered.
Mentoring staff to participate in the creation of new care delivery methods is an aspect of effective leadership. Although there appears to be no one right model of care, nurses will be involved in the planning for care delivery, tinkering with improvements in the current model, exploring new models developed by others, or attempting to develop their own new model of care delivery. The leadership and management challenge is to balance risk taking and adoption of innovations with the pragmatic necessity to be systematic, evaluative, and realistic. Knowing and understanding organizational culture and formal and informal networks for getting things accomplished and having complete knowledge of the origin and purpose of policies, practices, and procedures are critical for nursing leaders to be seen as leaders in care delivery redesign (Morjikian et al., 2007).
The central components of practice that need to be considered in the construction of a patient care delivery model are the direct and indirect patient care functions; provider roles and responsibilities; competencies and experience; fiscal accountability and changes in reimbursement; patient characteristics, severity, and clinical service intensity; evidenced-based practice; and new medical information and technology (Deutschendorf, 2003; Wolf & Greenhouse, 2007). The American Organization of Nurse Executives (AONE) (2012) has developed a Guiding Principles for the Role of the Nurse in Future Care Delivery toolkit to help organizations design and build the best location-specific care delivery model. Nurses' autonomy and job satisfaction are affected by the work environment and the structure of the care model used. Leadership is needed to strike a balance between nurses' needs and preferences and those of clients, physicians, and organizations.
CURRENT ISSUES AND TRENDS
The challenges for patient care in the future are massive. The work environment of the nurse is dramatically different now from any other time. Cost containment and demands for quality and safety outcomes will continue to drive systems of patient care delivery. The need for structures to incorporate real-time interdisciplinary communication and care planning over all care transitions is essential to improve patient safety outcomes. The “age of information” will test the ability of the system to integrate discovery into safe practice. Even though studies (Aiken et al., 2002) have demonstrated the relationship between nurse-to-patient ratios and patient outcomes in ICUs and have resulted in increased focus on the nurse's work environment and value, dramatic evaluation must occur to create a vision for health care delivery models of the future. Professional nursing has an opportunity and an obligation to participate in shaping future models that address the changes in patient populations, as well as clinical and financial trends.
The AONE presented a strategy focused on the future development of care delivery models based on the complexities of the current and future health care milieu (Haase-Herrick & Herrin, 2007). Guiding principles address the following: nursing work as knowledge and caring, patient/client-directed care, access to new medical information and technology, “critical synthesis” of knowledge, understanding the relationships of care, and management of care throughout the continuum (Haase-Herrick & Herrin, 2007). Operationalization of the guiding principles can occur only after careful examination and creation of supporting organizational structures and processes.
Clearly, forces and pressures outside of professional nursing influence care models. It is not known which is the best model for each patient care setting, and research evidence to support specific inpatient nursing care models is seriously limited (Jennings, 2008). The evaluation of new patient care delivery systems must include specific quality, financial, and patient satisfaction outcomes. Nurses are urged to examine their client populations, come to grips with the business aspects of health care, and remain vigilant in analyzing emerging economic and clinical trends in order to be active participants in the creation of patient care delivery models of the future.
