Chapter 21- Managing Client Care

-Nursing Care delivery Models

Nursing care delivery models- methods nurses use to provide care for clients. The selection of a care
delivery model is guided by the vision and philosophy nurses establish for the quality care of clients.
Care delivery has to be effective in helping nurses to achieve the desirable outcome for their clients.
Some important factor that contributes to the success are by decision making authority for nurses who
provide direct care, autonomy, collaborative practice and effective methods of communication with
colleagues, physicians and other health care provider

There are four different types of nursing care delivery models:

 Team nursing
 Total patient care
 Primary Nursing
 Case Management

Team Nursing

The team members provide care under the supervision of an RN. This team could be made up of other
RNs, LPV/LVN, CNA n technicians. Under this method, CNA have client assignments rather than being
assigned nursing tasks. The team leader (the RN that supervises), an experienced RN, develops client
care plans, coordinates care delivered by the team and provide care requiring complex skills. The team
leader also problem solves with physicians and members of other disciplines and assists the team in
evaluating the effectiveness of their care. Communication occurs in chain of command …….it goes from
CHARGE NURSE – CHARGE NURSE –TEAM LEADER- TEAM MEMBERS.

Cons –

 The team leader does not spend much time with the clients.
 Depending on the mix of staff members, a client might see an RN often. Risk exists with this if an
RN is unable to make necessary client assessment and be involved in important clinical decision
making.
 Lack of continuity of care becos the nurses do not have the same pt each day

Pro

 Collaborative style that encourages each mbr of the team to help the other members.
 High Level of autonomy for the team leader.
 Example of decision making at the clinical level.

Total Patient Care

The RN works directly with the patient, family, physician, and health care team members. An RN is
responsible for all aspects of care for one or more clients. The RN may delegate aspects of care to LVN
or unlicensed staff, but the RN is responsible for the care of the assigned clients. This model is typically
shift based. Continuity of care from shift to shift or day to day is a problem if staff members do not
clearly communicate client needs to one another. Client satisfaction is high; however total patient care
is not cost effective because it requires a high # of RNs to provide care.

Primary Nursing Care

RN assumes a caseload of clients during their entire stay. The RN selects the client for his or her caseload
and cares for the same clients during their hospitalization or stay. The primary nurse assesses the client
needs, develops a care plan, and makes sure that appropriate nursing interventions are delivered to the
client. The model is flexible. It maintains continuity of care across shifts, days or visits. When the primary
nurse is off duty, associate nurses, LVN or other RNS, follow through with the developed care plan. If
there is a difference in opinion regarding client’s needs, associates and primary nurses work together to
redefine the plan as needed. Communication in this model is lateral from nurse to nurse and caregiver
to caregiver. Model is not costly even though it requires the presence of more professional staff
members. It minimizes delay in therapies, improves collaboration with other professionals, and helps
build the client-nurse relationship. RN has high level of autonomy and authority that enhances the
collaboration with the physicians.

Case Management

RN maintains responsibility for client care from admission to discharge. Case management is a care
management approach that coordinates and links the health care services to clients and their families
while streamlining costs and maintaining quality. A case manager coordinates a client’s acute care in the
hospital, for example, and then follows up with the client after discharge. Case managers do not always
provide direct care but instead they work wit and supervise the care delivered by other staff members
and actively coordinate discharge planning. Case manager is usually an advanced practice nurses who
through special interventions helps to improve client outcomes such as decrease in readmissions to
hospital and to lower health care costs.

Decentralized Decision Making

This occurs at the unit level. Decision making is moved to the level of staff. It creates an environment
where managers and staff become more actively involved in shaping a health care organization identity
and determining success. Critical to the success of decentralized decision making is making staff
members aware that they have the responsibility, autonomy, authority and accountability for the care
they give and the decisions they make.

Responsibility refers to the duties and activities that an individual is employed to perform. It reflects
ownership. Each RN is on the work team is responsible for knowing his or her role and how to perform
that role on a busy nursing unit
Autonomy- is freedom of choice and responsibility for the choices. It maximizes your effectiveness as a
nurse. Nurses make independent decisions about nursing care. A nurse has the autonomy to develop
and implement a discharge plan based on specific client needs for any client who has been hospitalized.

Authority – refers to the legitimate power to give commands and make final decisions specific to a given
position. Primary nurse has the authority to consult other nurses to learn why the team did not follow
recommendations on the plan of care and to choose the appropriate teaching strategies that all
members of the team will follow.

Accountability refers to individuals being answerable for their actions. Accepting the commitment to
provide excellent client care and the responsibility for the outcome of the actions in providing that care.
A primary nurse is accountable for his or her client’s outcomes and for ensuring that the client learns the
information necessary to improve self-care.

Leadership Skills for Nursing Students

Clinical Care Coordination

This involves accurate clinical decision making, priority setting, efficient organizational skills, use of
resources, time management, and evaluation.

Clinical decision making- This involves using the critical thinking approach, applying previous knowledge
and experience to the decision making process

Priority setting- It is important to prioritize in all care giving situations because it allows you to see
relationships between client problems and avoid delays in taking action that might cause serious
complications for a client. Classify client problems in 3 priority levels – High priority (an immediate
threat to a client’s survival or safety, Intermediate priority (Non emergency, non life threatening actual
or potential needs that the client and family members are experiencing) and Low priority (actual or
potential problems that may not be directly related to the client’s developmental needs and or long
term health care needs). Being able to also identify which of your patient requires attention first.

Efficient organizational skills- Implementing a plan of care requires you to be effective and efficient.
Effective use of time means doing the right things and efficient use of time means doing things right. A
well organized, you approach any planned procedures by having all of the necessary equipment
available and making sure the client is prepared.

Use of resources- Resources include member of the health care team. Never hesitate for a staff to help
you during procedures and patient care.

Evaluation- an ongoing process that starts immediately after therapy has started. It compares actual
client outcomes with expected outcomes.

Team Communication- staff members respect one another’s ideas, share info and keep one another
informed
Delegation- Delegation is transferring responsibility for the performance of an activity or task while
retaining accountability for the outcome. It results in improved efficiency, increased productivity and
development of others. Effective delegation requires the use of good communication skills.