Discussion: Community Health Nursing

Purpose The purpose of this assignment is to identify nursing care models utilized in today’s various health care settings and enhance your knowledge of how models impact the management of care and may influence delegation. You will assess the effectiveness of models and determine how you would collaborate with a nurse leader to identify opportunities for improvement to ensure quality, safety and staff satisfaction. Course Outcomes Completion of this assignment enables the student to meet the following course outcomes. CO1: Apply leadership concepts, skills, and decision making in the provision of high quality nursing care, healthcare team management, and the oversight and accountability for care delivery in a variety of settings. (PO2) CO2: Implement patient safety and quality improvement initiatives within the context of the interprofessional team through communication and relationship building. (PO3) CO3: Participate in the development and implementation of imaginative and creative strategies to enable systems to change. (PO7) CO6: Develop a personal awareness of complex organizational systems and integrate values and beliefs with organizational mission. (PO7) CO7: Apply leadership concepts in the development and initiation of effective plans for the microsystems and/or system-wide practice improvements that will improve the quality of healthcare delivery. (PO2, and 3) CO8: Apply concepts of quality and safety using structure, process, and outcome measures to identify clinical questions as the beginning process of changing current practice. (PO8) Directions 1. Read your text, Finkelman (2016), pp- 111-116 (I attached this). Discussion: Community Health Nursing

2. Observe staff in delivery of nursing care provided. Practice settings may vary depending on availability. 3. Identify the model of nursing care that you observed. Be specific about what you observed, who was doing what, when, how and what led you to identify the particular model. 4. Write a 5-7 page paper. 5. You are required to complete the assignment using the productivity tools required by Chamberlain University, which is Microsoft Office Word 2013 (or later version), or Windows and Office 2011 (or later version) for MAC. You must save the file in the “.docx” format. Do NOT save as Word Pad. 6. Review and summarize two scholarly resources (not including your text) related to the nursing care model you observed in the practice setting. 7. Review and summarize two scholarly resources (not including your text) related to a nursing care model that is different from the one you observed in the practice setting. 8. Discuss your observations about how the current nursing care model is being implemented. Be specific. 9. Recommend a different nursing care model that could be implemented to improve quality of nursing care, safety and staff satisfaction. Be specific. 10. Provide a summary/conclusion about this experience/assignment and what you learned about nursing care models. 11. Write your paper using APA format using Microsoft Office 2010 or later. 6/2/18, 9)53 PM Professional Nursing Practice within Nursing Care Models The American Nurses Association (2010) defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suf‐ fering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, https://jigsaw.vitalsource.com/api/v0/books/9781323605547/print?from=111&to=116 Page 1 of 18 6/2/18, 9)53 PM PRINTED BY: cervantesneme@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher’s prior permission. Violators will be prosecuted. communities, and populations” (66). The American Organization of Nurse Executives (AONE) assumptions for future patient care delivery include the following: Assumption 1: The role of nurse leaders in future patient care delivery systems will continue to require a systems approach with all disciplines involved in the process and outcome models. Assumption 2: Accountable Care Organizations will emerge and expand as key defin‐ ing and differentiating healthcare reform provisions that will impact differing care deliv‐ ery venues. Assumption 3: Patient safety, experience improvement and quality outcomes will re‐ main a public, payer and regulatory focus driving work flow process and care delivery system changes as demanded by the increasingly informed public. Assumption 4: Healthcare leaders will have knowledge of funding sources and will be able to strategically and operationally deploy those funds to achieve desired out‐ comes of improved quality, efficiency, and transparency. Discussion: Community Health Nursing

Assumption 5: The joint education of nurses, physicians, and other health profession‐ als will become the norm in academia and practice promoting shared knowledge that enables safer patient care and enhancing the opportunity for pass-through dollars to apply to APRN residencies and/or related clinical education (2010, pp. 1–3). The five NAM core competencies are interrelated with these assumptions. Also, all of these elements have been discussed in earlier chapters or will be discussed in later chapters, as they are critical aspects of leadership and management. Intertwined within these critical elements is the recognition of the importance of leadership, autonomy, re‐ sponsibility, delegation, and accountability. Autonomy, which focuses on an individual’s ability to make decisions, requires compe‐ tence and skills that focus on the nurse–patient relationship. It also means that there needs to be an organized assessment method to determine patient care needs and reas‐ signing staff. Nurses also have the right to consult with others as professionals when they provide or manage care. Autonomy, control, and decision making are related, and state Nurse Practice Acts reflect on nurse autonomy. Nurses who feel that they have autonomy https://jigsaw.vitalsource.com/api/v0/books/9781323605547/print?from=111&to=116 Page 2 of 18 6/2/18, 9)53 PM know that they have the right to make decisions in their daily practice and also actively participate in developing organizational policy and change. Staff autonomy, however, does not work in organizations in which leaders are authoritarian and when centralized decision making and control are key characteristics of the organization. This situation will quickly lead to conflict. In addition, the work environment must be conducive to collabo‐ ration with physicians and all relevant staff, as is discussed in Chapter 13 . A nursing practice model that does not address responsibility will not be effective.

Along with this is the need to clearly recognize the importance of delegation. Delegation is discussed in more detail in Chapter 15 . Accountability is a term that is typically found in job de‐ scriptions and descriptions of organizational structure. “It is related to answerability and to responsibility—judgment and action on the part of the nurse for which the nurse is an‐ swerable to self and others for those judgments and actions” (Fowler, 2015, p. 44). “Re‐ sponsibility refers to the specific accountability or liability associated with the perfor‐ mance of duties of a particular nursing role and may, at times, be shared in the sense that a portion of responsibility may be seen as belonging to another who was involved in the situation” (Fowler, 2015, p. 44). Nurses need to know that when they provide patient care, their work has relevance—it must reach outcomes. Accountability, autonomy, and responsibility need to be considered when nursing prac‐ tice models are assessed. Nursing models of care are developed to support or enhance professional practice, and by considering these elements and characteristics, the models will be more effective. Within an HCO, how do nurses provide nursing care? What is a model of care? Are these elements found in the model? Models might also be called nursing or patient care delivery systems. These models have undergone major changes over the past several decades. Nursing practice models have been used to implement resource-intensive strategies with the goal of decreasing expenses and using staff more effectively. Nursing models help to identify and describe nursing care. The NAM empha‐ sis on the five core competencies could also be used for a model, and as newer models are discussed later, it is easy to see how these five competencies are the key elements of healthcare delivery. https://jigsaw.vitalsource.com/api/v0/books/9781323605547/print?from=111&to=116 Page 3 of 18 6/2/18, 9)53 PM PRINTED BY: cervantesneme@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher’s prior permission. Violators will be prosecuted. Historical Perspective of Nursing Models The following is a description of common models, some of which have undergone many changes over the years or are not used anymore, but they have had an impact on newer models. Total Patient Care/Case Method In this model, which is the oldest, the registered nurse is responsible for all of the care provided to a patient for a shift. A major disadvantage of this model is the lack of consis‐ tency and coordinated care when care is provided in eight-hour segments. Discussion: Community Health Nursing

This type of care is rarely provided today, except among student nurses who are assigned to provide all of the care for a patient during the hours that they are in clinical. Even in this case, the students frequently do not provide all of the care as they may not be qualified to do this, and a staff nurse maintains overall responsibility for the care. Home health agencies use a form of this model when nurses are assigned patients and provide all the required home care; however, even this has been adapted as teams provide more home care. An RN may coordinate the care and provide professional nursing services, but a home care aide may provide most of the direct care, and other providers such as a physical therapist, di‐ etician, and social worker may be required for specialty care. https://jigsaw.vitalsource.com/api/v0/books/9781323605547/print?from=111&to=116 Page 4 of 18 6/2/18, 9)53 PM Functional Nursing The model of functional nursing is a task-oriented approach, focusing on jobs to be done. When it was more commonly used, it was thought to be more efficient. The nurse in charge assigned the tasks (e.g., one nurse may administer medications for all or some of the patients on a unit; an aide may take vital signs for all patients). A disadvantage of this model is the risk of fragmented care. In addition, this type of model also leads to greater staff dissatisfaction with staff feeling they are just grinding out tasks. When different staff members provide care without awareness of other needs and the care provided by oth‐ ers, individualized care may also be compromised.

This model is not used much now. It can be found in some long-term care facilities and in some behavioral/psychiatric inpa‐ tient services, although in a modified form. In the latter situation, a registered nurse may be assigned the task of medication administration for the unit, and psychiatric support staff may be assigned such tasks as vital signs and safety checks of all patients. In this situation, RNs would still be assigned to individual patients to coordinate their care. Team Nursing This model was developed after World War II during a severe nursing shortage and other major changes in medical technology occurred. It replaced functional nursing. A nursing team consists of a registered nurse, licensed practical/vocational nurses, and UAP. This team of two or three staff provides total care for a group of patients during an 8- or 12hour shift. The RN team leader coordinates this care. In this model the RN has a high lev‐ el of autonomy and assumes the centralized decision-making authority. Although the past approach to team nursing was thought to use decentralized decision making with deci‐ sions made closer to the patient, there actually was limited team member collaboration. In addition, these teams tended to communicate only among themselves and not as well with physicians and other healthcare providers. Discussion: Community Health Nursing

The team concept or model also focused on tasks rather than patient care as a whole. More current versions of the team model are different from this earlier type. Currently the team model has been changed to meet shifts in organizations and leadership corresponding to the needs for better consistency and continuity of care as well as collaboration and coordination and patient-centered care. Primary Nursing https://jigsaw.vitalsource.com/api/v0/books/9781323605547/print?from=111&to=116 Page 5 of 18 6/2/18, 9)53 PM In the late 1970s, care became more complex, and nurses were dissatisfied with team nursing. In the primary nursing model, the primary nurse, who must be an RN, provides direct care for the patient and the family; an associate nurse provides care following the care plan developed by the primary nurse when the primary nurse is not working and as‐ sists when the primary nurse is working. The primary nurse needs to be knowledgeable about assigned patients and must maintain a high level of clinical autonomy. When pri‐ mary nursing was first used, it was easier to substitute RNs for other healthcare providers as cost was not as much of a focus as it is today. Discussion: Community Health Nursing

Over time the nursing shortage changed and salaries increased. Implementing primary nursing then became more diffi‐ cult, and healthcare cost moved to the top of the concerns. Primary nursing is often viewed as a model in which the primary nurse has to do everything, limiting collaborative or team efforts, although it does not have to be implemented in this way. Second-generation primary nursing clarified some of the issues about this practice mod‐ el. One of the critical problems with primary nursing was whether or not it required an allRN staff, https://jigsaw.vitalsource.com/api/v0/books/9781323605547/print?from=111&to=116 Page 6 of 18 6/2/18, 9)53 PM PRINTED BY: cervantesneme@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher’s prior permission. Violators will be prosecuted. which was thought to increase staff costs. The second-generation view of primary nurs‐ ing noted that the mix of staff was more important than having an all-RN staff. Another concern with primary nursing was a need to develop a clear definition of 24-hour ac‐ countability, which was interpreted by some as 24-hour availability.

This, of course, is not a reasonable approach, and it really does not apply to primary nursing. When the primary nurse is not working, the associate nurse provides the care. Primary nursing is a respon‐ sibility relationship between the nurse and the patient. The primary nurse is not the only caregiver but does have responsibility for planning nursing care and ensuring that care outcomes are met. Only registered nurses can be primary nurses. This role and the model require RNs who are competent and possess leadership skills. Primary nursing is not used as much today. Care and Service Team Models In the 1980s care and service team models began to replace primary nursing. These models are implemented differently in different hospitals, as is true of most of the models. Key elements of these models are empowered staff, interprofessional collaboration, skilled workers, and a case management approach to patient care—all elements related to the more current views of leadership and management (IOM, 2011). Care and service teams introduced the different categories of assistive personnel (e.g., multiskilled work‐ ers, nurse extenders, and UAP). There has been some disagreement as to whether these new staff member roles were complementary or involve the substitution of professional nursing care. https://jigsaw.vitalsource.com/api/v0/books/9781323605547/print?from=111&to=116 Page 7 of 18 6/2/18, 9)53 PM Complementary Models Complementary models began in 1988 by using nurse extenders, such as a unit as‐ sistant, who would be responsible for environmental functions. The nurse would then have more time for direct patient care. Does this reduce costs? When nurse positions are changed to nurse extender positions, there is some cost reduction, but this change can impact all nursing staff. Complementary models are not used as much today and have been replaced by substitution models in HCOs. Substitution models tend to use multi‐ skilled technicians to perform select nursing activities, and the RNs supervise these activities. Another approach is cross-training. Discussion: Community Health Nursing

This involves training staff to work in different spe‐ cialty areas or to perform different tasks. For example, a respiratory therapist may be trained not only to perform typical respiratory therapist tasks but also phlebotomy and basic nursing care. This offers much more flexibility in that staff can fulfill many different needs. They can then be used, as staffing adjustments are needed for changes in patient census or acuity. It is critical that this cross-training meet patient needs so staff will be able to deliver quality, safe care and not feel undue stress while delivering the care. It is also important that state practice act requirements are met, and this is not always easy to accomplish. It requires HCO education staff to provide support, ongoing educational training, and documentation of competencies, as well as management staff that under‐ stand which staff members are qualified to move from area to area. Hospitals and other HCOs have tried to find the best methods for using substitution without compromising quality and safety and yet control costs. As demands change, different models will be re‐ quired, and nursing leadership to develop these models will be critical. https://jigsaw.vitalsource.com/api/v0/books/9781323605547/print?from=111&to=116 Page 8 of 18 6/2/18, 9)53 PM Case Management Model As with earlier team models, the RN must spend time coordinating care and the work. The focus of the team is on patient-centered care as opposed to the nurse–patient rela‐ tionship. The case management model is based on the assumption that patients with complex health problems, catastrophic health situations, and high-cost medical condi‐ tions need assistance in using the healthcare system effectively, and a case manager can help patients with these needs (Finkelman, 2011). Case managers may also work with the teams to achieve outcomes, which increases shared accountability. Case manage‐ ment can be viewed as a nursing model when the case manager is a nurse; however, in some HCOs nurses are not used as case managers but rather other healthcare profes‐ sionals such as social workers serve as case managers.

Several healthcare professional organizations and experts have defined case management; however, there clearly is no universally accepted definition for case management. Case management is used in many different types of settings, and the setting also affects the definition. Examples of Newer Nursing Models https://jigsaw.vitalsource.com/api/v0/books/9781323605547/print?from=111&to=116 Page 9 of 18 6/2/18, 9)53 PM Interprofessional Practice Model The interprofessional practice model is emphasized in the IOM reports on quality im‐ provement by identifying the importance of all health professions meeting the in‐ terdisciplinary or interprofessional competency and emphasizing the need to https://jigsaw.vitalsource.com/api/v0/books/9781323605547/print?from=111&to=116 Page 10 of 18 6/2/18, 9)53 PM PRINTED BY: cervantesneme@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmit . Discussion: Community Health Nursing