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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).
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.
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Professional Nursing Practice within Nursing Care Models
The American Nurses Association (2010) defines nursing as â??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,
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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 di�erentiating healthcare reform provisions that will impact di�ering 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, e�ciency, and transparency.
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. 1â??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 individualâ??s ability to make decisions, requires compeâ?
tence and skills that focus on the nurseâ??patient relationship. It also means that there
needs to be an organized assessment method to determine patient care needs and reas�
signing sta�. 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
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know that they have the right to make decisions in their daily practice and also actively
participate in developing organizational policy and change. Sta� 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 sta�, as is discussed in Chapter 13 . A nursing
practice model that does not address responsibility will not be e�ective. 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. â??It is related to answerability and
to responsibilityâ??judgment and action on the part of the nurse for which the nurse is anâ?
swerable to self and others for those judgments and actionsâ? (Fowler, 2015, p. 44). â??Reâ?
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 relevanceâ??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 e�ective. 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 sta� more
e�ectively. 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.
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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. 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 sta� 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.
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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 e�cient. 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
sta� dissatisfaction with sta� feeling they are just grinding out tasks. When di�erent sta�
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
sta� 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 sta� 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. The team concept or model also focused
on tasks rather than patient care as a whole. More current versions of the team model are
di�erent 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
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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. Over time the nursing shortage
changed and salaries increased. Implementing primary nursing then became more di��
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 e�orts, 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 sta�,
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which was thought to increase sta� costs. The second-generation view of primary nurs�
ing noted that the mix of sta� was more important than having an all-RN sta�. 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 di�erently in di�erent hospitals, as is true of most of the models.
Key elements of these models are empowered sta�, interprofessional collaboration,
skilled workers, and a case management approach to patient careâ??all elements related
to the more current views of leadership and management (IOM, 2011). Care and service
teams introduced the di�erent categories of assistive personnel (e.g., multiskilled work�
ers, nurse extenders, and UAP). There has been some disagreement as to whether these
new sta� member roles were complementary or involve the substitution of professional
nursing care.
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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 sta�. 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. This involves training sta� to work in di�erent spe�
cialty areas or to perform di�erent 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 o�ers much more flexibility in that sta� can fulfill many di�erent
needs. They can then be used, as sta�ng adjustments are needed for changes in patient
census or acuity. It is critical that this cross-training meet patient needs so sta� 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 sta� to provide support, ongoing educational
training, and documentation of competencies, as well as management sta� that under�
stand which sta� 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, di�erent models will be re�
quired, and nursing leadership to develop these models will be critical.
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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 nurseâ??patient relaâ?
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 e�ectively, 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
di�erent types of settings, and the setting also a�ects the definition.
Examples of Newer Nursing Models
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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
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