14Organizing Patient CareThe underlying problem is that the American healthcare system is designed to deliver acute, not chronic, care.Bob Stone
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First- and middle-level managers generally have their greatest influence on the organizing phase of the management process at the unit or department level. It is here that managers organize how work is to be done, shape the organizational climate, and determine how patient care delivery is organized. It is the top-level manager, however, who is most likely to influence the philosophy and resources necessary for any selected care delivery system to be effective. Without a supporting philosophy and adequate resources, the most well-intentioned delivery system will fail. The unit leadermanager determines how best to plan work activities so organizational goals are met effectively and efficiently. This involves using resources wisely and coordinating activities with other departments. How activities are organized can impede or facilitate communication, flexibility, and job satisfaction. For organizing functions to be productive and facilitate meeting the organizations needs, the leader must know the organization and its members well. Activities will be unsuccessful if their design does not meet group needs. The roles and functions of the leadermanager in organizing groups for patient care are shown in Display 14.1.
MODES OF ORGANIZING PATIENT CAREChoosing the most appropriate organizational mode to deliver patient care for each unit or organization depends on the skill and expertise of the staff, the availability of registered professional nurses, the economic resources of the organization, the acuity of the patients, and the complexity of the tasks to be completed.
The five most well known means of organizing nursing care for patient care delivery are (1) total patient care, (2) functional nursing, (3) team and modular nursing, (4) primary nursing, and (5) case management (see Display 14.2). Each of these basic types has undergone many modifications, often resulting in new terminology. For example, primary nursing has been called case method nursing in the past and is now frequently referred to as a professional practice model. Team nursing is sometimes called partners in care or patient service partners and case managers assume different titles, depending on the setting in which they provide care. When closely examined, many of the newer models of patient care delivery systems are merely recycled, modified, or retitled versions of older models. Indeed, it is sometimes difficult to find a delivery system true to its original version or one that does not have parts of others in its design. Although some of these care delivery systems were developed to organize care in hospitals, most can be adapted to other settings. Choosing the most appropriate organizational mode to deliver patient care for each unit or organization depends on the skill and expertise of the staff, the availability of registered professional nurses, the economic resources of the organization, the acuity of the patients, and the complexity of the tasks to be completed.
Total Patient Care Nursing or Case Method NursingTotal patient care is the oldest mode of organizing patient care. In this method, nurses assume total responsibility during their time on duty for meeting all the needs of assigned patients. At the turn of the 19th century, total patient care was generally provided in the patients home, and the nurse was responsible for cooking, house cleaning, and other activities specific to the patient and family, in addition to traditional nursing care (Nelson, 2000). It is important to note that most medical and nursing care for the
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Display 14.1 Leadership Roles and Management Functions Associated with Organizing Patient CareLeadership Roles 1. Periodically evaluates the effectiveness of the organizational structure for the delivery of patient care. 2. Determines if adequate resources and support exist before making any changes in the organization of patient care. 3. Examines the human element in work redesign and supports personnel during adjustment to change. 4. Inspires the work group toward a team effort. 5. Inspires subordinates to achieve higher levels of education, clinical expertise, competency, and experience in differentiated practice. 6. Ensures that chosen nursing care delivery models advance the practice of professional nursing. Management Functions 1. Examines the unit philosophy to ensure it supports any change in patient care delivery system. 2. Selects a patient care delivery system most appropriate to the needs of the patients being served. 3. Uses scientific research and current literature to analyze proposed changes in nursing care delivery models. 4. Uses a patient care delivery system that maximizes human and physical resources as well as time. 5. Ensures that nonprofessional staff are appropriately trained and supervised in the provision of care. 6. Organizes work activities to attain organizational goals. 7. Groups activities in a manner that facilitates communication and coordination within and between departments. 8. Organizes work so that it is as cost-effective as possible. 9. Makes changes in work design to facilitate meeting organizational goals. 10. Clearly delineates criteria to be used for differentiated practice roles.
Display 14.2 Common Patient Care Delivery MethodsTotal patient care Functional nursing Team and modular nursing Primary nursing Case management
wealthy and middle class during this time occurred in the home; hospitals at the time were used primarily by the poor and very acutely ill. Total patient care nursing is sometimes referred to as the case method of assignment because patients were assigned as cases, much like contemporary private-duty nursing is carried out.
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During the Great Depression of the 1930s, people could no longer afford home care and began using hospitals for care that had been performed by private-duty nurses in the home. During that time, nurses and students were the caregivers in hospitals and in public health agencies. As hospitals grew during the 1930s and 1940s, providing total care continued as the primary means of organizing patient care. A structural diagram of this method is shown in Figure 14.1. This method of assignment is still widely used in hospitals and home health agencies. This organizational structure provides nurses with high autonomy and responsibility. Assigning patients is simple and direct and does not require the planning that other methods of patient care delivery require. The lines of responsibility and accountability are clear. The patient theoretically receives holistic and unfragmented care during the nurses time on duty. Each nurse caring for the patient can, however, modify the care regimen. Therefore, if there are three shifts, the patient could receive three different approaches to care, often resulting in confusion for the patient. To maintain quality care, this method requires highly skilled personnel and thus may cost more than some other forms of patient care. This methods opponents argue that some tasks performed by the primary caregiver could be accomplished by someone with less training and therefore at a lower cost. The greatest disadvantage of total patient care delivery occurs when the nurse is inadequately prepared to provide total care to the patient. In the early history of nursing, only RNs provided care; now a variety of nursing care personnel, many of who have no license and limited education, work with patients. During
Nursing Staff Nursing Staff Nursing Staff
Patients Patients Patients
Figure 14.1 Case method or total patient care structure.
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nursing shortages, many hospitals assign healthcare workers who are not RNs to provide most of the nursing care. Because the co-assigned RN may have a heavy patient load, little opportunity for supervision exists. This potentially could result in unsafe care.
Functional NursingThe functional method of delivering nursing care evolved primarily as a result of World War II and the rapid construction of hospitals as a result of the Hill Burton Act. Because nurses were in great demand overseas and at home, a nursing shortage developed and ancillary personnel were needed to assist in patient care. These relatively unskilled workers were trained to do simple tasks and gained proficiency by repetition. Personnel were assigned to complete certain tasks rather than care for specific patients. Examples of functional nursing tasks were checking blood pressures, administering medication, changing linens, and bathing patients. Registered nurses became managers of care rather than direct care providers, and care through others became the phrase used to refer to this method of nursing care (Nelson, 2000, p. 156). Functional nursing structure is shown in Figure 14.2. This form of organizing patient care was thought to be temporary as it was assumed that when the war ended, hospitals would not need ancillary workers. However, the baby boom and resulting population growth immediately following World War II left the country short of nurses. Thus, employment of personnel with various levels of skill and education proliferated as new categories of healthcare workers were created. Currently, most healthcare organizations have continued this practice of employing healthcare workers of many educational backgrounds and skill levels.
RN Medication Nurse RN Treatment Nurse Nursing Assistants/ Hygienic Care Clerical/ Housekeeping
Figure 14.2 Functional nursing organiza