Models of Care

One challenge for nursing will be to address the viability of primary nursing. (Note: italics denote changes made March 2001) While current perspectives and applications of primary nursing are absent from the literature, two editorials published in the Journal of Professional Nursing by Joyce Clifford of Beth Israel, Boston (1988) and Kathleen Andreoli of Rush Presbyterian/St.Lukes, Chicago (1992) remain valid. Clifford (1988) began her piece by challenging the statement that "Primary Nursing is dead." She argues that "Primary Nursing is alive and well." Why the confusion? She asserts that it is not always clearly understood that the development of primary nursing and a professional practice model comes from a strong philosophical commitment rather than merely from the understanding of a nurse-patient assignment method.

Clifford (1988) notes that time has shown that nurses will no longer accept the mere performance of tasks as their practice goal outcomes. Nor will they remain in systems that promote fragmented, uncoordinated care leading to dissatisfaction for everyone - the patient, nurse, and hospital. Instead, nurses seek opportunities to provide comprehensive, professional care through a system that allows for continuity of patient care as well as the opportunity for them to maximize their knowledge and skill. The change they made from a functional/team delivery system of care to a system that provides for a comprehensive, coordinated approach to patient care required the best prepared, i.e., the registered nurse, rather than the least prepared to be placed in the most direct and constant care relationship with patients and families. It is this relationship with patients that must be preserved for the future if a balance is to be struck between the goals of cost and quality in health care. This nurse-patient relationship is, of course, the underlying principle of primary nursing.

In the early 1990's, management consultants advocated for the development of a model called Patient Focused Care. However, for many, this model resulted in an increase of nursing aides and a decrease of professional nurses. Andreoli (1992 ) identifies the 1990's as the decade of ideal nursing skill mixes and delegation. Nurses must know what tasks are appropriate to "give away," how to manage the workload and be accountable for outcomes, and how to provide for the growth and development of non-RN caregivers and other support staff. Andreoli envisioned that this change would not come easily, and, it hasn't. Nurses sometimes feel less valued when they must delegate tasks to a non-nurse. However, nursing can consider delegation, along with shared governance, as another form of empowerment.

Delegation, though, must be learned, practiced, evaluated, and improved. Delegation is an art, and the delegator must have an understanding of the essentials of management, chain of command, span of control, licensed versus unlicensed assistive personnel, nursing task versus professional responsibilities, liabilities, mentorship, evaluation, and continuous quality improvement. Andreoli stresses that in a successful delegation model, primary nurses will have time to give patients the benefit of their knowledge and skills. Tasks not requiring a nurse's educational preparation will be delegated to qualified assistive personnel. Nursing leadership must create an environment where delegation is supported and valued and positive outcomes are rewarded. The patient then is the winner with the best of both types of providers.

Numerous studies on delivery models and restructuring demonstrate that different staff mixes and approaches work in different settings. There isn't a "one size fits all" model. However, what must remain constant is the guarantee that every patient has a nurse.

An example of a futuristic model of care was developed at the Massachusetts General Hospital and presented as a Harvard Business School case study (1999). Similar to almost every other healthcare institution in America, this system of care delivery emerged after careful reflection on many factors: the local and national labor market, the changing profile of patients served, the nature of the workforce, and the systems or infrastructure that supported practice. The Massachusetts General Hospital Patient Care Delivery Model (Figure 1 ) was derived after careful development of vision, values and long-range goals. In this model vision, values and goals converge to support the delivery of patient care. The model depicts the dynamic and therapeutic interaction that occurs between the professional care provider and the patient around issues of health and illness. The model reflects an open, evolving interactive system where there is continuous exchange occurring between the patient and the clinician (nurse, therapist, or social worker). The model also depicts the multiple internal and external forces that impact upon the patient's experience as well as the structures supporting the delivery of patient care.

Figure 1.

EXTERNAL HEALTH CARE ENVIRONMENT

The larger, important circle surrounding the core represents the interdisciplinary partnerships within the multiple settings where patient care is delivered. This is an important message for staff nurses who feel supported in their practice by all team members. While this is an example of one model that considered internal and external factors, it does reflect the elements that must be considered during this time of a structural shortage of healthcare workers.

Again, this shortage is different and most likely not cyclical in nature. In any model a balance must be struck between: a) supply and demand, b) quality and organizational effectiveness, c) staff satisfaction, and d) financial viability.