Advocacy and moral agency

Professional Nursing Practice within Nursing Care Models

Finkelman, A. (2016). Leadership and management for nurses: Core competencies for quality care (3rd ed.). Boston, MA: Pearson.

The American Nurses Association ( 2010 ) defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, 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 defining and differentiating healthcare reform provisions that will impact differing care delivery venues.

· Assumption 3: Patient safety, experience improvement and quality outcomes will remain 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 outcomes of improved quality, efficiency, and transparency.

· Assumption 5: The joint education of nurses, physicians, and other health professionals 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, responsibility, delegation, and accountability.

Autonomy, which focuses on an individual’s ability to make decisions, requires competence 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 reassigning 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 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 collaboration 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 descriptions 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 answerable to self and others for those judgments and actions” ( Fowler, 2015 , p. 44). “Responsibility refers to the specific accountability or liability associated with the performance 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 practice 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 emphasis 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.

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 consistency 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 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, dietician, and social worker may be required for specialty care.

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 others, 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 inpatient 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 12-hour shift. The RN team leader coordinates this care. In this model the RN has a high level of autonomy and assumes the centralized decision-making authority. Although the past approach to team nursing was thought to use decentralized decision making with decisions 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 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

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 assists 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 primary 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 difficult, 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 model. One of the critical problems with primary nursing was whether or not it required an all-RN staff, which was thought to increase staff costs. The second-generation view of primary nursing 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 accountability, 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 responsibility 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 workers, 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.

Complementary Models

Complementary models began in 1988 by using nurse extenders, such as a unit assistant, 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 multiskilled technicians to perform select nursing activities, and the RNs supervise these activities.

Another approach is cross-training. This involves training staff to work in different specialty 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 understand 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 required, and nursing leadership to develop these models will be critical.

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 relationship. The case management model is based on the assumption that patients with complex health problems, catastrophic health situations, and high-cost medical conditions 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 management 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 professionals 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

Interprofessional Practice Model

The interprofessional practice model is emphasized in the IOM reports on quality improvement by identifying the importance of all health professions meeting the interdisciplinary or interprofessional competency and emphasizing the need to work in interprofessional teams “to cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable” ( 2003 , p. 4). These teams include providers from different healthcare professions and occupations designed to meet the required patient needs. With increasing complex patient care needs, this model is better able to address needs and to effectively use a mix of expertise and knowledge to reach patient outcomes. Patient-centered care is the focus.

Synergy Model for Patient Care™

This model of care was developed by the American Association of Critical-Care Nurses, but it has been applied in all types of nursing units. The model recognizes the need to match the nurse’s competence with the patient’s characteristics, needs, and the clinical unit ( American Association of Critical-Care Nurses, 2014 ). Patient characteristics incorporated into this model are as follows ( American Association of Critical-Care Nurses, 2014 ):

· Resiliency: the capacity to return to a restorative level of functioning using compensatory/coping mechanisms; the ability to bounce back quickly after an insult

· Vulnerability: susceptibility to actual or potential stressors that may adversely affect patient outcomes

· Stability: the ability to maintain a steady-state equilibrium

· Complexity: the intricate entanglement of two or more systems (e.g., body, family, therapies)

· Resource availability: extent of resources (e.g., technical, fiscal, personal, psychological, and social) the patient/family/community brings to the situation

· Participation in care: extent to which patient/family engages in aspects of care

· Participation in decision making: extent to which patient/family engages in decision making

· Predictability: a characteristic that allows one to expect a certain course of events or course of illness

The Synergy model ties the above patient characteristics with the following nurse competencies ( American Association of Critical-Care Nurses, 2014 ):

· Clinical judgment: clinical reasoning, which includes clinical decision making, critical thinking, and a global grasp of the situation, coupled with nursing skills acquired through a process of integrating formal and informal experiential knowledge and evidence-based guidelines.

· Advocacy and moral agency: working on another’s behalf and representing the concerns of the patient/family and nursing staff; serving as a moral agent in identifying and helping to resolve ethical and clinical concerns within and outside the clinical setting.

· Caring practices: nursing activities that create a compassionate, supportive, and therapeutic environment for patients and staff, with the aim of promoting comfort and healing and preventing unnecessary suffering. Includes, but is not limited to, vigilance, engagement, and responsiveness of caregivers, including family and healthcare personnel.

· Collaboration: working with others (e.g., patients, families, healthcare providers) in a way that promotes/encourages each person’s contributions toward achieving optimal/realistic patient/family goals. Involves intra- and interprofessional work with colleagues and community.

· Systems thinking: body of knowledge and tools that allow the nurse to manage whatever environmental and system resources exist for the patient/family and staff, within or across healthcare and nonhealthcare systems.

· Response to diversity: the sensitivity to recognize, appreciate, and incorporate differences into the provision of care. Differences may include, but are not limited to, cultural differences, spiritual beliefs, gender, race, ethnicity, lifestyle, socioeconomic status, age, and values.

· Facilitation of learning: the ability to facilitate learning for patients/families, nursing staff, other members of the healthcare team, and community. Includes both formal and informal facilitation of learning.

· Clinical inquiry (innovator/evaluator): the ongoing process of questioning and evaluating practice and providing informed practice. Creating practice changes through research use and experiential learning.

Patient Navigation

Patient navigation is a model that has primarily focused on patients with cancer who are at risk for poor cancer outcomes though other types of patient populations have also benefited from patient navigation ( Wells et al., 2008 ). Clinical nurse leaders often hold the position of nurse navigator. Patient navigation focuses on decreasing barriers to better ensure that patients get the care they need when they need it ( Finkelman, 2011 ). This model is “an intervention designed to reduce health disparities by addressing specific barriers to obtaining timely, quality healthcare” ( Wells et al., 2008 , p. 2010).

The ACA and New Models

The Future of Nursing ( Institute of Medicine, 2011 ) includes content about transformational models of nursing across different care settings. The report notes there are some common themes from the examples reviewed. “In order to meet the challenges of the future, we must embrace technology, foster partnerships, encourage collaboration across disciplines and settings, ensure continuity of care and promote nurse-lead/nurse managed health care” (402). The ANA has also commented on the ACA and its potential impact on nursing models of care. The ANA notes, as do other sources such as the NAM, that the healthcare system is dysfunctional and fragmented. A major goal of the ACA is to rebalance the healthcare system’s resources by identifying several models of care, focusing on primary care, that might help to reach this goal ( 2010 ):

· Accountable Care Organization (ACO): Provides a collaborative model for primary care providers and specialists who work together to achieve quality care and control costs. ACOs that are successful receive financial incentives. ACOs are part of the Medicare Program. Providers may include MDs, APRNs, CNSs, and PAs.

· Medical/Health Homes: The focus in this model is on primary care providers coordinating patient care. Financial incentives as well as interprofessional teams may also be part of this model.

· Nurse-Managed Health Clinic (NMHC): This is a clinic that is managed by nurses that provides comprehensive primary care and wellness services and must be associated with a university/college/department of nursing, a federally qualified health center, or an independent nonprofit health or social services agency. This type of clinic is led by APRNs.

Shared Governance and Empowerment

Shared governance is an approach to management that engages staff at all levels in the decision-making process. This does not mean that there are inactive or ineffective leaders and managers, but rather they meet their management responsibilities by ensuring that staff are active in the processes, which increases each nurse’s influence over the organization, empowering staff.

Shared governance can be viewed as a management philosophy, a professional practice model, and an accountability model that focuses on staff involvement in decision making, particularly in decisions that affect their practice. In doing this, the model provides staff with autonomy and control over implementation of their practice—legitimizing control over their own practice. Nurses in these organizations usually feel less powerless and are more efficient and accountable.

A critical factor in shared governance is that accountability and responsibility are found in the same person. Accountability should rest in the person who is most likely to be the most effective person to complete the function. For individual staff to be accountable and responsible for a function or task, staff must also have the authority to make sure that the right decisions are made.

Transformational leadership enhances shared governance. As was discussed in  Chapter 1 , an important element of leadership is self-awareness, and it is essential in shared governance. In this type of organizational arrangement, staff members feel committed to the HCO and view themselves

Case Study Does a Nursing Model Make a Difference?

You are the director of staff development in a large university hospital, and the chief nurse executive (CNE) has met with you to discuss orientation for student nurses and faculty. The CNE is concerned that students and faculty do not understand the hospital’s new nursing model, Synergy Model for Patient CareTM. She tells you it is your job to correct this problem. You leave the meeting overwhelmed. This seems like a big responsibility to you. The hospital has many nursing students from three schools of nursing that use its services for practicum. All have to attend a four-hour orientation to the hospital, which is already overburdened with content, and the faculty and students have limited time for orientation. The units have also been struggling with applying the model since it was initiated six months ago.

Questions

1. Why is it important for the students and faculty to understand the model?

2. How does the nursing model relate to the organization’s theory or approach?

3. How would you describe this model? Consider methods and examples.

4. Develop a plan that you will submit to the CNE explaining how you will address this problem. Whom might you include in developing the plan and in implementing it?

as partners in meeting the goals of the HCO. In shared governance nurse managers typically are not directly involved in daily direct patient care, although there are some managers who are still involved in direct care. The typical responsibilities of the nurse manager are staffing, program evaluation, personnel evaluation, coordination, allocation of resources, financial activities, and planning, as discussed in  Chapter 1 . If patient care outcomes are not met, it is the responsibility of the nurse providing the care to address this issue. The nurse manager may become involved, but it is the direct care provider who should take the lead. In other words, clinical practice is the responsibility of the practitioners. When clinical problems occur, the nurse who provides direct care must be the one to solve these problems, working with the care team. The main factor in shared governance is that decision making is spread over a larger number of staff and is decentralized. Nurses are accountable for not only their management activities but also their practice. Healthcare organizations that use shared governance must have clear communication processes, or the organization will encounter problems and confusion in the decision-making process. The key components of shared governance are practice, quality, education, and peer process/governance. How are these accomplished? As with any such change, some organizations actually change and others merely appear to change to this model, but in the latter situation, very little has really changed in the decision-making process or in actual practice. Shared governance is associated with collaboration, horizontal relationships, and investment, and these need to be demonstrated in the organization. The change has to be real, and typically when it is, staff are more satisfied.

Organizations that use this model require some type of structure that relates to the shared accountability, such as councils, cabinets, committees, or a combination of these groups or teams that make the decisions. The chain of command is not the same as in traditional organizations. In the shared governance model, these groups make many of the decisions about policies, procedures, and other aspects of getting the work done. How might shared governance be implemented?

Healthcare organizations have been working for several years to create leaner and more effective organizations. It is important to recognize that to move toward a shared governance model, the organization must take a comprehensive change approach and not an incremental approach. All parts of the organization and all staff must be expected to change. This is very difficult to accomplish, but if shared governance is the goal, it is necessary.

Decentralized decision making is now found in many HCOs, and it is frequently associated with participative management strategies such as a shared governance model. This approach to organizational structure and process is associated with the economy, job satisfaction, and retention. For decentralization to be effective, staff must have autonomy to make decisions. All of this is intimately connected with shared governance. It requires staff members who are committed to the organization’s values and goals and demonstrate this by working to meet the goals.

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