14

327

C H A P T E R

14

Organizing Patient Care

The underlying problem is that the American

healthcare system is designed to deliver acute,

not chronic, care.

—Bob Stone

First- and middle-level managers generally have their greatest influence on theorganizing phase of the management process at the unit or department level. It ishere that managers organize how work is to be done, shape the organizational cli-mate, and determine how patient care delivery is organized. It is the top-level man-ager, however, who is most likely to influence the philosophy and resources necessaryfor any selected care delivery system to be effective. Without a supporting philosophyand adequate resources, the most well-intentioned delivery system will fail.

The unit leader–manager determines how best to plan work activities so organi-zational goals are met effectively and efficiently. This involves using resourceswisely and coordinating activities with other departments. How activities areorganized can impede or facilitate communication, flexibility, and job satisfaction.

For organizing functions to be productive and facilitate meeting the organization’sneeds, the leader must know the organization and its members well. Activities will beunsuccessful if their design does not meet group needs. The roles and functions of theleader–manager in organizing groups for patient care are shown in Display 14.1.

MODES OF ORGANIZING PATIENT CARE

The five most well known means of organizing nursing care for patient care deliv-ery 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 thesebasic types has undergone many modifications, often resulting in new terminology.For example, primary nursing has been called case method nursing in the past andis now frequently referred to as a professional practice model. Team nursing issometimes called partners in care or patient service partners and case managersassume different titles, depending on the setting in which they provide care. Whenclosely examined, many of the newer models of patient care delivery systems aremerely recycled, modified, or retitled versions of older models. Indeed, it is some-times difficult to find a delivery system true to its original version or one thatdoes not have parts of others in its design. Although some of these care deliverysystems were developed to organize care in hospitals, most can be adapted toother settings. Choosing the most appropriate organizational mode to deliverpatient care for each unit or organization depends on the skill and expertise ofthe staff, the availability of registered professional nurses, the economic resourcesof the organization, the acuity of the patients, and the complexity of the tasks tobe completed.

Total Patient Care Nursing or Case Method Nursing

Total patient care is the oldest mode of organizing patient care. In this method, nursesassume total responsibility during their time on duty for meeting all the needs ofassigned patients. At the turn of the 19th century, total patient care was generally pro-vided in the patient’s home, and the nurse was responsible for cooking, house cleaning,and other activities specific to the patient and family, in addition to traditional nursingcare (Nelson, 2000). It is important to note that most medical and nursing care for the

328 UNIT 4 � Roles and Functions in Organizing

Choosing the most appropriateorganizational mode todeliver patient care foreach unit or organizationdepends on the skill andexpertise of the staff, theavailability of registeredprofessional nurses, theeconomic resources ofthe organization, theacuity of the patients,and the complexity ofthe tasks to becompleted.

wealthy and middle class during this time occurred in the home; hospitals at the timewere used primarily by the poor and very acutely ill.Total patient care nursing is some-times referred to as the case method of assignment because patients were assigned ascases, much like contemporary private-duty nursing is carried out.

329CHAPTER 14 � Organizing Patient Care

Leadership Roles1. 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 Functions1. 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.

Leadership Roles and Management FunctionsAssociated with Organizing Patient Care

Display 14.1

Total patient careFunctional nursingTeam and modular nursingPrimary nursingCase management

Common Patient Care Delivery MethodsDisplay 14.2

During the Great Depression of the 1930s, people could no longer afford homecare and began using hospitals for care that had been performed by private-dutynurses in the home. During that time, nurses and students were the caregivers inhospitals and in public health agencies. As hospitals grew during the 1930s and1940s, providing total care continued as the primary means of organizing patientcare. A structural diagram of this method is shown in Figure 14.1.

This method of assignment is still widely used in hospitals and home healthagencies. This organizational structure provides nurses with high autonomy andresponsibility. Assigning patients is simple and direct and does not require theplanning that other methods of patient care delivery require. The lines of responsi-bility and accountability are clear. The patient theoretically receives holistic andunfragmented care during the nurse’s time on duty.

Each nurse caring for the patient can, however, modify the care regimen. There-fore, if there are three shifts, the patient could receive three different approaches tocare, often resulting in confusion for the patient. To maintain quality care, thismethod requires highly skilled personnel and thus may cost more than some otherforms of patient care. This method’s opponents argue that some tasks performed bythe primary caregiver could be accomplished by someone with less training andtherefore at a lower cost.

The greatest disadvantage of total patient care delivery occurs when the nurseis inadequately prepared to provide total care to the patient. In the early historyof 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

Charge Nurse

Patients

Patients

Patients

Nursing Staff

Nursing Staff

Figure 14.1 Case method or total patient care structure.

nursing shortages, many hospitals assign healthcare workers who are not RNs toprovide most of the nursing care. Because the co-assigned RN may have a heavypatient load, little opportunity for supervision exists. This potentially could resultin unsafe care.

Functional Nursing

The functional method of delivering nursing care evolved primarily as a result ofWorld War II and the rapid construction of hospitals as a result of the Hill BurtonAct. Because nurses were in great demand overseas and at home, a nursing shortagedeveloped and ancillary personnel were needed to assist in patient care. These rela-tively unskilled workers were trained to do simple tasks and gained proficiency byrepetition. Personnel were assigned to complete certain tasks rather than care forspecific patients. Examples of functional nursing tasks were checking blood pres-sures, administering medication, changing linens, and bathing patients. Registerednurses became managers of care rather than direct care providers, and “care throughothers’’ 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 wasassumed that when the war ended, hospitals would not need ancillary workers. How-ever, the baby boom and resulting population growth immediately following WorldWar II left the country short of nurses. Thus, employment of personnel with variouslevels of skill and education proliferated as new categories of healthcare workers werecreated. Currently, most healthcare organizations have continued this practice ofemploying healthcare workers of many educational backgrounds and skill levels.


RN MedicationNurse

RN TreatmentNurse

Nursing Assistants/Hygienic Care

Clerical/Housekeeping

Patients

Charge Nurse

Figure 14.2 Functional nursing organization structure.

Most administrators consider functional nursing an economical means of provid-ing care. This is true if quality care and holistic care are not regarded as essential. Amajor advantage of functional nursing is its efficiency; tasks are completed quickly,with little confusion regarding responsibilities. Functional nursing does allow care tobe provided with a minimal number of registered nurses. In many areas, such as theoperating room, the functional structure works well and is still very much in evidence.Long-term care facilities also frequently use a functional approach to nursing care.

During the past decade,the use of unlicensed assistive personnel (UAP) inhealthcare organizations has increased. Many nurse administrators believe thatassigning low-skill tasks to UAPs frees the professional nurse to perform morehighly skilled duties and is therefore more economical; however, others argue thatthe time needed to supervise the UAP negates any time savings that might haveoccurred. Most modern administrators would undoubtedly deny that they are usingfunctional nursing, yet the trend of assigning tasks to workers, rather than assign-ing workers to the professional nurse, resembles, at least in part, functional nursing.

Functional nursing may lead to fragmented care and the possibility of overlook-ing patient priority needs. Because some workers feel unchallenged and under-stimulated in their roles, functional nursing also may result in low job satisfaction.Nelson (2000) argues that functional nursing “mutes’’ the nursing process as nurseswho are trained as clinicians become managers of patient care, and that keepingcare patient-centered and individualized is jeopardized. In addition, functionalnursing may not be cost-effective due to the need for many coordinators. Employ-ees often focus only on their own efforts, with less interest in overall results.


Transitioning to Total Patient CareMost nursing students begin their clinical training doing some form of func-tional nursing care and then advancing to total patient care for a smallnumber of patients. Reflect back to your earliest clinical experiences as a stu-dent nurse. Which tasks were easiest for you to learn? How did you gainmastery of those tasks? Was task mastery a time consuming process for you?Was it difficult to make the transition to total patient care? If so, why? Whatskills were most difficult for you to learn in providing total patient care? Doyou anticipate having to learn additional skills to feel comfortable in therole of total care provider as an RN? What higher level (non-functional) skillsdo you think will be the hardest to learn and be confident with?

Learning Exercise 14.1

Team and Modular Nursing

Team nursing was developed in the 1950s in an effort to decrease the problemsassociated with the functional organization of patient care. Many believed thatdespite a continued shortage of professional nursing staff, a patient care system hadto be developed that reduced the fragmented care that accompanied functionalnursing. Team nursing structure is shown in Figure 14.3.

In team nursing, ancillary personnel collaborate in providing care to a group ofpatients under the direction of a professional nurse. As the team leader, the nurseis responsible for knowing the condition and needs of all the patients assigned tothe team and for planning individual care. The team leader’s duties vary depend-ing on the patient’s needs and the workload. These duties may include assistingteam members, giving direct personal care to patients, teaching, and coordinatingpatient activities.

Through extensive team communication, comprehensive care can be providedfor patients despite a relatively high proportion of ancillary staff. This communica-tion occurs informally between the team leader and the individual team membersand formally through regular team planning conferences. A team should consist ofnot more than five people or it will revert to more functional lines of organization.

Team nursing is usually associated with democratic leadership. Group membersare given as much autonomy as possible when performing assigned tasks, althoughthe team shares responsibility and accountability collectively. The need for excellentcommunication and coordination skills makes implementing team nursing difficultand requires great self-discipline on the part of team members.

Team nursing allows members to contribute their own special expertise or skills.Team leaders, then, should use their knowledge about each member’s abilities when


Nursing Staff

Charge Nurse

Patients

Patients

Patients

Team Leader

Team Leader

Team Leader

Nursing Staff

Nursing Staff

Figure 14.3 Team nursing organization structure.

making patient assignments. Recognizing the individual worth of all employeesand giving team members autonomy result in high job satisfaction.

Disadvantages to team nursing are associated primarily with improper imple-mentation rather than with the philosophy itself. Frequently, insufficient time isallowed for team care planning and communication. This can lead to blurred linesof responsibility, errors, and fragmented patient care. For team nursing to be effec-tive, the leader must have good communication, organizational, management, andleadership skills and must be an excellent practitioner.

Team nursing, as originally designed, has undergone much modification in thelast 30 years. Most team nursing was never practiced in its purest form but wasinstead a combination of team and functional structure. Recent attempts to refineand improve team nursing have resulted in the concept of modular nursing, which isa mini-team (two or three members) approach. Members of the modular nursingteam are sometimes called care pairs. Keeping the team small and attempting toassign personnel to the same team as often as possible should allow the professionalnurse more time for planning and coordinating team members. Additionally, asmall team requires less communication, allowing members better use of their timefor direct patient care activities.

Primary Nursing

Primary nursing, also known as relationship-based nursing, developed in the early1970s, uses some of the concepts of total patient care and brings the registerednurse back to the bedside to provide clinical care. Indeed, Manthey (2001) suggeststhat primary nursing is the only type of patient care delivery that requires a one-to-one relationship between a nurse and a patient with responsibility for planning andmanaging care clearly established.

As originally designed, primary nursing requires a nursing staff comprised totallyof RNs. The RN primary nurse assumes 24-hour responsibility for planning thecare of one or more patients from admission or the start of treatment to dischargeor the treatment’s end. During work hours, the primary nurse provides total directcare for that patient. When the primary nurse is not on duty, associate nurses whofollow the care plan established by the primary nurse provide care. Primary nursingstructure is shown in Figure 14.4.

Although designed for use in hospitals, this structure lends itself well to homehealth nursing, hospice nursing, and other healthcare delivery enterprises. An inte-gral responsibility of the primary nurse is to establish clear communication amongthe patient, the physician, the associate nurses, and other team members. Althoughthe primary nurse establishes the care plan, feedback is sought from others in coor-dinating the patient’s care. The combination of clear interdisciplinary group com-munication and consistent, direct patient care by relatively few nursing staff allowsfor holistic, high-quality patient care.

Although job satisfaction is high in primary nursing, this method is difficult toimplement because of the degree of responsibility and autonomy required of theprimary nurse. However, for these same reasons, once nurses develop skill in pri-mary nursing care delivery, they feel challenged and rewarded.


Disadvantages to this method, as in team nursing, lie primarily in improper imple-mentation. An inadequately prepared or incompetent primary nurse may be inca-pable of coordinating a multidisciplinary team or identifying complex patient needsand condition changes. Many nurses may be uncomfortable in this role or initiallylack the experience and skills necessary for the role. Although an all-RN nursing staffhas not been proved to be more costly than other modes of nursing, it sometimes hasbeen difficult to recruit and retain enough RNs, especially in times of nursing short-ages. Currently, licensed vocational and practical nurses serve as associate nurses insome facilities, although the role of the primary nurse should be reserved for an expe-rienced RN who has an appropriate scope of requisite skills for the role.

Case Management

Case management is the latest work design proposed to meet patient needs. Casemanagement is defined by the Case Management Society of America (CMSA) asa collaborative process that assesses, plans, implements, coordinates, monitors, andevaluates options and services to meet an individual’s health needs through com-munication and available resources to promote quality, cost-effective outcomes(Powell, 2000). The focus in case management is on individual patients, not popu-lations of patients. Case managers handle each case individually, identifying themost cost-effective providers, treatments, and care settings for insured individuals(Finkleman, 2001).


Associate Nurse(as needed)

(days)

Associate Nurse(evenings)

Associate Nurse(nights)

HealthcareOrganizations

ResourcesPhysician

ChargeNurse

Primary Nurse

Patient

Figure 14.4 Primary nursing structure.

While case management referrals often begin in the hospital inpatient setting,with length of stay and profit margin per confinement used as measures of efficiency,case management in the managed care era frequently extends to outpatient settings aswell. Historically, however, the focus has been episodic or component-style orienta-tion to the treatment of disease in inpatient settings and post acute care settings forinsured individuals (Finkleman, 2001).

Acute care case management integrates utilization management and dischargeplanning functions and may be unit based, assigned by patient, disease based, orprimary nurse case managed (Powell, 2000). Assignment by unit is most common,particularly in mid- to large-sized hospitals because patient units typically care forpatients with like diagnoses (Smith, 2003). “The advantages of this model includeadditional work efficiency due to geographic proximity, but more importantly, thebenefit of establishing solid working relationships with the nursing and ancillary


Reorganizing to Accommodate a Change in Staffing MixYou are the head nurse of an oncology unit. At present, the patient caredelivery mode on the unit is total patient care. You have a staff composedof 60% RNs, 35% practical nurses (LPNs/LVNS), and 5% clerical staff. Yourbed capacity is 28, but your average daily census is 24. An example of day-shift staffing follows:• One charge nurse who notes orders, talks with physicians, organizes care,

makes assignments, and acts as a resource person and problem solver• Three RNs who provide total patient care, including administering all

treatments and medications to their assigned patients, giving IV med-ications to the practical nurses’ assigned patients, and acting as a clini-cal resource person for the practical nurses

• Two licensed practical nurses assigned to provide total patient careexcept for administering IV medicationsYour supervisor has just told all head nurses that because the hospital

is having difficulty recruiting nurses, it has decided to hire nursing assis-tants. The nurses on your unit will have to assume more supervisoryresponsibilities and focus less on direct care. Your supervisor has askedyou to reorganize the patient care management on your unit to bestuse the following day-shift staffing: three RNs, which will include thepresent charge nurse position; two practical nurses; and two nursingassistants. You may delete the past charge nurse position and dividecharge responsibility among all three nurses or divide up the work anyway you choose.Assignment: Draw a new patient care organization diagram. Who wouldbe most affected by the reorganization? Evaluate your rationale, both forthe selection of your choice and the rejection of others. Explain how youwould go about implementing this planned change.


The focus in casemanagement is onindividual patients, notpopulations of patients.

staff working on the unit’’ (p. 238). In general, a case manager can handle a load of25 patients (Smith).

The premise of inpatient case management is that hospitals are better off “man-aging the demand for care’’ than attempting to try to increase the “supply ofresources’’ such as beds or personnel (Smith, 2003). Case managers do this by usingcritical pathways (see Chapter 10) and multidisciplinary action plans (MAPs) to planpatient care.

The care MAP is a combination of a critical pathway and a nursing care plan. Inaddition, the care MAP indicates times when nursing interventions should occur.All healthcare providers follow the care MAP to facilitate expected outcomes. If apatient deviates from the normal plan, a variance is indicated. A variance is any-thing that occurs to alter the patient’s progress through the normal critical path.Benson et al. (2001) states that the true utility of clinical pathways is derived frominformation obtained through variance tracking—documenting when and why apatient’s care varies from the clinical pathway.

Furlow (2003) suggests a different type of care MAP in her discussion ofcycle time reduction. Cycle time reduction involves reviewing an existing processthat provides a product or service, determining where there’s wasted time oreffort, and developing an improved, streamlined way to achieve the same resultsmore efficiently.

Many other types of case management occur in outpatient settings, althoughonly a few are discussed here. With insurance case management (also known as third-party payor case management), the case manager works as the insurer’s liaison toresolve disputes between providers, patients, and the insurer regarding needed lev-els of care and authorizations for reimbursement. Workers’ compensation case man-agement is directed at preventing worker injuries, when possible, and managingsuch injuries when they occur (Powell, 2000). Entrepreneurial case management usesindependent case management consultants who contract with patients, familymembers, physicians, or insurance companies. These individuals coordinate allaspects of care, in the home and in any level of care needed. Hospice case managerscoordinate end of life care. Finally, home health case managers service the needs ofthe chronically ill in the home setting (Powell). This might include the coordina-tion of wound care, infusion therapy services, physical therapy, speech therapy,occupational therapy, coordination of durable medical equipment, medicationmonitoring and skilled nursing services.

Because the role expectations and scope of knowledge required to be a casemanager are extensive, some experts have argued that this role should bereserved for the advance practice nurse or registered nurse with advanced train-ing (Huston, 2002), although this is not usually the case in the practice settingtoday. Smith (2003) argues that effective case managers should have three to fiveyears of direct care experience, preferably within the specialty area in which theycase manage. They should also be extremely bright, have well-developed inter-personal skills, be able to multitask, have a strong foundation in utilizationreview, and understand payer-patient specifics and hospital reimbursementmechanisms.


DISEASE MANAGEMENT AND CASE MANAGEMENT

One role increasingly assumed by case managers is coordinating disease managementprograms. Disease management (DM), also known as population-based health careand continuous health improvement, is a comprehensive, integrated approach to thecare and reimbursement of high-cost, chronic illnesses. The goal of DM is toaddress such illnesses or conditions with maximum efficiency across treatment set-tings regardless of typical reimbursement patterns (Huston, 2002). Thus, a contin-uum of chronic illness care is established that includes early detection and earlyintervention. This prevents or reduces exacerbation of the disease, acute episodes(known as cost drivers), and the use of expensive resources such as hospital inpatient


Developing a Case Management PlanJimmy Jansen is a 44-year-old man with type I diabetes mellitus. He wasrecently referred to your home health agency for case management follow-up at home. He is experiencing multiple complications from his diabetesincluding the recent onset of blindness and peripheral neuropathy. Hisleft leg was amputated below the knee last year as a result of a gan-grenous infection of his foot. He is unable to wear his prosthesis at pres-ent since he has a small ulcer at the stump site. His chart states that he hasbeen only “intermittently compliant’’ with blood sugar testing or insulinadministration in the past despite the visit of a community health nurseon a weekly basis the past year. His renal function has become progres-sively worse over the past six months and it is anticipated that he willneed to begin hemodialysis soon.

His social history reveals that he recently separated from his wife andhas no contact with an adult son who lives in another state. He has notworked for over 10 years and has no insurance other than Medicaid. Thehome he lives in is small and he says he hasn’t been able to keep it upwith his wife gone. No formal safety assessment of his home has beenconducted. He also acknowledges that he’s not eating right since he nowmust do his own cooking. He cannot drive and states “I don’t know howI’m going to get to the clinic to have my blood cleaned by the kidneymachine.’’Assignment: Mr. Jansen has many problems that would likely benefitfrom case management intervention.1. Make a list of five nursing diagnoses for Mr. Jansen that you would use

to prioritize your interventions.2. Then make a list of at least five goals you would like to accomplish in

planning Mr. Jansen’s care. Make sure these goals reflect realisticpatient outcomes.

3. What referrals would you make? What interventions would you imple-ment yourself? Would you involve other disciplines in his plan of care?

4. What is your plan for follow up and evaluation?

Learning Exercise 14.3A

care, making prevention and proactive case management two important areas ofemphasis (Huston). In addition, DM programs include comprehensive tracking ofpatient outcomes. Thus, the goals for disease management are focused on integrat-ing components and improving long-term outcomes.

In DM programs, common high-cost, high-resource utilization diseases areidentified and population groups are targeted for implementation. This is one ofthe most important differences between case management and disease manage-ment. In population-based health care, the focus is on “covered lives’’ or populationsof patients, rather than on the individual patient (Huston, 2002). The goal in DMis to service the optimal number of covered lives required to reach operational andeconomic efficiency. Providing optimum, cost-effective care to individual patientsis critical to the success of a DM program; however, the focus for planning, imple-mentation, and evaluation is population based.

Other primary features of DM programs include the use of a multidisciplinaryhealthcare team, including specialists in the area, the selection of large populationgroups to reduce adverse selection, the use of standardized clinical guidelines–clinicalpathways reflecting best practice research to guide provider practice, and the useof integrated data management systems to track patient progress across care set-tings and allow continuous and ongoing improvement of treatment algorithms(Reeder, 1999; Huston, 2002). Common features of DM programs are shown inDisplay 14.3.

One thing is clear; DM continues to grow as a means of organizing patient care.This is particularly true in the government sector where there was almost a com-plete absence of DM services in the traditional Medicare plan until early thisdecade (Huston, 2002). Beginning in 2000, Medicare embraced a new round oftrial DM demonstration projects, many of which are now mainstream initiatives, inan effort to deliver better outcomes at better prices (Carroll, June 2000).

In addition, the National Committee for Quality Assurance (NCQA), theDepartment of Health and Human Services, the Joint Commission for the


The goal of diseasemanagement is toaddress a high-cost,chronic illness orcondition with maximumefficiency acrosstreatment settings.

1. Provide a comprehensive, integrated approach to the care and reimbursement ofcommon, high-cost, chronic illnesses.

2. Focus on prevention as well as early disease detection and intervention to avoid costlyacute episodes, but provides comprehensive care and reimbursement.

3. Target population groups (population based) rather than individuals.4. Employ a multidisciplinary healthcare team, including specialists.5. Use standardized clinical guidelines–clinical pathways reflecting best practice research

to guide providers.6. Use integrated data management systems to track patient progress across care settings

and allow continuous and ongoing improvement of treatment algorithms.7. Frequently employ professional nurses in the role of case manager or program

coordinator.

Common Features of Disease Management Programs

Display 14.3

Accreditation of Healthcare Organizations, and the American AccreditationHealthCare Commission (URAC) have all launched initiatives to accredit DMcompanies (Conversation with Bob Stone, 2001). The NCQA accreditationprocess began in January 2002 for organizations that offer comprehensive DMprograms with services to patients, practitioners, or both, and certification fororganizations that provide specific DM functions. URAC announced the first sixDM program accreditation recipients in August 2002 and JCAHO granted its firstDM program certification to a diabetes DM program in April 2002 (DMO pro-gram is first, 2002). The use of impartial, independent, and credible third-partyprograms to evaluate and certify DM programs will increase the validity of suchprograms to both providers and consumers alike.

Another exciting new development is the movement by some DM vendors awayfrom a single disease program to systems that try to deal with all the complicatedoverlaps of co-morbid chronic illnesses, such as heart failure and diabetes (Carroll,March 2000).

DM continues to hold significant promise as a strategy for promoting cost-effective, quality health care in the next millennium, and DM programs can only beexpected to expand in scope and quantity. Similarly, registered nurses, in their rolesas case managers, will continue to experience new and expanded roles as key play-ers in the development, coordination, and evaluation of DM programs in the future(Huston, 2002).


Researching Disease Management ProgramsDo an Internet search on disease management programs. What chronicdiseases were most commonly represented in the disease managementprograms you identified? What entities (private insurance companies,managed care insurers, government, pharmaceutical companies, privatecompanies, etc.) sponsored these programs? What is the process for refer-ral? Are the programs accredited? Are registered nurses used as case man-agers or program coordinators? What standardized clinical guidelines areused in the program and are they evidence based?Assignment: Select one of the disease management programs you foundand write a one-page summary regarding your findings.


SELECTING THE OPTIMUM MODE OF ORGANIZING PATIENT CARE

Most healthcare organizations use one or more modes to organize patient care.Europe currently is experiencing a rapid proliferation of primary nursing, while theUnited States has tended toward more functional and team nursing models thatutilize support and ancillary staff (Nelson, 2000). Nelson suggests that with time, itwill be seen if these models prove to be effective care delivery strategies or simplymore managerial systems to add to the current list.

Manthey (2001) is clear in her assertion that that not all care must be providedby RNs, but states that the care delivery system chosen should be based on patientacuity and not on finances. In addition, she argues that the knowledge and skillrequired for particular activities with specific populations should always be the truedriver in determining appropriate care delivery models.

If evaluation of the present system reveals deficiencies, the manager needs toexamine available resources and compare those with resources needed for thechange. Nursing managers often elect to change to a system that requires a highpercentage of RNs, only to discover resources are inadequate, resulting in a failedplanned change. One of the leadership responsibilities in organizing patient care isto determine the availability of resources and support for proposed changes. Theremust be a commitment on the part of top-level administration and a majority ofthe nursing staff for a change to be successful. Because health care is multidiscipli-nary, the care delivery system used will have a heavy impact on many others outsidethe nursing unit; therefore, those affected by a system change must be involved inits planning. Change affects other departments, the medical staff, and the health-care consumer.

Perhaps most importantly, the philosophy of the nursing services division mustsupport the delivery model selected. Additionally, without support from top-levelhealth facility administration, reorganization of patient care delivery will fail.

Another mistake frequently made when changing modes of patient care deliveryis not fully understanding how the new system should function or be implemented.Managers must carry out adequate research and be well versed in the system’s properimplementation if the change is to be successful. It is important also to rememberthat not every nurse desires a challenging job with the autonomy of personal deci-sion making. Many forces interact simultaneously in employee job design situa-tions. Satisfaction does not occur only because of role fulfillment but also becauseof social and interpersonal relations. Therefore, the nurse leader–manager needs tobe aware that redesigning work that disrupts group cohesiveness may result inincreased levels of job dissatisfaction.

Such change should not be taken lightly. The leader–manager should considerthe following when evaluating the current system and considering a change:

• Is the method of patient care delivery providing the level of care stated in theorganizational philosophy? Does the method facilitate or hinder other orga-nizational goals?

• Is the delivery of nursing care organized in a cost-effective manner?• Does the care delivery system satisfy patients and their families? (Satisfac-

tion and quality care differ; either may be provided without the otherbeing present.)

• Does the organization of patient care delivery provide some degree of fulfill-ment and role satisfaction to nursing personnel?

• Does the system allow implementation of the nursing process?• Does the system promote and support the profession of nursing as both

independent and interdependent?• Does the method facilitate adequate communication among all members of

the healthcare team?


Many nursingdepartments have ahistory of selectingmethods of organizingpatient care based onthe most current popularmode rather thanobjectively determiningthe best method for aparticular unit ordepartment.

• How will a change in the patient care delivery system alter individual andgroup decision making? Who will be affected? Will autonomy decrease orincrease?

• How will social interactions and interpersonal relationships change?• Will employees view their unit of work differently? Will there be a change

from a partial unit of work to a whole unit? (For example, total patient carewould be a whole unit of work, whereas team nursing would be a partial unit.)

• Will the change require a wider or more restricted range of skills and abili-ties on the part of the caregiver?

• Will redesign change how employees receive feedback on their performance,either for self-evaluation or by others?

• Will communication patterns change?

DIFFERENTIATED NURSING PRACTICE

Differentiated nursing practice refers to “the sorting of the roles, functions, and workof registered nurses according to some identified criteria—usually education, expe-rience, and competence—or some combination of these (Huber, 2000, p. 584). Thephilosophy behind differentiated nursing practice is that registered nurses shouldwork within the role structure and responsibilities that correspond best with theirindividual capabilities.

Two basic models are used to differentiate practice (see Display 14.4). The olderone, the education model, reflects the ADN, BSN, and MSN programs and includesthree basic components of nursing: provision of care, communication, and manage-ment. The competency model is based partly on the eight American Nurses Associa-tion’s Standards of Nursing and also reflects Benner’s (1984) five levels of practice:novice, advanced beginner, competent, proficient, and expert. Brady et al. (2001)suggest, however, that the 21 Pew Health Professional Commission Competenciescould serve as a useful tool to nurses and health system leaders as they attempt toadapt the current model of nursing practice to the demands and realities of thecontemporary and continually evolving healthcare environment. Brady et al. arguethat this framework would offer an approach to rationalizing both nursing educa-tion and practice, with the potential for improving the quality of care and reducingfragmentation, cost, and public confusion about a nurse’s educational preparationand scope of practice.


The philosophy behinddifferentiated nursingpractice is thatregistered nurses shouldwork within the rolestructure andresponsibilities thatcorrespond best withtheir individualcapabilities.

Type Type of DifferentiationEducation Model Role differentiation based on type of educational

preparation (ADN, BSN, and MSN)Competency Model Role differentiation based on individual nurse skill level,

expertise, experience, etc.

Two Basic Differentiated Practice ModelsDisplay 14.4

The rationale for differentiated practice is to match patient needs with nursingcompetencies; facilitate the effective and efficient use of nursing resources; provideequitable compensation based on education, productivity, and expertise; increasenurse satisfaction; build loyalty; and increase the prestige of the nursing profession.It also recognizes the broad domain of professional nursing, the multiple roles andresponsibilities that nurses assume, and the contribution of all nursing personnel asvaluable and unique (Blais, Hayes, Kozier, & Erb, 2002). Differentiated nursingpractice is still too new to determine whether it has met the intended goals. It ishoped that the effectiveness of this concept will be thoroughly demonstrated beforeit is widely embraced and, if it is proven to be effective, that it be implemented cor-rectly so that its adaptation will be successful.


Differentiating Practice at the Unit LevelYou are serving on a committee of nurse–managers and staff nurses todevelop guidelines and job descriptions for a new pay structure based ondifferentiated nursing practice. Several members of the committee areresistant to change. Your committee is now looking at four clinical levelsof registered nurses, with different salary ranges for each level. Somebelieve both education and expertise should be required for advance-ment from one level to the next, and others believe it should be basedonly on expertise.

So far, the committee has agreed that nurses who wish to advance tothe next clinical level must (1) apply for an open position at that level, (2) be recommended by both their immediate supervisor and one othernurse of an advanced clinical level, and (3) possess the expertise and education necessary to fulfill the job functions. It is on number three thatyou are having difficulty. You cannot agree on the type (formal or certifi-cations) and amount of education necessary for each level or on how youwill document expertise.Assignment: Write a proposal for differentiating practice at the unitlevel. Will you use education, years of experience, or skill level to differ-entiate your career ladder or will you use some combination of thethree? What would you name each of the four levels of nursing? Willyour minimum requirements for each level be fixed or will you allow forindividual variations?


INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN ORGANIZING PATIENT CARE

Organizing is an important management function. The work must be organized soorganizational goals are sustained. Activities must be grouped so resources, people,materials, and time are used fully. The integrated leader–manager understands thatthe organization and unit’s nursing philosophy and the availability of resources

greatly influence the type of patient care delivery system that should be chosen andthe potential success of future work redesign.

The integrated leader–manager then is responsible for selecting and implement-ing a patient care delivery system that facilitates the accomplishment of unit goals.All members of the work group should be assisted with role clarification, especiallywhen work is redesigned or new systems of patient care delivery are implemented.This team effort in work activity increases productivity and worker satisfaction.The emphasis is on seeking solutions to poor organization of work, rather thanfinding fault.

There is no one “best’’ mode for organizing patient care. Integrating leadershiproles and management functions ensures that the type of patient care deliverymodel selected will provide quality care and staff satisfaction and that change in themode of delivery will not be attempted without adequate resources, appropriatejustification, and attention to how it will affect group cohesiveness. Historically,nursing has frequently adopted models of patient care delivery based on societalevents (e.g., a nursing shortage, a proliferation of types of healthcare workers)rather than upon well-researched models with proven effectiveness that promoteprofessional practice. The leadership role demands that the primary focus ofpatient care delivery be on promoting a professional model of practice that alsoreduces costs and improves patient outcomes.

❊ Key Concepts

• Total patient care, utilizing the case method of assignment, is the oldestform of patient care organization and is still widely used today.

• Functional nursing organization requires the completion of specific tasks bydifferent nursing personnel.

• Team or modular nursing organization uses a leader who coordinates teammembers in the care of a group of patients.

• Primary care nursing is organized so the patient is at the center of the struc-ture. One nurse has 24-hour responsibility for the nursing care plan.

• Case management is a collaborative process that assesses, plans, implements,coordinates, monitors, and evaluates options and services to meet an indi-vidual’s health needs through communication and available resources topromote quality, cost-effective outcomes.

• While the focus historically for case management has been the individualpatient, the case manager employed in a disease management program plansthe care for populations or groups of patients with the same chronic illness.

• Differentiated nursing practice delineates different roles for nurses based ontheir skill, knowledge, educational level, and motivation.

• The care MAP (multidisciplinary action plan) is a combination of a criticalpath and a nursing care plan, except that it shows times when nursing inter-ventions should occur as well as variances.

• Delivery systems may have elements of the various designs present in thesystem in use in any organization.


• Each unit’s care delivery structure should (1) facilitate meeting the goals ofthe organization; (2) be cost-effective; (3) satisfy the patient; (4) providerole satisfaction to nurses; (5) allow implementation of the nursing process;and (6) provide for adequate communication among healthcare providers.

• When work is redesigned, it frequently has personal consequences foremployees that must be considered. Social interactions, the degree of auton-omy, the abilities and skills necessary, employee evaluation, and communica-tion patterns are often affected by work redesign.

More Learning Exercises and Applications


Creating a Plan to Reduce ResistanceYou work in an intensive care unit where there is an RN staff. The unitworks 12-hour shifts, and each nurse is assigned one or two patients,depending on the nursing needs of the patient. The unit has always usedtotal patient care delivery assignments. Recently, your unit manager hasinformed the staff that all patients in the unit would be assigned a casemanager in an effort to maximize the use of resources and to reducelength of stay in the unit. Many of the unit staff resent the case managerand believe this has reduced the RN’s autonomy and control of patientcare. They are resistant to the need to document variances to the careMAPs and are generally uncooperative, but not to the point that they areinsubordinate.

Although you feel some loss of autonomy, you also think that the casemanager has been effective in coordinating care to speed patient dis-charge. You believe that at present the atmosphere in the unit is verystressful. The unit manager and case manager have come to you andrequested that you assist them in convincing the other staff to go alongwith this change.Assignment: Using your knowledge of planned change and case manage-ment, outline a plan for reducing resistance.


Types of Patient Care Delivery Models Used in Your AreaIn a group, investigate the types of patient care delivery models used inyour area. Do not limit your investigation to hospitals. One healthcareorganization should be assigned to a group. If possible, conduct inter-views with nurses from a variety of delivery systems. Share the report ofyour findings with your classmates. How many different models of patientcare delivery did you find? What is the most widely used method inhealthcare facilities in your area? Does this vary from models identifiedmost frequently in current nursing literature?


Web Links

University of Colorado Health Sciences Center. Colorado Differentiated PracticeModel.http://www.uchsc.edu/ahec/cando/nursing/diffpractice97.htmExamines history, purposes, goals, and implementation of Colorado Differentiated Prac-tice Model for Nursing.

M. L. Birnbaum. Guidelines, Algorithms, Critical Pathways, Templates, and Evi-dence-based Medicine (Last modified June 2000)http://pdm.medicine.wisc.edu/birnbaum6.htmDifferentiates between standardized guidelines, algorithms, critical pathways, and tem-plates and urges critical analysis of all these components that form the standards of prac-tice for evidence-based medicine.

Case Management Society of Americahttp://www.cmsa.org/The professional society for case management professionals. This site includes societyinformation, links to other case management sites, and other information about casemanagement.

CNA’s Position on Differentiated Practice/Competency-Based Role Differentia-tion in Nursinghttp://www.calnurse.org/cna/np/np6101599.htmlExamines the California Nurses Association’s 1999 House of Delegates unanimous voteto reaffirm opposition to differentiated nursing practice.


Implementing a Managed Care SystemYou are the director of a home health agency that has recently comeunder a managed care system. In the past, only a physician’s order wasnecessary for authorization from the Medicare system, but now approvalmust come from the managed care organization (MCO). In the past, pub-lic health certified nurses (all BSNs) have acted as case managers for theirassigned caseload. Now the MCO case manager has taken over this role,creating much conflict among the staff. Additionally, there is pressurefrom your board to cut costs by using more less-skilled nonprofessionalsfor some of the home care. You realize that unless you do so, your agencywill not survive.

You have visited other home health agencies and researched youroptions carefully. You have decided you must use some type of teamapproach.Assignment: Develop a plan, objectives, and a time frame for implemen-tation. In your plan, discuss who will be most affected by your changes. Asa change agent, what will be your most important role?


ReferencesA conversation with Bob Stone: How time and circumstance changed disease

management. (2001, December ). Managed Care. Available at:http://www.managedcaremag.com/archives/0112/0112.qna_stone.html.Accessed January 10, 2004.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice.Menlo Park, CA: Addison-Wesley.

Benson, L. M., Bowes, J., Cheesebro, K., Stasa, C., Horst, T., Blyskal, S., et. al. (2001).Using variance tracking to improve outcomes and reduce costs. Dimensions of CriticalCare Nursing, 20(2), 34–42.

Blais, K. K., Hayes, J. S., Kozier, B. & Erb, G. (2002). Professional nursing practice: Conceptsand perspectives (4th ed.). Upper Saddle River, NJ: Prentice Hall Health.

Brady, M., Leuner, J. D., Bellack, J. P., Loquist, R. S., Cipriano, P. F, & O’Neil, E. H.(2001). A proposed framework for differentiating the 21 Pew competencies by level ofnursing education. Nursing and Health Care Perspectives, 22(1), 30–35.

Carroll, J. (2000). DM vendors start to address costs created by comorbidities. Managed Care.Available at: http://www.managedcaremag.com/archives/0203/0203.dmconsolidate.html.Accessed January 10, 2004.

Carroll, J. (2000). DM and Medicare: A marriage made in heaven? Managed Care. Avail-able at: http://www.managedcaremag.com/archives/0206/0206.medicare_dm.html.Accessed January 10, 2004.

DM program is first to be accredited by JCAHO . . . disease management. (2002). Healthcare-Benchmarks, 9(4), 46–47.

Finkelman, A. W. (2001). Managed care: A nursing perspective. Upper Saddle River, NJ:Prentice Hall.

Furlow, L. (2003). Cut the clutter with cycle time reduction. Nursing Management, 34(3),42–44.

Huber, D. (2000). Leadership and nursing care management (2nd ed.). Philadelphia: W.B.Saunders.

Huston, C. (2002). The role of the case manager in a disease management program.Lippincott’s Case Management, 7(6), 221–227.

Manthey, M. (2001). A core incremental staffing plan. Journal of Nursing Administration,31(9), 424–425.

Nelson, J. W. (2000). Models of nursing care: A century of vacillation. Journal of NursingAdministration, 30(4), 156, 184.

Powell, S. K. (2000). Case management: A practical guide to success in managed care (2nd ed.).Philadelphia: Lippincott.

Reeder, L. (1999). Anatomy of a disease management program. Nursing Management,30(4), 41–45.

Smith, A. P. (2003). Case management. Key to access, quality, and financial success. Nurs-ing Economic$, 21(5), 237–240, 244.

BibliographyAckermann, R. J. (May 2001). Primary care. Nursing home practice: Strategies to manage

most acute and chronic illnesses without hospitalization. Geriatrics, 56(5), 37, 40, 43–44.Barkell, N. P. (2002). The relationship between nurse staffing models and patient outcomes:

A descriptive study. Outcomes Management, 6(1), 27–33.Burke, R. J. (2001). Surviving hospital restructuring. Journal of Nursing Administration,

31(4), 169–172.


Coughlin, C. (2000). Is now the time to design new care delivery models? Journal of NursingAdministration, 30(9), 403–404.

Drennan, V. (2001). An assessment of dual-role primary care nurses in the inner city.British Journal of Community Nursing, 6(7), 336–341.

Ebert, J. (2000). Utilizing the nursing “team model’’ to enhance the role of the case manager.Lippincotts Case Management, 5(5), 199–201.

Enhance care by making CM part of Medicare: Value of case managers “yet to be recognized.’’(2003). Hospital Case Management, 11(10), 157.

Gerrish, K., Ferguson, A., Kitching, N., & Mischenko, J. (2000). Developing primary carenursing: The contribution of nursing development units. Journal of Community Nursing,14(6), 8, 10, 12.

Goode, D. (2001). Perceptions and experiences of primary nursing in an ICU: A combinedmethods approach. Intensive Critical Care Nurse, 17(5), 294–303.

Henderson, C. W. (2001, January 15). Study looks at case management intervention toimprove access to care. AIDS Weekly, 10–12.

Horst, L., Werner, R. R., & Werner, C. L. (2000). Case management for children andfamilies. Journal of Child and Family Nursing, 3(1), 5–15.

Ibbs, L. (2001). A team approach stretches RN’s ability to care . . . “Kaiser outlines newnurse staffing ratios,’’ July 30. Nurseweek Calif, 14(17), 2.

Kovner, C. (September 2001). The impact of staffing and the organization of work onpatient outcomes and healthcare workers in healthcare organizations, Joint CommissionJournal on Quality Improvement, 27(9), 458–468.

Make sure that you are culturally competent: CMs should prepare to treat a diverse popula-tion. (2003). Hospital Case Management, 11(10), 149–150.

Mancher, T. (May 2001). A better model by design—and it works. Nursing Management,32(5), 45–47.

Makinen, A. ( July 2003). Organization of nursing care and stressful work characteristics.Journal of Advanced Nursing, 43(2), 197–205.

Mueller, C. (2000). GN management: A framework for nurse staffing in long-term carefacilities. Geriatric Nursing, 21(5), 262–267.

Pesut, D. (2002). Education. Differentiation: Practice versus services. Journal of ProfessionalNursing, 18(3), 118–119.

Potter, P. & Grant, E. (2004). Understanding RN and unlicensed assistive personnel work-ing relationships in designing care delivery strategies. Journal of Nursing Administration,43(1), 19–23.

Powell, S. (2000). Advanced case management: Outcomes and beyond. Philadelphia: Lippincott.Rick, C. (2003). AONE’s leadership exchange. Differentiated practice: Get beyond the fear

factor. Nursing Management, 34(1), 11.Ritter-Teitel, J. (2002). The impact of restructuring on professional nursing practice.

Journal of Nursing Administration, 32(1), 31–41.Ross, F. (2002). Mapping research in primary care nursing: Current activity and future

priorities . . . including commentary by Pearson, P. Nursing Research 7(1), 46–59.Schriefer, J. A., & Botter, M. L. (2001). Tools and systems for improved outcomes. Nurse

case management skills required for care management. Outcomes Management for NursingPractice, 5(2), 48–51.

Smith, A. P. (2003). Case management: Key to access, quality, and financial success. NursingEconomic$, 21(5), 237–240.

Strategies to build high performance nursing teams. (2003). COR Clinical Excellence,4 (1), 6–8.


14

Documents

delivery of patient

organization of patient

total patient care nursing

provision of care

selected care delivery

patient service partners

team nursing

primary nursing