93
Chapter 12
Understanding Nursing
Care Models: Industrial
Engineering Healthcare Book
Marvina Williams
Introduction
ere are many professions in healthcare, but registered nurses (RNs) are denitely the majority.
Registered nurses are the backbone of the hospital and ambulatory care facilities. eir expertise
is essential in the care of patients. Nursing care is carried out through various organizational
methods. ese methods are models of nursing care [1]. A model determines the roles of the nurse
and other caregivers, and the way they all work together to provide care for the patient [2]. ese
models address and aect the following issues:
1. Stang of nurses and their partners in care
2. Salaries or operating costs
3. Eectiveness and eciency of care for the patients
Nurse stang and the nursing care models vary depending on the following:
Contents
Introduction .............................................................................................................................. 93
Nursing Care Models ................................................................................................................ 95
Team/Functional Nursing Care Model ................................................................................. 95
Primary Nursing Care Model ................................................................................................ 95
Patient-Focused Nursing Care Model ................................................................................... 95
Future of Nursing Care Models ................................................................................................. 96
References ................................................................................................................................. 97
94 ◾ Marvina Williams
1. Acuity of the patient
2. Area to which the nurse is assigned
3. Duties or tasks required
4. Partnerships with the nurse
5. Culture of the facility
e nursing care model can aect the outcomes and safety of patients. Patients are grouped by
age, such as pediatric and adult, and by the acuity of nursing care required. Some facilities will set
the cuto for pediatric patients at age 16, while others set this age at 18. Depending on the facility,
there may not be pediatric services and the facility may transfer the patient to another facility if
admission is needed.
With regard to acuity, there are acute care oors and critical care or intensive care oors. Most
of patients in the hospital setting are considered acute care patients, and are separated into medi-
cal and surgical patients. e location of the patient depends on the type of service the patient
requires. Some facilities will break down medical services even further into areas such as an oncol-
ogy oor or pulmonary oor, and surgical services into subspecialties such as orthopedics. Smaller
facilities may merge the medical and surgical patients together. e higher-acuity patients are in
critical care units such as:
a. Intensive Care Unit
b. Cardiac Care Unit
c. Trauma Intensive Care Unit
d. Pediatric Intensive Care Unit
e. Neonatal Intensive Care Unit
Based on the facility type and size, there may not be all of the intensive care units previously
listed. Some smaller facilities have a mix of intensive care patients in one unit, while others may
not provide pediatric or neonatal intensive care.
ere is another group of patients that some facilities recognize by providing care in step-down
or telemetry units. ese patients may be released from the intensive care settings and require less
care, but still need more care than can be given on an acute care oor. Others may be admitted,
and need more than just an acute care setting but not need intensive care services. Not all facili-
ties have step-down units and may have patients stay longer in the intensive care setting. Patients
remaining in the intensive care setting for extended periods of time may remain there due to
physician preference for their patients. is situation is controversial with respect to inappropriate
use of resources and the inability of the facility to accommodate patients that need this level of
care into this setting because beds are being taken by patients who no longer need intensive care.
In nursing models, nursing management must provide safe patient care at a responsible cost
[3]. It is very important that the model used in a particular setting provides safe care of the patient
and the prevention of adverse outcomes. Adverse outcomes can be described as events such as
patient falls, hospital-acquired infections, medication errors, or pressure sores, to name a few.
At this point, there is no proven right or wrong nursing care model. Nursing care models have
developed over time. ey will continue to develop along with changes in technology, society,
patient care needs, and human knowledge [2].
e caregivers in a nursing care model may include certied nursing assistants (CNAs), licensed
practical and vocational nurses (LPNs/LVNs), and registered nurses (RNs), and at times, clinical
nurse specialists (CNSs) and clinical nurse leaders (CNLs), who have a master’s or doctorate [4].
Understanding Nursing Care Models: Industrial Engineering Healthcare Book ◾ 95
Nursing Care Models
Team/Functional Nursing Care Model
In this model, the focus is primarily on a sta and skill mix structure. It was created in response to
the nursing shortage resulting from World War II. It is based on the premise of collaboration and
division of responsibilities for the nursing care of patients [5]. A team is developed that includes
RNs, LPNs, and CNAs. e nurses are is assigned to tasks according to skill level and qualica-
tions. A registered nurse is assigned as a team leader and the LPN and CNA perform activities
such as bathing, feeding, and other duties. ey work as a team with specic job responsibilities.
Each team is assigned a group of patients. In some team models, the work is divided up by func-
tion such as medication nurse or treatment nurse. e team model is a very ecient way to deliver
care, but care of the patient is fragmented. One RN may be the team leader one day and a team
member the next day, thus continuity of care may suer [6]. is can create dissatisfaction among
patients and nurses.
Many facilities have adopted this type of model or created a hybrid. ey use senior RNs in a
supervisory role on a team. ey function as the leader, guide newer RNs and LPNs, coordinate
with physicians, and navigate some of the paperwork needed such as in discharging patients. e
new RN or LPN assumes the majority of frontline tasks with the patient, such as administering
treatments and some medications, and executing the patient care plan. In one particular model,
there is no CNA but there are 2 RNs or 1 RN and 1 LPN assigned to 7–10 patients. In some
facilities this model has worked, while in other facilities the model has failed because the nurses
feel that it has not lessened their burden.
Primary Nursing Care Model
Primary nursing refers to comprehensive, individualized care provided by the registered nurse
throughout the period of care. It emphasizes continuity of care and provides a nurse to direct
patient care with a small group of patients [1]. e primary nurse (PN) accepts total 24-hour
responsibility for planning and overseeing care. Each time the PN works, they are assigned the
primary patient for as long as the patient remains on the unit [6]. e advantages are the increased
satisfaction and continuity of care for the patient. is model was seen as a way of improving qual-
ity of care and increasing job satisfaction among nurses. e disadvantage is the greater number of
RNs needed and the need for RNs to spend time doing tasks that other less-expensive sta could
perform. Some argue that this is neither a cost-eective nor an ecient model.
Patient-Focused Nursing Care Model
As mentioned earlier, nursing care models evolve and with this come hybrids. is model involves
the use of multiskilled sta and a team approach to nursing [5]. Services are brought closer to the
patient and sta skills are broadend by cross-training. is model recognizes support services in
the ecient delivery of quality care. A pharmacist being involved in the distribution of medication
and linen being delivered from the laundry to a patient room are examples. ese support services
allow nurses time to care for the patient rather than using their skills on non-nursing functions.
Medications are a major source of potential errors. Examples of such errors include medication
lists lost during transfer of a patient, the patient receiving old medications rather than newly pre-
scribed medications, or errors in recording the medication history. Medication management has
96 ◾ Marvina Williams
usually been handled by the nurse. Many facilities are bringing in the pharmacist to complete the
team. e pharmacist partners with the physicians for medication management and helps the RN
on some of the medication record tasks. In critical care units, such as the intensive care unit (ICU)
and the emergency department (ED), the pharmacist may actually work in those departments at
satellite pharmacies and help give medications.
Ooading some of these medication responsibilities can help increase RN productivity and
provide more accuracy in paperwork and medications delivery. In this type of collaboration, there
can be substantial reductions in costs per case. e RN is a care manager, and LPNs and CNAs
have expanded roles such as lab draws and performing certain assessment activities. With this
type of model, there may be design changes in a unit such as the addition of a satellite pharmacy.
Technological advancements such as improved computer systems and wireless phones play a major
role in improving the nurses’ eectiveness. e sta becomes multiskilled and clinical case man-
agement is incorporated into the operational process. is model has shown increased patient and
sta satisfaction. More direct patient care time is available to the RN.
Future of Nursing Care Models
ere are many more nursing care models, but those previously discussed are the three most com-
mon. In 1996, the Institute of Medicine reported that there were insucient data to draw conclu-
sions about the relationship between nurse stang and inpatient outcomes. However, later studies
have revisited this issue, allowing a review of the literature relating patient outcomes to various
measures of nurse stang levels, such as full-time equivalents (FTEs), skill mix (proportion of RN
hours to total hours), or RN hours per patient day [5].
With the Aordable Care Act, payment transformation is reshaping healthcare. Nursing care
models will play an important role. ere are many cost-cutting campaigns being conducted
throughout the country due to forecasts of a tough road ahead. Restructuring costs and operations
to break even requires assessing stang eciency, sta consolidation, premium labor, and salaries.
Many organizations are looking at how they can redesign inpatient nursing care models.
Some facilities have laid o employees and shifted to team-based nurse stang; others have
closed services and reduced inpatient beds, and still others have implemented wage freezes and
reduced hiring and eliminated underperforming employees.
According to the Institute of Medicine, U.S. healthcare wasteful spending in 2009 was
reported to be $1.47 billion and wasteful spending at $765 billion. e Healthcare Advisory Board
states that labor costs comprise the majority (51%) of the costs. Some of their ndings recommend
maximizing stang eciency through redening the core stang models, changing composition
of support sta, and nontraditional shifts to minimize handos and maximizing PRN (as needed)
pool participation [7].
ere are important items to keep in mind when changing stang models. e success of any
stang model depends on how nurses are assigned to the work area and their duties, who they
partner with (i.e., CNA, LPN, pharmacist, etc.), and the technology available to them. Tasks that
are nonvalue-added will hinder the performance of the sta in any model. e Journal of Nursing
Administration shows that RN nonvalue-added time represents a majority of the total cost in a
hospital. It is estimated that nurses only spend 20%–30% of their time on direct patient care [8].
Nursing sta are at times assigned many tasks that are below or above their competencies. is
can cause a high turnover rate in sta and can waste resources. So it is important to align roles and
Understanding Nursing Care Models: Industrial Engineering Healthcare Book ◾ 97
responsibilities within the nursing model. Trying to reduce costs but relieve unnecessary work on
the RN has opened up other models of care.
Some studies show that there is evidence that leaner nurse stang is associated with increased
length of stay, hospital-acquired infections, and pressure sores [3]. Other studies show that increas-
ing skill mix with richer nurse stang is associated with better patient outcomes. However, no
studies specically identify the ratios or hours of care that produce the best outcomes for dierent
groups of patients or dierent nursing units [3]. More studies are underway to look at the work
environment of nurses, nursing interventions, and adverse events. Future research may one day
establish a best practice in nursing care models.
References
1. “Models of Nursing Care Delivery,” Nursing eories, January 28, 2012, http://currentnursing.com/
nursing_theory/models_of_nursing_care_delivery.html (accessed December 13, 2012).
2. Sanford, K.D. Care Models and the Bottom Line. Healthcare Financial Management Association, January
6, 2010.
3. Seago, J.A. “Nurse Stang, Models of Care Delivery, and Interventions,” in Patient Safety and Quality:
An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality,
2008.
4. Neisner, J., and Raymond, B. Nurse Stang and Care Delivery Models: A Review of the Evidence.
Oakland, CA: Kaiser Permanente Institute for Health Policy, March 2002.
5. University of North Carolina at Chapel Hill School of Nursing. Leadership in Nursing Practice:
Nursing Care Delivery Systems, 2005.
6. e Advisory Board Company, Risk and Reward: Positioning Your Health System to Deliver Value in a
Transforming Health Care Marketplace Report. Atlanta, GA: Advisory Board Company, 2012.
7. Storel J. et al. “Non-Value-Added Time: e Million Dollar Nursing Opportunity.” Journal of Nursing
Administration 39, no. 1 (2009): 38–45.
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