Chapter 3: Delivering Nursing Care

After completing this chapter, you will be able to:

 Describe how the delivery system structures nursing care.
 Describe what types of nursing care delivery systems exist.
 Discuss the positive and negative aspects of different systems.
 Describe the new types of delivery systems that have emerged.
 Explain what skills are required to use the system effectively.
Traditional Models of Care
FUNCTIONAL NURSING TOTAL PATIENT CARE
TEAM NURSING PRIMARY NURSING
Integrated Models of Care
PRACTICE PARTNERSHIPS
CASE MANAGEMENT
CRITICAL PATHWAYS
DIFFERENTIATED PRACTICE
PATIENT-CENTERED CARE
CLINICAL MICROSYSTEMS
OTHER INNOVATIVE SYSTEMS
Comparing Nursing Care Delivery Systems
Introduction
Nursing care is delivered amidst a number of different structural designs in health care. Each design has
its own strengths and weaknesses. In functional nursing, different health care givers are assigned tasks
according to their skills and licensure. In team/modular nursing, groups of health care providers are
assigned to a group of clients. The case or total patient care method makes one nurse completely
responsible for all aspects of nursing care required by one or more clients. In primary nursing, one nurse
coordinates all aspects of a client's care and develops a plan for others to follow. Practice partnerships
between an RN and an assistant are designed to achieve the same outcomes of two RNs by selectively
delegating less specialized tasks to the assistant under the direction of the RN. Differentiated practice
also capitalizes on the different educational, experiential, and competence levels of health care
providers by defining their roles and functions accordingly. Patient-centered care is a unit-based system
of delivery in which nurses coordinate client care and unlicensed assistive personnel (UAP) help with
delegated client care tasks, perform environmental services, or provide administrative support. In this
system, care is decentralized, and UAPs are given more responsibility. Case management is a method of
coordinating and monitoring client services to achieve desired outcomes, within a specific time frame,
that are usually defined in critical pathways.
Instructions
You have been hired as the new nurse manager for a pediatric rehabilitation unit in a long-term care
facility. Select the nursing care delivery system you would prefer to implement.
Activity
Identify the skill mix of care providers you would need in this kind of clinical setting, and what the roles
of each would be. Consider necessary capabilities and cost efficiency in your decision.

Provide a rationale for your decisions.

What are the strengths and weaknesses associated with the nursing care delivery system you selected?

Briefly study the patient care delivery system(s) at your place of work or clinical placement site. Make a
drawing of the system and explain which model it most closely resembles. In what ways does it deviate
from the ideal models presented in the text?

Pretend that the long-term care unit where you are employed is changing from a functional model of
nursing care delivery to a team model. How will staff be affected? Discuss how changes in the
communication structure will affect individual and group decision making.

As a manager of an acute care unit, which system do you think most supports the independent functions
of the nurse? Explain your choice.
Discuss the use of critical pathways to improve quality of care in hospitals. Identify the benefits and
problems related to their use.
Use and Evaluation of Critical Pathways in Hospitals

Review "Nursing's Agenda for the Future" on the ANA Web site. Select one of the 10 areas of concern,
and describe how you will work to bring about positive change for nursing and health care systems in
this area.

Exercises
1) A nurse is considering employment at a long-term care facility that has a functional nursing
delivery system. Knowing this, the nurse could expect that:
a. Each RN would deliver total care to an assigned group of clients.
b. Each RN would coordinate care for a group of clients.
c. One RN would pass meds for all clients on a unit.
d. One RN, one LPN, and one unlicensed assistive personnel would share responsibility for
a group of clients.
Correct Answer: C. One RN would pass meds for all clients on a unit. This represents team nursing; a
team of personnel provides total care to a group of clients.
2) Which of the following would a nurse suggest are significant benefits to an organization that is
considering adoption of a practice partnership model? (Select all that apply.)
a. It is less expensive to implement than other models.
b. Clients express greater satisfaction.
c. Continuity of care is facilitated.
d. It takes less planning to implement.
e. Leadership is well accepted.
Correct Answers: A. It is less expensive to implement than other models.and C. Continuity of care is
facilitated. Continuity of care is enhanced when all members of the health care team work together to
plan and implement care. Client satisfaction is independent of the type of nursing care delivery system.
Leadership is independent of the care delivery system; effective leadership is necessary for successful
implementation of any care delivery system.
3) Which of the following clients would most likely be selected for case management?
a. A young adult with a fractured pelvis.
b. An elderly client awaiting a hip replacement
c. A 41-year-old client admitted for outpatient tonsillectomy.
d. An adolescent with a gunshot wound who is in the ER.
Correct Answer: B. An elderly client awaiting a hip replacement. This is a common surgical problem that
is high volume for most hospitals so it would be appropriate for case management.
4) Which of the following conditions would be well suited to use of a nursing critical pathway?
a. Foreign object in ear
b. Hip replacement surgery
c. Bacterial infection acquired in a foreign country
d. Fever of unknown origin
Correct Answer: B. Hip replacement surgery. Until a diagnosis is made, the interventions and outcomes
are not known; therefore, a critical path is not indicated.
5) The nurse is developing a critical pathway for congestive heart failure (CHF). Which components
are essential to include? (Select all that apply.)
a. Expected length of stay
b. Assigned staff nurse
c. Medical diagnosis
d. Patient outcomes
Correct Answers: D. Patient outcomes; A. Expected length of stay; C. Medical diagnosis..Critical
pathways are developed when there are usual expected outcomes for client's with a particular medical
diagnosis. A critical pathway can be developed for any medical diagnosis that has a usual set of
outcomes and length of stay.
6) A staff nurse is working with a patient who is on a critical pathway for education in preparation
for home care. Which one of the following responsibilities would the nurse address first?
a. Answering the client's questions
b. Taking vital signs
 c. Reviewing the information with the client and family
d. Evaluating client teaching
Correct Answer: C. Reviewing the information with the client and family. Assessment is the first phase
of the nursing process and history is part of client assessment that precedes all others. The nurse should
review pertinent information with the client and family and establish goals for care.
7) What are the key elements essential to implementation of case management? (Select all that
apply.)
a. Established critical pathways
b. Qualified nurse case manager
c. Quality management system
d. Collaborative practice teams
Correct Answers: A,B, C, D Established critical pathways, collaborative practice teams, qualified nurse
case managers, and quality management systems are the key elements of case management.
8) The staff nurse is caring for the client with total accountability and is in continual
communication with the client, the family, the physicians, and other members of the health care
team. This type of nursing delivery system is known as: Total Patient Care. Total patient care is
the original model of nursing care delivery, in which one RN is responsible for all aspects of one
or more patients' care.
9) A high-volume maternity unit uses differentiated practice as its staffing model. As a new
graduate employed on this unit, the nurse can expect that:
a. Seniority is the main determination of client assignments.
b. Evidence-based practice guides risk management principles.
c. Client teaching is the responsibility of the team leader.
d. The initial level of practice responsibility will be limited.
Correct Answer: D. The initial level of practice responsibility will be limited. The scope of nursing
practice and responsibility are defined for each level of practice. A new graduate will have limited
experience so the level of practice will be limited.
10) When would a critical pathway need to be revised?
a. When it becomes too long.
b. When the variances show a new trend.
c. When a member of the team retires.
d. When the client leaves the hospital.
Correct Answer: B. When the variances show a new trend. Critical pathways are revised when new
trends are noted or a pattern of variances emerges