Leadership and Management in Nursing Care Delivery Models

A care delivery model is an integral component for delivering patient care. Nursing care delivery model is a way of organizing at the unit level to facilitate the delivery of nursing care to the patients (Tiedeman & Lookinland, 2004). Organization of care is a key factor that determines quality of nursing care (Tiedeman & Lookinland, 2004). Various types of care delivery models have been designed to meet the goals of efficient and effective nursing care

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While many different care delivery models are practiced in the wards and departments of the acute care hospital that I work in, it is beyond the scope of this paper to discuss them all. In the 20 bedded medical oncology ward that I work in, nursing care delivery is organised into team and primary nursing. Six beds are allocated to transplant patients. One registered nurse is assigned to be the primary nurse of three transplant patients each. The other fourteen patients are split between two teams of nurses. Each team has a registered nurse, an enrolled nurse and a patient care assistant. Thus, this paper is concerned with these two modes of organization of care. An overview of primary and team nursing models of care will be presented. Thereafter, the experiences of nurses involved in the delivery of care using these models of care will be discussed with regards to job satisfaction and quality of care.

Description of Care Delivery Model

Primary Team

Emerging in the United States in the1960s, the primary nursing model involves patients being allocated to individual nurses (Tiedman & Lookinland, 2004). One registered nurse is allocated a number of patients for whose care this nurse is accountable during the patient’s

hospital stay (O’Connell, Duke, Bennett, Crawford, & Korfiatis, 2006; Tiedman & Lookinland, 2004).The nurse-patient relationship is the backbone of primary nursing. The primary nurse collaborates with other health team members, the patient and family to continually assess, plan, implement, and evaluate the patient’s nursing care (Reed, 1988; Sellick, Russell, & Beckmann, 2003; Tiedman & Lookinland, 2004). When the primary nurse is unavailable to provide care, associate nurses follow the plan of care developed by the primary nurse, unless a change in patient’s condition necessitates a modification of the care plan, so as to maintain the continuity of care for the patients (Tiedman & Lookinland, 2004).

Team Nursing

Implemented in the 1940s as a response to the nursing shortage resulting from the

World War II, team nursing is based on the premise of collaboration and division of responsibilities for the nursing care of patients (Tiedman & Lookinland, 2004).

In team nursing, nurses and ancillary staff with different levels of education, skills and licensure are assigned to teams and each team provides total nursing care to the patients assigned to that team (O’Connell et at., 2006; Tiedman & Lookinland, 2004). Leadership for each team is provided by a team leader, who is an experienced registered nurse responsible for planning and supervising the provision of nursing care for patients cared for by team members. The team leader has overall accountability for coordinating the nursing care provided, while the team members are accountable for completing their assigned tasks and for documenting the care delivered (O’Connell et at., 2006).

Nursing Staff Job Satisfaction

Primary Team

One of the most important gains of primary nursing for the nurses interviewed was more contact and enhanced relationships with patients. One nurse said, “I know more about each of my patients and do not constantly have to get to know new ones.” These views are consistent with Mccleod and Stella’s (1992) study where nursing staff on medical and surgical wards were asked what they liked about primary nursing. Participants liked the enhanced relationships and collaboration with patients and other members of the healthcare team. To be able to take care of the same patients day after day was greatly appreciated by the nurses interviewed. This continuity of care led to the development of good relationships between the primary nurse and the patient as well as with relatives. This is an aspect that the nurses found increased their levels of job satisfaction (McCleod & Stella, 1992).

Primary nursing facilitated an in-depth knowledge of their patients and as a consequence, the nurses felt more able to act as a patient’s advocate. Nurses verbalised they had additional responsibility and accountability as all duties and responsibilities in taking care of a patient for his or her duration of stay is delegated entirely on a single nurse. The primary nurses interviewed perceived that they had the authority to make clinical judgments and decisions for the benefit of the patient. Their use of phrases such as “freedom from control by others”, “ability to plan and organize the workday”, “using knowledge to make decisions” and “advocating for the patient” described autonomy. Autonomy refers to the ability to act according to one’s knowledge and judgment, providing nursing care within the full scope of practice as defined by existing professional, regulatory, and organizational rules (Gagnon, Bakker, Montgomery, & Palkovits, 2010). The nurses noted that through practicing primary nursing, their autonomy was increased.

There is a substantial body of evidence indicating that nurses’ perceived autonomy is linked to job satisfaction. A study by Melchior, Halfens, Abu-Saad, Philipsen, van den Berg & Grassman (1999) investigated the effects of a primary nursing care delivery system on the work environment among nurses working in long-stay psychiatric care settings. Results showed that as a result of primary nursing, the nurses found more autonomy in their work and thus experienced increased job satisfaction. Similarly, Macguire and Botting (1990) analysed the perceptions of nursing staff, following the introduction of primary nursing into an acute medical ward for elderly people. Nurses reported better communication, improved relationships and increased responsibility after implementing primary nursing. It appeared that both increased autonomy of practice and increased knowledge of specific patients, coupled with a greater continuity of care, gave nurses a high level of satisfaction than did previous methods of care delivery (Macguire & Botting, 1990).

On the downside, some nurses commented that working in a primary care system tends to be isolating and this proved to be particularly difficult when they were looking after a critically ill patient. These experiences mirrored those reported by nurses in the study by Manley, Hamill, and Hanlon (1997).

Team Nursing

Nurses practicing team nursing commented that working as a team was a lot better, because then they can have somebody else backing them up. According to O’Connell et at. (2006), working collaboratively with team members serves to enhance job satisfaction, as many find this to be a learning experience that utilizes the expertise of each team member. This was supported by Rafferty, Ball, and Aiken (2001) who demonstrated that nurses who report a higher level of teamwork are more satisfied with their jobs, plan to stay in them, and are likely to experience less stress.

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However, enrolled nurses and the patient care assistants interviewed added that they felt the staff nurses were spending too much time with medications and writing reports while they were left to do the heavy manual work. A similar finding was demonstrated by O’Connell et al. (2006). In this study, both registered nurses and enrolled nurses felt that the team-nursing model sometimes involved an uneven and unfair division of tasks that overburdened some nurses. The medication responsibilities of registered nurses within the team-nursing model imposed excessive demands on enrolled nurses as they were left with meeting the hygiene needs for the patients in their group without assistance. These tensions led to a decrease in job satisfaction.

Quality of Care

Primary Team

The nurses interviewed felt patients were more satisfied when primary nursing was in place because they received individualized care as a result of continuity and coordination of care. Primary nursing has led to the nurses having a better knowledge of the patient. Nurses pointed out that primary nursing enabled them to know each patient more closely. One nurse remarked, “I know my patients like the back of my hand.” Therefore, it was easier to find out what each patient needed and to meet those needs appropriately. Jenny and Logan (1992) suggest that greater knowledge of the patient is linked to the increased likelihood of picking up subtle changes in the patient’s condition. In addition, Perala and Hentinen (1989) found that through primary nursing, doctors received information about patients that was more exact and relevant because nurses knew their patients better. This enabled nurses to provide more applicable and effective patient centred nursing care. In response to this therapeutic relationship, the patient feels more secure about and satisfied with nursing care (Jenny & Logan, 2000). The nurses’ views were supported by the findings of Radwin (2000). In this study conducted over a 3-year period, oncology patients were asked to identify qualities of nursing care that were important to them. Professional knowledge, joint decision making between the patient and the nurse, individualized treatment plans, promptness to addressing individualized needs and continuity of care were some aspects of care delivery that were identified.

Team Nursing

Nurses interviewed said that since staff was supervised more closely, the likelihood of missing things out was low. This, they felt, resulted in patients receiving better care. This sentiment was echoed by the nurses in O’Connell et al.’s (2006) study. Moreover, nurses added that the patients benefitted from the combined skills of the team. According to the study by Cioffi and Ferguson (2009), team nursing made a difference to patient care as it was patient-oriented, all the nurses in the team were familiar with the patients receiving care, care was more complete as things were missed less often and staffs were supervised more closely. This resulted in patients receiving better care.

In conclusion, providing care to a group of patients require nurses to be more efficient and use their time more effectively. Nursing care delivery models facilitate this. This paper has provided an overview of primary and team nursing care delivery models. The experiences of nurses were discussed with regards to job satisfaction and quality of care in the two models. Literature supporting the nurses’ experiences was then explored.