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Nursing care can be carried out through a variety of organizational methods. The model of nursing care used varies greatly from one facility to another and from one set of patient circumstances to another. A review of past and current models provides a background for understanding the nursing models and methods needed for today’s changing health care delivery system.
TEAM NURSING
Team nursing, which had its origins in the 1950s and 1960s, involved use of a team leader and team members to provide various aspects of nursing care to a group of patients. In team nursing, medications might be given by one nurse while baths and physical care are given by a nursing assistant under the supervision of a nurse team leader. Skill mixes include registered nurses (RNs), often as team leaders; licensed practical nurses; and nursing assistants or unlicensed assistive personnel (UAP). With the current emphasis on cost containment in health care agencies, variations of team nursing are being used, and UAPs are increasingly being included as team members. There has been little substantiation, however, that team nursing is cost-effective. The quality of patient care with this system is questionable, and fragmentation of care is of concern.
PRIMARY NURSING
Primary nursing (not to be confused with primary health care, which pertains to first-contact general health care) refers to comprehensive, individualized care provided by the same nurse throughout the period of care. This type of nursing care allows the nurse to give direct patient care rather than manage and supervise the functions of others who provide direct care for the patient. This care method is rejected by many institutions as too costly; the patient–nurse ratio is small, and a larger professional staff is needed, because the primary nurse is usually an RN. However, primary nursing may provide a foundation for transition to case management in some institutions. The primary nurse accepts total 24-hour responsibility for a patient’s nursing care. Nursing care is directed toward meeting all of the individualized patient needs. The primary nurse is responsible and accountable for involving the patient and family directly in all facets of care and has autonomy in making decisions in this regard. The primary nurse communicates with other members of the health care team regarding the patient’s health care.This process promotes continuity of care and collaborative efforts directed toward quality patient care.
During times when the primary nurse is not scheduled to work, an associate nurse or co-nurse assists in overseeing the delivery of care. The associate nurse implements the nursing plan of
care and provides feedback to the primary nurse for evaluating the plan of care. The primary nurse assumes responsibility for making appropriate referrals and for ensuring that all relevant information is provided to those who will be involved in the patient’s continuing care, including the family. The long-term survival of primary nursing as it is currently designed is uncertain. As cost-containment measures continue and patient acuity increases, staffing ratios of patients to nurses are increasing. Many nursing service departments and agencies are meeting the increased workload demands by making modifications in their approach to primary nursing or by reverting to team or functional systems for delivering care. Others are changing their staffing mix and redesigning their models of practice to accommodate nurse-extender roles. Still others are changing to more innovative systems such as case management.

Professional nursing is adapting to meet changing health needs and expectations. One such adaptation is through the expanded role of the nurse, which has developed in response to the need to improve the distribution of health care services and to decrease the cost of health care. NPs, clinical nurse specialists (CNSs), certified nurse-midwives, and certified registered nurse anesthetists are identified as advanced practice nurses. The nurse who functions in an advanced practice role provides direct care to patients through independent practice, practice within a health care agency, or collaboration with a physician. Specialization has evolved within the expanded roles of nursing as a result of the recent explosion of technology and knowledge.
Nurses may receive advanced education in such specialties as family, critical care, coronary care, respiratory care, oncologic care, maternal and child health care, neonatal intensive care, rehabilitation, trauma, rural health, and gerontologic nursing, to name just a few. With the expanded role of the nurse, various titles have emerged that attempt to specify the functions as well as the educational preparation of nurses, although functions are less distinct than in previous years. In medical-surgical nursing, the most significant
of these titles are nurse practitioner and clinical nurse specialist, and the more recent title of advanced practice nurse, which encompasses both NPs and CNSs. Initially the educational preparation for NPs was in certificate programs. Most states now require both NPs and CNSs to have a graduate-level education. The two programs, which originally
differed significantly in scope and in their definition of role components, now have many similarities and areas of overlap. NPs are, for the most part, prepared as generalists (eg, pediatric NP, geriatric NP). They define their role in terms of direct provision of a broad range of primary health care services to patients and families. The focus is on providing primary health care to patients and collaborating with other health professionals. NPs practice in both acute and nonacute care settings. The 1997 Balanced Budget Act provided for NPs to receive direct Medicare reimbursement. In addition, in some states—and with new legislation possibly nationwide—NPs have prescriptive authority (Boyd, 2000). CNSs, on the other hand, are prepared as specialists who practice within a circumscribed area of care (eg, cardiovascular CNS, oncology CNS). They define their role as having five major components: clinical practice, education, management, consultation, and research. Studies have shown that in reality the CNS focus is
often on the education and consultation roles: education and counseling of patients and families and education, counseling, and consultation with nursing staff. Some states have granted CNSs prescriptive authority if they have the required educational preparation. CNSs practice in a variety of settings, including the community and the home, although most practice in acute care settings. Recently, CNSs have been identified by many nursing leaders as ideal case managers. They have the educational background and the clinical expertise to organize and coordinate services and resources to meet the patient’s health care needs in a cost-effective and efficient manner. With advanced practice roles has come a continuing effort by professional nursing organizations to define more clearly the practice of nursing. (continue reading…)

Community-based care and community health–public health (CH-PH) nursing are not new concepts for nursing. Nursing has played a vital role in the community since the middle to late 1800s, as visiting nurses provided care to the sick and poor in their homes and communities and educated patients and family members. Although community health (CH) nursing, public health (PH) nursing, community-based nursing, and home health nursing may be discussed together and aspects of care in each type do overlap, there are distinctions among these terms. Confusion exists regarding the differences, and the similar settings may blur these distinctions (Hunt, 2000; Kovner, 2001). The central idea
of CH-PH nursing is that nursing intervention can promote wellness, reduce the spread of illness, and improve the health status of groups of citizens. CH-PH nursing practice is concerned with the general and comprehensive care of the community at large, with emphasis on primary, secondary, and tertiary prevention. Nurses in these settings have traditionally focused on health promotion, maternal and child health, and chronic care.
Community-based nursing occurs in a variety of settings within the community and is directed toward individuals and families (Hunt, 2000). It includes home health care nursing. Most community-based and home health care is directed toward specific patient groups with identified needs; these needs usually relate to illness, injury, or disability resulting most often from advanced age or chronic illness. However, both community-based and CH-PH nurses are now expanding to meet the needs of many groups of patients with a variety of problems and needs. Home health care will be a major aspect of community-based care discussed throughout this text. Home health care services are provided by communitybased programs and agencies for specific populations (eg, the elderly, ventilator-dependent patients), as well as by hospital-based home health care agencies, hospices, independent professional nursing practices, and freestanding health care agencies. As trends continue toward shortened hospital stays and increased use of outpatient health care services, the need for nursing care in the home and community setting has increased dramatically. Because nursing services are being provided outside as well as within the hospital, nurses have a choice of practicing in a variety of health care delivery settings. These settings include acute care medical centers, ambulatory care settings, clinics, urgent care centers, outpatient departments, neighborhood health centers, home health care agencies, independent or group nursing centers, and managed care agencies. Community nursing centers, which have emerged over the past two decades with the advent of NPs, are nurse managed and provide primary care services that include ambulatory and outpatient care, immunizations, health assessment and screening services,
and patient and family education and counseling. (continue reading…)