Question

You are a nurse manager for a 30-bed pediatric unit in a large urban hospital. According to the patient classification system used by the hospital, the level of acuity of pediatric patients on your unit is con­sistently very high, and the patient census averages 26. The only pediatric oncologist in town practices at your hospital and has told you in the past that he preferred to have his patients admitted to your unit because of the quality of nursing care provided, thus the unit always has a high number of pediatric patients with cancer. Additionally, two pediatric sur­geons have told you that they prefer the care pro­vided in your unit versus that at the other hospital in town. However, recently, there has been an in­crease in the number of complaints from families—twice in the past week—and one of the physicians has come to your office to talk about patient care problems. You also sense increased tension and dissatisfaction among the RNs because you have had to fill some vacant RN positions with LVNs or nursing assistants.

As you analyze the problem, you note the following facts:

• The current staff mix is 40% RNs, 30% LVNs, and 30% nursing assistants.

• One year ago, the staff mix was 60% RNs, 20% LVNs, and 20% nursing assistants, but this has changed because of the nursing short­age and hospital budget cuts.

• Quality management studies indicate that the length of stay (LOS) for your unit has increased and is now 3 days longer than the DRG allowable, and readmissions have increased over the past 6 months.

• The common theme of family member complaints is that "no one seems to know what is going on with my child's case".

• The common theme of recent physician comments is that "I can never find a nurse who knows what is going on".

In the past, the unit used the primary nursing care delivery model, but with the changes in staff mix, the unit went to a team nursing model. How­ever, when you review how assignments have been made over the past month, you find that the charge nurse has been assigning patient care according to tasks. When you ask her about the change in assignment patterns, she states that this was done because they have been so busy and short-staffed, assignment by tasks seems to be the only way to get everything done.

1. How would the nurse manager evaluate and decide which patient care delivery system would be best for the patients, staff, physicians, and other team members, as well as being cost-effec­tive and utilizing the current staffing mix?

1. Who should be involved in evaluating and making decisions about nursing care delivery models?

1. What factors related to staffing might have positively and/or negatively affected the cost-effectiveness of care provided on this pediatric unit?

1. How could you make a case to the vice president of nursing for an increase in the number of RNs to staff the pediatric unit?



1. How could clinical pathways be used to improve the quality and cost-effectiveness of care on this unit?

Answer 1

1. Patient care delivery system  that is best for the patient, staffs and physicians:

Nurse manager is a person, who performs the managerial functions of nursing department, such as planning, staffing, organizing, controlling and directing. Nurse manager can evaluate the patient care delivery models and can decide which is best for the patients, physicians and staff, based on following factors:

* the number of staff : Number of staff is one of the main factor , that influences the nurse manager's decision on which  Patient care delivery model is apt for the unit.

For example: Primary nursing is best , when there is adequate number of staffs.

* Patient satisfaction: Nurse manager can obtain the response of the patient's satisfaction about the nursing care and it will help her to evaluate the effectiveness of the current patient care delivery model.

* Feedback from physicians: Physician's opinion and feedback regarding tbe existing Patient care delivery model gives a valuable feedback, that help a nurse manager for evaluation.

* Nurses' opinion and the comments regarding the existing Care delivery model , can give the key points regarding the advantage and disadvantages of one specific Care delivery model.

* Nurse manager can calculate the cost effectiveness and study the outcomes like patient' s length of stay, number of readmissions, complications developed, mortality rate of the unit etc for evaluating the suitableness of a particular Patient care delivery model.  

2. Who should be involved:

Evaluation and the decision making process on Patient care delivery model has to be conducted by the Nurse manager with the help of Head nurse or Nurse - in - charge. Nurse manager can consult with Nursing Superintendent/ Nursing president or the Administration -in - charge regarding the budget , organizational policy that may affect the staff schedule or pattern of care delivery.  

3. Factors related to sttafing  that positively or negatively affect the Cost effectiveness of care are :

(Cost effectiveness refers to the quality in which the usage and benefits of an object/ service are worth , when compare with the cost paid for it. )

* Adequacy of staff: The proper Nurse - Patient ratio proved to be associated with fast recovery of patients, decreased mortality and adverse events like complications , less number of days of hospital stay , which causes less cost for Health services.

* Proper staff mixing: There are interventions that can be performed only by RN and interventions , can be performed by LVN , Patient care assistant etc. There should be proper staff mixing ratio, otherwise it may lead to confusion, work load and burn out in one category of nurses that inturn can affect quality patient care and may increase cost of health care received by the client.  

* Pattern of Care delivery: The type of Patient Care delivery model influences the Cost effectiveness positively or negatively. Team nursing is an effective method in which a team of nurses are assigned for a specific number of patients and their quality care. All the team members will be knowing about the assigned patients well. Where as Functional nursing focuses on completion of tasks of Patient care in the whole unit . For example 'vital signs monitoring ' task. Here nurse's will be unaware about the condition or state of the patient. She goes to the patient and finish her task ( vital signs monitoring) and coming back.There will not be an accountable person for the patient.  

4. Nurse manager is responsible for requesting to the addition of RNs or increasing the number of staff in the Paediatric unit . She can give a proposal for additional RNs to the Paediatric unit . In the request / proposal fom , nurse manager has to explain the need of additional staff and present condition. A request form for asking additional staff has to be submitted to Vice president of Nursing and also she has to do the follow up for the same.  

5. Clinical pathway is a multidisciplinary management intervention for patient care in which the professionals from different discipline are engaged for a group of patients. It is also known as critical pathway. Provision of Patient care in Clinical pathway is based on Evidence based medicine . It reduces cost by standardizing the care and also maximizing patient outcome by increasing the efficiency of Patient care.