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ASSIGNMENT SYSTEMS FOR STAFFING

Case Method
Each patient is assigned to a nurse for total patient care while that nurse is on duty. The
patient has a different nurse each shift and no guarantee of having the same nurses the
next day. The patient care coordinator, with no obligation to assign nurses to the same
patient, supervises and evaluates all care given on the unit. The case method emphasized
following the physicians order.
Functional Method
In functional nursing, hierarchical structure predominates. The medication nurse, the
treatment nurse, and bedside nurse are all products of this system. The functional method
implements classic scientific management, which emphasizes efficiency, division of labor and
rigid controls. It is an efficient system that is the least costly and requires few registered nurses.
Procedural descriptions are used to describe the standard of care, and psychological needs
typically are slighted. Care tends to be fragmented and depersonalized. Nurses keep busy with
managerial and non-nursing duties, and nurses aides deliver the majority of patient care
Although efficient, the functional assignment method does not encourage patient and
staff satisfaction. Regimentation of tasks may bore nurses because they no longer have the
satisfaction of seeing the effects of their total patient care. On the other hand, the functional
system may work satisfactorily during critical staffing shortages. Routinized patient care for
patients with similar needs may meet those needs more consistently than other systems, and
some staff members may be satisfied by doing repetitious jobs well.
Team Nursing
Team nursing was introduced to improve nursing services in hospitals and nursing homes
by using the knowledge and skills of professional nurses and to supervise the increasing numbers
of auxiliary nursing staff. The result was an improvement in patient and staff satisfaction. Team
nursing is based on a philosophy that supports the achievement of goals through group action.
Each team member is encouraged to make suggestions and share ideas. When team members see
their suggestions implemented, their job satisfaction increases and they are motivated to give
even better care.
The team is led by a professional or technical nurse who plans, interprets, coordinates,
supervises and evaluates nursing care. Team leaders assign team members to patients by
matching patient needs with staffs knowledge and skills. They also do the work other members
of the team are not qualified to perform. They set goals and priorities for patient care; centralize
information through the use of Kardex; direct the planning of care by directing care conferences

and developing care plans; fix responsibility for the work; provide for coverage during absences,
such as breaks, meals and conference, and coordinate and evaluate team activities. The team
members report to the team leader, who reports to the patient care coordinator. This is a form of
decentralization that frees the patient care coordinator manages the unit.
One of the main features of team nursing is the nursing care conference. Its primary
purpose is the development and revision of nursing care plans by providing an opportunity to
identify and solve problems. Precision in the identification of problems is increased through
information sharing.
Modular or District Nursing
Modular, or district nursing is a modification of team and primary nursing. It uses smaller
teams for patients who are grouped geographically. It is sometimes used when there are not
enough RNs to practice primary nursing. Each RN, assisted by the paraprofessionals, delivers as
much care as possible to a group of patients. The RN plans the care, delivers as much of it as
possible, and directs the paraprofessionals for the more technical aspects of care. The RNs role
is closer to that of a coordinator and information processor than that of a charge nurse.
Modular nursing decreases the sense of isolation and unrealistic expectations often
associated with primary nursing. When the nurses are consistently assigned to the same module,
continuity and quality of care can increase. More time may be spent in direct care. Closer
monitoring is possible. Morale can improve when staff knows they are making a difference. It is
less costly and less efficient than team nursing
Primary Nursing
Primary nursing was instituted in some hospitals with the philosophy that patients,
instead of tasks, should be the focus of professional nurses. Primary nursing features an RN who
gives total patient care to four to six patients. The RN remains responsible for the care of those
patients 24 hours per day throughout the patients hospitalization. The associate nurse cares for
the patients by using the care plan developed by the primary nurse while the primary nurse is off
duty. The associate nurse is expected to contact the primary nurse regarding the changes in the
care plan. The number of patients assigned to one nurse varies according to length of
hospitalization, complexity of care, number of medical and paramedical personnel involved with
the patients care, availability of support systems, and the shift worked. Day-shift nurses are
assigned the greatest number of patients; evening nurses have some, and night nurses are
primarily auxiliary nurses because of their reduced contact with patients and families.
The primary nurse does the admission interview and develops the nursing care plan,
including teaching and discharge planning, which is shared with the associate nurse. Primary
nurses have autonomy and authority for the care of their patients. Consequently, accountability is
placed and continuity of care is facilitated. Primary nursing decreases the number of people in
the chain of command and reduces the number of errors that can result from a relay of orders.
Other advantages include mobile use of auxiary workers and increased satisfaction by both the

nurse and patient. Nurses can identify patient outcomes as a result of their work. Patients have
the security of knowing the nurse is available and has to cope with fewer people than in other
assignment systems.
Case Management
It focuses on the entire episode of illness, including all settings in which the client
receives care. A case manager coordinates services for the patient and family. Options for
alternative healthcare, living arrangements, and community and social services are considered.
Arrangements with non-preferred providers may be negotiated to reduce claim costs. Case
management can cross departmental and disciplinary boundaries. It involves critical paths,
variation analysis, inter-shift reports, case consultation, health care team meetings and quality
assurance.
Collaborative Practice
Collaborative practice can include interdisciplinary teams, nurse physician interaction in
joint practice, or nurse-physician collaboration in care-giving. Collaboration is cooperative and
assertive. Interaction between nurses and physicians or other health care team members in
collaborative practice should enable the knowledge and skills of the professions to influence the
quality of patient care provided synergistically.
Managed care
Managed care involves financing care and risk management of acute, chronic, and
terminal diseases as health maintenance organizations; preferred provider organizations and
integrated care system proliferate.
Pros and Cons of Various Assignment systems
Assignment System
Case Method

Pros
Total patient care

Functional Nursing

Efficiency

Team nursing

Team effort
Frees patient care
coordinator to manage the
unit
Nursing care conferences
help problem solve and
develop staff

Cons
Different nurse, different
shifts, different days
Nurses do managerial
work
Time needed to coordinate
delegated work.

Modular nursing

Primary nursing

Managed care

Case management

Nursing care plan


Useful where there are few
RNs
RNs plan care
RNs give total patient care
Primary nurse has 24 hour
responsibility
Associate nurse works
with the patient while
primary nurse is off duty
Accountability in place
Continuity of care is
facilitated
Reduces number of errors
from relay of orders
Fewer patient complaints
Shorter hospitalization
Incorporates case

management
Can be used with any
nursing care delivery
system
Standard critical paths
Increases efficiency
Reduces costs
Focuses on entire episode
of illness
Emphasizes achievement
of outcomes
Care is coordinated by a
case manager
Second-generation
primary nursing
Critical paths
Variation analysis
Intershift reports
Health care team meetings
Interdisciplinary approach

Paraprofessionals do
technical aspects
Associate nurse may
change care plan without
discussing with primary
nurse

Questionable continuity of
care

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