Roles
Attending Nurse. The ANs are seasoned practitioners knowledgeable of patient care needs. They ensure the patient’s needs are identified appropriately and care is delivered in accordance with hospital policy and national standards. More often than not the AN will complete the patient’s admission assessment. The AN rounds on his/her caseload of patients several times a day and collaborates with colleagues in the service lines and members of other disciplines to establish and implement the plan of care. It is anticipated the AN will demonstrate leadership within the inter-disciplinary team. The AN’s work is tightly focused on care coordination and transition planning.
Service Lines. Rather than belonging to a nursing unit and being a generalist, nurses belong to a service line and become specialists. Nurses are not assigned to a group of patients located on one unit; they carry a caseload of patients across several geographic locations. Nurses working within a service line are accountable for the assessment, planning, implementation, and evaluation of their patients’ care needs, as they relate to the domain of caredelivered by their service line.
Domains of Nursing Care
Care Planning and Coordination - See Attending Nurse.
Mobility and Sensory - Activities of daily living optimization. Sensory optimization.
Mind-body and Mental Health - Orientation optimization. Self-generated healing.
Fluid Balance - Intravascular access. Intake and output optimization.
Wound and Skin - Prevention and treatment of skin and tissue deficits. Healthy skin promotion.
Nutrition and Elimination - Bowel and bladder optimization. Food intake.
Heart, Lung and Data - Cardiopulmonary optimization. Management of clinical data streams to relevant service lines.
Medication Management - Medication distribution. Medication reconciliation.
Quality and Safety - Staff and systems competency. Learning organization optimization.
Supporting Roles - Two additional roles support the SLM. Admission nurses serve as backup to the AN when the AN is unavailable to perform the initial nursing assessment. When not admitting patients Admission Nurses are helping out in the emergency department to facilitate identification, decision-making, and patient flow related to potential admissions. Patient care nursing assistants, unaligned with a service line and probably geographically based, work closely with the AN to assure technical and routine tasks are performed efficiently and effectively.
How Patients Are Cared For
Instead of being generalists, organized by nursing units, and receiving daily assignments, medical/surgical nurses are specialists, belong to service lines, and manage caseloads of patients (15-20 patients/caseload).
The “rounding model” of care delivery works effectively providing physician services and could work effectively delivering nursing services. Each service line will round on their patient caseloads at least once per shift, more often as need indicates.
All service lines will be initially involved with each patient. The amount of their ongoing contribution to care will be determined by the patient’s needs.
Service lines will be comprised of RN/technician dyads.
Nurses will carry caseloads, not be given assignments. Caseloads are shared by several nurses to ensue continuous coverage. After an absence the nurse will return to his or her caseload. When a patient is readmitted to the hospital the caseload concept maximizes the opportunity that they will be cared for by the same staff
Service lines will be responsible for ensuring an adequate number of staff is available.
Governance
A shared governance structure within each service line will be responsible for most required management activities.
A shared governance coordinating council of service line representatives report to nursing administration.
Peer review committees within each service line will be responsible for evaluating ongoing and annual competency of staff.
Potential Benefits
Reduces clinical variation: Rather than being a series of tasks, “care” becomes the business of the service line. Nurses will “own” care and work to establish the evidence base for care provided by their service line. The SLM gives nursing control over its practice and may virtually eliminate missed care.
Identifies nursing’s contribution: The SLM provides clarity to identify and measure nurses’ contribution. Encounters will be coded in relative value units. Ultimately, such knowledge will lead to formulas for determining the true costs of providing nursing services.
Next steps
Determine model’s strengths and weaknesses: Focus groups can determine the robustness of SLM domains for capturing all potential patient needs and the strengths and weaknesses of the model.
Development of productivity standards: The basic unit of nursing service delivery is the “encounter”. Caseload size will be determined by the number of patients a service line nurse could round-on during 8 and 12 hour shifts.
Determine the clinical divisions differentiating caseloads: Caseloads would be derived first by medical/ surgical patients, then in larger hospitals, by specialty areas. The acuity of patient needs predictably present in the population will determine the number of caseloads.
Conclusion
The healthcare industry is perfectly designed to achieve the outcomes it produces. In years past the nursing unit was pragmatic and effective; however, hospital and medical technological growth, and the emergence of professional nursing practice have surpassed the nursing unit’s capacity to serve as an effective organizing platform. To eliminate the task orientation in nursing it may be time to rethink the nursing unit. The SLM is an organizational design capable of consistently meeting the range of patient care needs while creating a unified mental model of nursing service delivery.