The development of more collaborative practice models is one solution to address the barriers to delegation of nursing care. These models have also been linked to better patient outcomes. Examining staffing patterns and assignment practices may identify changes that would improve nurses’ knowledge of staff capabilities, clarify staff roles and scope of practice, improve interpersonal relationships and support the registered nurse in leading the clinical care team.
Three weeks ago we asked how the charge nurse should delegate responsibility for nursing care in a case example from Chapter 17 of the Essentials of Correctional Nursing. Compare how you made those assignments to the three practice models described in the paragraphs below. You might also consider how assignments in the case example might be made more consistent with the paired and partnered practice models which are more collaborative. This information is synthesized from several articles listed in the references below if you are interested in learning more about collaborative practice models.
Parallel practice: In this model staff use a list of tasks that are found in the job description or post order to organize and prioritize their work for the shift. This practice model requires almost no delegation and minimal direction or communication between staff because the duties are already spelled out. Registered nurses and practical or vocational nurses may be interchanged because the job descriptions overlap significantly. While task completion is emphasized it is not tied to patient outcomes. Accountability of staff for task completion may not be clear or it may be to someone not on shift, such as the nurse manager. Individuals work independently and may be unaware of other staffs’ roles or priorities creating potential for conflict and adverse patient outcomes. Because meaningful communication about patients does not take place in any regular or substantive way there is less opportunity to develop healthy working relationships between staff.
Paired practice: This model is characterized by assignments that pair a registered nurse with a practical/vocational nurse or unlicensed assistive personnel (UAP) for a shift. The job descriptions differentiate the role of the registered nurse from other staff as responsible for directing patient care and they are expected to identify checkpoints for communication about patients’ status during the shift. Staff are also expected to participate in formal care planning conferences. Delegation is increased in this model because the pair discusses how care is to be prioritized, how it is to be done and identifies expected patient outcomes for the shift. Both formal and informal communication are increased because there is ongoing deliberation about patients to adjust plans and priorities for care. The members of each pair have more opportunity to understand roles, display mutual respect and communicate meaningfully. Additional steps that have supported the paired practice model are to provide training and discussion to clarify roles and development of behavioral norms that support healthy relationships.
Partnered practice: This model consists of staff partners who have the same schedule, days off and their leave time is planned to coincide. It also is referred to as an “apprenticeship model” because the partners make a commitment to maintain a healthy work relationship, trust and advance each other’s knowledge by working together consistently. This model reflects a philosophy that values continuity and relationship-based care. The registered nurse has clear authority to delegate and direct care. As trust and knowledge about staff capabilities is enhanced, delegation potential increases. As information flow becomes more frequent and substantive subordinate staff anticipate what patient care is needed and care delivery becomes more timely and coordinated. As the relationship between partners develops they are able to manage more complex situations and produce better patient outcomes.
Further thoughts and a challenge: Hospitals, nursing homes and ambulatory care settings are looking for new staffing models that support more effective and efficient patient-centered care. Nursing practice models that effectively utilize the diversity of providers to deliver quality patient care are being developed. Reflecting on my experience the majority of staffing patterns in correctional settings seem to be more consistent with the parallel practice model than either paired or partnered practice. In light of the evidence about better patient outcomes emerging from other health care settings perhaps it is time to examine the patterns of nursing practice and assignment in our setting to see if staff can be utilized more effectively in delegation and delivery of patient care? Do you think the paired and partner practice patterns have a place in correctional nursing? Let us know your opinion by responding in the comments section of this post.
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Corazzini, K.N.; Anderson, R.A.; Mueller, C.; Hunt-McKinney, S.; Day, L.; Porter, K. (2013). Understanding RN and LPN Patterns of Practice in Nursing Homes. Journal of Nursing Regulation. 4(1); 14-18.
Corazzini, K.N.; Anderson, R.A.; Rapp, C.G.; Mueller, C.; McConnell, E.S.; Lekan D (2010). Delegation in long term care: scope of practice or job description? Online Journal of Issues in Nursing. 15 (2); 4.
Potter, P. & Mueller, J. R. (2007). How well do you know your patients? Nursing Management. 38 (2): 40-48.
Ray, J.D. & Overman, A.S. (2014) Hard facts about soft skills. The American Journal of Nursing. 114 (2): 64-68.
Weydt, A. (May 31, 2010). “Developing Delegation Skills” OJIN: The Online Journal of Issues in Nursing Vol. 15, No.2, Manuscript 1.
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