Total Patient Care Nursing or Case Method Nursing

1st

Total patient care is the oldest mode of organizing patient care. With total patient care, nurses
assume total responsibility during their time on duty for meeting all the needs of assigned
patients.
Total patient care nursing is sometimes referred to as the case method of assignment
because patients may be assigned as cases, much like private-duty nursing was historically
carried out.

2nd
Indeed, at the turn of the 19th century, total patient care was the predominant nursing
care delivery model. Care was generally provided in the patient’s home, and the nurse was
responsible for cooking, house cleaning, and other activities specific to the patient and family
in addition to traditional nursing care.
During the Great Depression of the 1930s, however,
people could no longer afford home care and began using hospitals for care that had been
performed by private-duty nurses in the home. During that time, nurses and students were
the caregivers in hospitals and in public health agencies.
As hospitals grew during the 1930s
and 1940s, providing total care continued to be the primary means of organizing patient care.

This method of assignment is still widely used in hospitals and home health agencies.
This organizational structure provides nurses with high autonomy and responsibility.
Assigning patients is simple and direct and does not require the planning that other
methods of patient care delivery require. The lines of responsibility and accountability are
clear. The patient theoretically receives holistic and unfragmented care during the nurse’s
time on duty.
Each nurse caring for the patient can, however, modify the care regimen. Therefore, if there
are three shifts, the patient could receive three different approaches to care, often resulting
in confusion for the patient. To maintain quality care, this method requires highly skilled
personnel and thus may cost more than some other forms of patient care. This method’s
opponents argue that some tasks performed by the primary caregiver could be accomplished
by someone with less training and therefore at a lower cost. A structural diagram of total
patient care is shown in Figure 14.1.

The greatest disadvantage of total patient care delivery occurs when the nurse is
inadequately prepared or too inexperienced to provide total care to the patient. In the early
days of nursing, only registered nurses (RNs) provided care; now, many hospitals assign
LVNs/LPNs as well as unlicensed health-care workers to provide much of the nursing care.
Because the coassigned RN may have a heavy patient load, little opportunity for supervision
may exist and this could result in unsafe care.

Functional Method
1st
The functional method of delivering nursing care evolved primarily as a result of World War
II and the rapid construction of hospitals as a result of the Hill Burton Act. Because nurses
were in great demand overseas and at home, a nursing shortage developed and ancillary

personnel were needed to assist in patient care. These relatively unskilled workers were
trained to do simple tasks and gained proficiency by repetition. Personnel were assigned to
complete certain tasks rather than care for specific patients. Examples of functional nursing
tasks were checking blood pressures, administering medication, changing linens, and bathing
patients. RNs became managers of care rather than direct care providers, and “care through
others” became the phrase used to refer to this method of nursing care. Functional nursing
structure is shown in Figure 14.2.

The functional form of organizing patient care was thought to be temporary, as it was
assumed that when the war ended, hospitals would not need ancillary workers. However,
the baby boom and resulting population growth immediately following World War II left
the country short of nurses. Thus, employment of personnel with various levels of skill and
education proliferated as new categories of health-care workers were created. Currently,
most health-care organizations continue to employ health-care workers of many educational
backgrounds and skill levels.
Most administrators consider functional nursing to be an economical and efficient means
of providing care. This is true if quality care and holistic care are not regarded as essential.

A major advantage of functional nursing is its efficiency; tasks are completed quickly, with
little confusion regarding responsibilities. Functional nursing does allow care to be provided
with a minimal number of RNs, and in many areas, such as the operating room, the functional
structure works well and is still very much in evidence. Long-term care facilities also
frequently use a functional approach to nursing care.
During the past decade, however, the use of unlicensed assistive personnel (UAP), also
known as nursing assistive personnel, in health-care organizations has increased. Many nurse
administrators believe that assigning low-skill tasks to UAP frees the professional nurse to
perform more highly skilled duties and is therefore more economical; however, others argue
that the time needed to supervise the UAP negates any time savings that may have occurred.
Most modern administrators would undoubtedly deny that they are using functional nursing,
yet the trend of assigning tasks to workers, rather than assigning workers to the professional
nurse, resembles, at least in part, functional nursing.

Functional nursing may lead to fragmented care and the possibility of overlooking patient
priority needs. In addition, because some workers feel unchallenged and understimulated in
their roles, functional nursing may result in low job satisfaction. Functional nursing may also
not be cost-effective due to the need for many coordinators. Employees often focus only on
their own efforts, with less interest in overall results.

Team Nursing
Despite a continued shortage of professional nursing staff in the 1950s, many believed that a
patient care system had to be developed that reduced the fragmented care that accompanied
functional nursing. Team nursing was the result. In team nursing, ancillary personnel
collaborate in providing care to a group of patients under the direction of a professional nurse.
As the team leader, the nurse is responsible for knowing the condition and needs of all the
patients assigned to the team and for planning individual care. The team leader’s duties vary
depending on the patient’s needs and the workload. These duties may include assisting team
members, giving direct personal care to patients, teaching, and coordinating patient activities.
Team nursing structure is illustrated in Figure 14.3.
Through extensive team communication, comprehensive care can be provided for patients
despite a relatively high proportion of ancillary staff. This communication occurs informally
between the team leader and the individual team members and formally through regular team
planning conferences. A team should consist of not more than five people, or it will revert to
more functional lines of organization.
Team nursing is also usually associated with democratic leadership. Group members are
given as much autonomy as possible when performing assigned tasks, although the team
shares responsibility and accountability collectively. The need for excellent communication
and coordination skills makes implementing team nursing difficult and requires great selfdiscipline
on the part of team members.
Team nursing also allows members to contribute their own special expertise or skills.
Nagi, Davies, Williams, Roberts, and Lewis (2012, p. 56) note that “overall, the team
model encompasses all levels of skills and is characterized by a sharing of workload and
the supervisory/evaluative role of the team leader.” Team leaders, then, should use their
knowledge about each member’s abilities when making patient assignments. Recognizing
the individual worth of all employees and giving team members autonomy results in high
job satisfaction.

Disadvantages to team nursing are associated primarily with improper implementation

Modular Nursing
Team nursing, as originally designed, has undergone much modification in the last 30 years.
Most team nursing was never practiced in its purest form but was instead a combination of
team and functional structure. More recent attempts to refine and improve team nursing have
resulted in many models including modular nursing.
Most team nursing was never practiced in its purest form but was instead a combination of team
and functional structure.
Modular nursing uses a mini-team (two or three members with at least one member being
an RN), with members of the modular nursing team sometimes being called care pairs.
In modular nursing, patient care units are typically divided into modules or districts and
assignments are based on the geographical location of patients.
Keeping the team small in modular nursing and attempting to assign personnel to the same
team as often as possible should allow the professional nurse more time for planning and
coordinating team members. In addition, a small team requires less communication, allowing
members better use of their time for direct patient care activities.