Delivery of Patient Care

May 1, 2021

Today three levels of health promotion are recognized. Their purpose is to promote health through maintaining wellness, preventing disease-related complications, and reducing the infirmity associated with disease states. Primary prevention seeks to avoid disease states through wellness activities and preemptive screening programs such as mammograms, colonoscopies, and glucose screening. Secondary prevention recognizes the presence of disease but seeks to reduce the impact of the condition by encouraging behaviors to promote health. An example of this type of prevention is dietary teaching to a patient with diabetes with intention to reduce episodes of hyperglycemia. The management of care activities for those with serious health problems who seek to improve the quality of life and reduce further loss of function are captured by tertiary prevention.

Continuity of Care

The patient is the focus of the health care system. However, many factors in our holistic health care system determine what actually happens in the care of each patient. The number of health care providers and health care agencies involved in the care and treatment of a single patient is extensive. Increased specialization by health care providers and health care institutions, reimbursement procedures by third-party payers (e.g., insurance companies), cumbersome federal regulatory organizations, and state health care regulatory agencies all affect the consumer (the patient) and the type and quality of care provided.

One of the greatest challenges for the consumer of medical care is artful navigation of the health care delivery system. The consumer faces challenges to maintain autonomy and obtain continuity of care. Patients who are already weakened by the stressors of actual or potential medical conditions can become frightened as they attempt to understand the medical care and related choices available to them.

Delivery of Patient Care

The care of patients is a humanistic enterprise. It involves not only treating disease and injury but also preventing disease, restoring optimal wellness through rehabilitation, caring for the chronically ill, and educating patients and families. To identify the individual needs of the patient and to plan a systematic approach to meet those needs, nurses participate in developing an individualized care plan with use of the nursing process (see Chapter 5). The purpose of the care plan is to meet the expressed needs of the patient. Its development involves the patient and all health care providers who, through a coordinated and cooperative effort, work toward meeting the patient’s total needs in a holistic caring manner.

Participants in the Health Care System

Professional Health Care Specialists

The patient is the central focus of activities performed by more than 200 types of health care providers identified in the health care system in the United States. Many professions require certification or licensure of their members. Within many disciplines are subspecialties of individuals who have advanced training and licensure.

Registered Nurses

The RN is a direct health care provider who is licensed after completion of one of three types of nursing education programs: a 4-year baccalaureate degree program, a 2-year associate degree program, or a 3-year diploma program. RNs practice in a variety of settings inside and outside of the care facility. The RN’s duties and tasks vary according to educational background and the state’s nurse practice act. Educational and career opportunities exist for the registered nurse beyond initial licensure. Nurses with master’s degrees or doctorates represent a small but growing segment of the profession. These individuals are often termed advanced practice nurses. Their roles are expanded and may involve educator, administrator, and prescriptive authority.

Licensed Practical/Vocational Nurses

The LPN/LVN practices under the supervision of the RN or the physician. Working together, the LPN/LVN and the RN are the direct patient caregivers in most institutions. The role of the LPN/LVN is based on the scope of practice outlined in each state’s nurse practice act (see Chapter 57 for more information on nurse practice acts).

Other Caregivers

Other caregivers are also required to be registered or licensed and to have the specialized education and training dictated by their professional organizations. Holistic care requires that professionals from differing areas come together to provide comprehensive care. When a patient’s condition dictates, referral to other care providers may be indicated. For example, social workers are trained to counsel patients who have social, emotional, or environmental problems. Physical therapists use precise methods of massage, exercise, and hydrotherapy to help restore physical function of the body. Dietitians are trained to determine the foods that meet the nutritional requirements of the patient. Respiratory therapists assist the patient by administering oxygen, monitoring and maintaining ventilators, drawing blood for blood gas analysis, and performing other pulmonary function tests.

Technologists, Medical Technicians, and Paraprofessionals

Diagnostic personnel work in the laboratory and radiology departments. Their roles involve assisting the medical professional staff in testing for disease states and injury. The term technologist refers to those who have a baccalaureate degree, whereas the term technician refers to those who have had training and have earned an associate degree or certificate. Paraprofessionals are educated to assist the professional in providing care for patients. An unlicensed assistive personnel (UAP) is educated in basic nursing techniques and performs under the supervision of the RN. The unit secretary prepares and maintains patient records, orders supplies, schedules tests, and performs receptionist duties on the care unit.
These are only a sampling of the health care participants in the health care system. Each participant has a valuable contribution to make toward ensuring the safety and well-being of the patient.

Economic Factors That Affect Health and Illness

Rising Health Care Costs

Health care costs have reached a critical height. A large portion of the country’s financial resources are committed to health care–related costs. Several factors have been highlighted as playing a role in the increase in costs, including an aging population, increased use of advanced technologies, rising cost of private health care insurance, the rising cost of medical malpractice insurance, and a struggling economy.

Increasing number of aging Americans

As the baby boom generation nears the age of retirement, their health problems increase; this onset of chronic diseases in a large segment of the population strains the health care system. Diseases associated with aging include heart disease, diabetes, and osteoporosis. As the U.S. population ages, an increasing number of older adults needs nursing home care, which is costly and has limited coverage under traditional insurance plans.

Advances in technology

Advances in technology have led to better diagnosis and treatment of illness, but such progress carries a large price tag. Research and the development of technology cost millions of dollars, a price that is passed on to the patient in the cost of the individual tests or treatments. Technological advances have resulted in concerns for patient privacy as electronic piracy has become increasingly possible. Safeguards for the electronic health records add to the costs for health care.

Health care insurance

Private health care insurance was initially developed to defray some or all of the cost of health care. It made health care more affordable, but it also raised the demand for it. As more individuals sought care, the price of health care services and insurance costs spiraled. This trend continues at an alarming and seemingly uncontrollable speed. The underinsured and uninsured population faces hardship when health care is needed. Determination of who receives care and who does not is becoming an ethical issue at all levels of the health care delivery system. To further compound the current economic problems, nearly 16% of Americans or 48.6 million people are without health care coverage (United States Census Bureau, 2011). Although this number has declined for the first time in several years, it is still a cause for concern because these individuals too often avoid preventive and routine care and are seen only in crisis situations.

Malpractice insurance.

Nurses and doctors carry medical malpractice insurance to protect themselves in the event a malpractice claim is filed against them. As malpractice claims have increased in frequency and amount, the premiums for this insurance have also risen. In response, physicians sometimes resort to practicing “defensive medicine.” That is, they become overly cautious out of fear of a claim, ordering costly tests and procedures not because they are medically necessary but to protect themselves. These behaviors have resulted in higher medical costs for the patient.
These issues are alarming for health care providers. Nurses can help keep costs to a minimum by using materials and time economically and providing knowledgeable efficient care.

Changes in Delivery System

Hospitals throughout the United States are changing delivery systems to make care more cost effective. Case management and cross training are two commonly encountered methods for modifying the systems used to deliver care.

Case management nursing revolves around the use of clinical pathways, which map out expectations of the hospitalization according to a designated time frame. The RN functions as a case manager, coordinating and planning the care of a group of patients, or caseload. An LPN/LVN works with the RN to assist the patient in attaining desired outcomes of care. Case management nursing has been proven to reduce the length of stay for the patient, which in turn reduces the overall cost of the patient’s health care.

Cross training allows employers to maximize the use of available staff. Workers are trained to perform duties that cross traditional role boundaries. Cross training may involve combining the roles of differing categories of workers or expanding the responsibilities of staff members to cover multiple care units. Two groups of workers frequently cross trained to expand their roles include unit secretaries and UAPs. This training provides a single worker who is able to perform UAP-related tasks (e.g., ambulating patients and taking vital signs) and receptionist duties (e.g., transcribing orders and ordering unit supplies). Another type of cross training involves linking patient care units, frequently identified as sister units. Common sister units are maternal child care and women’s health, and the nursing staff are trained to work in both areas. Individuals receive training to perform duties that vary according to the needs at a given time. This training can be as narrowly defined as medical training to care for surgical patients or as broadly defined as housekeeping personnel training to give basic morning care to patients. The scope of cross training is usually defined by the individual institution, and the purpose is to reduce the number or cost of employees without compromising the quality of patient care.

Other trends that affect the economics of health care include the development of multisystem health care chains or networks that may include several hospitals, clinics, nursing homes, and pharmacies. These systems share expenses and generally achieve an overall reduction in operating expenses. Health maintenance organizations (HMOs) or group health care practices provide health care to members for a fixed prepaid rate. This service includes medical care, nursing care, diagnostic tests, hospitalization, and various inpatient and outpatient treatments. This service has shown a high quality of low-cost health care.

Social and Environmental Factors That Affect Health and Illness

Social and environmental factors do not necessarily cause illness, but they do influence the development or progression of an illness. Financial hardship, lifestyle choices, and social pressures all influence an individual’s willingness or ability to actively maintain health or prevent illness. In addition, personal behavior choices such as smoking, drug abuse, alcoholism, and obesity impact an individual’s health and wellness. The individual’s mental state has an influence on patient outcomes. Emotions associated with fear, loss of identity, and loss of control are commonly experienced during illness. An imbalance in body functions can affect one’s physical condition and ultimately the position along the wellness-illness continuum. Although there is often a tendency to separate social factors from physical factors, remember that the two areas affect each other reciprocally.

Each patient possesses a unique personality, background, lifestyle, and level of education. Early recognition of the effect of environmental factors on a patient and prompt intervention by family, health care providers, or the patients themselves can decrease or keep any negative impact to a minimum.

Health Promotion

Most people in the United States believe that everyone has a right to health care, regardless of race, color, creed, or economic status. This health care includes the treatment of disease, and health promotion and preventive medicine. In many cases, treatment of illness is less of a concern than its prevention. The acute awareness of preventive medicine has resulted in today’s emphasis on education about issues such as smoking, heart disease, drug and alcohol abuse, weight control, and mental health and wellness promotion activities.

During illness or after a change in health status, people often feel they are not in control of their health, but they do typically trust in the health care system. The presumption is that care will be highly satisfactory and lead to a cure. Health care providers are expected to provide service in a knowledgeable, safe, and expeditious manner and to work in a cooperative manner for their benefit. Patients also expect the cost of care to be reasonable and, most importantly, paid by somebody else (an insurance company or the government).

Patients’ Rights

In 1972, the American Hospital Association (AHA) issued the Patient’s Bill of Rights in an effort to ensure the patient’s fundamental rights for treatment with dignity and compassion were fulfilled. The trailblazing document was revised again in the 1990s and was finally replaced in 2003 when the AHA adopted the Patient Care Partnership (Box 1-2). Under the terms of this document, patients are assured that they can expect high-quality hospital care, a clean and safe

environment, involvement in their care and the decision-making process, protection of privacy, help when leaving the hospital, and help with billing concerns (American Hospital Association, 2003). Nursing home patients also have their rights protected. The Resident’s Bill of Rights is a document that has been developed to provide clarity to the needs and rights of the individual who resides in a long-term care environment (Centers for Medicare and Medicaid Services, 2012).

Health Care Providers’ Rights

The delivery of health care has to be a process of mutual exchange between patients and health care providers. Patients expect their rights as just outlined to be respected, but health care workers have expectations as well. Health care professionals expect that patients will do the following to actively participate in their care as much as possible: take an active role in the planning process, have an understanding of the care and the treatment given, ask questions, follow the treatment plan prescribed, act responsibly with respect to their own conditions, and give health care workers the same respect to which patients are entitled.

Interdisciplinary Approach to Health Care

The primary goal of the health care team is the optimal physical, mental, and social well-being of the patient. This goal is achieved by promoting and restoring health within the wellness-illness continuum. Health care personnel, when working to meet the needs of the patient, must work together as a health care team. Following this interdisciplinary approach to treatment prevents the fragmentation of patient care. Just as the plan of care for patients is developed in a holistic manner, so is the actual delivery of health care. All health care providers must remember that the central focus of all their activity is the patient.
Each member of the team is responsible for coordinating activity with every other member of the team by developing a comprehensive care plan, effectively communicating, and keeping accurate records (Figure 1-9).

Care Plan

The care plan is a document that outlines the individual needs of the patient and the approach of the health care team to meet these needs. It is developed in cooperation with the patient and, in some cases, the patient’s family. It further identifies who will assist in treating the patient. The plan of care is a “living document” that is updated as the patient’s condition warrants. The goal of the document is to guide and direct the activities surrounding the patient’s care, ensure continuity and consistency of care, and eliminate duplication of services. (See Chapter 5 for further

FIGURE 1-9 Nurse collaborating with other members of the interdisciplinary team.

Communication

Good communication is essential for the exchange of information among the members of the health care team. Communication is the prerequisite for meeting the needs of the patient or, if necessary, making appropriate changes to do so. (See Chapter 4 for further discussion of communication.)

Documentation

Documentation in any form is the permanent record of the patient’s progress and treatment. It constitutes the formal and legal record of care received by the patient and the patient’s response to that care (Figure 1-10). The information recorded during the entire course of treatment serves many purposes. It provides a progress record of treatment so that all the involved health care members are aware of what treatment the patient is receiving. It also provides a chronicle of

FIGURE 1-10 Nurse documenting patient care at a computer.

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events, which becomes a valued piece of the patient’s health history that may be referenced for future health care needs. (See Chapter 3 for further discussion of documentation.)