Nursing Care Models

Home , Home health nursing, Nursing management, Nursing theory, Primary Nursing, Surgical nursing

AMERICAN NURSING HISTORY

Nursing Care Models

Historical Review

Davida Michaels 2/27/2020

Table of Contents Caring ...... 3

Preface...... 3

Concept of Caring and Nursing ...... 4

Using Nursing Theory in Our Everyday Care ...... 5

Nursing Practice ...... 6

How Is Nursing Care Provided? ...... 6

A Bit of History ...... 6

Nursing Care Models ...... 7

Organization of Delivery of Care/ Staffing Considerations ...... 7

Historical Review of Nursing Care Models ...... 7

Total Patient Care ...... 8

Functional Nursing...... 9

Team Nursing Modular Nursing(Varient) ...... 11

Primary Nursing ...... 13

(Variant) Relationship Based Care ...... 13

Primary Nursing Variant -Partnership Model (Co-Primary Nursing) ...... 14

Relationship Based Care ...... 15

Compassionate Connected Care Model Care Team Approach ...... 16

References ...... 19

Caring

Preface

This author’s basic nursing program was a hospital based, diploma program in the late 1960’s. Our fundamentals of nursing course introduced Alice Price’s concept of the art, science and spirit of nursing. i Price defined nursing as an art which referred to the skilled techniques that nursing must acquire in order to give individual care to patients. Nursing is a science “in that the underlying principles of nursing lie in the knowledge of the biological sciences Nursing is possessed of a spiritual quality in that its primary aim is to serve humanity. As a new nurse I embraced this philosophy as my guide in my practice – caring based on scientific principles which, I believe includes the social sciences. As a student nurse in 1967 we were taught early AM cares – before breakfast –routine AM care included preparing those patients who were able to eat breakfast -washing face and hands, straightening the bed and positioning the patient so he or she could eat. A complete bath – either assisting the patient or in many cases provided by the nurse was provided during the morning. PM care (evening) and HS (hour of sleep) care were also provided. Backrubs several times a day were common for bed bound patients. Each ‘routine ‘care’ provided the nurse an opportunity to assess patients physically, communicate and teach each patient. These “Cares” occupied the majority of the nurse’s time. The role of the nurse has changed, and one result has been these ’Cares ‘have been either assigned to ancillary personnel or eliminated. ii

A former Director of a Hospital School of Nursing was one of the participants in the oral history project . This participant had received her Ed.D after she had retired. One of her research goals was “To identify those qualities essential in the good nurse from the employer’s perspective with emphasis on the clinical abilities the new graduate brings from the educational setting.” In her discussion of the studies major findings she stated that “The one quality which this researcher had anticipated would be high on the list received minimal comment. Few persons spoke of looking for nurses who had a caring attitude, a concern for the patient and compassion. The importance of this quality came though more clearly when they were asked about the qualities of

3 a good nurse. When describing the good nurse, respondents spoke of a caring compassionate person, someone who would care for patients as she would want to be cared for.iii

Concept of Caring and Nursing

“Nursing is a significant, therapeutic interpersonal process. It functions co-operatively with other human processes that make health possible for individuals in communities - Hildegard Peplau.”iv

Caring is about interpersonal relationships - nurse – patient ; nurse -patient family; nurse - members of the care team; Rosanne Raso, in her editorial in Nursing Management “It’s All About Relationships” v states that the criticality of effective 360° relationships is fundamental to a successful leader. It really is all about relationships, and not only with our patients. Furthermore, just as we lose the magic of nursing … when we fail to have effective patient relationships, we lose the magic of leadership when we fail to have effective working relationships. We succumb to transactional, rather than transformational, leadership”

Outstanding outcomes are achieved when patients feel safe within a trusting relationship. The nurse-patient relationship is strengthened through continuity of care and collaboration of interdisciplinary teamsvi In 1979 Dr. Jean Watson introduced the Human Caring Theory. Watson’s theory of human caring focuses on the role of caring in a nurse- patient relationshipvii

Watson’s Core Principles/Practices include:

 Practice of loving-kindness and equanimity  Authentic presence: enabling deep belief of other (patient, colleague, family, etc.)  Cultivation of one’s own spiritual practice toward wholeness of mind/body/spirit—beyond ego  “Being” the caring-healing environment  Allowing miracles (openness to the unexpected and inexplicable life events)

See Watson’s theory briefly explained: https://www.americannursinghistory.org/nursing- theorists

Exemplar:

University of Rochester/Highland Hospital nursing care model utilizes Watson’s Human Caring Theoryviii https://www.urmc.rochester.edu/highland/departments- centers/nursing/nursing-philosophy/model-of-care.aspx

“Here at Highland Hospital’s Department of Nursing, our nursing practice is guided by Dr. Jean Watson’s Human Caring Theory evidenced through Patient- Centered Care and Patricia Benner’s Model of Novice to Expert.”

Using Nursing Theory in Our Everyday Care  Nursing theory strengthens our practice by providing structure and a common language. The Human Caring Theory allows us to proclaim our beliefs, values and the very essence of why we became nurses. Our deep roots in caring set Highland nurses apart.  Caring is based on continuous healing relationships  Patients are the source and center of care  Care is customized and reflects values and needs of patients  Families are an integral part of the care team  All team members are caregivers  Caring is provided in an environment of comfort and support  Transparency is the rule in patient care  Safety is a visible care priority  Caregivers focus on the best interest and goals of the patient

Nursing Practice

How Is Nursing Care Provided?

Nursing theory is the term given to the body of knowledge that is used to support nursing practice. Nursing models are constructed of theories and concepts. Nursing care delivery models are used to help nurses assess, plan and implement patient care by providing a framework within which to work. Nursing models also help nurses achieve uniformity and seamless care.ix.

Care models pertain to the organization of nursing care and may be found in every setting where nurses provide care. This includes hospitals inpatient setting, ambulatory care, home care, and nursing homes. Care models also exist for specific patient populations such as elderly patients, people with mental health needs, and individuals with chronic conditions including disease management.

A Bit of History

Until the mid- nineteenth century, when illness occurred the last place a person wanted to be was in what passed for a hospital; if you were sick you were cared for in the home. The expectation was that women were responsible for caring for members of their family as well as friends, and neighbors. Family-centered sickness care remained traditional until the mid nineteenth century. Those without families or anyone to care for them, such as seamen who became ill and could not continue their voyage, were cared for in a hospital established by the shipping company. For those without families there were public hospitals - nursing care in these institutions was provided by women who called themselves nurses but had no formal training.

Before Florence Nightingale brought her nursing theory, xreforms and formal education to nursing, there were religious women ─ Catholic Nursing Sisters (Nuns) and Protestant Deaconesses ─whose vows included the care of the sick. They were often called to nurse victims of typhoid, cholera and other epidemics- their religious communities were responsible for starting hospitals throughout the young country.

In Say Little, Do Much, Sioban Nelson casts light on the work of women’s religious communities. According to Nelson, “the popular view that nursing invented itself in the second half of the nineteenth century is historically inaccurate and dismissive of the major advances in the care of the sick as a serious and skilled activity, an activity that originated in seventeenth- century France with Vincent de Paul's Daughters of Charity”xi.

After the civil war Nightingale’s philosophy and theories regarding nursing care began to be integrated into nurse education and practice. – a brief overview of Nightingale’s theory may be found on the following page on the website —Nursing Theorists

Nursing Care Models

Organization of Delivery of Care/ Staffing Considerations

Historical Review of Nursing Care Models

Providing safe, quality nursing care requires well-educated, competent, professional staff members who are committed to providing safe, high-quality care while meeting the needs of the organization such as budget constraints. Providing an appropriate level of care in facilities operating 24 hour/ 7 day/year such as hospitals and skilled nursing facilities creates staffing challenges. In order to meet these challenges, organizations have developed different models, each designed by leadership to provide appropriate staff to meet the needs of the people seeking care.

Ideally nursing care delivery models match number and type of caregivers to patient care needs determine who is going to perform what tasks, who is responsible, and who makes decisions and detail assignments, responsibility, and authority to accomplish patient care.

Historically, four care models have dominated the organization of inpatient nursing care – total patient care, functional nursing, team nursing and primary care. Functional nursing and team nursing are task-oriented and use a mix of nursing personnel; total patient care and primary nursing are xii patient-oriented and rely on nurses to deliver care. , xiii

Total Patient Care

The oldest method of organizing patient care is to have each nurse responsible for planning, organizing, and performing all care for assigned patients.

In the early 1800’s nurses received no training and were expected to clean and do laundry as well as caring for patients. Most nurses knew almost nothing about medicines or symptoms and physicians often regarded nurses as little more than maids. It wasn’t until 1873 that nurse education based on the Nightingale model produced trained graduate nurses. A few graduate nurses were hired by the hospital where they received their training ,usually as supervisors. Total patient care continued to be provided by students.

SCRUBS published the following nursing job description from1887:

1887 Nursing Job Descriptionxiv In addition to caring for your 50 patients, each bedside nurse will follow these regulations:

1. Daily sweep and mop the floors of your ward, dust the patient’s furniture and window sills. 2. Maintain an even temperature in your ward by bringing in a scuttle of coal for the day’s business. 3. Light is important to observe the patient’s condition. Therefore, each day fill kerosene lamps, clean chimneys and trim wicks. 4. The nurse’s notes are important in aiding your physician’s work. Make your pens carefully; you may whittle nibs to your individual taste. 5. Each nurse on day duty will report every day at 7 a.m. and leave at 8 p.m., except on the Sabbath, on which day she will be off from 12 noon to 2 p.m. 6. Graduate nurses in good standing with the director of nurses will be given an evening off each week for courting purposes, or two evenings a week if you go regularly to church. 7. Each nurse should lay aside from each payday a goodly sum of her earnings for her benefits during her declining years, so that she will not become a burden. For example, if you earn $30 a month, you should set aside $15. 8. Any nurse who smokes, uses liquor in any form, gets her hair done at a beauty shop or frequents dance halls will give the director of nurses good reason to suspect her worth, intentions and integrity. 9. The nurse who performs her labors [and] serves her patients and doctors faithfully and without fault for a period of five years will be given an increase by the hospital administration of five cents per day

Currently students provide total patient care as part of their clinical but they are not considered to be hospital staff. Total patient care is the nursing model used in areas where patients require intensive nursing care such as intensive care units (ICU) and post anesthetic care unit (PACU) .These areas utilize an all RN staff. The main concerns regarding the total patient care provided by RN’s are cost and availability of qualified nurses.

Functional Nursing

Functional nursing was designed around an efficacy model that seeks to get many tasks accomplished in a short period of time. Functional Nursing evolved during World War II as a

9 result of the nursing shortage as registered nurses were needed to nurse the troops. Staff members assigned to complete specific tasks for a group of patients. Unskilled workers trained to perform routine, simple tasks. Hospitals adopted functional nursing due to lack of qualified staff and the decreased cost of using lesser skilled personnel..

Functional nursing is task-oriented in scope. Instead of one nurse performing many functions, several nurses are given one or two assignments. For example, there is a medicine nurse whose sole responsibility is administering medications. A treatment nurse is charged with giving patients diagnostic tests as well as providing accurate diagnoses according to the patient's symptoms and test results. A charge nurse works in tandem with the physician and ensures that the patient receives optimum care. The principle idea of functional nursing is for nurses to be assigned tasks, not patients.xv

xvi

Advantages of functional nursing:

 Care is provided economically and efficiently  Cost effective as minimum number of RNs required  Tasks are completed quickly

Disadvantages

 Fragmented care

 Communication issues - patient condition changes and changes in physician orders may be “lost” resulting in comments such as -- “Nobody let me know” – leading to safety and quality of care issues.  Patient may be confused with many care providers  Caregivers feel unchallenged xvii  Often exceeds the Charge Nurse’s span of control.

Team Nursing Modular Nursing(Varient)

xviii

Eleanor C. Lambertsen introduced team nursing to help improve patient care. xix Her dissertation, “Education for Nursing Leaders,” completed in 1957, introduced the model of team nursing, a model that is still influential in nursing practice today Lambertsen’s concept called for registered nurses and doctors to coordinate the work of occupational and physical therapists, social workers and other health care professionals. Daily consultations were held to review nursing operations and arrange patient care. While Lambertsen’s model called for registered nurses and doctors to coordinate the work of multiple disciplines, the majority of hospitals modified the concept to utilize registered nurses to coordinate nurses and unlicensed assistive personnel (UAP).

Team nursing involves use of a team leader and team members to provide various aspects of nursing care to a group of patients. In team nursing, medications might be given by one nurse

11 while baths and physical care are given by a nursing assistant under the supervision of a nurse team leader. Skill mixes include experienced and specially qualified nurses to nursing orderlies.

Kalish and Schoville described how team nursing is intended to work:

“RN team leader to oversee the care of a group of patients with the assistance of LPNs and NAs - each patient was assigned to a team member, who was supposed to perform total patient care except for responsibilities requiring an RN license, such as giving medications. The RN team leader obtained the patient report from the head (or charge) nurse at the beginning of the shift and then gave report to team members. The hallmark of this delivery system, a daily team conference about the patients, was meant to ensure that everyone on the team knew the status of all patients the team cared for.” xx

Website Author’s experience::I graduate d in 1969 from a hospital school of nursing. During our senior year clinical on medical surgical units, as students we worked a full 8 hour shift– day, evening or night shift. We were considered part of the team and expected to be on the unit at the same time as the staff. The team nursing model was used; the prior shift covered the unit while we listened to the prior shift’s charge nurse give report on all the patients on our team to our team’s leader. Report was given using a Kardexxxi which contained information on each patient, the plan of carexxii and medications list. At the end of report we checked the Kardex for our assigned patient’s orders, and then checked the medication Kardex - reviewed their medications and the medication cards we would need during our shift. By the end of the clinical rotation, we were expected to act as team leader. The team leader made out our assignments. We started with a ‘light’ assignment but by the end of the rotation were expected to be able to care for multiple patients based on their needs.

Genesee Hospital was a teaching hospital - part of the University of Rochester’

medical school, as students we worked with fourth year medical students, interns (what are now titled first year residents), residents and attending physicians. As students – and later as graduates -in the hospital school of nursing, often we knew more about” how to get things done within the hospital organization” and were sought out by new Interns and residents. In this way we were part of the larger team –I believe this experience was invaluable all through my nursing career.

Modular Nursing is a modification of team nursing and focuses on the patient's geographic location for staff assignments; the unit is divided into groups referred to as modules - also called districts or pods.

The same team of caregivers is assigned consistently to the same geographic location. Each location, or module, has an RN assigned as the team leader, and the other team members may include LVNs/LPNs and Unlicensed Assistant Personnel (UAP) (Yoder - Wise, 1999).xxiii

Primary Nursing

(Variant) Relationship Based Care Primary Nursing evolved in 1969 from the work of a team of direct care providers on Unit 32 an acute medical care ward at the University of Minnesota Medical Center. The nursing staff was experiencing extreme frustration with their chaotic work environment; the nursing care delivery model was "too fragmented and diffuse -- one in which 'everybody's responsible for everything and nobody's responsible for anything'.xxiv At that time Marie Manthey was head of a team of nurses that designed and implemented. Manthey was later named Associate Director of Nursing at the University of Minnesota.

xxvAt the time, it was quite revolutionary to allow the nurse providing care for the patient to determine the amount and type of nursing care the patient would receive. Nurses had been expected to follow policies and orders rather than

13 making decisions based on their own professional judgment. Nurses providing direct care also did not generally communicate with physicians. Instead, patient information was communicated by the unit manager or nurse in charge. These individuals served as a go between, transmitting patient information/messages and orders between the nurses providing patient care and the patient's physician.

"The change to primary nursing eliminated one level of nursing supervision, the traditional team leader, and flattened the well-worn hierarchical structure. Each registered nurse on Station 32 assumed 24-hour responsibility and accountability to plan nursing care for a small group of patients. The results were positive, totally unplanned and nearly palpable. The staff nurse instantly earned, and claimed, the power to make nursing decisions. Almost overnight, communication changed to a direct, person-to-person pattern; physicians discussed patients with the nurse caregiver, not the head or charge nurse." xxvi

 Advantages  High-quality, holistic patient care  Allows for time/opportunity to establish relationship with patient and their family / support system  RN – autonomy; ability to make nursing care decisions  Disadvantages  Primary nurse must be able to practice with a high degree of responsibility and autonomy  RN must accept 24-hour responsibility  Issue – how to staff to allow for primary nurses absence (days off, illness); alternate shifts ;  Communication – changes in patient condition  Reluctance of other RN’s to follow nursing orders.  More RNs needed; not cost-effective  Patient condition change requiring movement to different level of care – different location-different nurse.

Primary Nursing Variant -Partnership Model (Co-Primary Nursing) Modification of primary nursing to make more efficient use of the RN as the primary RN is partnered with another nurse:- allows for the use of a licensed practical nurse/licensed vocational nurse (LPN/LVN) ) as partner.

Advantages

 Assists communication  RN can encourage training and growth of LPN/LVN partner  More cost-effective than primary nursing

Disadvantages

 RN may have difficulty delegating to partner  Consistent partnerships difficult to maintain due to varied schedules

Authors Note: is A partnership model is viable in Home Health Care - For an example see Michaels, Davida R. Home Health Nursing: Towards Professional Practice Model, Nursing Management, April, 1992 vol 25 no9. Pp68- 72. .xxvii

Relationship Based Care Relationship-Based Nursing Practice is a care delivery model designed to transition nursing care from task-focused to relationship-based..xxviii Three main relationships —the nurse with the patient, the nurse with colleagues, and the nurse with self—provide the foundation for the creation of guiding principles. This actualizes the role of the professional registered nurse in and contributes to job satisfaction; increased patient and family satisfaction. is to support 1 or more of the 3 relationships, contribute to improved patient safety, and actualize the role of the professional registered nurse, in daily patient care. Outcomes include improvement in patient safety, increased patient satisfaction, and perception of improved teamwork among nurses. The process for sustainability and ongoing evaluation of the model is discussed.

Compassionate Connected Care Model Care Team Approach The "Compassionate Connected Care: A Care Model to Reduce Patient Suffering," xxixdetails Press Caney’s model for connecting with patients. First and foremost, connecting with patients and improving care requires acknowledging that patients are, indeed, suffering. Patients who are involved in decisions about their care tend to have better outcomes. Focusing on the patient and taking actions that involve them in their care are evidence-based initiatives that resonate with caregivers.xxx

The Compassionate Connected Care framework organizes the actions that providers take into four areas: the clinical, operational, behavioral and cultural aspects of patient care. These domains exist across settings, services and caregivers:

■ The Clinical domain connects clinical excellence with outcomes using clinical data as well as patient-reported outcome measures and nursing sensitive indicators.

■ The Operational domain connects operational effectiveness and efficiency with quality using financial data, patient-flow metrics and staffing/ scheduling data.

■ The Behavioral domain connects behaviors with engagement of both providers and nurses through patient experience data.

■ The Cultural domain connects organizational mission, vision and values with provider engagement using patient, physician, nurse and employee experience data.

Press Ganey identified six themes of Compassionate Connected Care:

 Acknowledge Suffering: We should acknowledge that our patients are suffering and show them that we understand.  Body Language Matters: Non-verbal communication skills are as important as the words we use.  Anxiety is Suffering: Anxiety and uncertainty are negative outcomes that must be addressed

 Coordinate Care: We should show patients that their care is coordinated and continuous, and that “we” are always there for them.  Caring Transcends Diagnosis: Real caring goes beyond delivery of medical interventions to the patient.  Autonomy Reduces Suffering: Autonomy helps preserve dignity for patients.

xxxi

Exemplar: Baystate Medical Center, Springfield, Mass.: Nursing Care Delivery Modelxxxii

“In 2018, much of the Department of Nursing work continued to revolve around support for Baystate’s Compassionate Connections and the Nursing Care Delivery Model – Compassionate Connections in Caring. All inpatient units are currently participating and engaged in our care delivery model and are using the agreed upon behaviors of Moment of Caring, Words and Ways That Work, No Pass Zone, Purposeful Rounding and Bedside Report. After great success in the initial roll out it was identified by a group of nurses that a plan to nurture sustainability was needed. Enter the Medical/Surgical Nursing Model of Care (MOC) Education & Support Team, enthusiastically referred to as the MOC SQUAD! This committee is focused on educating and promoting the use of our Nursing Model of Care. The team is in pilot mode and is currently comprised of RN champions from each of the Med/Surg Units (W3, W4, S2, S64, S3 Oncology, D6A, and D6B) as well as educators and manager sponsors. The plan is to expand the team to the departments of Surgery, Heart & Vascular, Labor and Delivery, as well as Neurology. The MOC SQUAD conducted its first monthly unit assessment of the behaviors in September 2018 using a basic assessment tool. Teams of RNs go to unit areas and assessed for behavioral interactions using a basic observational tool with supportive material to facilitate open discussion and anecdotal story sharing. The group then reconvenes after the assessment to debrief. For this work, three specific questions on the Press Ganey Patient Satisfaction Survey are monitored: 1) Recommend the hospital; 2) Nurses treat with courtesy and respect, and; 3) Call button help soon as wanted it. We are seeing forward progress in all three areas. The most significant progress has been with “Nurses treat with courtesy and respect.”

References

i Price, Alice, 1954. The Art, Science and Spirit of Nursing. W.B. Saunders ii On a very personal note, after I had major abdominal surgery for cancer in 2000, I received no personal care for several days until a nurse’s aide asked if I’d like some help and provided much needed care. As a result of the lack of care, my wound opened (wound dehiscence) and I developed a nasty wound infection requiring several months to fully heal. iii Murphy, Jeanne. May, 1990. “A Nurse is A Nurses is A Nurse” in Search of Clinical Competence: The Employer’s Perspective.” P. 10 6 Dissertation Doctorate Education (unpublished paper) iv Peplau, Hildegard, 1952., Interpersonal Relations in Nursing. Putnam & Sons, New York.p.16 v Rasco, R MS, RN, NEA-BC, Editor-in-Chief. 2014. It’s all about relationships. November 2014 • Nursing Management [email protected] DOI-10.1097/01.NUMA.0000455731.25755.20 vi Mid Coast Hospital Nursing Care. Relationship Based Care https://www.midcoasthealth.com/nursing/philosophy-values vii For complete information about Jean Watson and the Theory of Caring visit her website at https://www.watsoncaringscience.org/jean-bio/caring-science-theory/ viii https://www.urmc.rochester.edu/highland/departments-centers/nursing/nursing-philosophy/model-of-care.aspx ix Price, Alice, op.cit. x Nightingale, Florence, Notes on Nursing xi Sioban Nelson, Say Little, Do Much,Nursing, Nuns, and Hospitals in the Nineteenth Century xii Jennings, Bonnie, Ch. 19 Care Models in xii Hughes RG (ed.). Patient safety and quality: An evidence-based handbook for nurses. (Prepared with support from the Robert Wood Johnson Foundation). AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; March 2008. U.S. Department of Health and Human Services. xiii Historically, total patient care was care provided before there were registered nurses – untrained or ‘professed’ nurses, and nursing students . xiv Downloaded from SCRUBS https://scrubsmag.com/a-list-of-rules-for-nurses-from-1887/2/ {SCRUBS does not provide any reference as to the origin of this job description. In this authors opinion it appears to be written based on oral histories of nurses of that era. xv https://pocketsense.com/the-advantages-disadvantages-of-functional-nursing-12582245.html xvi Figure downloaded from https://nursekey.com/care-delivery-strategies/ xvii Staffing and Nursing Delivery Models, - Power Point Presentation Downloaded 1//2020 xviii Brooks, Ethel, 1949, The First Seven Years Are the Hardest, American Journal of Nursing, vol.49, No. 5, May. P. 276-279 xix https://www.modernhealthcare.com/awards/health-care-hall-fame-inductees-eleanor-c-lambertsen; https://www.mcall.com/news/mc-xpm-1998-04-11-3204449-story.html xx Beatrice Kalisch, PhD, RN, and Rhonda Schoville, MSBA, RN, It Takes a Team, AJN, October, 2012, vol. 112, no.10, pp 52-54

xxi A Kardex is a medical information system used by nursing staff as a way to communicate important information on their patients. It is a quick summary of individual patient needs that is updated at every shift change. The term s a generalized trademark for a medication administration record.(The Kardex system has been largely supplanted by computerized patient information systems (Electronic Health Records) xxii One problem using the Kardex was keeping it current. Orders were transcribed in pencil; new orders required that the old orders were either erased or a line was drawn thru the order resulting in a messy, hard to follow system. Nursing orders were allowed but physician orders took precedent; nurses had a difficult time accepting and following orders written by other nurses. xxiii https://www.slideserve.com/varen/staffing-and-nursing-care-delivery-models; Yoder-Wise, Patricia, 1999, Leading and Managing in Nursing xxiv Wikapedia references from (1) Manthey, Marie (1999) I Never Saw Myself as a Change Agent. & Williams, Sarah T (2014). "One Woman's Effort to Understand the Problem of Nursing and Addiction." MinnPost. 5/28/14 xxv https://nursekey.com/care-delivery-strategies/

xxvi Ibid xxvii See Michaels, Davida R. Home Health Nursing: Towards Professional Practice Model, Nursing Management, April, 1992 vol 25 no9. Pp68-72. xxviii Cathleen C. Hedges, MSN, RN, B-C; Amy Nichols, EdD, CNS, RN; Lourdes Filoteo, BSN, RN, Relationship-Based Nursing Practice Transitioning to a New Care Delivery Model in Maternity Units. J Perinat Neonat Nurs _ Volume 26 Number 1, 27–36 _ Copyright C _ 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins xxix Press Ganey 2014. Compassionate Connected Care: A Care Model to Reduce Patient Suffering Press Ganey Associates, Inc, 404 Columbia Place South Bend, IN 46601 xxx 2014 Press Ganey Associates, Inc. Compassionate Connected Care: A Care Model to Reduce Patient Suffering xxxi ibid xxxii Baystate Medical Center, Nursing Report 2018 p.5