1.4: Health Care Settings and Team

Health Care Settings

There are several levels of health care including primary, secondary, and tertiary care. Each of these levels focuses on different aspects of health care and is typically provided in different settings.

Primary Care

Primary care promotes wellness and prevents disease. This care includes health promotion, education, protection (such as immunizations), early disease screening, and environmental considerations. Settings providing this type of health care include physician offices, public health clinics, school nursing, and community health nursing.

Secondary care

Secondary care occurs when a person has contracted an illness or injury and requires medical care. Secondary care is often referred to as acute care. Secondary care can range from uncomplicated care to repair a small laceration or treat a strep throat infection to more complicated emergent care such as treating a head injury sustained in an automobile accident. Whatever the problem, the patient needs medical and nursing attention to return to a state of health and wellness. Secondary care is provided in settings such as physician offices, clinics, urgent care facilities, or hospitals. Specialized units include areas such as burn care, neurosurgery, cardiac surgery, and transplant services.

Tertiary Care

Tertiary care addresses the long-term effects from chronic illnesses or conditions with the purpose to restore a patient’s maximum physical and mental function. The goal of tertiary care is to achieve the highest level of functioning possible while managing the chronic illness. For example, a patient who falls and fractures their hip will need secondary care to set the broken bones, but may need tertiary care to regain their strength and ability to walk even after the bones have healed. Patients with incurable diseases, such as dementia, may need specialized tertiary care to provide support they need for daily functioning. Tertiary care settings include rehabilitation units, assisted living facilities, adult day care, skilled nursing units, home care, and hospice centers.

Health Care Team

No matter the setting, quality health care requires a team of health care professionals collaboratively working together to deliver holistic, individualized care. Nursing students must be aware of the roles and contributions of various health care team members. The health care team consists of health care providers, nurses (licensed practical nurses, registered nurses, and advanced registered nurses), unlicensed assistive personnel, and a variety of interprofessional team members.

Health Care Providers

The Wisconsin Nurse Practice Act defines a provider as, “A physician, podiatrist, dentist, optometrist, or advanced practice nurse.”^[1] Providers are responsible for ordering diagnostic tests such as blood work and X-rays, diagnosing a patient’s medical condition, developing a medical treatment plan, and prescribing medications. In a hospital setting, the medical treatment plan developed by a provider is communicated in the “History and Physical” component of the patient’s medical record with associated prescriptions (otherwise known as “orders”). Prescriptions or “orders” include diagnostic and laboratory tests, medications, and general parameters regarding the care that each patient is to receive. Nurses should respectfully clarify prescriptions they have questions or concerns about to ensure safe patient care. Providers typically visit hospitalized patients daily in what is referred to as “rounds.” It is helpful for nurses and nursing students to attend provider rounds for their assigned patients to be aware of and provide input regarding the current medical treatment plan, seek clarification, or ask questions. This helps to ensure that the provider, nurse, and patient have a clear understanding of the goals of care and minimize the need for follow-up phone calls.

Nurses

There are three levels of nurses as defined by each state’s Nurse Practice Act: Licensed Practical Nurse/Vocational Nurse (LPN/LVN), Registered Nurse (RN), and Advanced Practice Nurse (APRN).

Licensed Practical/Vocational Nurses

The NCSBN defines a licensed practical nurse (LPN) as, “An individual who has completed a state-approved practical or vocational nursing program, passed the NCLEX-PN examination, and is licensed by a state board of nursing to provide patient care.”^[2] In some states, the term licensed vocational nurse (LVN) is used. LPN/LVNs typically work under the supervision of a registered nurse, advanced practice registered nurse, or physician.^[3] LPNs provide “basic nursing care” and work with stable and/or chronically ill populations. Basic nursing care is defined by the Wisconsin Nurse Practice Act as “care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.”^[4] LPN/LVNs typically collect patient assessment information, administer medications, and perform nursing procedures according to their scope of practice in that state. The Open RN Nursing Skills textbook discusses the skills and procedures that LPNs frequently perform in Wisconsin. See the following box for additional details about the scope of practice of the Licensed Practical Nurse in Wisconsin.

Scope of Practice for Licensed Practical Nurses in Wisconsin

The Wisconsin Nurse Practice Act defines the scope of practice for Licensed Practical Nurses as the following: “In the performance of acts in basic patient situations, the LPN shall, under the general supervision of an RN or the direction of a provider:

(a) Accept only patient care assignments which the LPN is competent to perform.

(b) Provide basic nursing care.

(c) Record nursing care given and report to the appropriate person changes in the condition of a patient.

(d) Consult with a provider in cases where an LPN knows or should know a delegated act may harm a patient.

(e) Perform the following other acts when applicable:

1. Assist with the collection of data.
2. Assist with the development and revision of a nursing care plan.
3. Reinforce the teaching provided by an RN provider and provide basic health care instruction.
4. Participate with other health team members in meeting basic patient needs.”^[5]

Registered Nurses

The NCSBN defines a Registered Nurse as “An individual who has graduated from a state-approved school of nursing, passed the NCLEX-RN examination and is licensed by a state board of nursing to provide patient care.”^[6] Registered Nurses (RNs) use the nursing process as a critical thinking model as they make decisions and use clinical judgment regarding patient care. The nursing process is discussed in more detail in the “Nursing Process” chapter of this book. RNs may be delegated tasks from providers or may delegate tasks to LPNs and UAPs with supervision. See the following box for additional details about the scope of practice for Registered Nurses in the state of Wisconsin.

Scope of Practice for Registered Nurses in Wisconsin

(1) GENERAL NURSING PROCEDURES. An RN shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill.  The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:

(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.

(b) Planning. Planning is developing a nursing plan of care for a patient, which includes goals and priorities derived from the nursing diagnosis.

(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to LPNs or less skilled assistants.

(d) Evaluation. Evaluation is the determination of a patient’s progress or lack of progress toward goal achievement, which may lead to modification of the nursing diagnosis.

(2) PERFORMANCE OF DELEGATED ACTS. In the performance of delegated acts, an RN shall do all of the following:

(a) Accept only those delegated acts for which there are protocols or written or verbal orders.

(b) Accept only those delegated acts for which the RN is competent to perform based on his or her nursing education, training or experience.

(c) Consult with a provider in cases where the RN knows or should know a delegated act may harm a patient.

(d) Perform delegated acts under the general supervision or direction of provider.

(3) SUPERVISION AND DIRECTION OF DELEGATED ACTS. In the supervision and direction of delegated acts, an RN shall do all of the following:

(a) Delegate tasks commensurate with educational preparation and demonstrated abilities of the person supervised.

(b) Provide direction and assistance to those supervised.

(c) Observe and monitor the activities of those supervised.

(d) Evaluate the effectiveness of acts performed under supervision.^[7]

Advanced Practice Nurses

Advanced Practice Nurses (APRN) are defined by the NCSBN as an RN who has a graduate degree and advanced knowledge. There are four categories of Advanced Practice Nurses: certified nurse-midwife (CNM), clinical nurse specialist (CNS), certified nurse practitioner (CNP), and certified registered nurse anesthetist (CRNA). APRNs can diagnose illnesses and prescribe treatments and medications. Additional information about advanced nursing degrees and roles is provided in the box below.

Advanced Practice Nursing Roles ^[8]

Nurse Practitioners: Nurse practitioners (NPs) work in a variety of settings and complete physical examinations, diagnose and treat common acute illness and manage chronic illness, order laboratory and diagnostic tests, prescribe medications and other therapies, provide health teaching and supportive counseling with an emphasis on prevention of illness and health maintenance, and refer patients to other health professionals and specialists as needed. In many states, NPs can function independently and manage their own clinics, whereas in other states physician supervision is required. NP certifications include, but are not limited to, Family Practice, Adult-Gerontology Primary Care and Acute Care, and Psychiatric/Mental Health.

To read more about NP certification, visit Nursing World’s Our Certifications web page.

Clinical Nurse Specialists: Clinical Nurse Specialists (CNS) practice in a variety of health care environments and participate in mentoring other nurses, case management, research, designing and conducting quality improvement programs, and serving as educators and consultants. Specialty areas include, but are not limited to, Adult/Gerontology, Pediatrics, and Neonatal.

To read more about CNS certification, visit NACNS’s What is a CNS? web page.

Certified Registered Nurse Anesthetists: Certified Registered Nurse Anesthetists (CRNAs) administer anesthesia and related care before, during,  and after surgical, therapeutic, diagnostic, and obstetrical procedures, as well as provide airway management during medical emergencies. CRNAs deliver more than 65 percent of all anesthetics to patients in the United States. Practice settings include operating rooms, dental offices, and outpatient surgical centers.

To read more about CRNA certification, visit NBCRNA’s website.

Certified Nurse Midwives: Certified Nurse Midwives provide gynecological exams, family planning advice, prenatal care, management of low-risk labor and delivery, and neonatal care. Practice settings include hospitals, birthing centers, community clinics, and patient homes.

To read more about CNM certification, visit AMCB Midwife’s website.

Unlicensed Assistive Personnel

Unlicensed Assistive Personnel (UAP) are defined by the NCSBN as, “Any unlicensed person, regardless of title, who performs tasks delegated by a nurse. This includes certified nursing aides/assistants (CNAs), patient care assistants (PCAs), patient care technicians (PCTs), state tested nursing assistants (STNAs), nursing assistants-registered (NA/Rs), or certified medication aides/assistants (MA-Cs). Certification of UAPs varies between jurisdictions.”^[9]

CNAs, PCAs, and PCTs in Wisconsin generally work in hospitals and long-term care facilities and assist patients with daily tasks such as bathing, dressing, feeding, and toileting. They may also collect patient information such as vital signs, weight, and input/output as delegated by the nurse. The RN remains accountable that delegated tasks have been completed and documented by the UAP.

Interprofessional Team Members

Nurses, as the coordinator of a patient’s care, continuously review the plan of care to ensure all contributions of the multidisciplinary team are moving the patient toward expected outcomes and goals. The roles and contributions of interprofessional health care team members are further described in the following box.

Interprofessional Team Member Roles ^[10]

Dieticians: Dieticians assess, plan, implement, and evaluate interventions including those relating to dietary needs of those patients who need regular or therapeutic diets. They also provide dietary education and work with other members of the health care team when a client has dietary needs secondary to physical disorders such as dysphagia.

Occupational Therapists (OT): Occupational therapists assess, plan, implement, and evaluate interventions, including those that facilitate the patient’s ability to achieve their highest possible level of independence in their activities of daily living such as bathing, grooming, eating, and dressing. They also provide patients adaptive devices such as long shoe horns so the patient can put their shoes on, sock pulls so they can independently pull on socks, adaptive silverware to facilitate independent eating, grabbers so the patient can pick items up from the floor, and special devices to manipulate buttoning so the person can dress and button their clothing independently. Occupational therapists also assess the home for safety and the need for assistive devices when the patient is discharged home. They may recommend modifications to the home environment such as ramps, grab rails, and handrails to ensure safety and independence. Like physical therapists, occupational therapists practice in all health care environments including the home, hospital, and rehabilitation centers.

Pharmacists: Pharmacists ensure the safe prescribing and dispensing of medication and are a vital resource for nurses with questions or concerns about medications they are administering to patients. Pharmacists ensure that patients not only get the correct medication and dosing, but also have the guidance they need to use the medication safely and effectively.

Physical Therapists (PT): Physical therapists are licensed health care professionals who assess, plan, implement, and evaluate interventions including those related to the patient’s functional abilities in terms of their strength, mobility, balance, gait, coordination, and joint range of motion. They supervise prescribed exercise activities according to a patient’s condition and also provide and teach patients how to use assistive aids like walkers and canes and exercise regimens. Physical therapists practice in all health care environments including the home, hospital, and rehabilitation centers.

Podiatrists: Podiatrists provide care and services to patients who have foot problems. They often work with diabetic patients to clip toenails and provide foot care to prevent complications.

Prosthetists: Prosthetists design, fit, and supply the patient with an artificial body part such as a leg or arm prosthesis. They adjust prosthesis to ensure proper fit, patient comfort, and functioning.

Psychologists and Psychiatrists: Psychologists and psychiatrists provide mental health and psychiatric services to patients with mental health disorders and provide psychological support to family members and significant others as indicated.

Respiratory Therapists: Respiratory therapists treat respiratory-related conditions in patients. Their specialized respiratory care includes managing oxygen therapy; drawing arterial blood gases; managing patients on specialized oxygenation devices such as mechanical ventilators, CPAP, and Bi-PAP machines; administering respiratory medications like inhalers and nebulizers; intubating patients; assisting with bronchoscopy and other respiratory-related diagnostic tests; performing pulmonary hygiene measures like chest physiotherapy; and serving an integral role during cardiac and respiratory arrests.

Social Workers: Social workers counsel patients and provide psychological support, help set up community resources according to patients’ financial needs, and serve as part of the team that ensures continuity of care after the person is discharged.

Speech Therapists: Speech therapists assess, diagnose, and treat communication and swallowing disorders. For example, speech therapists help patients with a disorder called expressive aphasia. They also assist patients with using word boards and other electronic devices to facilitate communication. They assess patients with swallowing disorders called dysphagia and treat them in collaboration with other members of the health care team including nurses, dieticians, and health care providers.

Ancillary Department Members: Nurses also work with ancillary departments such as laboratory and radiology departments. Clinical laboratory departments provide a wide range of laboratory procedures that aid health care providers to diagnose, treat, and manage patients. These laboratories are staffed by medical technologists who test biological specimens collected from patients. Examples of laboratory tests performed include blood tests, blood banking, cultures, urine tests, and histopathology (changes in tissues caused by disease).^[11] Radiology departments use imaging to assist providers in diagnosing and treating diseases seen within the body. They perform diagnostic tests such as X-rays, CTs, MRIs, nuclear medicine, PET scans, and ultrasound scans.

Chain of Command

Nurses rarely make patient decisions in isolation, but instead consult with other nurses and interprofessional team members. Concerns and questions about patient care are typically communicated according to that agency’s chain of command. In the military, chain of command refers to a hierarchy of reporting relationships – from the bottom to the top of an organization – regarding who must answer to whom. The chain of command not only establishes accountability, but also lays out lines of authority and decision-making power. The chain of command also applies to health care. For example, a registered nurse in a hospital may consult a “charge nurse,” who may consult the “nurse supervisor,” who may consult the “director of nursing,” who may consult the “vice president of nursing.” In a long-term care facility, a licensed practical/vocational nurse typically consults the registered nurse/charge nurse, who may consult with the director of nursing. Nursing students should always consult with their nursing instructor regarding questions or concerns about patient care before “going up the chain of command.”

Nurse Specialties

Registered nurses can obtain several types of certifications as a nurse specialist. Certification is the formal recognition of specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty. See the following box for descriptions of common nurse specialties.

Common Nurse Specialties

Critical Care Nurses provide care to patients with serious, complex, and acute illnesses or injuries that require very close monitoring and extensive medication protocols and therapies. Critical care nurses most often work in intensive care units of hospitals.

Public Health Nurses work to promote and protect the health of populations based on knowledge from nursing, social, and public health sciences. Public Health Nurses most often work in municipal and state health departments.

Home Health/Hospice Nurses provide a variety of nursing services for chronically ill patients and their caregivers in the home, including end-of-life care.

Occupational/Employee Health Nurses provide health screening, wellness programs and other health teaching, minor treatments, and disease/medication management services to people in the workplace. The focus is on promotion and restoration of health, prevention of illness and injury, and protection from work-related and environmental hazards.

Oncology Nurses care for patients with various types of cancer, administering chemotherapy and providing follow-up care, teaching, and monitoring. Oncology nurses work in hospitals, outpatient clinics, and patients’ homes.

Perioperative/Operating Room Nurses provide preoperative and postoperative care to patients undergoing anesthesia or assist with surgical procedures by selecting and handling instruments, controlling bleeding, and suturing incisions. These nurses work in hospitals and outpatient surgical centers.

Rehabilitation Nurses care for patients with temporary and permanent disabilities within inpatient and outpatient settings such as clinics and home health care.

Psychiatric/Mental Health Nurses specialize in mental and behavioral health problems and provide nursing care to individuals with psychiatric disorders. Psychiatric nurses work in hospitals, outpatient clinics, and private offices.

School Nurses provide health assessment, intervention, and follow-up to maintain school compliance with health care policies and ensure the health and safety of staff and students. They administer medications and refer students for additional services when hearing, vision, and other issues become inhibitors to successful learning.

Other common specialty areas include a life span approach across health care settings and include maternal-child, neonatal, pediatric, and gerontological nursing.^[12]

Now that we have discussed various settings where nurses work and various nursing roles, let’s review levels of nursing education and the national licensure exam (NCLEX).

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1. Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses.https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵
2. NCSBN. https://www.ncsbn.org/↵
3. NCSBN. https://www.ncsbn.org/index.htm↵
4. Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵
5. Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵
6. NCSBN. https://www.ncsbn.org/index.htm↵
7. Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵
8. Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academies Press. https://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-health↵
9. NCSBN. https://www.ncsbn.org/index.htm↵
10. Burke, A. (2020, January 15). Collaboration with interdisciplinary team: NCLEX-RN. RegisteredNursing.org. https://www.registerednursing.org/nclex/collaboration-interdisciplinary-team/#collaborating-healthcare-members-disciplines-providing-client-care↵
11. This work is a derivative of StatPearls by Bayot and Naidoo and licensed under CC BY 4.0↵
12. Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academies Press. https://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-health↵