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PATTERNS OF NURSING CARE DELIVERY IN INDIA INTRODUCTION:Since the time of FLORENCE NIGHTINGALE there have been a variety of nursing care delivery models, methods by which nursing care is provided for clients. Ideally, the vision & philosophy nurses establish for the quality care of clients should drive the selection of a care delivery model. However, too often the scarcity of nursing resources & business initiatives from the health care organization influence the final decision. Care delivery must be effective in helping nurses achieve desirable outcomes for their clients. Key factors contributing to success are decision-making authority for nurses who provide direct care, autonomy, collaborative practice, & effective methods of communicating with colleagues, physicians, & other health care providers. DEFINITION:A nursing care model or the method or system of nursing care delivery is defined as a method of organizing & delivering nursing care. ELEMENTS OF NURSING CARE DELIVERY:MANTHEY identified the basic elements of nursing care delivery systems. There are four fundamental elements namely:• • • • Clinical decision-making. Work allocation. Communication & Management.
TYPES OF NURSING CARE DELIVERY:The major means organizing nursing care delivery are as follows:• • • • • • • Total patient care or case method nursing. Functional nursing. Team nursing. Modular nursing. Primary nursing. Case management. Progressive patient care or client care nursing.
TOTAL PATIENT CARE NURSING OR CASE METHOD NURSING:It is the oldest mode of organizing nursing care. It was the original care delivery model developed during Florence Nightingale’s time. A Registered Nurse (R N) is responsible for all aspects of care for one or more patients during an assigned shift. DEFINITION:-
A total patient care is one in which the nurse is responsible for planning, organizing &performing all care, including personal hygiene, medication, treatment, emotional support & education required for their assigned group of patients during their assigned shift. • The patient theoretically receives holistic & unfragmented care during the nurses time on duty. Each nurses caring for the patient, can however modify the care regimen. OBJECTIVES OF TOTAL PATIENT CARE:• To provide a high quality of therapeutic comprehensive care for each patient to meet immediate health needs. • To provide appropriate designed facilities with sufficient number of beds, trained staff & technical personnels at a slightly lowest cost than that of traditional system.
To provide different levels of medical & nursing care in the various units in accordance with nurse’s skill in performing equipments & supplies to meet the patient’s needs. To dedicate a multi disciplinary group of professionals to frame appropriate policies, plans & programmes & evaluate them periodically to assure that all patients are placed properly & receive high quality care by trained personnels & technical workers.
To initiate suitable hospital admission & transfer policies & procedures to that patient who can be assigned to the appropriate unit in accordance with their medical & nursing care needs. To initiate & support the participant & management approach among physician & nurse towards planning & giving care required to various units.
To shorten the average length of patients hospitalization period. To help the patient & family to solve health problems in the hospital & home.
MEMBERS:The members are:• • • • Charge nurse Registered nurse Student nurse Private duty nurses.
It is used commonly in speciality unit such as ICU, ICCU. FUNCTION & MODEL:Each nurse caring for the patient can modify care regimen. If there are three shifts, the patient could receive there different approaches to care. MODEL-I
MODEL-II CHARGE NURSE NURSING STAFF PATIENTS MERITS:NURSING STAFF PATIENTS NURSING STAFF PATIENTS
• • • • • • • • • • • •
The nurse can see better & attend to the total needs of clients. Continuity of care can be facilitated with care. Client / nurse interaction / rapport can be developed. Client may feel secure, knowing than one person is thoroughly familiar with the needs & the course of treatment of his/ her disease. Educational needs of the clients can be closely monitored. Family & friends become better known by nurse & get more involved in the care of the client. Workload for the unit can be equally divided among the available staff. Nurse’s accountability for their function is built- in. The patient receives holistic unfragmented care by only one nurse per shift. The nurse maintains a high degree to practice autonomy. Lines of responsibility are clear. Centralization of skilled staff to take care of critically ill patients instead of nursing them to different wards. Centralization of costly diagnostic & the therapeutic equipments instead of having such equipments in every ward. There is greater likelihood of availability of skilled personnels on duty.
DEMERITS: Many clients do not require the inherent care of intensity in this type of service. This method must be modified if non- professional health workers are to be used effectively. Nurses are not enough to comply the demand of this model; cost- effectiveness must be considered. It is difficult for nurses to use this method to become involved in long- term planning & evaluation of care.
4 The greatest disadvantage to case nursing occurs, when the nurse is inadequately trained or
operated to provide total care to the patient. ASPECTS OF TOTAL PATIENT CARE:PHYSIOLOGICAL ASPECT:The client has one person who plans his care during the entire stay. The associate nurses on three shifts are also kept consistent. If care is not given effectively by one person, the primary nurse is accountable. Feedback both good & bad is bounded to the nurse. SOCIAL ASPECT: Communication facilitated by nurse improves the sense of responsibility for following the plan of care in a better way by nurse & client. EMOTIONAL ASPECT:The emotional support given by nurse adds to the client’s sense of worth. FUNCTIONAL NURSING:Functional nursing is a model of care that evolved in the 1950s, when there was a severe shortage of nurses during world war II. This system of assignment, which evolved from concepts of scientific management used in the field of business administration, focuses on the jobs to be completed. In this taskoriented approach, personnel with less preparation than the professional nurse fulfil less complex care requirements. DEFINITION:Functional nursing is a method of providing patient care by which each licensed & unlicensed staff member performs specific tasks for a large group of patients. Eg. RN administers IV medications. Lower primary nurse gives oral medications. Assistants perform hygiene tasks. Another assistant checks vital signs. MEMBERS:Charge nurse Registered nurse Lower primary nurse Nursing assistants. FUNCTION & MODEL:Here all the responsibilities of a unit are assigned to selected people in accordance with their expertise. A charge nurse co-ordinates care & assignments & may ultimately be the only person familiar with all the needs of the patient MODEL-I CHARGE NURSE LICENSED RN TREATMENT RN INTERVENOUS NA VITAL PRACTICE ADMISSIONS MEDS SIGNS NA HYGIENE SUPPILES
UNIT OF 30 PATIENTS MODEL-II HEAD NURSE REGISTERED NURSE LICENSED PRACTICAL NURSE NURSING AIDES PATIENTS MERITS:-
The person can become particularly skilled in performing assigned tasks, it can be efficient &
economical. The best utilization can be made of a person’s aptitudes, experience & desires. Less equipment is needed & what is available is usually better cared for when used only by a few personnel. This method saves time because it lends itself to strict organizational protocol. The potential for development of technical skills is amplified.There is a sense of productivity for the task oriented nurse & this is an efficient method. It is easy to organize the work of the unit & staff & tasks are completed quickly. It is cost effective to mix staff. Unskilled person can be trained to one specific task. DEMERITS: Client care may become impersonal, compartmentalized & fragmented.
There is a tremendous risk for diminishing continuity of care.
Staff may become bored & have little motivation to develop self & others, work may become monotonous. The staff members are accountable for the task; only the nurse incharge of the unit has accountability for the individual, whole clientele. There is little avenue for staff development, except as it relates to tasks. Clients may tend to feel insecure, not knowing who is their own nurse. Only parts of the nursing care plan are known to personnel. It is difficult to establish client priorities & operationalise the care reflecting same. It is only safe when the head nurse can co-ordinate the activities of all members of the staff & make certain that nothing essential in client care is overlooked or forgotten. This is a tremendous
responsibility on one person who probably has to think of approximately thirty or more clients, plus the staff. Poor staff development & involvement in framing care. Responsibilities of staff nurse are more. TEAM NURSING:ORIGIN:In the early 1950s, Eleanor lamberston (1953) & her colleagues proposed a system of team nursing to overcome the fragmentation of care resulting from the task-oriented functional approach & to meet increasing demands for professional nurses created by advances in technological aspects of care. DEFINITION:Team nursing is a method in which group of nursing personnels undr the leadership of a qualified nurse, having the goal of comprehensive nursing care renders service to the patients. A team made up of a registered nurse & other caregivers provides care to a designated group of patients on a given shift. This is termed as team nursing. “Care through others’’ is the hall-mark of team nursing. PHILOSOPHY:In this a group of professional & non-professional personnels work together to identify, plan, implement & evaluate comprehensive client-centered care. MEMBERS & THEIR ROLES:• • • Nurse manager Team leader (registered nurse) Registered nurse Licensed practical nurseNursing aides.
CONCEPTS FOR PRACTISING TEAM NURSING: Leadership by a registered nurse. Effective communication among team members. Leadership techniques by a team leader. -Assess patient & determine nursing interventions. -Co-ordinate medical & nursing care plan. -Keeping nursing care plan up to date. - Recording care & outcome of care. Team members must accept the leadership of the team leader. Head nurse is an important person in team nursing. - Determine standards of work performance. Helping team members to develop leadership skills. Orientation of new employees.
Keeping channel of communication open with all. Encouraging staff to improve quality of care.
FUNCTION & MODEL:- Team leader is responsible for co-ordinating a group of licensed & unlicensed personnel to provide patient care to a small group of patients. Team leader assigns each member specific responsibilities according to role, licensure, education, ability & the complexity of the care required. Communication is enhanced through written patient assignments, nursing care plans & team conferences. MODEL HEAD NURSE TEAM LEADER RN LPN NA TEAM LEADER RN LPN NA
TEAM CONFERENCES:The heart of team concept is team conference. At some times during the day, after the patients have received their morning care, the team members sit together in conference. It requires half to three fourth of an hour. The team leader assumes the role of chairmen. It includes:-Reports by each team member. -Planning care for new patients. -Planning the next day assignment. MERITS:• • • • • • It includes all health care personnel in the groups functioning & goals. Feeling of participation & belonging are facilitated with team members. Workload can be balanced & shared. Division of labour allows members the opportunity to develop leadership skills. Every team members has the opportunity to learn from & teach colleagues. There is a variety in the daily assignment. Interest in client’s well-being & care shared by several people; reliability of decisions is increased. Nursing care hours are usually cost- effective. The client is able to identify personnel who are responsible for his care. All care is directed by a registered nurse. Continuity care is facilitated, especially if teams are constant.
• • Barriers between professional & non- professional workers can be minimized; the group efforts prevails. Everyone has the decision increased as clients’ well- being is shared by several people. Each member of team is able to participate in decision- making & problem-solving
Establishing the team concept takes time, effort & constancy of personnel. Merely assigning people to
a group does not make them a “group’’ or “team’’. Unstable staffing patterns make team nursing difficulty. All personnel must be client-centered. The team leader must have complex skills & knowledge. Ie. Communication, leadership organization, nursing care, motivation & other skills. There is less individual responsibility & independence regarding nursing functions. Continuity of care may suffer. Team leader may not / have less leadership skills. Needs more nursing personnels. MODULAR NURSING:DEFINITION:-
Modular nursing uses the strengths of both teams. In modular nursing staff are geographically assigned to patients for whom they co-ordinate & provide comprehensive care. Modular nursing is enhanced when nursing units are physically designed & built with the nursing delivery system in mind.
MEMBERS & ROLES:• • • • • Head nurse Registered nurse-district leader. Licensed practical nurse. Nursing aides.
FUNCTION & MODEL:Staff nurses work independently or together, depending on the size of a modular district. Each district has a district hospital whose responsibilities include giving & receiving shift report & offering & receiving help from the district leader of the next module. • • The solid lines represent direct lines of communication & the broken lines represent indirect lines of communication. The nursing aides may perform specific tasks or provide direct patient care.
• The head nurse co-ordinates the work schedule & supervises all care in / on the unit. continuity of care is maintained when the head nurse makes patient care assignments. ADVANTAGES: Better communication & co-operation among staff & less time is spent in walking between patients. Modular nursing is easier for less experienced nurses because they have other nurses directly available to them for support. MODEL HEAD NURSE RN-DISTRICT LEADER RN- DISTRICT LEADER & RN PATIENT DISADVANDAGES:• • In modular nursing, there is an eight hour rather than twenty four accountability & much less direct nurse-to-nurse communication & accountability for patient care. Patient satisfaction will be less; if the patient changes rooms, he will get a change in the nurses also. NA RN- DISTRICT LEADER & LPN
PRIMARY NURSING:CONCEPT:• • • • The primary nursing model of care delivery was developed in the 1960s with the aim of placing RNs at the bedside & improving the professional relationship among staff nurses / members. The model became popular in the 1970s & early 1980s as hospitals began to employ more RNs. The aim of this method is to improve autonomy & quality care in professional nursing practice. In this a registered nurse or primary nurse assumes 24 hrs responsibility for planning, directing & evaluating the patient’s care from admission through discharge. DEFINITION:Primary method is a method of patient care delivery where one registered nurse functions autonomously as the patient’s main nurse for 24 hrs day from admission till discharge. A nurse is accountable for planning, evaluating & directing the care of patient 24 hrs a day throughout the patient’s stay. This is a method of providing comprehensive, individualized & consistent care & it is also an expensive method. GOAL:Its goal is to achieve patient centered individualized care that is comprehensive in scope, coordinated & continues from patient’s admission till discharge.
BASIC CONCEPTS:• • Fixed responsibility & accountability. Patient’s involvement in care & identification of patient’s goals. Patient’s assessment by primary nurse who plans the care to be given by secondary nurse. Complete communication of care. Discharge planning.
MEMBERS & ROLES:The primary nurse & head nurse. Head nurse assign new patient to the primary nurse based on her assessment of patients’ need & her knowledge of primary nurse. She communicates with them, but she delegates complete authority to them for the care of their patients. • • Licensed practical nurses function as associate nurse & are supervised by the head nurse. Nursing assistants are also used but to assist primary & nurses.
PRIMARY NURSING SYSTEM & MODEL OF ORGANISATION:The primary nurse is responsible for 24 hrs a day total patient care from admission till discharge. While on duty the nurse may provide care or delegate some patients’ care to an associate nurse. When the primary nurse is off duty, care is provided by an associate nurse who follows the care plan established by the primary nurse. MODEL PATIENT TOTAL PATIENT CARE 24 HR / DAY COMMUNICATES WITH SUPERVISIOR PRIMARY NURSE CONSULTES WITH PHYSICIANS/ OTHER HEALTH CARE PROVIDERS ASSOCIATE (DAYS) PRIMARY NURSE NOT AVAILABLE ASSOCIATE (EVENINGS) WHEN PRIMARY NURSE NOT AVAILABLE s MODEL HEAD NURSE ASSOCIATE (NIGHTS) WHEN WHEN PRIMARY NURSE NOT AVAILABLE
PRIMARYNURSES ADVANTAGES:• • • • • • • • • • • • • There is opportunity for the nurse to see the client & family as one system. Nursing accountability, responsibility & independence are increased. The nurse is able to use a wide range of skills, knowledge & expertise. This method potentiates creativity by the nurse. Work satisfaction may increase significantly. The scene is set for increased trust & satisfaction by the client & nurse. Establishes good rapport between nurse & client & his /her family. Aims at providing holistic patient care. PATIENTS
DISADVANTAGES:The nurse may be isolated from colleagues. There is little avenue for group planning of client care. Nurse must be mature & independently competent. Staffing patterns may necessitate a heavy client load. An inadequately prepared or educated primary nurse may be incapable of coordinating a multidisciplinary team or identifying complex patient needs & condition changes. CASE MANAGEMENT:ORIGIN:Case management is considered to be the newest type of nursing care delivery system. It is a care management approach that co-ordinates & links health care services to clients & their families while streamlining costs & maintaining quality. DEFINITION:-
The case management society of America (2003) defines case management as “a collaborative process
which assess, plans, implements, co-ordinates, monitors & evaluates the options & services required to meet an individual’s health needs, using communications & available resources to promote quality, cost- effective outcomes.” Case management is a set of logical steps & a process of interaction within a service network which assure that a client receives needed services in a supportive, effective & cost- effective manner.
Here one nurse is responsible for overseeing the quality & financial outcomes of patient care; the
nurse works collegially with physicians & other care givers as well as with payers to manage patients along an agreed- on clinical pathway. The focus is on the individual patient & not population of patients. PURPOSES:-
• • Provision of services, care, treatment & opportunities to which a client is entitled. Accountability for cost of resources & use of funds.
MEMBERS & ROLES:The main member involved in giving care is the case manager. They handle each case individually, identify cost- effective providers, treatment & care settings. Referrals begin from hospital & extend to outpatient settings. SERVICE ACCESS:• Case management is needed mainly for the following groups of patients:-
Chronically disabled with functional or emotional impairments.
Patients with long- term medically complex needs.
Clients severely compromised with acute illness
FUNCTION & MODEL:The nurse case manager provides direct nursing care or delegate it to others, her role is the coordination of services for quality & cost- effective care. She reports directly to her employer or in hospitals, a head nurse or physician. Her range of services include case finding, intake, assessment, direct care, provision, advocacy, monitoring, cost containment & termination. MODEL-I NURSING ADMINISTRATION
MEDICAL NURSE CASE ALL MEDICAL PATIENTS
PAEDIATRIC NURSE CASE MANAGERS ALL PAEDIATRIC
OB NURSE CASE MANAGER ALL OB PATIENTS PATIENTS
TRAUMA NURSE CASE MANAGERS ALL TRAUMA PATIENTS
ADVANTAGES: Clients receive more services. Enhanced personal satisfaction & increased autonomy. More efficient use of resources. DISADVANTAGES: Lack of clarity about its functions. Lack of research that clearly documents the outcomes of nursing case management.
Duplication of services & possible “turf wars” of other professionals like i.e. social worker believe it
is their role to manage some of the services. PROGRESSIVE PATIENT CARE OR CLIENT CARE:CONCEPT:It is a new concept where the patients are classified according to the degree of their illness & according to their medical, physical & psychological need irrespective of their illness. DEFINITION:It is the systematic classification of patients according to their medical needs & this method provides better treatment & care by organizing hospital services around the individual patients. Here the clients are evaluated with respect to all level ( intensity ) of care needed. As they progress towards increased self care ( as they become less ethically ill or in need of intensive care or monitoring ) they are marked to units / wards staffed to best provide the type of care needed. PRINCIPLES & OBJECTIVES: To provide a higher quality of care. To provide appropriately designed facilities. To provide different levels of medical & nursing care in different units. To delegate multi disciplinary group of professionals. To initiate suitable admission & transfer policies & procedures. Shortens the average length of patients’ hospitalization period. To provide the best nursing services under trained supervisors.
To provide the community sources in an organized way.
ELEMENTS OR AREAS OR LEVELS OF CARE: Intensive care unit. Intermediate care unit. Self care unit. Home care unit. Outpatient care.
Intensive care unit:It is the unit where constant observation & interventions are provided to the critically ill patients with life threatening health problems according to his / her needs. Intermediate care unit:When the patients no longer need the close attention by the nurses, they are transferred to the intermediate units. Long term care unit:Patients who are under long term care are admitted in this unit. This unit serves. • • • Chronically ill patients. Convalescent patients. Patients who are under rehabilitation.
Self care unit:Here ambulatory patients are given the nursing care needed & are encouraged to care for themselves in many ways. Home care unit:A follow-up home care plan becomes the last & final unit of hospital care. Here the family members give care rather than the specially trained personnels. Out patient care:It is for ambulatory patients. It renders diagnostic, curative, preventive & rehabilitative services. ADVANTAGES:• • • • • • • • • • • • Efficient use is made of personnel & equipment. Clients are in the best place to receive the care they require. Use of nursing skills & expertise are maximized due to different staffing patterns of each unit. Clients are moved towards self care, independence is fostered where indicated. Efficient use & placement of equipment is possible. Personnel have greater probability to function towards their fullest capacity. Helps in providing maximum care to the patient. Patients are given special attention & care according to need. It is cost-effective & infection is minimized. Nurse spends more time with the patient & can utilize her competencies effectively. Efficient use of personnels can be made. Nursing skills are maximized.
DISADVANTAGES: There may be discomfort to clients mho are moved often.
15 Continuity care is difficult, even though possible.
Long term nurse / client relationship are difficult to arrange. Great emphasis is placed on comprehensive, written care plan. There is often difficulty in meeting administrative need of the organization, staffing, evaluation & accreditation. Requires skilled personnels in the team. Requires more number of nursing staff. SUMMARY:In this seminar, we have discussed about the nursing care delivery system, various methods, their principles, models, advantages & disadvantages in a detailed manner. CONCLUSION:Nursing care delivery can be seen as the dynamic balance between routine resource management & the structure, process & content of practice. Utilizing human resources decisions such as staffing & skills, the care models form a network for the nursing staff & their assignments to client care.
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