ORGANISATION OF NURSING SERVICES

Nursing is vital aspect of health care and needs to be properly organized. A nurse is in frequent
contact with the patients and hence his/her role in restoring health and confidence of the patients
is of utmost importance the quality of nursing care and the management of the nursing staff,
reflect an image the hospitals or nursing homes.

Nursing services administration is a complex of elements in interaction. It results in

output of clients whose health is unavoidably deteriorating, maintained, or improved through
input of personnel and material resources used in an orderly process of nursing services.

DEFINITION- Nursing care refers to the care of the clients with specific regard to nursing,
while the nursing service refers to the co-ordinating responsibity of the nurse who, in addition to
giving nursing per se, also works with members of allied disciplines such as dietetics, medical
social service, pharmacy and various others in supplying a comprehensives programe of hospital
care.

Objectives Of Nursing Services In Hospital-

Objectives of nursing service in hospital include-

1. Management of nursing care and services

2. Education, training and staff development programs
3. Nursing research
4. Community health programs

Management of nursing care and services-

 Initiates a set of human relationships at all levels of nursing personnel to accomplish their
job and responsibilities through systematic management process by establishing flexible
organizational design.
 Establish adequate staffing pattern for rendering efficient nursing services to clients and
its management.
 Develop and implement proper communication system for communicating policies,
procedures and updating advance knowledge.
 Develop and initiate proper evaluation and periodic monitoring system for proper
utilization of personnel.
 Develop or revise proper job description for nursing personnel at all levels and all units
for proper delivery of nursing care.
 Assist hospital authorities for effective personnel management.
 Share nursing information system with other discipline functionaries in the hospital.
 Formulate and interpret nursing service policies in the context of general policies of the
hospital for improvement of nursing care.
  Assist the hospital authorities for preparation of budget by involvement.
 Participate in interdepartmental programs and other programs conducted by other
disciplinaries for improvement of hospital services.

Education , Training and staff developments-

 Encourage a stimulating environment in which the personnel have opportunities to be

creating innovators in the improvement of nursing services.
 Develop and initiate orientation and training programs for new employees in co-
operation with authorities and other disciplines.
 Create an atmosphere that conducive to give proper required learning experiences for
the students.
 Assist in the development of a sound, contructive programe of leadership in nursing
to assure intellectual administration and management to safeguard , conserve and
preserve nursing resources of the hospital.
 Initiate programes to improve the practice of nursing in keeping with advances in the
relative areas and disciplines affecting the quality of nursing.

Research-

 Participate in identifying the areas for research.

 Participate in the application of data and research.
 Provide conducive environment for research.

Community health programs-

 Participate in community health programs, associated with hospital.

 Interpret the roles and responsibilities in community health programs.
 Participate in extramural health programs of the hospital and other related
professional organization.

GOALS OF NURSING SERVICE DEPARTMENT-

The primary aim of any hospital is to care for the sick. Additional aims, such as research and
education. Each department within the hospital enlarges on the primary aim by relating its
specific objectives and activities to the patient and his welfare. The nursing service department is
always giving continuous goal patient care to each individual and also serving to help research
and education. The following are the examples of goals related to nursing service department-

 All nursing staff will recognize the patients need for independence and right to privacy
and will assess the patients level of readiness to learn in relation to their illness.
  The nursing staff will provide “an effective patient care”, relative to patients needs till
date on the hospital and community facilities permit through the use of care plans,
individual patient care, and discharge planning including follow up contact.
 An ongoing effort will be made to create an atmosphere conducive to favourable patient
and employee morale and that fosters personal growth.
 The performance of all the employees in the nursing department will be evaluated in a
manner that produces growth in the employee and upgrades nursing standards.
 All the nursing units within the hospital will work co-operatively with other departments
within the hospital to further the purpose, philosophy and goals of the institution.

OBJECTIVES OF THE NURSING SERVICE DEPARTMENT-

It is the interesting and heartening to find a description of nursing care that places the primary
emphasis on the total care of the patient, which will be an objective for the nursing service.

 To give the highest possible quality of nursing care in terms of total patient needs. This
will involve physical needs which must always have priority in nursing service, followed
by spiritual, psychological, social, reliabilities and educational needs as they are defined
by nursing service personnel and diagnosed in order of priority.
 To assist the doctor in the medical care of the patient, and to carry out such therapy as he
prescribed.
 To promote programs of nursing education, to provide facilities for the development of
all catagories of nursing service personnel.
 To promote and encourage nursing research studies in order that the quality of
performance may be improved and maximum utilization of personnel obtained.
 To assess the quality of the nursing service and continuously build facilities and prepare
personnel to improve upon this quality.
 To promote participation in the allied health organisations and supportive community
activities.

Develops an organizational structure that will-

 Permit the nursing staff to meet the physical, socio-emotional and spiritual needs
of the client.
 Permit adaptiveness to a given situation at a given point of time.
 Permit decision making at the level the action takes place.
 Exact accountability for the job at each level of the organization.
 Foster a team approach to client care.
 Allow for grouping of patients by level of care and/or speciality service.

Develops a competent staff in adequate numbers-

 Maintains an active recruitment programe.

  Maintains an active staff development programe.
 Recognizes superior performance by promotion whenever possible.
 Collaborates with administration and personnel to keep positions competitive
with community practice with regard to salaries and fringe benefits.

Develops and /or supports educational program-

 Maintains educational programmes as needed to meet the community or

educational needs.
 Supports and/ or participate in educational programs in the hospital and
community.

Seeks ways to improve patient care-

 Encourages and supports research endeavours of the staff.

 Participates in research programs conducted by the university and/or other health
profeesionals.

Strives to increase organizational effectiveness-

 Periodic evaluation of all departments.

 Makes necessary revisions/ changes as indicated.

ORGANIZATION AND MANAGEMENT OF NURSING SERVICE UNIT-

Nursing is defined as an art and service which involves the whole patient body, mind and spirit,
promotes spiritual, mental and physical health by teaching and by example; stresses health
education and health preservation, as well as ministrations to the sick; involves the care of the
patients environment social and spiritual as well as physical; and gives health care to the family
and community as well as to the individual.

Nursing service is one service which must be maintained continuously

throughout the 24 hours period, 365 days in a year. Good nursing considers the whole patient
body, mind and spirit and recognizes him as an individual. It deals with prevention as well as
care and assumes a large responsibility for health teaching. Good nursing needs good nurses, but
they alone are no assurance that patients will be well nursed. Other factors enter into the
situation, i.e. the amount of nursing care provided, the stability of the service and the quality of
work management.

In a hospital, many variable factors influence the number of nurses which are needs
in a ward on order to render a high quality of nursing care. These factors include (Jean Barrett)-

1. The type of service, i.e. medical, surgical, obstetrical and gynaecology, paediatric,
psychiatric etc.
2. The acuteness of the service and the rate of turnover in patients according to the degree or
period of illness.
3. The experience of the nurses who are to give the patient care.
4. The number of non-nurses who involved in the patient care, the quality of their work,
their stability in service.
5. The amount and quality of teaching which proceeds the assignment of personnel to the
service as well as that given as in- service preparation.
6. The amount of quality of supervision and ward teaching.
7. The method of appointment of the medical staff.
8. Affiliation of the hospital with medical college/ nursing colleges/school.
9. The plan of the ward-floor plan.
10. The physical facilities.
11. The amount, type and location of equipment and supplies.
12. The number of hours in the working week of nurses and other ward personnel and the
flexibility in hours.
13. The morale of the worker.
14. Methods of performing nursing performances.
15. The time required for hospital routines, i.e. record keeping and reporting.
16. The method of assignment.
17. The standards of nursing care.
18. Good ward management.

MANAGEMENT- Management is essentially the same as administration in its two fold

nature of purpose and the various means used to provide care, cure and comfort to groups of
patients. The nurse managers/ supervisors task is plan, organize, direct and control available
financial, material and human resources in order to provide effective, economic care to
groups of patients.

The management process, like the nursing process has certain steps, which
includes gathering facts (assessment), diagnosing problems, planning interventions,
executing plans, and evaluating outcomes. The steps in management process are more
complex than nursing process as follows-

1. Assessment or data gathering step of the management process consist of

accumulating, information not only about patients but also about the agency,
community, workforce and environmental constrains, which helps to proper
identification of problems.
2. Planning step in management process consists of determining care needs of different
patient groups, nursing objectives, budgetary allotment, required staff, operation
organizational structure and appropriate policies and procedures.
 3. Implementation step in management process consists of directing groups of nurses to
implement planned actions. This directing includes leading, communicating and
motivating.
4. Evaluation step in management process, includes the action of multiple care givers,
patient outcomes and costs. It is cost control and quality improvement step.

ELEMENTS OF NURSING MANAGEMENT-

It consist of five elements, input, processor, output, control and feedback mechanism as follows-

1. INPUT- Nursing management inputs are information regarding personnel, equipment,

supplies and patients, data gathering which includes information about agency, clients,
employees and resources.
2. PROCESSOR- The system processor is the group of nurse managers who have
authority for planning, organizing, directing and controlling nursing operation.
a. The planning of nursing operation will include formulation of objectives, systems,
standards, policies procedures and budgeting.
b. Organizing will include preparing table or organization job evaluation, job description
and group work and team building operations.
c. Staffing operation will include patient classification, determining staff need,
recruitment, selection, orientation, scheduling, assigning job, minimizing absenteeism,
decreasing turnover and staff development.
d. Leading operation will be include using the power or authority for problem solving,
decision making, effecting change, handling conflict, communication and transational
analysis.
e. Controlling operation will include quality improvement, patient audit, performance
appraisal, discipline, labour relations, and computer information system.

3.OUTPUT-Nursing management outputs are patient care, staff development and research.

4.CONTROL-Nursing management controls are agency philosophy, nursing goals, nursing

budget, personnel policies, disciplinary process, union contracts and licensing or

accreditation regulations.

5.FEEDBACK-Nursing management feedback includes financial reports, quality

monitoring reports, employees peer reviews, and accreditation survey reports.

FACTORS INFLUENCING WARD MANAGEMENT

Ward management is one of the prerequisites for good nursing care. There are many factors
involved in good ward management, which the nurse manager/supervisor need to understand
thoroughly for good management of the ward as follows-
1.Knowledge of the ward means that knowledge of all the duties and activities to be performed
in ward.

2.Planning the schedule of the ward refers to a planned programme for each day’s work to save
time and use available time in an useful way for nursing the clients.

3. Starting the work on time: Proper arrangements are made so that all nurses do their job in
right time as assigned promptly.

4. Preventing interruptions: Good management requires avoidance of interruption whenever

possible, e.g. Changing assignments are anticipated.

5. Establishment of ward routines provide a plan for delegation of duties and getting the work
done in an efficient way. Policy manuals of the institution help to establish ward routines which
include handling orders, writing and giving reports, checking medicine cards, summarizing
charts, handling telephone calls, checking and ordering, supplies, keeping cupboards stocked,
distributing linen, collecting specimens, there is more time left for individualized nursing,
supervision and teaching.

6. Use of democratic method in establishing ward policy: When ward objectives are to be
determined and policies to be established or changed, better co-operation is achieved if
participation of the entire staff is encouraged.

7. Orientation of new personnel: Well developed orientation program helps good ward
management. When new staff have entered the hospital, they must be oriented to hospital as well
as the ward, which helps new nurses develop desirable understanding and attitudes.

8. Orientation of hospital will include the type of hospital, organization of hospital, aim of
nursing, relationship of hospital with medical/nursing schools or colleges, doctors, different
departments in relation to nursing services, health services for nurses, meal hours, plans for
periodic conferences and staff development.

9. Orientation of ward will include the introduction of new nurses to ward personnel, services
represented on the ward, methods of assignment, working schedule of the day (patient’s time of
awakening, taking meal etc.), resting hours, visiting hours etc., duties of non- professional
workers, methods of obtaining daily assignments (handling orders, charting), ward rounds,
location of equipment, and other sources of information such as procedures, routines and ward
policy book etc. and also introduction of required special experiences.

10. Maintenance of suitable environment: Elements which help to maintain suitable

environment in the ward include prevention of noise, good ventilation, cleanliness of ward, well-
functioning equipment, good housekeeping etc.
11. Providing supplies and equipment in the hospital: There should be provision for proper
supplies and equipment for efficient work supplies are expandable items or those articles which
are used up and must be recorded periodically such as soap and detergents, paper towels,
stationary, food, sterile goods etc.,

For good management, all material should be adequate, free from repair,
accessible and conveniently located and should maintain the standard in the materials, according
to their use, maintain good exchange system, inventory and requisition.

12. Clear cut specific orders for medical therapy and nursing: Good ward management needs
a clear cut doctor’s orders and nursing orders, which are very essential to safeguard the patient
welfare. They help to prevent errors and thus they protect the doctor, the nurse and the hospital.
It is always better that orders be written and signed by the doctor. There are some standing orders
that also should be written in the policy book of the hospital, then only the nurses are able to
carry out the standing orders.

13. Record keeping, maintain adequate record is essential for good management: They
might be patient clinical records, administrative records, all have legal and scientific value, so
recording competence should be maintained.

14. Reporting: Reports are of prime importance both to good ward management and well-
functioning hospital. Many reports are oral and concerned mainly with the doctors and
supervisors. Reports are written as they may be needed for legal purposes, when they are serves
as a source of reference, or to be used by several people. Written reports include day, night or
evening reports and those related to accidents and unusual condition which may reflect the
quality of care the patient has received.

15. Maintenance of high moral among all the members of the staff.

16. Establishment of good relationship.

17. Delegating responsibility: Whenever an individual is responsible to another person,

delegation of duties is essential. In a hospital ward the bedside care of patient is delegated to staff
and student nurses, housekeeping duties are assigned to other personnel.

18. Assigning duties and responsibilities: Well- planned assignment of duties and
responsibilities have following objectives-

a) To provide the patient with the best possible nursing care.

b) To plan assignment which are interesting and stimulating to professional growth.
c) To provide a well- rounded educational experiences for student nurses.
d) To achieve good ward management.
To achieve good ward management, seven principles should be kept in mind when planning
assignments which include-

 Activities are better performed when each is made the responsibility of a single person.
 If nurses are to use their time to good advantage they must be able to plan it.
 If there are not enough nurses on any duty to carry the nursing load it is better to use
students and nonprofessional worker according to their ability.
 Assignments of patients and duties should not be charged until or unless they are
absolutely essential.
 The care required by all patients in the group assigned to one nurse must be considered
when making assignments.
 Assignment planning is closely related to time planning.
 The best use will be made of the nurses time if the patients assigned to 1 nurse are
geographically close together.
19. Time planning refers to well arrangement of time for personal who are working in the
ward. For providing adequate care to the patients in the ward, time planning is very
essential. Time planning may affect the health and the morale of the staff. The objectives
of the time planning includes:-
 To provide adequate staff for good nursing care for 24 hours.
 To provide the best possible experience for nursing students.
 To comply with good personal practices and keep nurses happy and contended.
20. Good teaching: the education of the nurse is markedly influenced by the assignment
which is planned for nurse on the hospital ward. To plan assignments of educational
values the nurse supervisor must know the experiences the ward has to offer especially
those which are not available elsewhere. The abilities of the students are expected to
develop on the ward, and the experiences which will help to do so. Clinical experiences
for students include patient care, nursing procedures and general ward activities. Nurse
supervisor has to plan these experiences for the benefit of student to get good education.
21. Good supervision: supervision is a teaching learning process which help the nurse and
nursing students to think and act for themselves, set up their own objectives which have
meaning to them and it helps them to attain objectives through approval, self-analysis and
by physical assistance when it is indicated. It respect the personality of the nurse, it
inspires nurses to grow in effectiveness.
 Patient Care Delivery System
One important function of the professional nurse at the first-line management position of nursing
service department is organizing the activities of the staff into a workable pattern to meet patient
needs. She/he should establish effective relationships between the activities to be performed, the
workers to perform them.

DEFINITION OF ASSIGNMENT:
Assignment refers to “a written delegation of duties to care for a group of patients by trained
personnel assigned to the unit.”

PURPOSES OF ASSIGNMENT:
1- To delegate the work to be done to the nursing personnel.
2- To gain the cooperation of the nursing personnel by knowing and accepting the acceptance of
the work to be done.

PRINCIPLES OF PERSONNEL ASSIGNMENT:

1. Made by the head nurse or nurse in charge for each individual nurse.
2. Based on :
 Nursing needs of each patient and approximate time required to care for him.
 The capabilities, skill level, previous experience and the interest of the staff members.
 Job description.
3. Planned weekly, and revised daily if necessary to assure continuity of care.
4. Take into account all the direct, indirect and unit activities
5. Consider the geographical location of the unit and the assigned duties to save nurse’s time and
effort.
6. Must be balanced among nursing staff.
7. Never to assign the same task to more than one nurse.

CHARACTERISTICS OF EFFECTIVE ASSIGNMENT:

It should be
1. Definite and easily understood.
2. Simple.
3. Clear.
4. Signed.
5. Written.
6. Posted in advance.
PROCESS OF ORGANIZING PATIENT CARE:
The head nurse or the nurse in charge should carry out their duties and responsibilities through
applying the following steps:
Planning Assigning Leading Evaluating Reporting
1. Planning:
Is a process of developing a course of action for meeting the needs of patient. In planning, the
head nurse decides what should be done, when, how, where, by whom and to whom.

2. Assigning:
Assignment of patient and nursing activities are written in the assignment sheet by the head
nurse/nurse in charge, based on the principles of assignment.

3. Leading:
Includes issuing instructions, motivation, and coordination of activities, by making rounds,
checking performance and conducting conferences.

4. Evaluating:
By reviewing nursing performance and patient progress to be compared by the assignment and
nursing care plan.

5. Reporting:
The head nurse prepares a nursing unit report “e.g. shift report ” which includes patient’s needs,
special observations, census, bed number, all critically ill and post operative patients, patients
needs special preparation on the on-coming shift, abnormal change in patient’s condition, data
concerning admission, discharge, transfer and death.

METHODS OF PATIENT CARE DELIVERY:

(Methods of assignment):

Several methods of assignment are used to plan for patient care in a hospital. These methods are
the traditional methods and the in advanced methods.
I- The traditional methods
1. Case method.
2. Functional method.
3. Team method.
4. Modular nursing.
5. Primary nursing method.

II- The advanced method

Case management.

I- THE TRADITIONAL METHODS:

1. Case method:
It is the oldest patient care delivery method. In this method one professional nurse assumes total
responsibility of providing complete care for one or more patients (1-6) while she is on duty.
This method is used frequently in intensive care units and in teaching nursing students.
Advantages
 High degree of autonomy
 Lines of responsibility and accountability are clear
 Patient receives holistic, unfragmented care

Disadvantages
 Each RN may have a different approach to care
 Not cost-effective
 Lack of RN availability

MODEL

Registered Nurse Registered Nurse Registered Nurse

8- Hour 8- Hour 8- Hour

PATIENT
The RN plans, organizes and
performs all care
2. FUNCTIONAL METHOD:
Emerged during 1950s, due to shortage of nurses. This method focuses on getting the
greatest amount of tasks in the least time. In this method, the nursing care is divided into
tasks and each staff member is assigning to perform one or two tasks for all patients in
the unit according to the level of skill required for performance as follows:
• Registered professional nurses: Responsible for administering medication to all unit
patients, another for changing dressings and administering ordered treatments (such as
postural drainage or warm compresses) for all patients.

• Technical nurses: Responsible for taking vital signs and recording intake and output
for all patients in the unit, while another might be giving baths to all bedridden patients.

• Nurse aides: Responsible for making beds for all ambulatory patients and assisting
mobility-impaired patients to move in bed or walk in the hall.

• Unit clerk: Responsible for answering telephone, delivering messages, recording

admissions and discharges, etc.

Advantages:
 Care is provided economically and efficiently
 Minimum number of RNs required, so it is efficient when there is a shortage in the
staff or there is limited number of professional nurses
 Tasks are completed quickly
 Useful in emergency situations.

Disadvantages:
 Care may be fragmented
 Patient may be confused with many care providers
 Caregivers feel unchallenged
 Lack of communication among the different persons who care for the patient.
 Neglecting the humanity of the patient and the individual needs of the patient will
be lost in an effort to get the work done.
MODEL
Nurse Manager

LPN/ LVN RN Nurse Aide

PO Meds Assessment Vital signs

Treatment Care plans Hygiene

Assigned Patient

3. TEAM METHOD:
The concept of team nursing was introduced in the early 1950s. It is a method of nursing
assignment that binds professional, technical and nurse aides into small teams. This
method allows for efficient utilization of technical and/or nurses aide through the direct
supervision, guidance, and teaching of professional nurses.
Process of implementing the team method:
One registered nurse in the team is appointed by the head nurse to serve as a team leader.
The team members commonly consist of at least one professional nurse, one technical
nurse, nursing students and nursing aides. All team members may receive reports about
their patients’ care needs from the team leader or team member on previous shift.

The team leader usually assigns:

• professional nurse to care for the most seriously ill patients, to ensure informed
observation and skilled interventions.

• Often, the team leader assigns the technical nurse to bath, feed, and move and change
dressings for patients.

• Aides are assigned to make beds, assist ambulatory patients with bathing and grooming,
testing urine and performing simple nursing care procedures.

• Team leader usually administers medications and monitors parenteral fluid therapy for
all patients assigned to the team. Without team planning and communication through the
team conferences, team nursing may become in reality just a variation of the functional
method.

Advantages:
 High-quality, comprehensive care with a high proportion of ancillary staff
 Team members participate in decision making and contribute their own expertise

Disadvantages:
 Continuity suffers if daily team assignments vary
 Team leader must have good leadership skills
 Insufficient time for planning and communication

MODEL

Nurse

RN Team Leader RN Team Leader

RN RN
LPN/ LVN LPN/ LVN
Nursing Assistants Nursing Assistants

Assigned Assigned
Patient Group Patient Group
4. MODULAR NURSING:
Modular nursing assignment is used when the nursing staff includes technical and nurse
aides, as well as professional nurses.
Although two or three persons are assigned to each module, the greatest responsibility for
the care of assigned patients falls on the professional nurse. The professional nurse is also
responsible for guiding and teaching non-professional nurse.
Advantages
 Continuity of care is improved
 RN more involved in planning and coordinating care
 Geographic closeness and efficient communication.

Disadvantages
 Increased costs to stock each module
 Long corridors not conducive to modular nursing.

MODEL

Nurse Manager

Geographic Geographic Geographic

Patient Unit Patient Unit Patient Unit

Patient Care Team Patient Care Team Patient Care Team

RNS RNS RNS

LPN/ LVN LPN/ LVN LPN/ LVN

Nurse Aides Nurse Aides Nurse Aides

Meds Meds Meds

Supplies Supplies Supplies

Linens Linens Linens

 5. PRIMARY NURSING METHOD:

This method is the best in an agency with an all-professional nurse staff. It is: A
comprehensive, continuous and coordinated nursing process for meeting the total needs
of each patient.
Basic concepts in primary nursing:
• Patient assessment by a primary nurse, who plans the care to be given by secondary or
associate nurse when the primary nurse is off duty. The 24 hours responsibility for care is
put into practice through the primary nurse’s written directive on a preplanned
communication assignment.
Complete communication of care given in the nursing staff daily reporting method.
• Discharge planning including teaching, family involvement and appropriate references.
Process for implementing primary nursing method:
• The head nurse:
a. Assigns primary nurse to patients by matching the skills of the nurse to the needs of the
patients.
b. Ensures proper scheduling for all shifts so that if primary nurse is off the unit an
associate nurse is available for care.
c. Guides, counsels and evaluates care given.
d. May also assign herself to patients either as a primary nurse or associate nurse.

• Professional staff nurse:

1. Primary nurse:
Functions of primary nurse include performing the following:
1- Conducting an admission (initial) assessment.
2- Developing, planning, implementing, and revising the nursing care plan.
3- Directing care in her absence.
4- Collaborating with physicians and families.
5- Making referrals.
6- Teaching health concepts.
7- Making discharge plans.

2. Associate nurse:
Associate nurse may be professional or technical nurse. She carries out the nursing care
planned by the primary nurse when she is not on duty.
• Technical nurse:
Carry out the nursing tasks assigned by the primary or associate nurses in giving the care.

• Nurse aides:
Their activities are focusing away from direct contact with the patient and can be utilized
as messengers and transporters. Patient Care Delivery System 10
• Ward clerk:
Responsible for the non-nursing functions of administrative duties.

Advantages
 High-quality, holistic patient care
 Establish rapport with patient
 RN feels challenged and rewarded.

Disadvantages
 Primary nurse must be able to practice with a high degree of responsibility and
autonomy
 RN must accept 24-hour responsibility
 More RNs needed; not cost-effective

MODEL

PRIMARY NURSE
Physician and Associate Nurse
24-Hours responsibility for
Provide care when
ppp members of
other
planning, directing and
Health Care Plan primary nurse is off
evaluating patient
duty

PATIENT

II- THE ALTERNATIVE METHOD:

Case management:
Case management is a process of monitoring an individual patient’s health care by the
case manager, for the purpose of maximizing positive outcomes and containing costs.
The case manager has graduate-level preparation or is at an advanced level of nursing
practice. The case manager role requires not only advanced nursing skills but also
advanced managerial and communication skills.
The case manager is an individual "professional nurse” assigned responsibility for this
process.
• The case manager may follow the patient from the diagnostic phase through
hospitalization, rehabilitation and back to home care.
• Case manager has responsibility and authority for planning, implementing, coordinating
and evaluating care for the patient throughout the period of illness, regardless of the
patient’s movement among various units and services (such as emergency room, surgical
unit, recovery unit, etc.).
• The case manager ensures that plans are made in advance for the next needed step.
Through this, the manager assists with decision-making and helps to ensure that the
patient receives care that will achieve the most positive outcomes in the most efficient
manner. This process helps to eliminate costly delays in progress.

MODEL

Collaborate with
patient and family

NURSE CASE

Onset of illness Monitors and evaluates Resolution of illness

patient care options and
services to meet health

Collaborate with Co-ordinates

nursing, physician/ services, Home care,
speech/occupationa Hospice, Extended/
l Therapist, Dietary, Long Term Care ,
and Ancillary Ambulatory Care
Services Services
CASE MANAGEMENT TOOLS:
The case manager uses two tools:-
- Case Manager Plan ( CMP) .
- Critical Path Diagnosis ( CPD) to , design , map , track , monitor , and adjust the
patient’s course through the care-treatment process.
1-Case Manager Plan (C M P):
Is a multicolumn plan with accompanying time line that includes medical and nursing
diagnosis , desired care outcomes , intermediate daily goals to supports each outcome,
and the daily activities required of nurse, physicians, and other care givers to achieve
intermediate goal.
2- Critical Path Diagnosis (C P D):
Is an abbreviated , one – page version of the required physician and nurse action listed in
the C M P , together with the exact data on which all key events must occur to achieve
the desired outcome by the target date.
The case manager evaluates the patient’s progress toward care and treatment goal daily
by comparing signs, symptoms, and assessment data against information in the C M P
and C D P then tracking variances from the expected course of progress.

Advantages:
a) For the patient:
- Establishing and achieving a set of “expected” or standardized patient care outcomes for
each patient.
- Facilitating early patient discharge or discharge within an appropriate length of stay.
- Using the fewest possible appropriate health care resources to meet expected patient
care outcomes.
- Facilitating the continuity of patient care through collaborative practice of diverse
health professionals.

b) For the nurse:

- Enhancing nurse’s professional development and job satisfaction.
- Facilitating the transfer of knowledge of expert clinical staff of novice staff.

CHOOSING A NURSING CARE DELIVERY MODEL:

In order to determine the most proper model - for a current situation, the following
questions are to be answered:
 What staff mix is required?
 Who should make work assignments?
 Work assigned by task? By patient?
 How will communication be handled?
 Who will make decisions?
 Who will be responsible and accountable?
 Fit with unit/facility/organization management?
 PRIMARY HEALTH CARE

Primary health care, often abbreviated as “PHC”, has been defined as "essential health care
based on practical, scientifically sound and socially acceptable methods and technology made
universally accessible to individuals and families in the community through their full
participation and at a cost that the community and the country can afford to maintain at every
stage of their development in the spirit of self-reliance and self-determination"

In other words, PHC is an approach to health beyond the traditional

health care system that focuses on health equity-producing social policy.

GOALS-

The ultimate goal of primary health care is better health for all. The WHO has identified five key
elements to achieving that goal:

 reducing exclusion and social disparities in health (universal coverage reforms)

 organizing health services around people's needs and expectations (service delivery
reforms);
 integrating health into all sectors (public policy reforms);
 increasing stakeholder participation.

PRINCIPLES-

1. Equitable distribution of health care - according this principle, primary care and other
services to meet the main health problems in a community must be provided equally to
all individuals irrespective of their gender, age, caste, color, urban/rural location and
social class.
2. Community participation – Countries are now conscious of the fact that universal
coverage by primary health care cannot be achieved without the involvement of the local
community. There must be a continuing effort to secure meaningful involvement of the
community in the planning, implementation and maintenance of the health services.
Primary health care must be built on the principle of community participation.
3. Use of appropriate technology - Medical technology should be provided that is
accessible, affordable, feasible and culturally acceptable to the community (e.g. the use of
refrigerators for vaccine cold storage). Appropriate technology has been defined as
“technology that is scientifically sound, adaptable to local needs and acceptable to those
for whom it is used, and that which can be maintained by the people themselves in
keeping with the principle of self- reliance with the resources the community and country
can afford. The term “appropriate” is emphasized because in some countries large,
luxurious hospitals that are totally inappropriate to the local needs are built, which absorb
a major part of the National Health Budget. This also applies to using costly equipment,
procedures and techniques when cheaper, scientifically valid and acceptable ones are
available, e.g. Oral Rehydration Solution.
 4. Multi-sectional approach - recognition that health cannot be improved by intervention
within just the formal health sector; other sectors are equally important in promoting the
health and self-reliance of communities. These sectors include, at least: agriculture (e.g.
food security); education; communication (e.g. concerning prevailing health problems
and the methods of preventing and controlling them); housing; public works (e.g.
ensuring an adequate supply of safe water and basic sanitation); rural development;
industry; community organizations (including Panchayats or local governments,
voluntary organizations, etc.).

ELEMENTS-

1. Education concerning prevailing health problems & methods of preventing &

Controlling them
2. Promotion of food supply & proper nutrition
3. Adequate safe water supply & basic sanitation
4. MCH including Family planning
5. Immunization against major infectious diseases.
6. Prevention & control of locally endemic diseases
7. Appropriate treatment of common ailments
8. Provision of essential drugs

APPROACHES-

Different primary health care approaches have evolved in different contexts to account for
differences in availability of resources and local priority health problems

GOBI-FFF-One selective PHC approach is referred to collectively under the acronym “GOBI-
FFF”. These are strategies that are being adopted to improve maternal and child health as part of
primary care, especially in low income countries burdened with high infant and child mortality.
Respectively they include-

 Growth monitoring - to prevent most child malnutrition before it begins

 Oral rehydration therapy - to combat dehydration associated with diarrhea

 Breast feeding

 Immunization

 Family planning

 Family education

 Food supplementation- Iron and folic acid fortification/ supplementation to prevent

deficiencies in pregnant women.

PRIMARY HEALTH CARE IN INDIA-

DELIVERY SYSTEM IN INDIA

Health care services in general are rendered by the Government through a network of health
centers from the grassroots areas to the block level in the rural areas and through hospitals,
dispensaries, maternal, child health and family welfare centers in the urban areas. The hospitals
in the sub divisional/ Taluka level, district level etc. provide referral services to the infrastructure
in the rural area.

There are also voluntary and private agencies which are functioning to deal with the health
problems of people. The brief description of delivery systems follows.

1. PUBLIC SYSTEM

Public system is Government sponsored system. It is funded by the public funds which are
generated through general taxes. The services are rendered to the people at large in rural and
urban areas by three tier system developed at the block level, district and state level.

a) Health Services for Rural Areas :- The health services in the rural areas are rendered
through a network of infrastructure developed from within the village and in continuum up to
block level. The major emphasis is on promotive and preventive health care services and
comprise primary health care.

At the village level, elementary services are rendered by trained village health guides, birth
attendants (local dais) and Anganwadi workers, They belong to the village they serve and are
non-governmental functionaries. They are included in the health care delivery system to promote
and encourage community participation and to have a link between the community and the health
functionaries.

 The village health guides: provide simple treatment for common minor ailments, First
Aid during accidents and emergency, care to mothers and children including family
planning, health education
 The trained birth attendants: Provide personal and skill full care during prenatal
period, give health education on child care, immunization, nutrition, and family
planning.
 Anganwadi workers work in Anganwadis and carry on the responsibility of health
checkups, supplementary nutrition, immunization, non-formal education of children
enrolled in Anganwadi. They coordinate with ANMs in their areas for some of the
functions e.g. immunization and health checkup of children. Each one serve a
populations of 1000 in the village.

THE SUB-CENTRE - Serve a population of 5000 in plain area and 3000 population in hilly,
tribal and backward areas.
 SERVICES : Maternal and child health, family planning, prevention and control of
communicable diseases, treatment of minor ailments, record of vital events, emergency care,
maintenance of records and reports, supervision and training of dais and village health guides.
The services are rendered by ANM i.e. health workers (F) and health worker (M) under the
supervision and guidance of health supervisor (F and M) respectively.

THE PRIMARY HEALTH CENTRES : Population covered 1,00000 -1,20000 . The Each PHC is
to have 6-7 sub-centres in general and in hilly, tribal and back word areas. Each PHC has 2-3
beds for admitting patients to provide some emergency care and make observation, 4 to 6 beds
for maternity purpose and a labour room. There is also a small laboratory and a minor
operation theatre. The services which are rendered include medical care, MCH and family
planning, safe water supply and basic sanitation, prevention and control of locally endemic
diseases, collection and reporting of vital statistics, health education, national health programmes
(relevant), referral services, training of health workers, village health guides, local dais, basic
laboratory services.

Staff in PHC-

The medical officers

Nurse-midwife

Health supervisors (male and female),

Pharmacist and Block extensions educator.

AT THE BLOCK LEVEL- The primary Health Centre is upgraded to community health centre
with a bed strength of 30 beds, x-ray and laboratory facilities. It has specialists services in
surgery, medicine, obstetrics and gynaecology and a non-medical post of community health
officer. Staff nurses are posted to take care of indoor patients. The community health centre is
considered as the First Referal Unit (FRU) for patient from primary health centres and subcentres
of the respective block. From there, the patients are either referred to District hospital or state
level hospital/medical college hospital when necessary.

There are rural hospitals located at many of the tehsil/ sub-divisional/ taluka head quarters which
also have primary health centres. The proposal is to convert these hospitals into sub divisional
health 'centres and to shift these primary health centres to interior villages.

b) .Services In Urban Areas-

The services in the urban areas are rendered through district hospital, state level hospitals and
medical college hospitals. There are also hospitals and institutes of higher education and research
which are under Central Government and provide general as well as referral services. In addition
to these hospital services, there are maternal, child health and family welfare centers, family
planning clinics, dispensaries, maternity homes, community hospitals run by local Government
to provide specific primary level services to defined population.

REFERRAL SYSTEM :- In the present health care delivery system, the primary health care
infrastructure at the block level and hospital at the district and state level are linked with each
other. The cases beyond the competency of institution at one level are 'transferred' to the next
higher level or beyond.

For effective referral system, it is very important to have proper means of transportation

A well organised system implies that :

 There is linkage among the various level of services.

 The reference system is known to all.
 The referral is done in writing giving information about.
 Identification data about the client.
 The existing problem, complaints.
 Treatment and care given.
 Reasons for referral.
 Name and designation of person making the referral.
 Name of institution making the referral.
 Date and time of referral.
 The referral must be honoured by the referral agency.
 The referral agency must give feed back in writing to the referring agency about the
nature of problem, treatment, prognosis, further treatment and care to be continued,
follow up etc.

Health Services for Defence & Railway Employers :- The services to defence personnel
railway employees and their families are rendered by specially organised "Armed forces Medical
services" and Railways Health Services respectively. Comprehensive preventive, promotive,
curative and rehabilitative services are rendered through specially organized health units, clinics,
hospitals etc

National Health Programmes :- In addition to various level of health care services through
public system, the Government of India has put in lot of efforts to deal with various health
problem at the National level. These problems are related to communicable and non
communicable diseases, environmental sanitation problem, nutritional problems, population
problems etc. The Government of India through its Ministry of Health and Family Welfare have
launched ongoing various National Health Programmes in the successive five year plans since
independence. These organizations include WHO, UNICEF, World Bank UNFPA, USAD, DAN
IDA etc.

The Indigenous Systems of Medicine :- The Indigenous systems of medicine form an important
part of public system of health care delivery both in rural and urban areas. Services are rendered
through out-patient departments, dispensaries and hospitals. During he last few years, a number
of steps have been taken to strengthen Indigenous system of Medicine.

2. HEALTH INSURANCE SYSTEM

In India, Health Insurance System is restricted to factory/ Industrial workers and their families
and Central Government Employees and their families. They are covered by two different very
well organised health insurance schemes. These are :

I. Employees State Insurance Scheme (ESI) :- The ESI scheme was started under the
Parliament Act in 1948 to provide medical benefits in kind and cash during sickness,
employment injury, maternity etc. The scheme is based on the contributions from the
employer, employees and the Government. The scheme is already described in some
detail in chapter on occupational health.
II. Central Government Health Scheme (CGHS):- The CGHS scheme is for the Central
Government Employees. It was introduced in Delhi in 1954 to provide comprehensive
health care to Central Government Employees. Gradually it was extended to other cities
not only to central Government employees and their family members but also other
autonomous organisations employees, Members of Parliament, retired central
Government servants, widows receiving family pensions, Governors and retired judges.

The CGHS provides outdoor, domiciliary, indoor, specialists consultation, emergency, maternal
and child welfare and family welfare services. It also supplies optical and dental aids at
reasonable rate.

3. VOLUNTARY SYSTEM

There are variety of Non-Governmental Organisations (NGOs) which are voluntary in nature and
contribute tremendously in furthering the public health by providing health services, or health
education, by advancing research etc. The NGOs complement and supplement the role of
Government agencies. Some of the voluntary health agencies include Tuberculosis Association
of India, Family Planning Association of India, Indian Red Cross society, the All India Blind
Relief Society, Hind Kusht Nivaran Sangh, The Trained Nurses Association of India, The Indian
Medical Association, Help Age India etc.

4. PRIVATE SYSTEM

Like voluntary health sector, the private health sector also occupies an important place in health
care delivery system in the country. About 14-15 lakhs of medical practitioners including
allopathic and all others are estimated to be doing private practice in the entire country. The
different system of medicine include allopathic or modern medicine, homeopathy, ayurvada,
unani and sidha. Apart from these there are others like yoga, naturopathy and chiropractics.
There has been increase in the number of private hospitals including those owned by the
voluntary agencies. The private consultants are attached to these hospitals. They participate in
the services organized by the hospital as well as they have their own private OPD/clinics and
cases in the hospital. The fee which is charged for the services varies depending upon the level,
standard, popularity etc. of the hospital; consultants; locality etc.