BACHELOR OF SCIENCE IN NURSING:

NCM 107A – NURSING LEADERSHIP

and MANAGEMENT

COURSE MODULE COURSE UNIT WEEK

1 2 2

PATIENT HEALTH CARE DELIVERY SYSTEM

 Study the course and unit objectives

 Understand study guide prior to attending the class
 Read prerequisite learning resources
 Partake in classroom activity
 Be included in weekly discussion
 Answer and submit course unit task
At the end of this unit, the students are expected to:

Cognitive:

1. Discuss the patient classification systems and distinguish each category using
the four levels of nursing care intensity.
2. Identify and describe the various types of patient care delivery systems

3. Identify and describe at least three principles of organization.

4. Enumerate and explain the elements of organizing.
5. Describe the major characteristics of an organizational structure.

Affective:

1. Work effectively in collaboration with inter-, intra- and multi-disciplinary and multi-
cultural teams
2. Join actively in class discussions and group activities.
3. Appreciate and support one’s opinion and comments toward each other
4. Engage in life-learning with a passion to keep current with national and global
developments
5. Accept responsibility for life-learning, own personal development and
maintenance of competence.

Psychomotor:

1. Demonstrate effectiveness efficiency in the implementation of plans.

2. Apply essential task performed by managers in a variety of settings.
3. Use appropriate technology in the implementation of a good plan.
PATIENT CARE DELIVERY SYSTEM

NURSING PROCESS IN THE DELIVERY OF NURSING CARE SERVICE

Nursing process is defined as a systematic, rational method of planning and

providing individualized nursing care. It is utilized to identify a client’s health status and
actual or potential health care problems or needs, to establish plans to meet the identified
needs, and to deliver specific nursing
interventions to meet those needs.It
is cyclical and its components follow
a logical sequence, but more than
one component may be involved at
one time. At the end of the first cycle,
care may be terminated if goals are
achieved, or the cycle may continue
with reassessment, or the plan of
care may be modified (Berman,
Synder, & Frandsen, 2016).

PATIENT CLASSIFICATION SYSTEM

A patient classification system (PCS) predicts patient needs and requirements for
nursing care. A PCS groups patients according to acuity of illness and complexity of
nursing activities necessary to care for the patients. Typically, patient acuity data are
collected every shift by nursing staff and are analyzed to project nursing staff needs for
the next shift. The advantage of using a PCS is that it is an objective approach to
determining staffing based on patient care needs: a sicker patient requires more nursing
care and therefore would have a higher acuity level. However, there are numerous issues
regarding use of PCSs, including lack of standardization, lack of credibility among nurse
leaders and managers, and no consideration of patient flow (Hertel, 2012).

Patient classification systems (PCS), also known as workload management, or

patient acuity tools, were developed in 1960s. A PCS group patients according to specific
characteristics that measure acuity of illness in an effort to determine both the number
and mix of the staff needed to adequately care for those patients. Below is a sample
classification system.
 Patient classification systems are institution-specific and must be modified to
reflect the unique staff and patient population of each health-care organization. Other
variables within the system have an impact on nursing care hours (NCH) and are usually
not possible to transfer a PCS from one facility to another.

MODALITIES OF CARE

There are five most well-known means of organizing nursing care for patient care
delivery. These are the functional nursing, team and modular nursing, primary nursing,
and case management. Each of these basic types has undergone many modifications,
often resulting in new terminology. An example is the primary nursing which was once
called case method nursing and is now frequently referred to as professional practice
model. Team nursing is sometimes called partners in care or patient service partners,
and case managers assume different titles depending on the setting in which they provide
care.

Case Method Nursing or Total Patient Care Nursing

Total patient care is the oldest mode of organizing patient care. With total patient
care, nurses assume total responsibility during their time on duty for meeting all the needs
of assigned patients. Total patient care nursing is sometimes referred to as the case
method of assignment because patients may be assigned as cases, much like the way
private duty nursing was historically carried out.

This method of assignment is still widely used in hospitals and home health
agencies. Nurses are provided with high autonomy and responsibility. Assigning patients
is simple and direct and does not require the planning that other methods of patient care
delivery require. The lines of responsibility and accountability are clear. The patient
receives holistic and unfragmented care during the nurse’s time of duty.

Because the nurse practices with high autonomy, care regimen may be modified.
Therefore, if there are three shifts, the patient could receive three different approaches to
care, often resulting in confusion for the patient. To ensure quality of care delivered, highly
skilled personnel is required and may cost more than some other forms of patient care.
Opponents of this method argue that some tasks performed by the primary caregiver
could be accomplished by someone with less training and therefore at a lower cost. The
greatest disadvantage of this method occurs when the nurse is inadequately prepared or
too inexperienced to provide total care to the patient.
Functional Nursing

The functional method of delivering nursing care evolved primarily as a result of

World War II and the rapid construction of hospitals as a result of the Hill Burton Act.
Because nurses were in great demand overseas and at home, a nursing shortage
developed and ancillary personnel were needed to assist in patient care. Relatively
unskilled workers were trained to do simple tasks and gained proficiency by repetition.
Personnel were assigned to complete certain tasks rather than care for specific patients.
Examples of functional nursing tasks were checking blood pressures, administering
medications, changing linens, and bathing patients. RNs became managers of care rather
than direct care providers, and “care through others” became the phrase used to refer to
this method of nursing care.

This functional form of organizing patient care continued even after the war ended.
Most health-care organizations continue to employ health-care workers of many
educational backgrounds and skill levels. Functional nursing may lead to fragmented care
and the possibility of overlooking patient priority needs and may result in low job
satisfaction. It may also not be cost-effective due to the need for many coordinators.
Team Nursing

In team nursing, ancillary personnel collaborate in providing care to a group of

patients under the direction of a professional nurse. As the team leader, the nurse is
responsible for knowing the condition and needs of all the patients assigned to the team
and for planning individual care. The team leader’s duties vary depending on the patient’s
needs and the workload. These duties may include assisting team members, giving direct
personal care to patients, and coordinating patient activities.

Extensive team communication is required so that comprehensive care can be

provided for patients despite a relatively high proportion of ancillary staff. This
communication occurs informally between the team leader and the individual team
members and formally through regular team planning conferences. A team should consist
of not more than five people or it will revert to more functional lines of organization.

Team nursing is usually associated with democratic leadership as group members

are given as much autonomy as possible when performing assigned tasks, although the
team shares responsibility and accountability collectively. Disadvantages are associated
with improper implementation rather than with the philosophy itself. Frequently, team care
planning and communication is faced with insufficient time and can lead to blurred lines
of responsibility, errors, and fragmented care. For team nursing to be effective, the team
leader must be an excellent practitioner and have good communication, organizational
management, and leadership skills.
Modular Nursing

Team nursing, as originally designed, has undergone much modification in the last
30 years. Most team nursing was never practiced in its purest form but was instead a
combination of team and functional structure. Attempts to refine and improve team
nursing have resulted in many models including modular nursing.

Modular nursing uses a mini-team (two or three members with at least one member
being an RN), with members of the modular nursing team sometimes being called care
pairs. In modular nursing, patient care units are typically divided into modules or districts,
and assignments are based on the geographical location of patients.

Keeping the team small in modular nursing and attempting to assign personnel to
the same team as often as possible should allow the professional nurse more time for
planning and coordinating team members. In addition, a small team requires less
communication, allowing members better use of their time for direct patient care activities.
Primary Nursing

Primary nursing, also known as relationship-based nursing, was developed in the

late 1960s, uses some of the concepts of total patient care and brings the RN back to the
bedside to provide clinical care. In inpatient primary nursing, the primary nurse assumes
24-hour responsibility for planning the care of one or more patients from admission or the
start of treatment to discharge or the treatment’s end. During work hours, the primary
nurse provides total direct care for that patient. When the primary nurse is not on duty,
associate nurses, who follow the care plan established by the primary nurse, provide care.

Although originally designed for use in hospitals, primary nursing can also be applied
in home health nursing, hospice nursing, and other health-care delivery systems. An
integral responsibility off the primary nurse is to establish clear communication among the
patient, the physician, the associate nurses, and other team members. Feedback is
sought from others in coordinating the patient’s care. The combination of clear
interdisciplinary group communication and consistent, direct patient care by relatively few
nursing staff allows for holistic, high-quality patient care.

In these models of care, job satisfaction is high and nurses often feel challenged
and rewarded. Disadvantages to this method lie primarily in improper implementation. An
inadequately prepared or incompetent primary nurse may be incapable of coordinating a
multidisciplinary team or identifying complex patient needs and condition changes. Many
nurses may be uncomfortable in this role or initially lack the experience and skills
necessary for the role.

Case Management

Case management is defined by the Case Management Society of America

(CMSA, 2008-2016) as a collaborative process of assessment, planning, facilitation, and
advocacy for options and services to meet an individual’s health needs through
communication and available resources to promote quality cost-effective outcomes”.

In case management, nurses address each patient individually, identifying the

most cost-effective providers, treatments, and care setting possible. In addition, the case
manager helps patients access community resources, helps patients learn about their
medication regimen and treatment plan, and ensures that they have recommended tests
and procedures.
 Case managers often manage care using critical pathways and multidisciplinary
action plans (MAPS) to plan patient care. The care MAP is a combination of a critical
pathway and a nursing care plan. It also indicates times when nursing interventions
should occur. All health-care providers follow the care MAP to facilitate expected
outcomes. If a patient deviates from the normal plan, a variance is indicated. A variance
is anything that occurs to alter the patient’s progress through the normal critical path.

Because the role expectations

and scope of knowledge required to
be case manager are extensive,
some experts have argued that this
role should be reserved for the
advance practice nurse or RN with
advanced training, although this is not
usually the case in the practice setting
today. In fact, board certification as a
case manager is available to any
individual with a professional license
such as an RN, licensed clinical social
worker, or pharmacist, and with completed supervised field experience in case
management.

Contemporary Models

Contemporary models of care, also called innovative models are the newest approaches
to organizing patient care to foster patient safety and quality outcomes. These include the
Professional Nursing Practice Model, the Differentiated Nursing Practice Model, the
Clinical Nurse Leader Model, the Synergy Model for Patient Care, Transforming Care at
the Bedside, and the Patient- and Family-Centered Care Model.

Professional Nursing Practice Model. This provides a “framework for guiding and
aligning clinical practice, education, administration, and research in order to achieve
positive patient and nurse staff outcomes” (Lineweaver, 2013). This model is identified as
a core feature of Magnet hospitals (Neisner & Raymond), 2002) because Magnet
hospitals typically have higher RN-to-patient ratios, and many of these hospitals are
moving to all-RN staffs. In this model, TNs have greater autonomy and control over
practice, and there are higher rates of patient satisfaction, lower rates of nurse burnout,
and safer work environments. This model supports the RN’s control over the delivery of
nursing care as well as effective inter professional and intra professional communication.

Differentiated Nursing Practice Model. Care in this model is differentiated based on the
level of education, competence, and clinical expertise of RNs: nurses with an associate
degree function as technical nurses and provide the majority of bedside care;
baccalaureate-prepared nurse function on a broader scale, collaborating and facilitating
patient care from admission through discharge; and advanced practice nurses function
within the broad healthcare system and provide care across all settings throughout
wellness and death. Nurses must be clinically competent and flexible in providing nursing
care, and they must value the differing roles. Differentiated nursing practice recognizes
that all nurses, regardless of education, are needed to provide high-quality,
comprehensive care to all patients in all settings.

Clinical Nurse Leader Model. This was developed with the goal to improve the quality
of patient care across the continuum and as a way to engage highly skilled clinicians in
outcome-based practice and quality improvement. The CNL has responsibilities including
designing, implementing, and evaluating patient care by coordinating, delegating, and
supervising the care provided by an inter professional team. The nurse in this role is the
leader in the healthcare delivery system and is not in an administrative or managerial role
The CNL is a provider and coordinator of care and fosters inter professional and intra
professional communication.

Synergy Model for Patient Care. The American Association of Critical-Care Nurses
developed this model with the core concepts that needs of patients and families influence
and drive the competencies of nurses and that synergy occurs when the needs and
characteristics of the patient, clinical unit, or system are matched with the nurse’s
competencies. This model fosters effective communication and collaboration in achieving
optimal, realistic patient and family goals. Although the model was originally developed
for critical care units, it has been used in a variety of clinical settings. This model includes
eight patient characteristics (resiliency, vulnerability, stability, complexity, resource
availability, participation in care, participation in decision making, and predictability, and
eight nursing characteristics or competencies derived from patient’s needs (clinical
judgment, advocacy and moral agency, caring practices, collaboration, systems thinking,
response to diversity, facilitation to learning, and clinical inquiry).
Transforming Care at the Bedside. The goal of this model is to empower nurses and
other healthcare team members to redesign work processes to improve the quality of
patient care and decrease turnover. Five themes comprise the TCAB model of care:
transformational leadership, safe and reliable care, vitality and teamwork, patient-
centered care, and value-added care processes.

Patient- and Family-Centered Care Model. This model places an emphasis on

collaborating and planning care with patients (and their families) of all ages, at all levels
of care, and in all healthcare settings (Conway, 2006). In the patient-focused care, the
RN is the coordinator and planner of care who brings as many care services to the patient
as possible; in patient- and family-centered care, the patient has control over his or her
care, and all health-care decisions are made with the RN as a collaborator in his or her
care.

FORMAL AND INFORMAL ORGANIZATIONAL STRUCTURE

According to Fayol (1949), an organization is created when the number of workers
is large enough to require a supervisor. Organizations are essential because thru
organizations, collective effort is more effective than individual effort. As stated by Venzon
(2016), it pertains to the body of persons, methods, policies and procedures arranged in
a systematic process through the delegation of functions and responsibilities for the
accomplishment of purpose.
Every organization has a formal and an informal structure. In formal structure,
managerial authority, responsibility, and accountability is clearly defined. Roles and
functions are outlined, people have specific task to perform, and rank and hierarchy are
apparent. Informal structure, according to Education Portal (2003-2013), is the channel
“that fills in the gaps with connections and relationships that illustrate how employees
network with one another to get the work done.” As supported by Schatz (2013) informal
structures are typically centered on camaraderie and often produce direct response from
individuals, saving people’s time and effort. Informal structure is also useful when the
formal structure becomes non-effective.
The communication network used in informal structure is known as grapevine.
This is considered to be the heart of the informal organization as these are
communications that occur in the break room, down the halls, during the carpool, and in
between work that allows relationships of informal groups to develop. Also, social media
sites and electronic communication such as e-mail and text messages are also used to
facilitate communication among members. Because of the fast transfer of messages,
grapevine communication often becomes a source for rumor or gossip (Murray, 2017).

ORGANIZATIONAL THEORY AND BUREAUCRACY

Max Weber is known as the father of organizational theory. According to him,
bureaucracy is an institutional method for applying general rules to specific cases, making
the actions of management fair and predictable. Other characteristics of bureaucracy are
the following:
 There must be a clear division of labor.
 A well-defined hierarchy of authority must exist which separates the superiors from
subordinates. There must be remuneration for work, recognition of authority,
allotment of privileges and conferring of promotion.
 There must be impersonal rules and impersonality of interpersonal relationships.
 A system of procedures for dealings with work situations must exist.
 A system of rules covering the rights and duties of each position must be in place.
 Selection for employment and promotion is based on technical competence.

Organizing is the process of establishing formal authority and involves setting up

the organizational structure through identification of groupings, roles and relationships,
determining the staff needed by developing and maintaining staffing patterns and
distributing them in the various areas as needed. It includes developing job descriptions
by defining the qualifications and functions of personnel.

An organizational chart is a line drawing that shows how the parts of an

organization are linked. It depicts the formal organizational relationships, areas of
responsibility, persons to whom one is accountable and channels or organization.
Patient classification systems - also known as workload management or patient acuity
tools

Case method nursing or total patient care nursing – oldest form of patient care
organization and is still widely used today

Functional nursing – the modality of care that requires the completion of specific tasks
by different nursing personnel

Team nursing – typically uses a nurse-leader who coordinates team members of varying
educational preparation and skill sets in the care of a group of patients

Modular nursing – uses mini-teams, typically an RN and unlicensed health-care

workers, to provide care to a small group of patients, usually centralized geographically

Primary care nursing – one health-care provider (typically the RN) has a 24-hour
responsibility for care planning and coordination

Case management – a collaborative process that assesses, plans, implements,

coordinates, monitors, and evaluates opinions and services to meet an individual’s health
needs through communication and the use of available resources to promote quality and
cost-effective outcomes

Accountability – taking full responsibility for the quality of work and behavior while
engaged in the presence of the profession.
Authority – the right to act or make decisions without approval of higher administrators.
It includes the right to extract obedience from subordinates. In government hospitals, flow
of authority is from the Chief of Hospital down to the Heads of the various Divisions such
as the Administrative Officer, the Chief of the Nursing Division, and the Chief of Clinics.
Communication – the transmission of information between persons.
Power – the ability to influence another to behave in accordance with one’s wishes.
Relationships within Nursing Services – can be depicted through the organizational
chart.
a. Line relationship those that exists between the superior and subordinated
immediately and directly responsible to him/her. Ex: Chief Nurse to Supervising
Nurse, Head Nurse to all nursing staff.
b. Lateral relationship those that exists between position in various divisions and
sections of an undertaking where no direct authority is involve. Ex: Senior
Nurse and Physician, Staff Nurse and Clinical Pharmacist.
c. Functional relationship those that arise when duties are divided on a
functional basis like when an individual exercises authority on a particular
subject by special skill or knowledge. Ex: Chief Nurse with Administrative
Officer, Staff Nurse with Clinical Nurse Instructor.
d. Staff personnel provides advice, counsel, or technical support that may be
accepted, altered, or rejected by the line officer.
Responsibility – the obligation to perform the assigned tasks.
Status – the rank a group bestows on a person in accord with the group’s estimation of
the person’s value and significance to group goals. The status of the Nursing Director or
Chief Nurse is equal to that of the Administrative Officer and Chief of Clinics.

Toney-Butler TJ, Thayer JM. Nursing Process. [Updated 2021 Jul 9]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK499937/

Malloch, K. (2012). Changing Tides: Increasing Evidence to Embrace a Patient

Classification System. Nursing Economics. November-December 2012/Vol. 30/No. 6.
Avalable from: www.nursingeconomics.net/necfiles/staffingUnleashed/su_ND12.pdf
 Marquis, B. And Huston, C (2017) Leadership roles and management functions in
nursing, Theory and application, 9th ed. Philadelphia: Lippincott Williams and
Wilkins

Murray, E. (2017). Nursing Leadership and Management: For Patient Safety and
Quality Care. F.A. Davis Company.

Venzon, L. (2016) 12th Leadership Roles and Functions in Manage Care, 4th edition
Philippines

You are working at a large government teaching hospital in Quezon City. Your
institution caters to all patients from the NCR and other nearby provinces. Upon arrival at
work this morning, you looked at the census board and discovered that the surgical unit
that you are assigned in was filled, with some patients on queue for transfer from the ER
Department. The following are the patients assigned to his team. Classify the following
patients according to their patient acuity or level of care needed.

 Patient A – 36/F, scheduled for left modified radical mastectomy at 10 AM today

 Patient B – 28/M, post-op Day 4 Cholecystectomy, ambulatory and without IV
line.
 Patient C – 50/F, post- incision and drainage of left arm abscess and still with IV
line Patient D – 42/M, who is ready for discharge and needs discharge instruction
 Patient E – 39/F, scheduled for Emergency Exploratory Laparotomy, to consider
bowel obstruction
 Patient F – 20/M, for transfer to ICU, for insertion of intra-jugular vein catheter
and for emergency dialysis.
 Patient G – 55/F, on total bedrest, with NGT and chest tube
 Patient H – 61/M, post-op Day 5 Partial Hip Replacement and for referral to
Rehab Department.
 TASK:

In 200 works identify and discuss the levels of care that that each of the patient’s
needs. And submit in canvas within the week. (25 points)

Books

Berman, A., Snyder, S, and Frandsen, G. (2016). Kozier’s & Erb’s Fundamentals
of Nursing: Concepts, Process & Practice, 10th ed. Pearson

Kelly, P. (2010). Essentials of Nursing Leadership and Management, 2nd ed.

Delmar CENGAGE Learning.

Hospital Nursing Service Administration Manual, Department of Health

Website

http://www.jrrmmc.gov.ph/about-jrrmmc/organizational-chart

Images from

https://www.fundera.com/blog/business-organizational-chart
https://www.projectmanager.com/blog/project-organization-101
https://www.iedunote.com/organizational-structure-elements
https://conceptboard.com/blog/organizational-chart-template/