Introduction

As nursing has evolved over a period, nursing is still focused on caring. Rapid techno-
logic advances, knowledge explosion, emphasis on quality –cost effectiveness-accessibility of
health care and increased demand by the patients for advanced alternative health care modalities
present many challenges for nursing profession.

How are nurses responding to these challenges? How can we best utilize professional
nurses across various practice settings? The answer for this question is that it is possible by re-
shaping organizational (administrative) policies and developing such system of nursing care de-
livery as best suited to patients’ needs.

Nursing Care Delivery System

A system may be defined as a whole made up of integrated or joined and interrelated

parts. Although each component of the system has its specific function, yet all of them work har-
moniously for common out come. The nursing care delivery system is the process of delivering
care to the client by combining various aspects of nursing service which will fit to various patient
care settings to produce a common outcome of delivering quality care and meeting the needs of
clients. There are various types of nursing care delivery system which include total patient care
or case method, functional method, team or modular nursing, primary nursing, nursing care man-
agement, patient focused care.

Characteristics of Effective Health-Care Delivery Systems

• Elements of the various designs present in the system in use in any organization
• Facilitate meeting the goals of the organization
• Cost-effective
• Satisfy the patient
• Provide role satisfaction to nurses
• Allow implementation of the nursing process
• Provide for adequate communication among health-care providers
Principles of Nursing Care Delivery
 Holistic approach is used to identify nursing care needs: physical, mental, social and spir-
itual needs. Nursing care is based on a helping relationship. It is the unique function of the nurse
to provide nursing care according to client’s needs. The aspect of patient care has to be initiated
and controlled by nurse. There should be justification for selecting each delivery system before
planning care organizational policies to be considered.

Factors influencing nursing care delivery system:

• Availability of adequate staff in wards or units

• Patient census
• Extend of staff deficiency
• Organizational policies regarding it’s practice
• Patient’s preferences for care
• Availability of skilled staffs
• Opportunities for continuing and in-service education to the staffs
• Budget of the organization
• Socio economical condition of the patient
• The organization’s mission
• Patient and community needs

Nursing care delivery systems or models define how work is organized, how nursing
staffs are deployed and who will provide the nursing care. It details assignments, responsibility
and authority to accomplish patient care; matches number and type of caregivers to patient care
needs.

It is a process of delivering care to the client by combining various aspects of nursing ser-
vice that fit to various patient care setting to produce a common outcome of delivering quality
care and meeting the needs of the patients/clients.

Choosing the most appropriate organizational mode to deliver patient care for each unit
or organization depends on:
 • the skill and expertise of the staff required for particular activities with specific pop-
ulations.
• the availability of registered professional nurses. Not every nurse desires a challeng-
ing job with the autonomy of personal decision making.
• the economic resources of the organization
• the acuity of the patients
• the complexity of the tasks to be completed

Goals for Managing and Organizing Patient CareEnsure Quality of Care

• Patient and Family Satisfaction

• Staff/Employee Satisfaction
✓ Appropriate staffing of nursing units
✓ Resolution of scheduling issues
• Cost - Effectiveness

The Five Primary Means of Organizing Nursing Care for Patient Care Delivery

1. Total patient care

2. Functional nursing
3. Team and modular nursing
4. Primary nursing
5. Case management

Total Patient Care

Total Patient Care is also known as Case Method, the oldest means used in organizing pa-
tient care; wherein the nurses assume total responsibility for meeting the needs of all assigned
patients during their time on duty.
 One nurse is assigned to complete the total care to one or a specific number of patients.
Also, it is a method commonly used in Intensive Care Unit, Post-Anesthetic Care Unit, home
health care, private duty nurse and for student nurse assignments.
Total Patient Care

Advantages:

• High degree of autonomy

• Lines of responsibility & accountability are clear.
• Patient receives holistic, unfragmented care because the nurse has more time to observe &
monitor the progress of the patient.

Disadvantages:

• Each registered nurse have different approach to care.

• Not cost-effective
• Lack or Registered Nurses availability

Functional Nursing
 Functional Nursing Care evolved primarily as a result of WW2 and rapid construction of
hospitals as a result of Hill Burton Act.

Hill Burton Act, also known as Hospital Survey & Construction Act, is a United States
federal law passed in 1946 during 79th US Congress; sponsored by Senator Harold Burton of
Ohio & Senator Lister Hill of Alabama.

It is also called Task-Oriented and Efficient Method. Each nurse or ancillary personnel is
assigned to specific task rather than being assigned to certain patients. One nurse is assigned in
giving medication, another nurse provides treatment, nursing assistant or nursing aide takes the
vital signs and an ancillary personnel provides hygienic care.

Charge nurse coordinates care and assignments & may ultimately be the only person fa-
miliar with all the needs of any individual patients.
Advantages:

• Care is provided economically and efficiently.

• Minimum number of registered nurses required.
 • Task are completed quickly and can deliver care to a large number of patients.
• Less time needed to coordinate team work of staff
• Clearly defined roles.
• Improves nurse or staff efficiency.
• Cost effective

Disadvantages:

• Fragmentation of care
• Impersonal care
• Boring for staff
• Less communication between the patient , nurse and other health care providers
• Poor patient satisfaction

Team Nursing

Team nursing care was introduced in 1950’s to improve nursing services by using knowl-
edge and skills of professional nurses and supervise the work of auxiliary staffs.

Team nursing is the most popular approach in acute hospital care. Team consists of not
more than five members. The team leader should be a registered nurse and has the delegated au-
thority to make assignments for team members and guide their work. The team leader plans, in -
terprets, coordinates, supervise and evaluates the nursing care. Ancillary personnels collaborate
in providing care to a group of patients under the direction of a professional nurse.
 Team Nursing Delivery Care

This requires good communication among team members for planning and implementing
quality care; including written care patient assignments, nursing care plan, reports to and from
the team leader, team conferences in which patients care problems and team concerns are dis-
cussed, and frequent informal feedback among team members.

Advantages:

• Comprehensive
• Holistic nursing care
• Patient and staff satisfaction is higher.
• Recognition of staff members abilities are possible.

Disadvantages:
 If the team work is poor then care is fragmented; continuity of care decreases; care lacks
accountability; poor communication; and increased time in supervision by the team leader.

Modular Nursing

Modular Nursing is a modification of team and primary nursing. It is used frequently

during the 1980s and 1990s. Like team nursing, but uses a smaller team comprises of two to
three members. This pairs professional nurses with ancillary staffs to deliver care to groups of
patients. That is why members are sometimes called “care pairs”. Patient unit is divided into
modules or units with a registered nurse as a team leader. The concept evolved to increase
nurses involvement in the care.

This requires less communication allowing members to better use of their time for direct
patient care activities.
Modular Nursing Care

Primary Care Nursing

 Primary nursing was developed by Manthey et al in 1970 as a method of organising pa-
tient care delivery in which one registered nurse functions autonomously as the patient’s primary
nurse throughout the hospital stay.
This method is based on concept of “my patient-my nurse” and also known as Relation-
ship-Based Nursing Care. In this method, each registered nurse is assigned to provide total di-
rect care of a group of patient under 24-hour responsibility from admission to discharge. Auton-
omy, authority and accountability are basic to this model.

Each patient has a primary nurse responsible in assessing patient’s needs; developing
plan of care in collaboration with other health care providers; implementing plan of care using
non-licensed staff to assist in completing tasks and evaluating the outcomes of the nursing care
given.

Primary Care

Advantages:

• Job satisfaction is high.

 • Focus on client’s needs
• Greater nurse autonomy
• Greater continuity of care

Disadvantages:

• This method is difficult to implement because of the degree of responsibility and autonomy
required of the nurse.
• Isolation from colleagues
• May create tension between nursing personnel

Case Management Nursing

Case Management Nursing is a fastest growing “new model” and is defined as both a
process and a care delivery model.

It is a collaborative process that assesses, plans, implements, coordinates, monitors, and

evaluates options and services to meet an individual's health needs through communication and
available resources to promote quality, cost-effective outcomes. This method focuses on individ-
ual patients, not population of patients and is often associated with the use of critical pathways
and multidisciplinary action to plan patient care.

The success of nursing case management model has been demonstrated in all health care
settings including acute, sub-acute , ambulatory, long term care facelities, in health insurance
companies and in community.

Six Core Functions of Case Management

1. Assessment
2. Planning
3. Linking
 4. Monitoring
5. Advocacy
6. Outreach

Goals of Case Management

• Decreased hospital readmission

• Decreased length of stay
• Adherence to therapeutic regimen
• Achievement of desired outcomes
• Decreased resource use
• Improved quality of life
• Improved functional status
• Increased patient satisfaction
• Decreased symptom management

Patient and Family-Centered Care

This method is based on the principles of primary nursing and case management and puts
the patient at the centre of all of the redesigned and restructuring efforts. Patient and family per-
spectives are sought out and their choices are honored. Health-care providers communicate
openly and honestly with patients and families to empower them. Patients, families, and health-
care providers collaborate regarding facility design and the implementation of care.

The voice of the patient and family are represented at both the organizational and policy
levels as well as in the health system's strategic planning.

Common Themes Found Among Emerging Care Delivery Models

• Elevating the role of nurses and transitioning from caregivers to "care integrators"
• Taking a team approach to interdisciplinary care
• Bridging the continuum of care outside of the primary care facility
• Defining the home as a setting of care
• Targeting high users of health care, especially older adults
 • Sharpening focus on the patient, including an active engagement of the patient and her or
his family in care planning and delivery, and a greater responsiveness to the patient's wants
and needs
• Leveraging technology
• Improving satisfaction, quality, and cost

Patient Classification System

1. “Self care” or Minimal Care Patients

These patients are capable of carrying activities of daily living (ADL), convalescing, no
longer require intensive, moderate, or maximum care; those who require diagnosis studies; need
minimal therapy; are awayting elective surgery and home environment temporarily makes dis-
charge undesirable.

2. Intermediate or Moderate Care

These patients require some help from the nursing staff with special treatments; given to
moderately ill; recovering from immediate effects of a serious illness or operation; may be ambu-
latory for short periods and need assistance.

3. Total Care Patients

Those patients who are bedridden and who lack strength and mobility to do average
daily living. They need close attention; require nurse to initiate, supervise, and perform most of
the activities; and those who require frequent medication.
4. Intensive Care Patients

These are the patients who are critically ill and in constant danger of death or serious in-
jury. They are acutely ill patients with high level of nurse dependency; and those who have un-
stable condition which requires frequent evaluation with adjustment therapy.