PATTERN OF NURSING CARE DELIVERY IN INDIA

INTRODUCTION:As nursing has evolved over a period, nursing is still focused on caring. Rapid technologic advances , knowledge explosion, emphasis on quality cost effectivenessaccessibility 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? .So how can we best utilize professional nurses across various practice settings? The answer for this question is that it is possible by reshaping organizational (administrative) policies and developing such system of nursing care delivery as best suited to client needs. MEANING OF 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 harmoniously for common out come. The nursing care delivery system means 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 include case method, functional method, team nursing, primary nursing, modular nursing, nursing care management, patient focused care.

PRINCIPLES OF NURSING CARE DELIVERY :i) Holistic approach is used to identify nursing care needs; # physical needs # mental and social needs # spiritual needs Nursing care is based on a helping relationship It is the unique function of the nurse to provide nursing care according to clients 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

ii) iii) iv) v) vi)

Means

of

organizing

nursing

care(managing

resources

Tappen,page

252)

case method

case management

team nursing

modular nursing

functional method

primary nursing

I ) CASE METHOD The case method or total patient care method of nursing care delivery is the oldest method of providing care to a patient. The premise of the case method is that one nurse provides total care to one patient during her entire work period of one shift.This method was used in the era of Florence nightingale when patient received total care in the home. That time nurses were hired and they lived with in the family of the patient provided 24 hrs care to patient and even family including cooking and cleaning. But the case method developed over the years to the specialty of private duty nursing especially in critical care nursing where one nurse cared one or two clients. . Model analysis:During an 8-12 hour shift the patient receives consistent care from one nurse. The nurse , patient , family share mutual trust and work together toward specific goals. Usually the care is patient centered, comprehensive, holistic and continuous

Areas where this method can be used:Community health agencies often use this method to assign cases to individual nurses , intensive care agencies and also nurse educators often select this method of care when students are assigned for caring patients Organization of the case method-model(Leadership-A.Bernhard page-43)

REGISTERED NURSE

PATIENT

IMPORTANT POINTS REGARDING CASE METHOD; Oldest mode of organizing patient care It involves the assignment of one or more patients to a nurse for a specific period of time. Complete care including treatment, medication administration etc Nurses assume total responsibility for meeting all the needs of assigned patients Widely used in hospitals and in nursing homes Students , private duty nurses and specialty units like icu,iccu etc make use of this system Merits:Nurse can see better and attend to the total needs of the patient Continuity of care can be facilitated Client or nurse interaction and rapport can be developed Client may feel more secure Family friends become more known by nurse and get more involved Equal work load Demerits; Many clients do not require the inherent care Must be modified if non professional health workers are used Great disadvantage when nurse is inadequately trained Cost effectiveness

Nurse Manager role:o The nurse manager must consider the expense of the system before arranging the staff o Arrange skilled and qualified nurse so that she could manage all the care of the person o The manager also need to identify the level of education and communication skills of all staff. o Arrange for continuing education and in service education for the personnel Staff nurses role: Provide holistic care to assigned patient during a defined work period Assessment and teaching the patient and family FUNCTIONAL NURSING This system emerged in 1930s in USA Meaning:Individual care givers are assigned to specific tasks rather than being assigned to certain patients or clients . It is based on a division of labour similar to an assembly line This model is also referred to as task method . Functional nursing evolved during the depression when RNs went from being private practitioners to becoming employees for the job security Origin:Once world war II was broke out resulted in severe shortage of nurses in US. Many nurses entered the military to care for the soldiers. To accommodate this shortage, hospitals increased their usage of auxiliary personel. Functional nursing is a method of providing patient care by which each licensed and unlicensed staff members perform specific tasks for a large group of patients. For example RN may administer all intravenous medications one LPN /LVN may give treatments another LPN /LVN may give all oral medications , One assistant may do all hygienic tasks, and another assistant may take all vital signs. The nurse become expert in the particular task she is performing. A charge nurse co-ordinates care and assignments and may ultimately be the only person familiar with all the needs of any individual patient. The key idea was nurses to be assigned for tasks not to the patient

Functional method of nursing care delivery (Leadership-A.Bernhard page-44)

chargenurse

LVN oral med

RN treatments, admissions

RN intravenous meds

NA vital signs

NA hgienic supplies

unit of 30 patients

Important points: Merits:In 1930s when few registered nurses and only some practical nurses available , much patient care was given by nursing aids. RNs were keep busy with managerial and non-nursing duties and nurses aids eliver the majority of patient care The functional method of delivering nursing care evolved as a result of world war II as the lack of graduate , registered nurses became critical Auxiliary personnel were used to assist in patient care Unskilled workers were trained and assigning persons to complete certain tasks ,Eg; checking BP, changes linen, patients etc As a whole the nurses were assigned for certain tasks, not to patients Person can become particularly skilled in performing assigned tasks The best utilization of personnel can be done Less equipment is needed Saves time Potential for development of technical skills is amplified There is a sense of productivity for the task oriented nurse It is easy to organize the work of the unit and staff Task oriented and time saving

Reduced work load to the registered nurses.

Demerits:o Client care become impersonal o Diminishing continuity of care o Staff may become bored and have little motivation to develop self and others. o Work may become monotonous o Less accountability for the nurse o Lack of professional development o Client may tend to feel insecure and inconvenient o Only parts of the nursing care plan are known to personal Where the model is commonly used; In certain hospital wards, nursing homes,nurse consultants, operating rooms. Nurse managers role: The nurse manager must be sensitive to the quality of patient care delivered and the institutions budgetary constraints Achieving patient outcome is her responsibility Improve the staffs perception of their lack of independence Rotate assignments among staff , to alleviate boredom with repetition Conduct staff meeting frequently to encourage staff staff to communicate about patient care And unit functions. Staff nurses role:o They are skilled at the task which is assigned o Complete the task in an efficient and economical manner TEAM NURSING Meaning:Team nursing is the delivery of nursing care by a designated groupof staff members including both professional nurses and non-professional staff . This method of nursing care was introduced in early 1950s . It was designed by Several elements are considered necessary; 1. Team leader is the delegated authority to make assignments for team members and guide the work of the team. The leader of the team should be a registered nurse, not a practical nurse 2. The leader is expected to use a democratic or participative style in interactions with team members.

3. The team is responsible for the total care given to an assigned group of patients or clients. 4. Communication among team members is essential to its success, and includes written patient care assignments , nursing care plans, reports to and from the team leader, team conferences in which patient care problems and team concerns are discussed, and frequent informal feedback among team members. Team nursing was created at the end of World War II to make the best use of the limited nursing staff available and alleviate the problems created by the functional method . As more workers with minimum on the- job training were hired in the healthcare field, it became necessary to reorganize the delivery of care . It was also hoped that the use of team nursing would increase both staff and patient satisfaction and improve the quality of care. In team nursing , a team leader is responsible for coordinating the group of licensed and unlicensed personnel to provide patient care to a small group of patients. The team leader is a highly skilled leader , manager , and practitioner who assigns each member specific responsibilities according to role , licensure , education, ability, and the complexity of the care required. The members of the team report directly to the team leader , who then reports to the charge nurse or init manager . There are several teams per unit , and patient assignments are made by each team leader . Communication is enhanced through the use of written patient assignments , the development of nursing care plans, and the use of regularly scheduled team conferences to discuss patient status and formulate revision to the plan of care.

Model of a team nursing:(nursing leadership and management-Tappen , page 252)

CHARGE NURSE RN

TEAM LEADER RN

TEAM (RN)LEADER RNRNRNRNR N NA RN LVN RN

RN

LVN

GROUP OF PATIENTS

GROUP OF PATIENTS

Important points After the 2nd world war RN were still scarce , although the number of auxiliary personal had increased. It was introduced during the 1950s To improve nursing service by giving the knowledge and skill of professional nurses , and supervise the work of auxiliary nurses . the result was an improvement in patient and self satisfaction. Auxiliary personal collaborate in providing care to a group of patients under the direction of a professional nurse. Based on the philosophy that supports the achievement of goals through group actions Team is lead by a professional or technical nurse who plans , interprets, co-ordinates , supervise and evaluates the nursing care Responsibilities of team leader: Team leader assign team members to patients by matching patients needs and staff knowledge and skill.

 Advantages:-

Knowing condition and needs of all assigned patients Duty vary according to work load, I,e assisting the members and giving direct care to patients. Planning and conducting the conference. Improved patient satisfaction Cost effectiveness for the agency Care is less fragmented because of the increased communication and extensive co-ordination efforts of team leader Allows comprehensive , holistic nursing care when the team function best. Good interpersonal relationships among staffs and with the patients Satisfaction to the patient and the nurses

Disadvantages: Continuity of care is not given Changing team membership makes it difficult for the team leader to assign the patient. Team nursing requires a great deal of co-operation communication from all staff members The large number of people attending the same patient is causing some discomfort to the patient.

MODULAR NURSING
It is a modification of team nursing In modular nursing , staff are geographically assigned to patients for whom they co-ordinate and provide comprehensive care. It focuses on geographic location of patient rooms and assignment of staff members. It was developed by Magargal in 1987 Delivery model:The total unit is divided in to modules or districts and the same team of staff is assigned consistently to the module. Modular nursing is enhanced when nursing units are physically designed and built with this nursing delivery system in mind but it can also be used in nursing units that are not so designed. Each module has a modular, or team leader RN, who assigns the patient to module staff

Each module ideally consists of at least one RN, one LPN/LVN and one nursing assistant. A charge nurse will co-ordinate the work of all the modules in a unit. She expects the module leaders to be accountable for patient care but assist in problem solving when necessary. Staff nurses work independently or together, depending on the size of a modular districts . Modules may have same or different number of patients

Responsibilities of charge nurse / head nurse; Assign patients to different modules Co-ordinate the work schedule and supervises all care on the unit Make patient care assignments, and there by maintain continuity of care. Assist in problem solving when necessary Responsibilities of modular or team leader: Assigns patient to module staff Co-ordinate the module activity Accountable for the care and to the charge nurse Communicate with other modules Model of modular nursing: nursing leadership and managementTappen , page 252)
Head nurse

District leader (RN)with RN,LPN/LVN,AN

District leader (RN)with RN,LPN/LVN,AN

patients

patients

Advantages: Increased continuity of care Geographic closeness of the modular system saved nursing time Better communication and co-operation among staff

 Easier for less experienced nurses because they have other nurses directly available to them for support Patients are more secured Disadvantages: Less accountability Less direct nurse-to-nurse communication and accountability If patient changes room , he will also changes nurses , so patient satisfaction may be less Its a costly method as it should have a redesign of the work environment to allow medication cart , supplies and charts to be located in each module.

Primary nursing
Primary nursing developed by Manthey at al in 1970 as a method for organizing patient care delivery in which one RN functions autonomously as the patients primary nurse through out the hospital stay . This method is based on the concept of my patient-my nurse In this nursing care delivery system, each registered nurse is assigned to the care of group of patientfor which she plans complete 24 hrs care and writes the nursing careplan. The primary nurse cares for her patients every time she works for as long as the patient stay on her unit.(ideally from admission to discharge) .When she is not there , an associate nurse who will follow the primary nurses careplan is assigned to the care of primary nurses patient . The primary nurse is intensively involved with the patients. Licensed practical nurses function as associate nursesand are supervised by the head nurse. When nursing assistants are used in primary nursing system , they are generally assigned to assist primary and associate nursesby doing specific tasks for each nurse they assist.

Model of primary nursing;- nursing leadership and managementTappen , page 252)

Total patient care 24hr/day Communicate with supervisers Consults withphysicians or other health care providers

Primary nurse

Associate(days) when primary nurse is not available

Associate (evenings) when primary nurse is not available

Associate (nights)when primary nurse is not available

Advantages:o Satisfaction for both patients and nurses The relationship between nurses and patient is intimate Autonomy for the nurses Nurse is the person who is planning and providing complete care She communicates with all other health team members involved in client care Other health team members including physician tend to view her more knowledgable and responsible Patient receives quality and continuity of care Reduces the number of errors than can result from a relay of orders Increased satisfaction both to patients and nurses Nurse can identify patient outcome as a result of their work Demerits:Nurse may be isolated from colleagues

Nurses talent to a limited number of patients Nursing care plan can be changed only with the permission of primary nurse Creates separation anxiety in patients when nurse Nurses should be well educated and trained in all area of patient care , most of the time which may lack

CASE MANAGEMENT:Case management is considered as the newest type of nursing care delivery system developed in 1985 as an outgrowth of primary care , nursing case management is a model used to co-ordinate the care , maintain quality, and contain cost while focusing on the outcomes of care Nursing case management is a collaborative activity that focuses on comprehensive assessment and intervention and holistic care planning with appropriate referrals to meet the health care needs of the patient and family. The success of nursing case management models has been demonstrated in all health care settings including acute, sub-acute or ambulatory settings long term care facilities , in health insurance companies and in community. Model of nurse case management:- nursing leadership and management-Tappen , page 252)

Nursing administration

Medical nurse case manager

Pediatric nurse case manager

OB nurse case manager manager All Ob patients

Trauma nurse case manager

All medical pts

Pediatric pts

All trauma pts

Role of nurse case manager: Delivers client focused and outcome oriented care Cost effective care through integration of clinical services in combination with financial services Serves as an advocate for patient and family More patient and nurse satisfaction is achieved through intensive care

 They attend to a specific high risk population Advantages: Patient receives high standard care Nurse is highly qualified and skilled in the particular area, More satisfaction to the patient Increased professional standards can be developed by the nurses Disadvantages: Sometimes discomfort to clients Continuity care is difficult Long time nurse patient relationships are difficult to arrange Costly Time consuming No proper attachment between nurses and patients Factors influencing nursing care delivery system: Availability of adequate staff in wards or units Patient census Extend of staff deficiency Organizational policies regarding its practice Patients preferences for care Availability of skilled staff Opportunities for continuing and inservice education to the staffs Budget of the organization Socio economical condition of the patient The organizations mission Patient and community needs CONCLUSION:No single nursing care model works in all settings, or even necessarily across a single multiservice settings. Before selecting a model nurse manager must consider all the influencing facors.For a better care effective selection and mixing of these methods are essential. All the models should be evaluated periodically for its appropriateness to ensure safe and effective nursing care.