Organizing Nsg Service

ORGANIZING NURSING SERVICES AND PATIENT CARE INTRODUCTION “A hospital may be soundly organized, beautifully situated and well equipped, but if the nursing care is not of high quality the hospital will fail in its responsibility.” Jean barrett Who is the effective member of the patient care team? Sir William Osler said that the nurse is one of the greatest blessings of humanity. Nursing has a large, important and unique role in the health care delivery system of a country. Nursing care is extremely important for good patient outcome. While the physician plans the treatment and surgeon carries out the operation, it is the nurse who gives 24 hrs / round the clock nursing care and looks after the needs of the patient. The success of the patient care depends upon the competence of the nursing staff. Organizing the high level of nursing care is a big challenge for the nursing service administrator. Setting of standards and goals for providing care to patients depends upon the philosophy of nursing in order to organize the patient care. OBJECTIVES ♪ General objective: At the end of the seminar the student will be able to understand about the organizing of nursing service and patient care and its detail. ♪ Specific objectives: By the end of the seminar, the students will be able to: ► Explain the meaning of nursing service and nursing service administration. ► Define nursing service and patient care. ► Understand the philosophy of nursing service. ► Describe the objectives of nursing service. ► Know the principles of nursing service. ► Identify the functions of nursing service. ► Enumerate the essential characteristics of good nursing service department. ► Describe the organization of nursing service at various levels. ► List out the role and functions of nurse administrator. ► Mention the problems and challenges faced by the nursing service. ► Know about the patient classification system. 1

► Enumerate the modes of organizing patient care. ► Explain the factors influencing the quality patient care.

TERMINOLOGIES: Case method

In this method, nurses assume total responsibility for meeting all the needs of assigned patients during their time on duty.

Modular nursing

The patient unit is divided into modules or districts, and the same team of caregivers is assigned consistently to the same geographic location

Nursing service

It is the part of the total health organization which aims at satisfying the nursing needs of the patients/community.

Objective

The goal intended to be attained (and which is believed to be attainable).

Organizing

It involves grouping activities together and assigning the responsibility of each group of activity to a manager who has adequate authority to fructify the activity/task at hand.

Patient classification system

Patient classification system (PCS), which quantifies the quality of the nursing care, is essential to staffing nursing units of hospitals and nursing homes.

Patient care

Care of the sick and injured and restoration of the health of a diseased person without any decimation.

Performance appraisal

A formal assessment of an employee’s performance.

Philosophy

Statement of beliefs and values that directs behavior.

Primary nursing

It is a method of nursing practice which emphasizes continuity of care by having one nurse provides complete care for a small group of inpatients within a nursing unit of a hospital.

Team nursing

It is a group that works together toward a common goal, providing qualitative comprehensive nursing care.

ORGANIZING NURSING SERVICES Meaning of nursing service and nursing service administration 2

Nursing Service Nursing service is the part of the total health organization which aims at satisfying the nursing needs of the patients/community. In nursing services, the nurse works with the members of allied disciples such as dietetics, medical social service, pharmacy etc. in supplying a comprehensive program of patient care in the hospital. Nursing service administration Nursing service administration is a complex of elements in interaction and is organized to achieve the excellence in nursing care services. It results in output of clients whose health is unavoidably deteriorating, maintained or improved through input of personnel and material resources used in a process of nursing services. DEFINITION OF NURSING SERVICE WHO expert committee on nursing defines the nursing services as the part of the total health organization which aims to satisfy major objective of the nursing services is to provide prevention of disease and promotion of health. PHILOSOPHY OF NURSING SERVICE IN HOSPITAL The department of nursing services of hospital recognizes and appreciates the objectives of the hospital and acknowledges that the primary purpose of nursing is to provide the highest quality care services. ♦ The quality in nursing care and management of nursing services is achieved through professional nurses who assist in the development of comprehensive programs of delivering nursing care. ♦ The quality of nursing care services is clearly and directly related to continuing growth and development of nursing personnel. ♦ High quality of nursing care can be best provided by a mixture of professional and non professional personnel who are organized into self directed work teams. ♦ To ensure continuous improvement of nursing care quality, the role of professional nurse must include responsibility of nursing research and nursing education. OBJECTIVES OF NURSING SERVICE The first component of nursing service administration is the planning and it should be based on clearly defined objectives. The objectives of nursing service department are as follows: Objectives in relation to Patient care The primary emphasis is on total patient care that is:  To give highest possible quality care in terms of total patients need which include physical, psychological, social, educational and spiritual needs by collaborating with other health tem members. 3

 To assist the physician in providing medical care to the patients.  To provide preventive and rehabilitative services.  To provide round the clock nursing care to all the patients.  To render timely and appropriate nursing service to emergency patients.  To provide cost effective quality care as per the needs of patients.  Confidentiality and privacy of each patient should be maintained.  Constant monitoring and evaluating is of utmost importance to improve patient care continuously. Objectives in relation to Education  Planning of education and training programme for nurses are must for professional growth and development needs through in-service education and research support.  To provide regular staff development, in-service education and guidance services for all members of nursing staff.  To conduct regular orientation programme for new entrants and for those have been on the job for a long time.  To conduct training for operating procedure of latest gadgets and on handling sophisticated bio-medical equipment. Objectives in relation to Administration and Organization  To make regular supervision through rounds.  To ensure that the essential equipment is provided in functional status for nursing care services.  To provide regular flow of essential supplies to render quality nursingcare.  To have a proper system of rotation of staff, provision for annual leave and days off for the nursing staff without hampering patient care.  Establish a communication system for nursing personnel, other health worker, patients, health authorities, government authorities and public.  Ensure that each nurse identifies her job responsibilities and accountability.  Counseling for health personnel, patients and the public.  The formulation of policies, standards, goals of nursing service, education and practice.  Maintaining proper documentation of the personnel employed in nursing service. Objectives in relation to Research

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 Establish a system for collection of essential information, research and studies concerning all aspects of nursing.  To contribute in research programme conducted by hospitals and by other health personnel.  To encourage and support the nurse to conduct research projects/ activities. Objectives in relation to Performance appraisal  Appraise the performance of nursing service personnel regularly against set standards and performance indicators objectively with a view to maintain quality-nursing services. PRINCIPLES OF NURSING SERVICE ► Initiate 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 service 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 the levels and all units for proper delivery of nursing care. ► Share nursing information system with other discipline functionaries in the hospital. ► 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. ► Develop and initiate orientation and training programs for new employees in cooperative with authorities and other health disciplines ► Create an atmosphere that conductive to give proper required learning experience for the students ► Assist in the development of a sound, constructive program of leadership in nursing to assure intellectual administration and management to safeguard, conserve and preserve nursing resources of the hospitals. ► Participate in the application of data and research ► Participate in community health programs, associated with hospital. FUNCTIONS OF NURSING SERVICE 5

◘ To assist the individual patient in performance of those activities contributing to his health or recovery that he would otherwise perform unaided has had the strength, will or knowledge. ◘ To help and encourage the patient to carry out the therapeutic plan initiated by the physician. ◘ To assist other members of the team to plan and carry out the total programme of care. The organization of nursing care constitutes a subsystem for achieving the hospital’s overall objective. Nursing care of patients generally takes forms: •

Technical

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Educational

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Trusting relationship

The director of nursing service is delegated the authority and responsibilities for organizing and administrating the nursing services in hospital. It is her duty to institute the essential characteristics of good nursing services in her institute such as:

Written statement of purposes and objectives of nursing services Plan of organization Policy and administrative manuals Nursing practice manual Nursing service budget Master staffing pattern Nursing care appraisal plan Nursing service administrative meetings Adequate infrastructure facilities, supplies and equipment Written job description & job specifications Personnel records Personnel policies Health services In–service education

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Advisory committee

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Purposes and objectives of the nursing service: The purposes should be in accordance with the hospital philosophy regarding patient care and approved by administration. It must characterize the principles of excellence in service, in practice and leadership. Objectives are specific, practical, attainable, measurable and understandable to all the nursing staff.

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Plan of organization: Every hospital has the basic system of coordination of vast number of activities i.e. the Director of Nursing service, she is responsible for maintaining standards for patient care in terms of quality nursing service must be familiar with the formal organizational structure of the hospital and its relationship in various department and their functions. The plan of organization should indicate inter as well as intra-department relationship. The plan also should indicate area of responsibility and to whom and for whom each person is accountable and the channels of communication.

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Policy and administrative manuals: The policy and procedure manual are required for the operation of the hospital. Policies are established within the department to guide the nursing staff, which includes duty hrs, rules and regulations etc. These are periodically revised and reviewed at regular intervals.

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Nursing practice manual: This the written procedure available as evidence of the standards of performance established by nursing service organization for safe and effective practice after taking into consideration the best use of available resources. Liberal use of diagram and precautions in nursing manual helps to keep instruction direct and exact. The advantages are ensure economy of time effort & material and provides basis for training for new personnel to acquire knowledge and current skill.

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Nursing service budget: It is required for personnel budget, nurse’s welfare activities, staff development programme, equipment and capital expenditure, supplies and expenses. Budget preparation should includes analysis of past operation and anticipating the future revenue and expenses.

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Master staffing pattern: It is the number and composition of nursing personnel assigned to work in a hospital in different department / wards at a given time. This helps the director to visualize the equitable distribution of nursing personnel among various nursing unit. It serves as a guide for planning daily, weekly and monthly schedules.

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Nursing care appraisal plan: 7

Employing various techniques such as supervision, ward rounds, conference, anecdotal record, rating scale, checklist, suggestion box and peer review can do performance appraisal of nurses. This is done to improve the quality of service provided, determine the job competence and to enhance staff development. •

Nursing service administrative meetings: This meeting gives opportunity for free communication, planning and evaluation of the nursing service through regular meeting of the director of nursing with total nursing staff. The purposes are regular exchange of view between management and nursing service for improving working condition, welfare of patient and improvement in methods and organization of work.

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Adequate infrastructure facilities, supplies and equipments: The director of nursing evaluates periodically the adequate resources and arranges new facilities needed for patient care in discussion with the hospital administrator.

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Written job descriptions and job specifications: In job description the responsibility are clearly spelt out as precisely including the job content, activities to be performed, responsibility and result expected from various role required by the organization. It is useful for reducing conflict, frustration, overlapping duties and acts as a guide to direct and evaluate person.

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Personnel records: Personnel records include the information relating to the individual such as recruitment and selection, medical records, training and development, transfer records, promotion, disciplinary action records, performance records, absenteeism data, leave record and salary records, etc.

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Personnel policies: It reflects an analysis of the total job of nursing in accordance with the types of functions to be performed. It also indicates the qualitative and quantity of service to be maintained and the purpose for which the hospital exist.

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Health services: Supervision of health of each employee by means of pre-employment physical examination, periodic examination, immunization and provision of diagnostic, preventive and therapeutic measures. The education of employee in the principle of health and hygiene so that they may develop healthy habit of living and working.

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In-service education: It is the essential components of staff development programme, which aims at augmenting, reinforcing nurse’s knowledge, skill and attitude. It includes orientation

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programme, skill training, leadership and management training, on the job training, staff development. •

Co-ordination: Regular consultation and discussion between the heads of departments and with members of the medical staff could be an integral part of the administration.

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Advisory committee: Each committee has a clear statement and its membership is appropriate to the purpose. After carefully weighing the advice of the committee, she makes the final decision about the matter within her area of responsibility and becomes accountable for implementation.

ORGANISATION OF NURSING SERVICES:

DIRECTOR (hospital) SERVICE

DIRECTOR

OF

HEALTH

Chief Nursing Officer

Asst. Director of Health Service

Nursing Superintendent

Nursing Superintendent Grade-I

Deputy Nursing Superintendent

Nursing Superintendent Grade-II

Assistant Nursing Superintendent

Head Nurse

Ward Sister - Clinical Supervisor

Staff Nurse

Staff nurse

Student nurse

ORGANIZING NURSING SERVICE AT VARIOUS LEVELS The organization of nursing service varies from institution to institution. Organizational set-up at Directorate General of Health Services DGHS

Addl.DG (PH)

ADG (Community Nsg service)

DADG DADG

Addl.DG (N)

ADG (Nsg-education & research)

Addl.DG (M)

ADG (Hospital Nsg service)

DADG

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Community & Nsg officer

Principal

Nsg.Supdt

PHN Supervisor

Senior Tutor

Dy.Nsg.Supt

PHN

Tutor

Asst.Nsg.Supt

LHV

Clinical Instructor

Ward sister

ANM

Staff Nurse

Organizational set-up of Nursing Service at Central Level Secretary, Health Director Nursing Service Joint/Deputy Director Nursing services

ADNS

ADNS ADNS

(Community Nsg service)

(Nsg-education & research)

DADNS (Community Nsg service)

(Hospital Nsg service)

DADNS (Nsg-education & research)

DADNS Dist. Nsg officer PH. Nsg officer PHN at PHC LHV

DADNS (Hospital Nsg service)

DADNS

DADNS

DADNS

Nsg.Supdt

Principal

Dy.Nsg.Supt

Senior Tutor

Asst.Nsg.Supt

Tutor

ANM

Ward sister

Clinical Instructor

Staff Nurse

Organizational set-up of Nursing Service at State Level Director Nursing Services Deputy Director Nursing Services Assistant Director Nursing Services Deputy Assistant Director Nursing Services

DMO

DNO

DHO 10

ADNO (Hosp&Nsg.Edu)

Nsg Supt/Dy.Nsg.Supt Asst.Nsg.Supt Ward Sister

ADNO (Community)

Principal tutor Tutor Clinical Instructor

Dist.PNO PHN Supervisor (CHC) PHN (PHC)

Staff Nurse

LHV ANM

KEYS:  DGHS  Addl. DG (PH)

- Director General of Health Services - Additional Director General (Primary Health)

 Addl. DG (M)

- Additional Director General (Medical)

 Addl. DG (N)

- Additional Director General (Nursing )

 ADG

- Assistant Director General

 DADG

- Deputy Assistant Director General

 PHN

- Primary Health Nurse

 LHV

- Lady Health Visitor

 ANM

- Auxiliary Nurse Midwives

 ADNS

- Assistant Director Nursing Service

 DADNS

- Deputy Assistant Director Nursing Service

 DMO

- Director of Medical Office

 DNO

- Director of Nursing Office

 DHO

- Director of Health Office

ROLE AND FUNCTION OF NURSE ADMINISTRATOR The Principal Matron of the hospital will be responsible to the Commandant of the hospital for the following duties: ♪ Administration ♣ Organizes, directs and supervises the nursing services both day and night. ♣ Coordinates assignments of staff. ♣ Establishes the general pattern of delegation of responsibilities and authority. 11

♣ Formulates standing orders for the nursing care. ♣ Ensures appropriate allocation of duties and responsibilities to all nursing staff working under her. ♣ Formulates nursing policies to ensure quality patient care and adequate attention at all times. ♣ Responsible for efficient functioning of the nursing staff. ♣ Evaluates the personal performance of the nursing staff. ♪ Discipline ♣ Ensure that a standard of discipline of nursing staff is high at all times. ♣ Maintain good order and discipline in wards/departments. ♣ Makes daily rounds of the hospital wards/departments and also seriously ill patients. In addition she will make unscheduled rounds in the hospital in the evenings. ♣ Brings immediately to the notice of the medical superintendent all matters concerning neglect of duty, insubordination either by nursing staff, patients or visitors or any un-towards incident, which comes to her notice for taking suitable action as required as per the orders on the subject. ♪ Public Relations ♣ Promotes and maintains harmonious and effective relationship with the various administrative departments of the hospital and related community agencies. ♣ Maintain cordial relationships with the patients and their families. ♪ Office Routine ♣ Scrutinizes the reports and returns and submits in accordance with existing orders. ♪ Confidential Reports ♣ Initiates the confidential reports of nursing staff on due dates. ♣ Responsible for the nursing budget. ♪ Education ♣ Carries out in-service training for all categories of nursing staff and paramedical personnel and keeps the records of such trainings. ♣ Conduct various update courses based on the needs. ♣ Encourages the personnel to participate in the continuing education programme.

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♪ Welfare ♣ Responsible for health and welfare of nursing staff. ♣ Ensures annual and periodical health examination and maintenance of health records. ♪ Conferences ♣ Responsible for organizing and conducting staff meeting of the nursing staff once in three months. ♣ Holds conference in nursing care problems and discuss policies as regards to working conditions, working hrs and other facilities. ♪ Supervision ♣ Supervises nursing care given to the patients and all nursing activities within the nursing unit. ♣ Supervises the work of all paramedical staff of the hospital. ♪ Records and Reports ♣ Maintains various records such as duty roster nursing staff, day off book, personal bio-data, leave plan, staff conference book, courses file etc. PROBLEMS AND CHALLENGES FACED BY THE NURSE ADMINISTRATOR ♠ Lack of adequate training. ♠ Problem of personnel management. ♠ Inadequate number of nursing staff. ♠ Shortage of trained manpower. ♠ Lack of motivation. ♠ No involvement in planning. ♠ No career mobility. ♠ Poor role model. ♠ No research scope. ♠ Professional risk/hazards. ♠ No autonomy in nursing activities. Day to day problem in nursing services ♠ Shortage of nurses. ♠ Lack of motivation. ♠ Negative attitude. 13

♠ Lack of training. ♠ Lack of team approach. ♠ Inactive participation of program ♠ Lack of interpersonal relationship ♠ Less involvement in patients care by the nursing supervisors. ♠ Lack of supervision. ORGANIZING PATIENT CARE The overall goal of nursing is to meet the patient nursing needs with the available resources for providing smooth day and night 24 hrs quality care to patients and to honor his rights. To ensure that nursing care is provided to patients, the work must be organized. A Nursing Care Delivery Model organizes the work of caring for patients. The decision of which nursing care delivery model is used is based on the needs of the patients and the availability of competent staff in the different skill levels. For organizing function to be productive and facilitate meeting the organization’s needs, the leader must know the organization and its members well. ♣ The top level manager who influence the philosophy and resources necessary for any selected care delivery system to be effective ♣ The first and middle level managers generally have their greatest influence on the organizing phase of the management process at the unit or departmental level. The managers organize how work is to be done, shape the organizational climate, and determine how patient care delivery is organized. ♣ The unit leader-manager determines how best to plan work activities so organizational goals are met effectively and efficiently, involves using resources wisely and coordinating activities with other departments. DEFINITION OF PATIENT CARE  The services rendered by members of the health profession and non-professionals under their supervision for the benefit of the patient. OR  The prevention, treatment and management of illness and the preservation of mental and physical well-being through the services offered by the medical and allied health professions. PATIENT CLASSIFICATION SYSTEMS Patient classification system (PCS), which quantifies the quality of the nursing care, is essential to staffing nursing units of hospitals and nursing homes. In selecting or implementing a PCS, a representative committee of nurse manager can include a

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representative of hospital administration. The primary aim of PCS is to be able to respond to constant variation in the care needs of patients. Characteristics ♦ Differentiate intensity of care among definite classes. ♦ Measure and quantify care to develop a management engineering standard. ♦ Match nursing resources to patient care requirement. ♦ Relate to time and effort spent on the associated activity. ♦ Be economical and convenient to repot and use. ♦ Be mutually exclusive, continuing new item under more than one unit. ♦ Be open to audit. ♦ Be understood by those who plan, schedule and control the work. ♦ Be individually standardized as to the procedure needed for accomplishment. ♦ Separate requirement for registered nurse from those of other staff. Purposes ◘ The system will establish a unit of measure for nursing, that is, time, which will be used to determine numbers and kinds of staff needed. ◘ Program costing and formulation of the nursing budget. ◘ Tracking changes in patients care needs. It helps the nurse managers the ability to moderate and control delivery of nursing service ◘ Determining the values of the productivity equations ◘ Determine the quality: once a standards time element has been established, staffing is adjusted to meet the aggregate times. A nurse manager can elect to staff below the standard time to reduce costs. Components •

The first component of a PCS is a method for grouping patient’s categories. Johnson indicates two methods of categorizing patients. Using categorizing method each patient is rated on independent elements of care, each element is scored, scores are summarized and the patient is placed in a category based on the total numerical value obtained. Johnson describes prototype evaluation with four basic categories for a typical patient requiring one –on- one care. Each category addresses activities of daily living, general health, teaching and emotional support, treatment and medications. Data are collected on average time spent on direct and indirect care.

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The second component of a PCS is a set of guidelines describing the way in which patients will be classified, the frequency of the classification, and the method of reporting data.

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The third component of a PCS is the average amount of the time required for care of a patient in each category.

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A method for calculating required nursing care hours is the fourth and final component of a PCS.

Patient Care Classification Area of care

Category I

Category II

Eating

Feeds self

Needs some help in Cannot feed self but is Cannot feed self preparing able to chew and any may have swallowing difficulty swallowing

Grooming

Almost Need some help in Unable to do much for Completely entirely self bathing, oral hygiene … self dependent sufficient

Excretion

Up and to Needs some help in In bed, needs bedpan / Completely bathroom getting up to urinal placed; dependent alone bathroom /urinal

Comfort

Self sufficient

Needs some help with Cannot turn without Completely adjusting position/ bed.. help, get drink, adjust dependent position of extremities …

General health

Good

Mild symptoms

Treatment

Simple – Any Treatment more Any treatment more Any elaborate/ supervised, than once per shift, foley than twice /shift… delicate procedure simple catheter care, I&O…. requiring two dressing… nurses, vital signs more often than every two hours..

Health Routine Initial teaching of care education & follow up of ostomies; new teaching teaching diabetics; patients with mild adverse reactions to their illness…

Category III

Acute symptoms

Category IV

Critically ill

More intensive items; Teaching of teaching of resistive patients, apprehensive/ mildly resistive patients….

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MODES OF ORGANIZING PATIENT CARE / METHODS OF PATIENT ASSIGNMENT The most well known means of organizing nursing care for patient care delivery are, •

Case method or Total patient care

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Functional nursing

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Team nursing

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Modular or district nursing

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Progressive patient care

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Primary nursing

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Case management

Each of these basic types has undergone many modifications, often resulting in new terminology. For example, primary nursing has been called case method nursing in the past and is now frequently referred to as a 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. When closely examined most of the newer models are merely recycled, modified or retitled versions of older models. Choosing the most appropriate organizational mode to deliver patient care for each unit depends on the skill and expertise of the staff, the availability of registered professional nurse, the economic resources of the organization and the complexity of the task to be completely. CASE METHOD Features: It was the first type of nursing care delivery system. In this method, nurses assume total responsibility for meeting all the needs of assigned patients during their time on duty. It involves assignment of one or more clients to a nurse for a specific period of time such as shift. The patient has a different nurse each shift and no guarantee of having the same nurses the next day. Nurse’s responsibility includes complete care including treatments, medication and administration and planning of nursing care. This is the way most nursing students were taught – take one patient and care for all of their needs. This model is used in critical care areas, labor and delivery, or any area where one nurse cares for one patient’s total needs. Here nurses were self-employed when the case method came into being, because they were primarily practicing in homes. It lost much of that autonomy when healthcare became institutionalized in hospitals and clinics and now called as private duty nursing. Merits: ♣ The nurse can attend to the total needs of clients due to the adequate time and proximity of the interactions. 17

♣ Good client nurse interaction and rapport can be developed. ♣ Client may feel more secure. ♣ RNs were self-employed. ♣ Work load can be equally divided by the staff. ♣ Nurse’s accountability for their function is built-it. ♣ It is used in critical care settings where one nurse provides total care to a small group of critically ill patients. Demerits: ♠ Cost-effectiveness. ♠ The greater disadvantage to case nursing occurs, when the nurse is inadequately trained or prepared to provide total care to the patient. ♠ Nurse may feel overworked if most of her assigned patients are sick. ♠ She/he may tend to ‘neglect’ the needs of patient when the other patients ‘problem’ or ‘need’ demands more time.

FUNCTIONAL NURSING Features: This system emerged in 1930s in U.S.A during WWII when there was a severe shortage of nurses in US. A number of Licensed Practice Nurses (LPNs) and nurse aides were employed to compensate for less number of registered nurses (RNs) who demanded increased salaries. It is task focused, not patient-focused. In this model, the tasks are divided with one nurse assuming responsibility for specific tasks. For example, one nurse does the hygiene and dressing changes, whereas another nurse assumes responsibility for medication administration. Typically a lead nurse responsible for a specific shift assigns available nursing staff members according to their qualifications, their particular abilities, and tasks to be completed. Charge Nurse

RN Medication Nurse

RN Treatment Nurse

LPN Vital signs Nurse

UAP Hygiene Nurse

Patients assigned to the team 18

Merits: ♣ Each person become very efficient at specific tasks and a great amount of work can be done in a short time (time saving). ♣ It is easy to organize the work of the unit and staff. ♣ The best utilization can be made of a person’s aptitudes, experience and desires. ♣ The organization benefits financially from this strategy because patient care can be delivered to a large number of patients by mixing staff with a large number of unlicensed assistive personnel. ♣ Nurses become highly competent with tasks that are repeatedly assigned to them. ♣ Less equipment is needed and what is available is usually better cared for when used only by a few personnel.

Demerits: ♠ Client care may become impersonal, compartmentalized and fragmented. ♠ Continuity of care may not be possible. ♠ Staff may become bored and have little motivation to develop self and others. ♠ The staff members are accountable for the task. ♠ Client may feel insecure. ♠ Only parts of the nursing care plan are known to personnel. ♠ Patients get confused as so many nurses attend to them, e.g. head nurse, medicine nurse, dressing nurse, temperature nurse, etc.

TEAM NURSING Features: Developed in 1950s because the functional method received criticism, a new system of nursing was devised to improve patient satisfaction. Care through others became the hallmark of team nursing. Team nursing is based on philosophy in which groups of professional and non-professional personnel work together to identify, plan, implement and evaluate comprehensive client-centered care. In team nursing an RN leads a team composed of other RNs, LPNs or LVNs and nurse assistants or technicians. The team members provide direct patient care to group of patients, under the direction of the RN team leader in coordinated effort. The charge nurse delegates authority to a team leader who must be a professional nurse. This nurse leads the team usually of 4 to 6 members in the care of between 15 and 25 patients. The team leader assigns tasks, schedules care, and instructs team members in details of care. A conference is held at the beginning and end of each shift to 19

allow team members to exchange information and the team leader to make changes in the nursing care plan for any patient. The team leader also provides care requiring complex nursing skills and assists the team in evaluating the effectiveness of their care. Charge Nurse RN Team Leader RN RN

LPN

Team Leader RN NA

Group of Patients

RN

LPN

NA

Group of Patients

Advantages: ♣ High quality comprehensive care can be provided to the patient ♣ Each member of the team is able to participate in decision making and problem solving. ♣ Each team member is able to contribute his or her own special expertise or skills in caring for the patient. ♣ Improved patient satisfaction. ♣ Feeling of participation and belonging are facilitated with team members. ♣ Work load can be balanced and shared. ♣ Division of labour allows members the opportunity to develop leadership skills. ♣ There is a variety in the daily assignment. ♣ Nursing care hours are usually cost effective. ♣ The client is able to identify personnel who are responsible for his care. ♣ Barriers between professional and non-professional workers can be minimized, the group efforts prevail. Disadvantages: ♠ Establishing a team concept takes time, effort and constancy of personnel. Merely assigning people to a group does not make them a ‘group’ or ‘team’. ♠ Unstable staffing pattern make team nursing difficult. ♠ All personnel must be client centered. ♠ There is less individual responsibility and independence regarding nursing functions. 20

♠ The team leader may not have the leadership skills required to effectively direct the team and create a “team spirit”. ♠ It is expensive because of the increased number of personnel needed. ♠ Nurses are not always assigned to the same patients each day, which causes lack of continuity of care. ♠ Task orientation of the model leads to fragmentation of patient care and the lack of time the team leader spends with patients.

MODULAR NURSING Features: Modular nursing is a modification of team nursing and focuses on the patient’s geographic location for staff assignments. The concept of modular nursing calls for a smaller group of staff providing care for a smaller group of patients. The goal is to increase the involvement of the RN in planning and coordinating care. The patient unit is divided into modules or districts, and the same team of caregivers is assigned consistently to the same geographic location. Each location, or module, has an RN assigned as the team leader, and the other team members may include LVN/LPN or UAP. The team leader is accountable for all patient care and is responsible for providing leadership for team members and creating a cooperative work environment. The success of the modular nursing depends greatly on the leadership abilities of the team leader. Merits: ♣ Nursing care hours are usually cost-effective. ♣ The client is able to identify personnel who are responsible for his care. ♣ All care is directed by a registered nurse. ♣ Continuity of care is improved when staff members are consistently assigned to the same module ♣ The RN as team leader is able to be more involved in planning & coordinating care. ♣ Geographic closeness and more efficient communication save staff time. ♣ Feelings of participation and belonging are facilitated with team members. ♣ Work load can be balanced and shared. ♣ Division of labor allows members the opportunity to develop leadership skills ♣ Continuity care is facilitated especially if teams are constant. ♣ Everyone has the opportunity to contribute to the care plan. Demerits:

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♠ Costs may be increased to stock each module with the necessary patient care supplies (medication cart, linens and dressings). ♠ Establishing the team concepts takes time, effort, and constancy of personnel. ♠ Unstable staffing pattern make team difficult. ♠ There is less individual responsibility and autonomy regarding nursing function. ♠ All personnel must be client centered. ♠ The team leader must have complex skills and knowledge.

PROGRESSIVE PATIENT CARE: Features: It is a method in which client care areas provide various levels of care. The central theme is better utilization of facilities, services and personnel for the better patient care. Here the clients are evaluated with respect to all level (intensity) of care needed. As they progress towards increased self care (as they become less ethically ill or in need of intensive care or monitoring) they are marred to units/ wards staffed to best provide the type of care needed. Principal elements of PPC are: i) Intensive care or critical care: Patients who require close monitoring and intensive care round the clock, e.g. patients with acute MI, fatal dysarythmias, those who need artificial ventilation, major burns, premature neonates, immediate post or cardiothoracic, renal transplant, neurosurgery patients. These units have 9-15 numbers of beds, life-saving equipment and skilled personnel for assessment, revival, restoration and maintenance of vital functions of acutely ill patients. Nursing approach in these units is patient-centered. ii) Intermediate care: Critically ill patients are shifted to intermediate care units when their vital signs and general condition stabilizes, e.g. cardiac care ward, chest ward, renal ward. iii) Convalescent and Self Care: Although rehabilitation programme begins from acute care setting, yet patients in these areas participate actively to achieve complete or partial self-care status. Patients are taught administration of drugs, life style modification, exercises, ambulation, self-administration of insulin, checking pulse, blood glucose and dietary management. iv) Long-term care: Chronically ill, disabled and helpless patients are cared for in these units. Nurses and other therapists help the patients and family members in coping, ambulation, physical therapy, occupational therapy along with activities of daily living. Patients and family who need long-term care are, cancer patients, paralyzed and patients with ostomies. v) Home care: Some hospital/centers have home care services. A hospital based home care package provides staff, equipment and supplies for care of patient at home, e.g. paralyzed patients, post-operative, mentally retarded/spastic patient and patient on long chemotherapy. 22

vi) Ambulatory care: Ambulatory patients visit hospital for follow up, diagnostic, curative rehabilitative and preventive services. These areas are outpatient departments, clinics, diagnostic centers, day care centers etc. Merits: ♣ Efficient use is made of personnel and equipment. ♣ Clients are in the best place to receive the care they require. ♣ Use of nursing skills and expertise are maximized. ♣ Clients are moved towards self care, independence is fostered where indicated. ♣ Efficient use and placement of equipment is possible. ♣ Personnel have greater probability to function towards their fullest capacity. Demerits: ♣ There may be discomfort to clients who are moved often. ♣ Continuity care is difficult. ♣ Long term nurse/client relationships are difficult to arrange. ♣ Great emphasis is placed on comprehensive, written care plan. ♣ There is often times difficulty in meeting administrative need of the organization, staffing evaluation and accreditation. •

PRIMARY CARE NURSING Features:

It was developed in the 1960s with the aim of placing RNs at the bedside and improving the professional relationships among staff members. The model became more popular in the 1970s and early 1980s as hospitals began to employ more RNs. It supports a philosophy regarding nurse and patient relationship. It is a system in which one nurse is caring for all the needs of a patient or more within a 24 hour from admission to discharge. He or she is responsible for coordinating and implementing all the necessary nursing care that must be given to the patient during the shift. If the nurse is not available, the associate nurse responsible for filling in for the nurse’s absence will provide hospital care to the patient based on the original plan of care made by the nurse. In acute care the primary care nurse may be responsible for only one patient; in intermediate care the primary care nurse may be responsible for three or more patients This type of nursing care can also be used in hospice nursing, or home care nursing.

Patients Total patient care 24 23

Communicates with supervisors

Associate (days) when primary nurse is not available

PRIMARY NURSE

Associate (afternoon) when primary nurse is not

Consults with physician or other healthcare providers

Associate (evenings) when primary nurse is not

Advantages: ♣ Primary Nursing Care System is good for long-term care, rehabilitation units, nursing clinics, geriatric, psychiatric, burn care settings where patients and family members can establish good rapport with the primary nurse. ♣ Primary nurses are in a position to care for the entire person-physically, emotionally, socially and spiritually. ♣ High patient and family satisfaction ♣ Promotes RN responsibility, authority, autonomy, accountability and courage. ♣ Patient-centered care that is comprehensive, individualized, and coordinated; and the professional satisfaction of the nurse. ♣ Increases coordination and continuity of care. Disadvantages: ♠ More nurses are required for this method of care delivery and it is more expensive than other methods. ♠ Level of expertise and commitment may vary from nurse to nurse which may affect quality of patient care. ♠ Associate nurse may find it difficult to follow the plans made by another if there is disagreement or when patient’s condition changes. ♠ It may be cost-effective especially in specialized units such as the ICU. ♠ May create conflict between primary and associate nurses. ♠ Stress of round the clock responsibility. ♠ Difficult hiring all RN staff ♠ Confines nurse’s talent to his/her own patients.

CASE MANAGEMENT 24

Features: The case manager (RN or social worker with managerial qualification) is assigned responsibility of following a patient’s care and progress from the diagnostic phase through hospitalization, rehabilitation and back to home care. For eg; case manager for cardiac surgery patients assists them go through diagnostic procedures, pre-operative preparations, surgical interventions, family counseling, post-operative care and rehabilitation. Case managers are employed by third party payers (e.g. insurance companies) by the hospital authorities (e.g. for heart surgeries, renal transplant, reconstructive surgeries, etc.), by clubs, industrialists and associations or by individuals, e.g. geriatric, family or private patients case managers. No direct care by the manager whose main roles are of teaching, advocacy and coordinating with health care providers. Case manager (nurse) ensures quality care that is holistic and assisting the patient to attain self care status according to his/her potential. It emphasizes achievement of outcomes in designated time frames with limited resources. Case management involves critical paths, variation analysis, inter shift reports, case consultation, health care team meetings, and quality assurance. Critical paths visualize outcomes within a time frame. Variation analysis notes positive or negative changes from the critical paths, the cause, and the corrective action taken. Case consultation may be indicated when the client’s condition differs from the critical path as noted in the inter shift report. Case consultation is conducted about once a week for a few minutes immediately after inter shift report to deal with variations. Health care team meetings provide an interdisciplinary approach to problem solving. The case manager needs to identify no more than three priority goals and decide what team members should be present after considering the patient, family physician, social service, various therapists, and others involved. The case manager should set the time and place for the meeting, make the arrangements, and post the date, time, place, and people to attend. The case manager calls the meeting to order, states the goals, initiates discussion, documents the plans, and sets time limits for follow through. The variance between what is expected and what happened is assessed for quality assurance. Responsibilities of case managers: ♥ Assessing clients and their homes and communities. ♥ Coordinating and planning client care. ♥ Collaborating with other health professionals in the provision of care. ♥ Monitoring client progress and client outcomes. ♥ Advocating for clients moving through the services needed. ♥ Serving as a liaison with third party payers in planning the client’s care. Merits: ♣ Case management provides a well coordinated care experience that can improve the care outcome, decrease the length of stay, and use multiple disciplines and services efficiently. 25

♣ Provides comprehensive care for those with complex health problems. ♣ It seeks the active involvement of the patient, family and diverse health care professionals Demerits: ♠ Nurses identify major obstacles in the implementation of this service, financial barriers and lack of administrative support. ♠ Expensive ♠ Nurse is client focused and outcome oriented ♠ Facilitates and promotes co-ordination of cost effective care ♠ Nursing case management is a professionally autonomous role that requires expert clinical knowledge and decision making skills.

FACTORS INFLUENCING THE QUALITY PATIENT CARE Many variable factors influence the number of nurses needed on a ward in order to render a high quality of patient care. ◘ The total number of patient to be nursed ◘ The degree of illness of patients (physical dependency) ◘ Type of service: medical, surgical, maternity, pediatrics and psychiatric ◘ The total needs of the patients ◘ Methods of nursing care ◘ Number of nursing aids and other non professional available, the amount and quality of supervision available ◘ The amount, type and location of equipment and supplies ◘ The acuteness of the service and the rate of turnover in patients according to the degree or period of illness. ◘ The experience of the nurses who are to give the patient care. ◘ The number of non-nurses who involve in the patient care, the quality of their work, their stability in service. ◘ The physical facilities ◘ The number of hours in the working week of nurses and other ward personnel and the flexibility in hours ◘ Methods of performing nursing procedures ◘ Affiliation of the hospital with the medical school ◘ Methods of assignment-individual, team or functional method 26

◘ The standards of nursing care. CONCLUSION Nursing is vital aspect of health care and needs to be properly organized. A nurse is in frequent contact with of the patients hence his/her role in educational aspect and service aspect in restoring health and confidence of the patient is of utmost importance. The quality of nursing care and the management of the nursing staff, reflects an image of the hospital/ nursing home. Many changes have taken place in the health care delivery system as it struggles with cost and providing care corresponding to changes in the education of health professionals and their function within the system. According to their educational qualification and patient acuity they are delivering care to the patients throughout their hospital stay. The structures of the delivery of care have taken many different formats.

JOURNAL ABSTRACT: Present day concepts in nursing service administration in hospitals The present day concept in nursing service administration is to demonstrate administrative functions that will provide therapeutic and satisfying situations for patients and personnel. Administration is the management or guidance of an organization for the most effective accomplishment of its stated goal. The goal of a nursing service organization is more specifically to give continuous care to the patients; to recognize the physical, emotional and social needs of the patients; to meet these needs in so far as possible; to assist in restoring the patients to their optimum health status. In working toward this goal, nursing must maintain itself internally. Only through democratic administration can therapeutic and satisfying situations be created for both patients and personnel. Such administration recognizes the worth of each individual. When employees have a part in planning and when they feel respected and accepted, they derive more satisfaction from their work and are better able to respect and accept their patients and co-workers. Issues and Trends in Nursing Service Administration Education The Council on Graduate Education for Administration in Nursing (CGEAN) was established to further the development and improvement of graduate education for administration in nursing. The Council seeks to identify the nature and direction of education for administration in nursing in various healthcare systems, providing guidelines for programs offering administration. A major goal of CGEAN is facilitating dialogue between nursing service administrators and graduate level educators who are engaged in teaching and research related to administration in nursing. This column, sponsored by members of the Council, will analyze and respond to position statements and trends related to the delivery of health services and graduate education for administrators in nursing. Team or primary nursing care?

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This study was undertaken to help nursing administration make policy decisions regarding the initiation of primary care nursing and the need to hire RNS. The work involved an experimental design using 11 units in a 350-bed facility. The results show no significant differences between the two methods regarding quality, cost, job satisfaction, patient satisfaction, or patient education. Moreover, the 16-hour model produces more stress and more sick leave days than team nursing. It is also apparent that apart from salaries, the cost of nursing care is a function of the diagnoses of the patients in the hospital, which may account for some of the inconsistencies found in the literature. If the ratio of RN to non-RN staff had been increased, the results might have been different. It appears that individual RN's dedication and preparation for patient care may be more important than the method used to organize that care. BIBLIOGRAPHY: 

Basavanthappa B T. Nursing administration. Ist edn. New Delhi: Jaypee brothers; 2000.

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Chandra Ballabh. Encyclopedia of Hospital & Health Science Management. New Delhi: Alfa Publishers; 2008.

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Mary Lucita. Nursing: Practice and Public Health Administration. 2 nd Ed. Philadelpia: Elsevier Publishers; 2007.

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Patricia S Yoder. Leading and Managing in Nursing. 3rd Ed. Philadelpia: Elsevier publishers; 2003.

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All India Institute of Medical Science Nursing Service - Staffing Hospital & Nursing service in different unit. www.aiims.edu/aiims/nsg service/NURSING SERVICES.

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Chavigny K, Lewis A. Team or Primary Nursing Care 1984; 32: (6) 322-7.

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Meenakshi, Kalavathi. Primary Care Nursing. Nightingale Nursing Times 2008; 4: (9) 29-30.

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