You are on page 1of 22

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.

ORGANIZING NURSING SERVICES


Meaning of nursing service and nursing service administration
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.

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 team members.
 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


1
 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
 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


 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.
2
 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
 Educational
 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

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.
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.
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.
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.
Nursing service budget:
3
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.
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.
Nursing care appraisal plan:
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.
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.
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.
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.
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.
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.
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 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.
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.

4
FACTORS INFLUENCING WARD MANAGEMENT.
1. Knowledge of the ward means that knowledge of all the duties and activities to be performed in the ward.
2. Planning the schedule of the ward.
3. Starting the work on time.
4. Preventing interruptions.
5. Establishment of ward routines.
6. Use of democratic method in establishing ward policy.
7. Orientation of new personnel
8. Orientation of hospital
9. Orientation of the ward.
10. Maintenance of the suitable environment.
11. Supplies and equipment’s in a hospital
12. Clear cut, specific orders for medical therapy and nursing.
13. Record keeping and maintaining accurate records.
14. Reporting
15. Maintenance of high morale among all members of the staff.
16. Establishment of good working relationship.
17. Delegating responsibility
18. Assigning duties and responsibilities.
19. Time planning
20. Good teaching.
21. Good supervision.

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

5
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) Addl.DG (N) Addl.DG (M)

ADG ADG ADG


(Community Nsg service) (Nsg-education & research) (Hospital Nsg service)

DADG DADG DADG

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) (Hospital Nsg service)

DADNS DADNS DADNS


(Community Nsg service) (Nsg-education & research) (Hospital Nsg service)

DADNS DADNS DADNS

Dist. Nsg officer DADNS Nsg.Supdt

PH. Nsg officer Principal Dy.Nsg.Supt

PHN at PHC Senior Tutor Asst.Nsg.Supt

LHV Tutor Ward sister

ANM Clinical Instructor Staff Nurse


6
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

ADNO (Hosp&Nsg.Edu) ADNO (Community)

Nsg Supt/Dy.Nsg.Supt Principal tutor Dist.PNO

Asst.Nsg.Supt Tutor PHN Supervisor (CHC)

Ward Sister Clinical Instructor PHN (PHC)

Staff Nurse LHV


ANM
KEYS:
DGHS - Director General of Health Services
Addl. DG (PH) - 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.
7
♣ 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.
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.
8
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.
♠ 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.
9
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 SYSTEM.

Nurse administrators are facing lot of health care issues in hospitals, high rocketing health care cost, need for
decreasing length of hospital stay, quality and patient safety, cosumerism and lack of resources for nursing care.
These issues are affecting patients, families and nurses also. the management is constantly seeking reduction of
health cost at the same time intends to bring high quality patient care.

PURPOSE OF PCS
 To provide quality and safe patient care.
 PCS helps to decide the nursing hours required for each category of patients that will help to bring best possible
patient care outcome as per norms recommended by the health facility.
 Enhance staff satisfaction through a stress free work environment.
 Monitor changes in patient demographics and care needs.
 Provides information on each patient care unit that directs and support staffing decision-making.
 Ensures that quality of nursing care is provided in safe environment.
 Assesses the level and support services required for each category of patient.
 Enhances staff satisfaction through stress- free work environment.
 The PCS data generated is used to improve patient satisfaction by providing required time to the patient
according to his/her needs and enhances staff satisfaction by determining staffing needs and thus decreasing
workload.
 Monitors the provision of quality nursing care according to international standards in a safe work environment.
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.

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.

10
 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.
 The third component of a PCS is the average amount of the time required for care of a patient in each category.
 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 Category III Category IV
Eating Feeds self Needs some help Cannot feed self Cannot feed self
in preparing but is able to chew any may have
and swallowing difficulty
swallowing
Grooming Almost entirely Need some help in Unable to do much Completely
self sufficient bathing, oral for self dependent
hygiene …
Excretion Up and to Needs some help In bed, needs Completely
bathroom alone in getting up to bedpan / urinal dependent
bathroom /urinal placed;
Comfort Self sufficient Needs some help Cannot turn Completely
with adjusting without help, get dependent
position/ bed.. drink, adjust
position of
extremities …
General health Good Mild symptoms Acute symptoms Critically ill
Treatment Simple – Any Treatment Any treatment Any elaborate/
supervised, more than once more than twice delicate procedure
simple dressing… per shift, foley /shift… requiring two
catheter care, nurses, vital signs
I&O…. more often than
every two hours..
Health education & Routine follow up Initial teaching of More intensive Teaching of
teaching teaching care of ostomies; items; teaching of resistive patients,
new diabetics; apprehensive/
patients with mildly resistive
mild adverse patients….
reactions to their
illness…

TYPES OF PATIENT CLASSIFICATION SYSTEM


There are different kinds of PCS used in administration, but the three most commonly used types are:
1. Descriptive system- this is purely subjective system wherein the nurse selects which category the patient is best
suited.
2. Checklist system- another subjective system, wherein the patient is assigned to a numerical value based on the
level of activity in specific categories. The numerical values are added up to give the nurse an overall rating.
3. Time standard system- this is another method where the nurse assigns a time value based on the various
activities needed to be completed for the patient. This time value is sum up and converted to an acuity level.
Among these three, most commonly used is the descriptive kind of PCS. These are subdivided into four
classifications namely:

11
SELF CARE/MINIMAL CARE- the first classification of patient who are recovering and normally requires
only diagnostic studies, minimal therapy, less frequent observations, and daily care for minor conditions. For
example patient waiting for elective surgery.
MODERATE CARE – the patient in this category is moderately ill or under the recovery stage from a serious
illness or operation. They require nursing supervision or assistance that is related to ambulating and caring for
their own hygiene.
MAXIMUM CARE- Patient needs close attention and complete care all through the shift. The nurse initiate,
supervise and perform most of the patients activities.
INTENSIVE CARE- the last category or classification, wherein the patients are acutely ill and high level of
nurse dependency is required. Intensive therapy and/or intensive nursing care is needed because of the
unstable condition of the patient. Frequent evaluation, observation, monitoring, and adjustment of therapy is
also required. A patient in these levels includes those in critical conditions or in life and death situations.

DIAGNOSIS- RELATED GROUP(DRG) PATIENT CLSSIFICATION


The DGR system was created in 1983 to cut costs for medicare patients. The DGR system is a patient
classification system that groups of patient with similar diagnosis and or procedures into the same category
because the cost of care depends on the materials and procedures incurred to patients according to the diagnosis.
The grouping is based on diagnosis, procedures performed, age, sex, and status at discharge.

PURPOSE OF DGR METHOD OF PATIENT CLASSIFICATION


 DGRs are used for reimbursement in the prospective payment system of Medicaid health care insurance system.
 DGRs are design to support the calculation of reimbursement.

TYPES
Selfcare/minimal care: the first classification of patients who are normal and mostly ambulatory and able to
manage their care means the basic care. They are self- dependent and help themselves without nurses support.
These categories of patients require minimum nursing acre hours. They require less observation, and
monitoring.

Moderate care: the patients are moderately ill in this category and waiting for recovery. These types of patients
are guided and supported by nurses for early ambulation and self-care.

Maximum care: patients need maximum nursing care hours and medical supervision in this group in all shifts.
They need constant monitoring, supervision and evaluation.

METHODS OF PATIENT ASSIGNMENT


Assignment is defined as a written document of assignment of tasks to render patient care for a group of
patients by trained nursing personnel working in that ward.

PURPOSE OF ASSIGNMENT
 To distribute the to be done for patient care to the nursing staff.
 To ensure the cooperation of the nursing personnel by knowing and accepting of the work to be done.

MODES OF ORGANIZING PATIENT CARE / METHODS OF PATIENT ASSIGNMENT


There are several methods of patient care assignments practiced in hospital. In general, there are two main
classification:
Traditional methods
Advanced method
12
Traditional methods include
 Case method or Total patient care
 Functional nursing
 Team nursing
 Modular or district nursing
 Progressive patient care
 Primary nursing
Advance method
 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.
♣ 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.

13
♠ 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.

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.

14
♠ 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 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.

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.

15
♠ All personnel must be client centered.
♠ There is less individual responsibility and independence regarding nursing functions.
♠ 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:

16
♠ 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
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.
17
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.
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

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.
18
♣ 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

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 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:
For the patients:
 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.
 Provides comprehensive care for those with complex health problems.
 It seeks the active involvement of the patient, family and diverse health care professionals.
 The hospital length of stay of the patient is reduced.
19
 Using the minimal resources, maximal health care outcome is achieved.
 This method enhances continuity of patient care through collaborative practice of diverse health
professionals.
 Patients are moved towards self-care, independence is fostered where indicated.
For the nurse:
 This method facilitates for nurses professional development and job satisfaction.
 Facilitates the transfer of knowledge of expert clinical staff to novice staff.

Demerits:
o Nurses identify major obstacles in the implementation of this service, financial barriers and lack of
administrative support.
o Expensive
o Nurse is client focused and outcome oriented
o Facilitates and promotes co-ordination of cost effective care
o Nursing case management is a professionally autonomous role that requires expert clinical knowledge
and decision making skills.
o Continuity of care is difficult as case manger may not always available.
o Long term nurse patient relationship are difficult to arrange.

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
 The standards of nursing care.

20
REFERENCES
1. Vati Jogindra. Nursing Management and Administration.1st edition.2013; Jaypee Brothers Medical
Publishers (p) Ltd;New Delhi:
2. Bhaskara Raj Elakkuvana. Management of Nursing Services and Education.3rd edition.Emmess
Medical Publishers; Bangalore:
3. Stanhope Marcia & Jeanette Lancaster, "Public Health Nursing”, 8th edition, 2008; Elsevier publisher
printed in united states of America.
4. Basavanthappa B.T. Management of Nursing Services and Education.Jaypee publication;New Delhi:
5. Basavathappa B.T. Nursing Administration.2nd edition. 2009. Jaypee Brothers Medical Publishers;New
Delhi:
6. L Marquis Bessie, Husto J carol. Leadership roles and management functions in nursing. 7th edition.
2011.Wolters Kluvers India pvt Ltd;New Delhi:
7. Francis CM. Hospital Administration. 3rd ed. Jaypee medical publishers; new delhi:2004. P.125.
8. Alamelu venketraman. Newer trends in management of nursing services and education. 1st ed. Jaypee
health science publisher;New Delhi: 2017. P. 92-99.
9. Jean barrett. Ward management and teaching. Konark publishers. New Delhi: 2006.
10. Nursing administration and management. 1st ed. TNAI. New Delhi: 2007.

21
NURSING MANAGEMENT

GROUP DISCUSSION

ON

ORGANIZING NURSING SERVICES AND


PATIENT CARE AND METHODS OF
PATIENT ASSIGNMENT.

SUBMITTED TO:
MRS. RESHMI SIBY.
PROFESSOR.
TMMCON
KAVIYOOR
SUBMITTED BY:
2ND YEAR MSC NURSING
TMMCON
KAVIYOOR
22