organizing nsg service

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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 thenurse is one of the greatest blessings of humanity. Nursing has a large, important and uniquerole 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 theoperation, it is the nurse who gives 24 hrs / round the clock nursing care and looks after theneeds 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 nursingservice administrator. Setting of standards and goals for providing care to patients dependsupon 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 organizingof 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.

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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 theneeds of assigned patients during their time on duty.

Modular nursing The patient unit is divided into modules or districts, and the sameteam of caregivers is assigned consistently to the same geographiclocation

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

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

Organizing It involves grouping activities together and assigning theresponsibility of each group of activity to a manager who hasadequate 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 andnursing homes.

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

Performanceappraisal

A formal assessment of an employees 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, providingqualitative comprehensive nursing care.

ORGANIZING NURSING SERVICES

Meaning of nursing service and nursing service administration

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Nursing Service

Nursing service is the part of the total health organization which aims at satisfyingthe nursing needs of the patients/community. In nursing services, the nurse works with themembers 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 isorganized to achieve the excellence in nursing care services. It results in output of clientswhose 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 thetotal 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 theobjectives of the hospital and acknowledges that the primary purpose of nursing is to providethe 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 continuinggrowth and development of nursing personnel.

High quality of nursing care can be best provided by a mixture of professional andnon professional personnel who are organized into self directed work teams.

To ensure continuous improvement of nursing care quality, the role of professionalnurse 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 asfollows:

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 withother health tem members.

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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 carecontinuously.

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 beenon the job for a long time.

To conduct training for operating procedure of latest gadgets and on handlingsophisticated 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 nursingcare 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 studiesconcerning 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 standardsand performance indicators objectively with a view to maintain quality-nursingservices.

PRINCIPLES OF NURSING SERVICE

Initiate a set of human relationships at all levels of nursing personnel to accomplishtheir job and responsibilities through systematic management process by establishingflexible organizational design

Establish adequate staffing pattern for rendering efficient nursing service to clientsand 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 allunits 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 incooperative 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 nursingto 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

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To assist the individual patient in performance of those activities contributing to hishealth or recovery that he would otherwise perform unaided has had the strength, willor 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 hospitalsoverall 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 theessential characteristics of good nursing services in her institute such as:

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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

Inservice education

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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.

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 maintainingstandards for patient care in terms of quality nursing service must be familiar with theformal organizational structure of the hospital and its relationship in variousdepartment and their functions. The plan of organization should indicate inter as well

as intra-department relationship. The plan also should indicate area of responsibilityand 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, whichincludes duty hrs, rules and regulations etc. These are periodically revised andreviewed at regular intervals.

Nursing practice manual:

This the written procedure available as evidence of the standards of performanceestablished by nursing service organization for safe and effective practice after takinginto consideration the best use of available resources. Liberal use of diagram and

precautions in nursing manual helps to keep instruction direct and exact. Theadvantages are ensure economy of time effort & material and provides basis for training for new personnel to acquire knowledge and current skill.

Nursing service budget:

It is required for personnel budget, nurses welfare activities, staff development programme, equipment and capital expenditure, supplies and expenses.Budget preparation should includes analysis of past operation and anticipating thefuture revenue and expenses.

Master staffing pattern:

It is the number and composition of nursing personnel assigned to work in ahospital in different department / wards at a given time. This helps the director tovisualize 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:

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Advisory committee


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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 evaluationof the nursing service through regular meeting of the director of nursing with totalnursing staff. The purposes are regular exchange of view between management andnursing service for improving working condition, welfare of patient and improvementin 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 hospitaladministrator.

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 fromvarious 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 asrecruitment and selection, medical records, training and development, transfer records, promotion, disciplinary action records, performance records, absenteeismdata, 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 physicalexamination, 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 ataugmenting, reinforcing nurses 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 withmembers 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 finaldecision about the matter within her area of responsibility and becomes accountablefor implementation.

ORGANISATION OF NURSING SERVICES:

DIRECTOR (hospital) DIRECTOR OF HEALTHSERVICE

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 NurseStaff 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) Addl.DG (N) Addl.DG (M)

ADG ADG ADG

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

DADG DADG

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 ADNSADNS


DADNS DADNS DADNS


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

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

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

Nsg Supt/Dy.Nsg.Supt Principal tutor Dist.PNOAsst.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 thehospital 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.

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Formulates standing orders for the nursing care.

Ensures appropriate allocation of duties and responsibilities to all nursingstaff working under her.

Formulates nursing policies to ensure quality patient care and adequateattention 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 theevenings.

Brings immediately to the notice of the medical superintendent all mattersconcerning neglect of duty, insubordination either by nursing staff, patients or visitors or any un-towards incident, which comes to her notice for takingsuitable action as required as per the orders on the subject.

Public Relations

Promotes and maintains harmonious and effective relationship with thevarious administrative departments of the hospital and related communityagencies.

Maintain cordial relationships with the patients and their families.

Office Routine

Scrutinizes the reports and returns and submits in accordance with existingorders.

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 healthrecords.

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 toworking conditions, working hrs and other facilities.

Supervision

Supervises nursing care given to the patients and all nursing activities withinthe 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.

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representative of hospital administration. The primary aim of PCS is to be able to respond toconstant 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 beused 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 isadjusted to meet the aggregate times. A nurse manager can elect to staff below thestandard time to reduce costs.

Components

The first component of a PCS is a method for grouping patients categories. Johnsonindicates two methods of categorizing patients. Using categorizing method each

patient is rated on independent elements of care, each element is scored, scores aresummarized and the patient is placed in a category based on the total numerical valueobtained. Johnson describes prototype evaluation with four basic categories for atypical patient requiring one on- one care. Each category addresses activities of daily living, general health, teaching and emotional support, treatment andmedications. 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.

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 finalcomponent of a PCS.

Patient Care Classification

Area of care Category I Category II Category III Category IV

Eating Feeds self Needs some help in preparing

Cannot feed self but isable to chew andswallowing

Cannot feed self any may havedifficultyswallowing

Grooming Almostentirely self sufficient

Need some help in bathing, oral hygiene

Unable to do much for self

Completelydependent

Excretion Up and to bathroomalone

Needs some help ingetting up to

bathroom /urinal

In bed, needs bedpan /urinal placed;

Completelydependent

Comfort Self sufficient

Needs some help withadjusting position/ bed..

Cannot turn withouthelp, get drink, adjust

position of extremities

Completelydependent

Generalhealth

Good Mild symptoms Acute symptoms Critically ill

Treatment Simple

supervised,simpledressing

Any Treatment more

than once per shift, foleycatheter care, I&O.

Any treatment more

than twice /shift

Any elaborate/

delicate procedurerequiring twonurses, vital signsmore often thanevery two hours..

Healtheducation &teaching

Routinefollow upteaching

Initial teaching of careof ostomies; newdiabetics; patients withmild adverse reactions

to their illness

More intensive items;teaching of apprehensive/ mildlyresistive patients.

Teaching of resistive patients,

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MODES OF ORGANIZING PATIENT CARE / METHODS OF PATIENTASSIGNMENT

The most well known means of organizing nursing care for patient care delivery are,

Case method or Total patient care

Functional nursing

Team nursing

Modular or district nursing

Progressive patient care

Primary nursing

Case management

Each of these basic types has undergone many modifications, often resulting in newterminology. For example, primary nursing has been called case method nursing in the pastand is now frequently referred to as a professional practice model . Team nursing issometimes called partners in care or patient service partners and case managers assumedifferent titles, depending on the setting in which they provide care. When closely examinedmost 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 professionalnurse, the economic resources of the organization and the complexity of the task to becompletely.

CASE METHOD

Features:

It was the first type of nursing care delivery system. In this method, nurses assumetotal responsibility for meeting all the needs of assigned patients during their time on duty. Itinvolves assignment of one or more clients to a nurse for a specific period of time such asshift. The patient has a different nurse each shift and no guarantee of having the same nursesthe next day. Nurses responsibility includes complete care including treatments, medicationand administration and planning of nursing care. This is the way most nursing students weretaught take one patient and care for all of their needs. This model is used in critical careareas, labor and delivery, or any area where one nurse cares for one patients 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 becameinstitutionalized 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.

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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 persons aptitudes, experience and desires.

The organization benefits financially from this strategy because patient care can bedelivered 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, medicinenurse, 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 thehallmark of team nursing. Team nursing is based on philosophy in which groups of

professional and non-professional personnel work together to identify, plan, implement andevaluate comprehensive client-centered care. In team nursing an RN leads a team composedof other RNs, LPNs or LVNs and nurse assistants or technicians. The team members providedirect patient care to group of patients, under the direction of the RN team leader incoordinated 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 teammembers in details of care. A conference is held at the beginning and end of each shift to

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allow team members to exchange information and the team leader to make changes in thenursing care plan for any patient. The team leader also provides care requiring complexnursing 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 problemsolving.

Each team member is able to contribute his or her own special expertise or skills incaring 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, thegroup efforts prevail.

Disadvantages:

Establishing a team concept takes time, effort and constancy of personnel. Merelyassigning 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.

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Charge Nurse RN

Team LeaderRN

Team Leader RN

RN NALPN NA LPNRN

Group of

Patients

Group of

Patients


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The team leader may not have the leadership skills required to effectively direct theteam 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 patients

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 theinvolvement of the RN in planning and coordinating care. The patient unit is divided intomodules or districts, and the same team of caregivers is assigned consistently to the samegeographic location. Each location, or module, has an RN assigned as the team leader, andthe 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 acooperative work environment. The success of the modular nursing depends greatly on theleadership 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 thesame 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 centraltheme is better utilization of facilities, services and personnel for the better patient care. Herethe clients are evaluated with respect to all level (intensity) of care needed. As they progresstowards 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 careround the clock, e.g. patients with acute MI, fatal dysarythmias, those who need artificialventilation, major burns, premature neonates, immediate post or cardiothoracic, renal

transplant, neurosurgery patients. These units have 9-15 numbers of beds, life-savingequipment and skilled personnel for assessment, revival, restoration and maintenance of vitalfunctions 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 caresetting, yet patients in these areas participate actively to achieve complete or partial self-carestatus. Patients are taught administration of drugs, life style modification, exercises,ambulation, self-administration of insulin, checking pulse, blood glucose and dietarymanagement.

iv) Long-term care: Chronically ill, disabled and helpless patients are cared for in theseunits. 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 withostomies.

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.

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vi) Ambulatory care: Ambulatory patients visit hospital for follow up, diagnostic, curativerehabilitative 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 andimproving 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 withina 24 hour from admission to discharge. He or she is responsible for coordinating andimplementing 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 nursesabsence will provide hospital care to the patient based on the original plan of care made bythe nurse. In acute care the primary care nurse may be responsible for only one patient; inintermediate care the primary care nurse may be responsible for three or more patients Thistype of nursing care can also be used in hospice nursing, or home care nursing.

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Patients

Total patient care 24


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Advantages:

Primary Nursing Care System is good for long-term care, rehabilitation units, nursingclinics, geriatric, psychiatric, burn care settings where patients and family memberscan 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 expensivethan other methods.

Level of expertise and commitment may vary from nurse to nurse which may affectquality of patient care.

Associate nurse may find it difficult to follow the plans made by another if there isdisagreement or when patients 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 nurses talent to his/her own patients.

CASE MANAGEMENT

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Communicateswith supervisors

Consults withphysician or other

healthcare

providers

Associate (days)when primary

nurse is not

Associate(afternoon)

when primary

Associate(evenings)

when primary

PRIMARY

NURSE


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Features:

The case manager (RN or social worker with managerial qualification) is assignedresponsibility of following a patients care and progress from the diagnostic phase throughhospitalization, 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. Casemanagers are employed by third party payers (e.g. insurance companies) by the hospitalauthorities (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 casemanagers. No direct care by the manager whose main roles are of teaching, advocacy andcoordinating with health care providers. Case manager (nurse) ensures quality care that isholistic and assisting the patient to attain self care status according to his/her potential. Itemphasizes achievement of outcomes in designated time frames with limited resources.

Case management involves critical paths, variation analysis, inter shift reports, caseconsultation, health care team meetings, and quality assurance. Critical paths visualizeoutcomes within a time frame. Variation analysis notes positive or negative changes from thecritical paths, the cause, and the corrective action taken. Case consultation may be indicatedwhen the clients 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. Thecase 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 andwhat 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 clients 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 servicesefficiently.

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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 serviceaspect in restoring health and confidence of the patient is of utmost importance. The qualityof 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 itstruggles with cost and providing care corresponding to changes in the education of health

professionals and their function within the system. According to their educationalqualification 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 demonstrateadministrative functions that will provide therapeutic and satisfying situations for patientsand personnel. Administration is the management or guidance of an organization for the mosteffective accomplishment of its stated goal.

The goal of a nursing service organization is more specifically to give continuous careto 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 healthstatus. In working toward this goal, nursing must maintain itself internally . Only throughdemocratic administration can therapeutic and satisfying situations be created for both

patients and personnel. Such administration recognizes the worth of each individual. Whenemployees have a part in planning and when they feel respected and accepted, they derivemore satisfaction from their work and are better able to respect and accept their patients andco-workers.

Issues and Trends in Nursing Service Administration Education

The Council on Graduate Education for Administration in Nursing (CGEAN) wasestablished to further the development and improvement of graduate education for administration in nursing. The Council seeks to identify the nature and direction of educationfor administration in nursing in various healthcare systems, providing guidelines for

programs offering administration. A major goal of CGEAN is facilitating dialogue betweennursing service administrators and graduate level educators who are engaged in teaching andresearch related to administration in nursing. This column, sponsored by members of theCouncil, 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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organizing nsg service

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