Nursing care delivery system

Nursing care delivery
system
By/ Mahmoud Shaqria
‫شقريه‬ ‫محمد‬ ‫محمود‬

Outlines:
 Introduction
 Definition of nursing care delivery system
 Purpose of nursing care delivery system
 Criteria of selecting the appropriate method of
nursing care delivery system
 Principles of personnel assignment
 Characteristics of effective assignment

Cont,
 Methods of nursing care delivery system
(A)Traditional methods of nursing care delivery system:
1.Case method 2. Team method
3.Functional method 4. Modular method
5.Primary nursing
B) Advanced methods of nursing care delivery system:
1.Case management
2. Practice Partnership
3.Differentiated practice
4.Patient centered care

Introduction:
 One important function of the professional nurse at the
first-line management position of nursing service
department is organizing the activities of the staff into a
workable pattern to meet patient needs.
 She/he should establish effective relationships between
the activities to be performed, the workers to perform
them.
 One of the significant issues challenging nursing is the
way in which nursing care is delivered.

Cont,
 Since World War II, nursing care delivery systems have
undergone continuous and significant changes.
 Over the years, various nursing care delivery system have
been critiqued.
 Debates regarding each method focused on identifying the
prefect delivery system for providing nursing care to
patient.
 No delivery system is prefect. Most organization uses a
combination or modification of various nursing care
delivery systems to meet unique demands of different
patient care units.

Definition of nursing care delivery system
 "The process of delivering care to the client by
combining various aspects of nursing service which
will fit to various patient care settings to produce a
common outcome of delivering quality care and
meeting the needs of clients."
“A written delegation of duties to care for a group of
patients by trained personnel assigned to the unit based
on their knowledge, skills, job description, and patients
nursing needs.”

Another definitions
 Also called care delivery models or patient care delivery
models. Detail the way task assignments, responsibility,
and authority are structured to accomplish patient care.
 Is how work is organized, how nursing staff are deployed
and who will provide nursing care. Delivery system
identify who has the accountability for nursing clinical
outcomes and this system will provide the organization,
rules and structure that define responsibility and
accountability.

Purpose of nursing care delivery
system
1. To delegate the work to be done to the nursing
personnel employed in the unit based on the
administrative policies, lines of authority and job
description.
2. To gain the cooperation of the nursing personnel by
knowing and accepting the acceptance of the work to
be done.
3. Define responsibility of each staff member.
4. Provides for teaching of staff nurses and nursing
students.
5. Prevents overlapping of nursing functions.

Cont,
6.Increase skills of nursing personnel.
7.Facilitate accountability because of defined responsibility
of patient care.
8.Fairness distribution of staff responsibilities or activities.
9.Provide safe, competent, quality care that meets client
needs and maximizes client outcomes across the
continuum of care

Criteria of selecting the appropriate
method of nursing care delivery system:
1- The skills and expertise of the staff
2- The availability of registered professional nurses
3- The economic resources of the organization
4- The acuity of the patient
5- The complexity of the task to be completed

Principles of personnel assignment:
1. Made by the first line manger (head nurse or nurse in
charge) for each individual nurse.
Based on :
 Nursing needs of each patient and approximate time
required to care for him.
 The capabilities, skill level, previous experience and the
interest of the staff members.
 Job description.
2. Planned from week to week rather than from day to day to
assure continuity of care.

Cont,
3.Take into account all the direct , indirect and unit activities
4.Consider the geographical location of the unit and the
assigned duties to save nurse’s time and effort.
5.Must be balanced among nursing staff.
6.Never to assign the same task to more than one nurse.

Characteristics of effective assignment:
1. Should be done according to personnel abilities and
patients needs.
2. Should be written clearly, concisely and legibly.
3. Should be posted in a place easily accessible.
4. Should be related to previous assignments, in order to
provide for progressive learning experience.
5. Done on weekly basis and adjust daily to meet
changing patients needs or changes in nursing
personnel.
6. It must be signed .

Methods of nursing care delivery system:
(Methods of assignment):
Several methods of assignment are used to plan for patient
care in a hospital.
These methods are the traditional methods and the in
advanced methods.

Methods of nursing care delivery system
(A)Traditional methods
1. Case method
2. Functional method
3. Team method
4. Modular method
5. Primary nursing
B) Advanced methods
1. Case management
2. Practice Partnership
3. Differentiated practice
4. Patient centered care

A) Traditional methods:
1- Case method (total patient care) or (private method):
 The case method of assignment enables one worker to give all the
care that a patient needs.
 In this method, no gaps exist because the nurse knows what have
been done and what should be done for the patient. However, very
often little continuity of care exists from shift to shift. The hospital
needs all registered staff nurses to use this method of assignment.
 It is the oldest patient care delivery method. In this method one
professional nurse assumes total responsibility of providing complete
care for one or more patients (1-6) while she is on duty.
 This method is used frequently in intensive care units and in teaching
nursing students.

1. Case method
Advantages
1. High degree of autonomy
2. Lines of responsibility and
accountability are clear
3. Patient receives continuous,
holistic and unfragmented
care by only one nurse per
shift. (Individualized care)
4. Lead to patient satisfaction
and staff satisfaction
regarding patient progress
5. Continuity of communication
and close relationship of nurse
with patient and family
Disadvantages
1. One to one ratio is sometimes
unrealistic due to shortage in
the staff.
2. Method is expensive (nurse's
salaries).
3. it needs frequent supervision.
4. It needs more equipment and
supplies.
5. It results in crowdness in areas
such as medication and
dressing rooms.
6. Need large number of staff
nurse

2. Functional method (task oriented):
 Emerged during 1950s, due to shortage of nurses.
 This method focuses on getting the greatest amount of
tasks in the least time.
 In this method, the nursing care is divided into tasks and
each staff member is assigning to perform one or two
tasks for all patients in the unit according to the level of
skill required for performance as follows:
Head nurse:
 Responsible for the direction and supervision of the
staff, make rounds with physician, gives reports to the
next shift of nurses who would care for the patient.

 Registered professional nurses: Responsible for
administering medication to all unit patients, another for
changing dressings and administering ordered treatments
(such as postural drainage or warm compresses) for all
patient
 Technical nurses: Responsible for taking vital signs and
recording intake and output for all patients in the unit,
while another might be giving baths to all bedridden
patients.
 Nurse aides: Responsible for making beds for all
ambulatory patients and assisting mobility-impaired
patients to move in bed or walk in the hall.
 Unit clerk: Responsible for answering telephone,
delivering messages, recording admissions and
discharges, etc.

2. Functional method
Advantages:
1. Less equipment and supplies
are needed.
2. Each nurse become highly
skillful, she develops speed
and efficiency in doing her
assigned task.
3. She become more
independent and needs less
supervision.
Disadvantages:
1. Function centered method.
2. Fragmentation and
depersonalization of patient
care.
3. No one nurse knows or
evaluates patient care.
4. It is difficult to define
responsibility for errors in
patient care.
5. Some aspects of patient care are
omitted, e.g., teaching.

Cont,
4. Inexpensive method,
e.g., nurses are from
different categories
5. Care is provided
economically and
efficiently
6.Tasks are completed
quickly
7. Useful in emergency
situations
6. Poor nurse / patient
communication.
7. Monotony in doping the one
task.
8.Nurse become less skillful in
other tasks, their abilities are
not fully utilized.
9.Patient may be confused with
many care providers
10. Neglecting the humanity of
the patient and the
individual needs of the
patient will be lost in an
effort to get the work done.

3-Team method (democratic team leader)
 The concept of team nursing was introduced in the early
1950s. It is a method of nursing -assignment that binds
professional, technical and nurse aides into small teams.
 This method allows for efficient utilization of technical
and/or nurse's aide through the direct supervision,
guidance, and teaching of professional nurses.
 The most commonly used model and is still in use today.
The goal of the Team method is for a team to work
democratically.
 The Team Leader must be both a skilled clinician and an
effective group leader Team conferences occur in which
the expertise of every staff member is used to plan the
care

Process of implementing the team method:
 One registered nurse in the team is appointed by the head
nurse to serve as a team leader.
 The team members commonly consist of at least one
professional nurse, one technical nurse, nursing students
and nursing aides.
 All team members may receive reports about their
patients’ care needs from the team leader or team
member on previous shift.

 Professional nurse to care for the most seriously ill
patients, to ensure informed observation and skilled
interventions.
 Technical nurse to bath, feed, and move and change
dressings for patients.
 Aides are assigned to make beds, assist ambulatory
patients with bathing and grooming, testing urine and
performing simple nursing care procedures.
 Team leader usually administers medications and
monitors parenteral fluid therapy for all patients
assigned to the team.
 Without team planning and communication through the
team conferences, team nursing may become in reality
just a variation of the functional method.

3.Team method
Advantages:
1. Availability of professional
nurse's skills for large number
of patient.
2. Continuous supervision of
less trained personnel, thus
providing better patient care.
3. Increase in number and
duration of professional
nurse-patient interaction.
4. Help in developing leadership
skills.
Disadvantages:
1. Most nursing programs do not
prepare nurses for leadership
roles.
2. Nurses are more interested in
developing clinical patient care
skills than leadership abilities.
3. With staff shortage, it is difficult
to properly apply this method.

5.Great opportunity of initiative and
shared responsibility.
6.Maximal use of individual abilities.
7.Reduction of time spent in
performing non-nursing activities.
8.Total effort of the group is better
than that of each individual
member.
9.It promotes nurses sense of
belonging.
10.All nurses have contact with the
patient; they share in the
planning, and provision of his
care.
4. It needs more time by the
team leader to meet and
share ideas and
coordinates efforts.
5. Needs more supplies and
equipment.
6. Can lead to blurred lines
of responsibility , errors
and fragmented patient
care

4-Modular nursing or District Nursing:
-A modification to team nursing, focusing on the
geographic location of patient rooms and assignment
of staff members. This is mini team (two or three
members) approach.
-Modular nursing assignment is used when the nursing
staff includes technical and nurse aides, as well as
professional nurses.
-Although two or three persons are assigned to each
module, the greatest responsibility for the care of
assigned patients falls on the professional nurse.
-The professional nurse is also responsible for guiding
and teaching non-professional nurse

4-Modular nursing
Advantages:
1. It decreases the sense
of isolation and
unrealistic
expectations.
2. It increases continuity
and quality of care.
3. More time may be
spent in direct care.
4. Nurse's morale is
improved
Disadvantages:
1. Increased costs to stock each
module
2. Long corridors common in
many hospitals are not
conducive to modular
nursing.

6-Primary nursing:
 This method is the best in an agency with an all-
professional nurse staff. It is: A comprehensive,
continuous and coordinated nursing process for meeting
the total needs of each patient.
 A nursing care delivery system in which one nurse is
responsible and accountable for the nursing care of
specific patients for the duration of their stay
 It is also known as relationship-based nursing, developed
in the late 1960’s by Marie Manthey, uses some of the
concepts of total patient care, and brings the RN back to
the bedside to provide clinical care.

Cont,
 The Primary nurse is responsible for 24- hour-a-day
total patient care from admission through discharge.
 When the primary nurse is not on duty, associated
nurse, who follow the care plan established by the
primary nurse, provide care.
 The primary nurse, preferably baccalaureate prepared,
with autonomy, responsibility, and accountable for
meeting outcome criteria, and communicating with the
patient, the physician, the associated nurses, and other
team members.
 Also it is designed for hospitals; it is used in home
health nursing, hospice nursing, and other health care
delivery enterprises.

6-Primary nursing:
Advantages:
1. It decrease the number of
people in the chain of
commands
2. Reduce the number of error
and cost per patient per day.
3. Mobile use auxiliary
workers.
4. Increase satisfaction of nurse
and patient,
5. A patient is secured.
Disadvantages:
1. Primary nursing confines a nurse's
talent to a limited number of
patients.
2. Time consuming.
3. It success depends on the quality
of nursing staff and
administrative support.
4. It requires excellent
communication between the
primary nurse and associate
nurses.
5. RN may not have the experience
or educational background to
provide the total patient care.

6.Nurses identify the patient
outcome as a result of their
work.
7. Patient has fewer
complications and a shorter
hospitalization ( decrease
length of hospital stay).
8. Facilitate accountability as
the primary nurse is the one
accountable for nursing care
activities.
9.Decrease in the number of
unlicensed personnel.
6. The agency needs to educate
staff for an adequate
transmission from the
previous role to the primary
role, so it is costly for the
agency.
7. It requires enough professional
nurses to provide primary
nurse care.
8. The RN may not accept the
24hour responsibility for
patient care.
9.In times of nursing shortage,
the primary nursing may not
be the strategy for choice

B) Advanced methods:
1- Practice Partnership (Co-Primary Nursing):
 The partnership model, sometimes referred to as co-primary
nursing, is a modification of primary nursing and was
designed to make more efficient use of the RN.
 A nursing care delivery system in which senior and junior
staff members share patient care responsibilities.
 Is a more recent concept also introduced by Marie Manthey
(1989).

cont,
 It can be applied to Primary Nursing and used in team
nursing, modular nursing, and total patient care.
 It offered an efficient way of using the skills of a mix of
professional and nonprofessional staff with different
levels of expertise.
 In the partnership model the RN is partnered with an LPN
(licensed practical nurses), or UAP (unlicensed assistive
personnel), and the pair work together consistently to care
for an assigned group of patients.

1.Practice Partnership (Co-Primary Nursing):
Advantages:
1.More continuity of care and
accountability for patient care
than team and modular nursing.
2.Less expensive for the organization
and more satisfying
professionally for the partners
than total patient care and
primary care.
3.The RN can encourage the training
and growth of his or her partner.
Disadvantages:
1- The potential for the
junior member of the
team to assume more
responsibility than
appropriate.
2-The RN may have
difficulty delegating to
the partner.
3-Consistent partnerships
are difficult to maintain
based on varied staff
scheduled.

2- Case management
 As a dynamic and systematic collaborative approach to
providing and coordinating health care service to a
defined population.
 Case management is a process of monitoring an individual
patient’s health care by the case manger, for the purpose
of maximizing positive outcomes and containing costs.
 A model of identifying, coordinating, and monitoring the
implementation of services needed to achieve desired
patient care outcomes within a specified period of time.

Cont,
 It is a strategy to coordinate care, maintain quality, and
contain costs while focusing on the outcomes of care.
 It was developed in 1985 as an outgrowth of primary
care.
 It was used for decades in community and psychiatric
settings, was adopted for acute inpatient care and
outpatient services.

The case manager (case coordinator):
 The case manager is a professional nurse with advanced
level of nursing practice and advanced managerial and
communication skills.
 The (ANA) recommended a baccalaureate in nursing
with 3 years of clinical experience as the minimum
preparation for a nurse case manager.
 In an acute care setting the case manager has a case load
of 10 to 15 patients and follows patient’s progress
through the system from admission to discharge.

Cont,
 Case manager has responsibility and authority for planning,
implementing, coordinating and evaluating care for the
patient throughout the period of illness, regardless of the
patient’s movement among various units and services (such
as emergency room, surgical unit, recovery unit, etc.).
 The case manager ensures that plans are made in advance
for the next needed step.
 Through this, the manager assists with decision-making and
helps to ensure that the patient receives care that will
achieve the most positive outcomes in the most efficient
manner.
 This process helps to eliminate costly delays in progress.

Advantages:
1. Enhancing nurse’s professional development and job
satisfaction
2. Increase collaboration between different health
professionals.
3. Reduce patient complication.
4. Improve quality of care.
5. Facilitating the continuity of patient care.
6. Facilitate discharge of the patient within an
appropriate length of stay.
7. Reduce cost.

Critical pathway:
 Also called critical paths, practice protocols, clinical
practice guideline, patient care protocols or care maps, a
predetermined written plan of care for a particular health
problem.
 Tools or guidelines that direct care by identifying expected
outcomes that are developed by the collaborative practice
team.
 Successful case management relies on critical pathways to
guide care.

Cont,
 Critical pathway include: specific medical diagnosis, the
expected length of stay, patient identification data,
appropriate time frames (in days, hours, minutes, or
visits) for interventions, and patient outcomes.
 A recent evolution of critical paths is the incorporation
of actual and potential nursing diagnosis with specific
time frames into the critical pathway.
 A copy of this form is given to the patient and the
family, and the nurse reviews the information with them.
Thus, both the patient and the family know what to
expect during an anticipated, uncomplicated
hospitalization.

3-Patient -centered care:
 A nursing care delivery system that is unit-based and
consists of patient care coordinators, patient care
associates, unit support assistants, administrative support
personnel, and a nurse manager.
 It is developed in the late 1980s; it may be used in
outpatient and homecare settings, patient with chronic
conditions are appropriate candidates for patient-centered
care approaches.
 The role of the nurse is broadened to coordinate a team
of multifunctional unit-based caregivers.

Cont,
 All patient care services are unit-based, including
admission and discharge, diagnostic and treatment
services, and nutrition services and medical records.
 The focus of Patient -centered care is decentralization,
the promotion of efficiency and quality, and cost control.
 The number of care givers is reduced, but their
responsibilities are increased.

3-Patient -centered care:
Advantages:
1. Patient comes into
contact with fewer
workers.
2. Workers are unit based
and spend more time in
direct-care activities.
3. RN is accountable for a
wide range of services
and functions at a
higher level to ensure
more consistent patient
care.
Disadvantages:
1. Major change in
organizational structure
is required.
2. Major change is
required also in the roles
of the nurse manager
and the team members.
3. Departments other than
nursing must be willing
to accept nursing
leadership.

4. Increase the quality of care and
increase patient satisfaction.
5. Cost-effective.
4. Nurse Manager supervises
many types of workers.
5. Because many different
types of workers are
involved as a team, new
and different issues arise,
involving team conflict,
problem resolution and
multiple standards of care.

4- Differentiated practice:
 A nursing care delivery system that maximizes nursing
resources by focusing on the structure of nursing roles
according to education, experience, and competency.
 It has been used in a variety of inpatient, acute care
settings as well as in home care and clinics.
 It is designed to identify distinct levels of nursing
practice based on defined abilities that are incorporated
into job descriptions.

cont,
 The aim is to match patient needs with nursing
competencies to facilitate the effective and efficient use
of nursing resources.
 Nurses prepared at associate/ diploma, baccalaureate,
masters, and doctorate level are integrated.
 Each defined role is different and complementary.
 Nurses choose the role based on their competency,
skills, desire, and education.

Advantages:
1- Improve patient care, and contribute to patient safety.
2- Allow for the most effective and efficient use of scarce
resources.
3- Increase satisfaction for nurses.
4- Provide opportunity to compensate nurses fairly based
on their expertise, contributions, and productivity.

Nursing care delivery system

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