Nursing Care System

NURSING CARE SYSTEMS

INTRODUCTION

As it has evolved over a period, nursing is still focused on caring. Rapid technologic advances, knowledge explosion, emphasis on quality – cost effectiveness – accessibility of health care and demand for alternative health care modalities present many challenges for nursing profession.

·         By continuing to advance nursing education and inculcating attributes of quality improvement, accountability and holism in young nurses.

·         By collaborating with other health care providers and sections of society.

·         By redefining roles and functions of nurses and preparing, placing and utilizing them adequately in various health care settings in the community hospital.

·         By reshaping organizational (administrative) policies and developing such systems of nursing care delivery as best suited to clients needs.

A system may be defined as a composite whole made up of integrated or joined and interrelated parts. Although each component of the system has its specific function, yet all of them work harmoniously for common outcome. As our body is made up of different systems, each system having many organs/parts e.g. respiratory system that is made up of nasal cavity, larynx, trachea, bronchi-bronchioles and lungs. Each of these have specific functions such as conduction of air,filtering, protection, inspiration and expiration but the common outcome of the whole system is respiration or exchange of gases. Similarly, main outcome of nursing (product) is quality care for which various systems comprised of different parts/sections have to fit and function harmoniously. Nursing care system should be an open system – flexible yet organized. Basically nurses need to understand the positive and negative consequences of each model in order to plan and propose to decision-makers the most efficient and effective way to deliver care.

Nursing Care Systems

Case method

Functional nursing

Team Nursing

Basic Nursing

Primary Nursing

Palliative care

Self care

Case Management

So far, various nursing care systems or models have been developed and implemented due

to the influence of various societal, political, professional and organizational factors.

• These systems utilize different nursing care concepts, theories, nursing roles and functions.
• These are adapted as such or with modifications according to the clients’ health needs, organizational structure, facilities and availability of nursing manpower.
• None of these systems has ever claimed to be perfect or the best. Some of these, although developed in early years of nursing history, are used even today and are being perfected to fit into the current health care delivery system.

 Basic Nursing Care Concept

Basic nursing services have its roots in fundamental human needs. This domain of nursing is derived from the common needs of the people. In normal health, basic needs can be met by the individual unaided, but the need for nursing assistance arises when the person lacks the strength, knowledge or will to meet the basic needs for daily living, e.g. a patient had difficulty in swallowing food due to an esophageal problem, nursing assistance is required to help him get adequate nourishment.

CASE METHOD

The Case Method evolved into what we now call private duty nursing. It was the first type of nursing care delivery system. This is the way most nursing students were taught – take one patient and care for all of their needs. The consequences of teaching nursing this way was that reality shock hit upon graduation when the new graduate hit the floors and had to care for more than one patient. We still see this model used in critical care areas, labor and delivery, or any area where one nurse cares for one patient’s total needs. It is interesting to note that nurses were self-employed when the case method came into being, because we were primarily practicing in homes. We lost much of that autonomy when healthcare became institutionalized in hospitals and clinics and we naturally followed.

Features

·         This system of nursing care was very popular till the beginning of 20th century

·         Simple and primitive system

·         Clients used to ‘hire’ or appoint nurses to take care of sick patients at home or in the hospital. Payments were based upon a mutual agreement between the parties.

·         Provided one-to-one relationships. Nurse looked after all basic needs, e.g. hygiene, comfort, nutrition, elimination, recreation. Clients felt satisfied.

Nursing Concept/Approach

Basic Nursing Care (client-centered, need-based). Role of care-giver/physician’s assistant.

Challenges and Issues

Lack of standards, lack of coordination and supervision. Nurses were poorly paid and there were chances of manipulation from both parties. Nurses have less chances of self-development as professionals.

This system is good for home care agencies who act as mediators for proper placement and payment of nurses who are unemployed, retired or want to work on part-time basis.

Advantages:	RNSwere self-employed Patient needs were quickly met Close relationship between the RN and the patient The nurse can see better and attend to the total needs of the client due to the time and proximity of interactions. Continuity of care can be facilitated with care. Nurses accountability for their function is built in.
Disadvantages:	Many clients do not require the in this type of service. This method must be modified if non professional health workers are to be used effectively The greatest disadvantage to case nursing occurs, when the nurse is inadequately trained to provide total care to the patient. Cost! RNs are expensive!

FUNCTIONAL NURSING

Features

This system emerged in 1930s in U.S.A. the functional method of delivering nursing care evolved as a result of world war II because nurses were in great demand overseas and at home, many ancillary personnel were used to assist in patient care. These relatively unskilled workers were trained to do some simple tasks and gain proficiency by repetition. Persons were assigned to complete certain tasks rather than care of specific patients e.g. checking b.p, administering medication. Actually the functional method is a technical approach to nursing care that emphasizes the dependent functions of nursing practice. The available staff of one unit for a particular period of time, are assigned selected functions such as vital signs, treatments, medications. All responsibility of the unit are assigned to selected people according to their expertise.  

• A number of Licensed Practice Nurses (LPNS) and nurse aides were employed to compensate for less number of registered nurses (R.N.S.) who demanded increased salaries.
• Completion of routines and tasks is given more importance.

Nursing Concept/Approach:

Basic nursing care concept (task or work oriented), no specific nursing role, less scope for utilization of holistic nursing process.

Merits:

• The person can become particularly skilled in performing assigned tasks, it can be efficient and economical.
• The best utilization can be made of a persons aptitude, experience and desires.
• Less equipment is needed and what is available is usually better cared for when used only by a few personnel.
• This method saves time because it lends itself to strict organizational protocol.
• The potential for development of technical skills is amplified.
• There is sense of  productivity for task oriented nurse.
• It is easy to organize the work of the unit and staff.

Demerits:

• Client care may become impersonal, compartmentalized and fragmented.
• There is a tremendous risk for diminishing continuity of care.
• Staff may become bored and have little motivation to develop self and others, work may become monotonous.
• The staff members are accountable for the task only the nurse in charge of the unit has accountability for the individual whole clientale.

Challenges and Issues

Lack of individualised and coordinated care. Patient as a person is neglected although

routines were carried out very efficiently.

·         Patients get confused as so many nurses attend to them, e.g. head nurse, medicine nurse, dressing nurse, temperature nurse, etc.

·         Communication gaps may occur because of many nurses involved in doing a specific type of task.

In the modern context this method is good for long-term care settings/hospices with improved coordination, care-planning and communication

TEAM NURSING :

This method of nursing care was introduced in the early 1950s. 1950’s (under grant from W.K. Kellogg Foundation) directed by Eleanor Lambertson at Teachers college, Columbia University in New York. 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. It was developed in an effort to decrease the problems associated with the functional model of nursing care. Many people felt that, despite a continued shortage of professional nursing staff, a patient care delivery model had to be developed that reduced the fragmented care that accompanies functional nursing.

Team nursing was developed because of social and technological changes in World War II drew many nurses away from hospitals, learning haps, services, procedures and equipments became more expensive and complicated, requiring specialisation at every turn. It is an attempt to meet increased demands of nursing services and better use of knowledge and skills of professional nurses.

Team nursing is based on the belief that nursing personnel with different levels of competencies can make an effective contribution to total nursing care. The overall aim is to provide a range of nursing to the individual patient in an efficient and effective way.

A nursing team made up of professional nurses, nursing auxiliaries, and nursing aids. They can work together cooperatively under a well-qualified team leader to provide a range of nursing services which may vary from the very simple to the most complex nursing functions.

A typical nursing team in a ward may include the head nurse, staff nurses, nurse auxiliaries,nursing aids and nursing students.

Team nursing recognizes that within the scope of nursing, there is a differentiation of functions. The spectrum of nursing functions include:

• Simple nursing functions, which require little knowledge, skills and judgement, can be performed by nursing aides who receive on-the-job training.

Intermediate nursing functions of a technical, routine, repetitive type can be carried out by technically-trained nursing personnel.

Professional functions are complex nursing functions, which require expert knowledge, skills and judgement can be performed by a nurse with professional nursing education background.

Team conference is the main aspect of this system. There is better coordination, supervision and efficiency. Potential for high quality care.

Definitions

• Team nursing is based on philosophy in which groups of professional and non-professional personnel work together to identify, plan, implement and evaluate comprehensive clientcentred care. The key concept is a group that works together toward a common goal, providing qualitative comprehensive nursing care.
• Team nursing was designed to accommodate several categories of personnel in meeting the comprehensive nursing needs of a group of clients.

Objective of team nursing

The objective of team nursing is to give the best possible quality of patient care by utilizing the abilities of every member of the staff to the fullest extent and by providing close supervision both of patient care and of the individual who give it.

Line of organization of team nursing

A clear line of organization structure is needed for team nursing to provide a mechanism for horizontal and vertical communication, and an organized pattern is employed.

Functioning of team nursing

The two important points of functioning are:

1. The head nurse must know at all times the condition of the patients and the plan for their care and must be assured that assignments and workmanship contribute to quality nursing
2. The team leader must have freedom to use her initiative and the opportunity to nurse, supervise, and teach unencumbered by the responsibility for administrative detail

Functions of RN

• In the team nursing RN functions as a team leader and coordinates the small group (no more than four or five) of ancillary personnel to provide care to a small group of patients.
• As coordinator of the team, the RN must know the condition and needs of all patients assigned to the team and plan for the individualised care for each patient. (Marquis and Huston, 2003)
• The team leader is also responsible for encouraging a cooperative environment and maintaining clear communication among all team members.
• The team leader’s duties include planning care, assigning duties, directing and assisting team members, giving direct patient care, teaching and coordinating patient activities.
• The team leader assigns each member specific responsibilities dependent on the role.
• The members of the team report directly to the team leader, who then reports to the charge nurse or unit manager.
• Communication is enhanced through the use of written patient assignments, the development of nursing care plans, and the use of regularly scheduled team conferences to discuss the patient status and formulate revisions to the plan of care.
• However, for team nursing to succeed, the team leader must have strong clinical skills, good communication skills, delegation ability, decision-making ability, and the ability to create a cooperative working environment.

 Channels of communication in team nursing

1. Reports
2. Work or assignment conference
3. Patient care conference
4. Written nursing care plan

The greatest single distinguishing feature of team nursing is the team conference. In general, there are three parts to the conference;

• Report by each team member on her patients.
• Planning for new patients and changing plans as needed for others.
• Planning the next day’s assessment.

It is essential that the conference be well planned, brief but comprehensive and interesting. The team leader is the chair person for the conference. They offer opportunity for all personnel to evaluate patient care and solve the problems through team discussion.

According to the basic nursing care concept, the nurse should be an expert on planning and delivering basic nursing care. These aspects of nursing care have to be initiated and controlled by the nurse. The unique function of the nurse is to provide basic nursing care.

Now you need to review the chief characteristics of basic nursing care concept:

·         holistic approach is used to identify nursing care needs

·         physical needs

·         mental and social needs

·         spiritual needs

·         nursing care is based on a helping relationship

·         it is the unique function of the nurse to provide basic nursing care

this aspect of patient care has to be initiated and controlled by the nurse

Features

Effective team work has the following essential characteristics:

• commonly agreed goals
• clear division of labour
• adequate resources, human and material
• supportive and cooperative interpersonal relationships.
•  open, honest communication
• provision for evaluation and improvement.

Nursing Concept/Approach

Basic nursing care, self care concept is also used depending upon various stages of illness. Good scope for utilization of nursing process by the team.

Challenges and Issues

No direct care may be given by the team leader.

·         Individual members may not have comprehensive knowledge about the patient as a whole due to lack of communication.

·         Team members may become too much dependent on the leader for decision-making and may lack autonomy.

·         Nursing care may become fragmented.

·         Good system for critical care, special units, operation theatre, emergency and disaster settings where expert decision-making, planning and delegation by the leader, along with coordination, communication and flexibility in decision-making among the members can produce excellent results.

Advantages:  High quality comprehensive care can be provided despite a relatively high proportion of ancillary staff.

2. Each member of the team is able to participate in decision making and problem solving.

3. Each team member is able to contribute his or her own special expertise or skills in caring for the patient.

 4. Improved patient satisfaction.

 5. Organisational decision making occurring at the lower level.

 6. Cost-effective system because it works with expected ratio of unlicensed to licensed personnel.

7. Team nursing is an effective method of patient care delivery and has been used in most inpatient and outpatient health care settings.

Other advantages:

1. Feeling of participation and belonging are facilitated with team members.

2. Work load can be balanced and shared.

3. Division of labour allows members the opportunity to develop leadership skills.

4. Every team member has the opportunity to learn from and teach colleagues

5. There is a variety in the daily assignment.

6. Interest in client’s wellbeing and care is shared by several people, reliability of decisions is increased.

7. Nursing care hours are usually cost effective.

8. The client is able to identify personnel who are responsible for his care.

9. Continuity of care is facilitated, especially if teams are constant.

10. Barriers between professional and non-professional workers can be minimised, the group efforts prevail.

11. Everyone has the opportunity to contribute to the care plan.

Disadvantages:

1. 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’.

 2. Unstable staffing pattern make team nursing difficult. 3. All personnel must be client centred.

4. There is less individual responsibility and independence regarding nursing functions.

 5. Continuity of care may suffer if the daily team assignments vary and the patient is confronted with many different caregivers.

6. The team leader may not have the leadership skills required to effectively direct the team and create a “team spirit”.

7. Insufficient time for care planning and communication may lead to unclear goals. Therefore responsibilities and care may become fragmented.

Modifications: In an attempt to overcome some of its disadvantages, the team nursing design has been modified many times since its original inception, and variations of the model are evident in other methods of nursing care delivery such, as modular nursing

Modular nursing

Modular nursing is a modification of team nursing and focuses on the patient’s geographic location for staff assignments.

• 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. (Yoder Wise 2003)
• Just as in the team nursing, the team leader in the modular nursing is accountable for all patient care and is responsible for providing leadership for team members and creating a cooperative work environment.
• 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.
• Communication is more efficient among a smaller group of team members. (Marquis and Huston, 2003)
• The success of the modular nursing depends greatly on the leadership abilities of the team leader.

Advantages:  1. Continuity of care is improved when staff members are consistently assigned to the same module

2. The RN as team leader is able to be more involved in planning and coordinating care. 3. Geographic closeness and more efficient communication save staff time.

Disadvantages:  1. Costs may be increased to stock each module with the necessary patient care supplies (medication cart, linens and dressings).

3.      Long corridors, common in many hospitals, are not condusive to modular nursing.

Total Patient Care Features

Most widely used method in hospitals since past twenty five years.

·         A registered nurse is assigned a group of four to six patients in the ward or private rooms depending on the condition of patients. Patient assignment is restricted to one shift. Nursing care is focused on the total person rather than on tasks or procedures.

·         Nurse has greater sense of control, greater autonomy and involvement in patients outcomes.

·         Nurse clinicians roles are best suitable for the system.

·         Nurse learns to be accountable for quality of care, evaluation and improvement. She gets opportunity to make decision autonomously or in consultation with specialist.

Nursing Concepts/Approach

Patient centered approach (problem-oriented or need-based) with incorporation of self-care abilities/deficits. Like primary nursing, this method of patient assignment has a scope for comprehensive/holistic care.

Abdullah (1960) has identified Twenty-one Nursing Problems based on the health needs of

the patients as given below:

Twenty-one Nursing Problems:

1. To maintain good hygiene and physical comfort.

2. To promote optimal activity: exercise, rest and sleep.

3. To promote safety through prevention of accident, injury or other trauma and through the prevention of the spread of infection.

4. To maintain good body mechanisms and prevent and correct deformity.

5. To facilitate the maintenance of oxygen supply to all body cells.

6. To facilitate the maintenance of nutrition of all body cells.

7. To facilitate the maintenance of elimination.

8. To facilitate the maintenance of fluid and electrolyte balance.

9. To recognize the physiological responses of the body to disease condition– pathological, physiological and compensatory.

10. To facilitate the maintenance of sensory functions.

11. To facilitate the maintenance of regulatory mechanism and functions.

12. To identify and accept positive and negative expressions, feelings and reactions.

13. To identify and accept interrelatedness of emotions and organic illness.

14. To facilitate the maintenance of effective verbal and non-verbal communication.

15. To promote the development of productive interpersonal relationships.

16. To facilitate progress toward achievement of personal spiritual goals.

17. To create and/or maintain therapeutic environment.

18. To facilitate awareness of self as an individual with varying physical, emotional and developmental needs.

19. To accept the optimum possible goals in the light of limitations, physical and emotional.

20. To use community resources as an aid in resolving problems arising from illness.

21. To understand the role of social problems as influencing factors in the cause of illness.

The twenty-one nursing problems focus on physical, biological, social and psychological needs of the patient. The problems are identified according to the condition of the patient, and his self-help ability. Self-help ability of the patient refers to the ability of the patient to meet his health care needs. These abilities vary in accordance with the physical, mental and social capacities of the patient.

Challenges and Issues

Main challenge in this method is to ensure competence of each nurse who is responsible for

total care of patients.

·         Nurse may feel overworked if most of her assigned patients are sick.

·         She/he may tend to ‘neglect’ the needs of patient when the other patients ‘problem’ or ‘need’ demands more time.

Need for overall supervision and guidance by the head nurse, especially while developing care plans and giving-taking over. Very good system for general ward and private rooms.

Progressive Patient Care

Features

This system began to take shape in the 1950s with the aim to organise hospital and nursing

services in such a way that the patient receives optimal care according to his/her changing

health needs.

·         Under progressive patient care (PPC) system, medical/surgical care is delivered in various areas or units according to the changing condition or health status of the patient. The set up, policies, and staff allocation is also organized accordingly.

Principal elements of PPC are:

i) Intensive care or critical care: Patients who require close monitoring and intensive care round the clock, e.g. patients with acute myocardial infarction, fatal dysrythmias, those who need artificial ventilation, patients with major burns, premature neonates, immediate post or cardiothoracic, renal transplant, neurosurgery patients will their condition is stable. These units have 9-15 number 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/centres 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/centres. Nurses and other therapists help the patients and family members (residents) coping, ambulation, physical therapy, occupational therapy along with activities of daily living. Patients and family who need long-term care are, cancer patients, paralysed and patients with ostomies

.

v) Home care: Some hospital/centres have home care services. A hospital based home care package provides staff, equipment and supplies for care of patient at home, e.g. paralysed patients, post-operative, mentally retarded/spastic patient and patient on long chemotherapy (tubercolosis).

vi) Ambulatory care: Ambulatory patients visit hospital/centre for follow up,diagnostic, curative rehabilitative and preventive services. These areas are outpatient departments, clinics, diagnostic centres, day care centres, etc.

 Benefits of Progressive Patient Care are:

i) Patient receives specialized attention when they need it.

ii) Patient gets assistance in making adjustment to hospital, home and community.

iii) Nursing personnel can make effective use of special skills and capabilities.

iv) Quantity of nursing services can be increased by use of semi-skilled staff.

v) Quality nursing can be improved.

vi) Hospital can make efficient use of highly skilled personnel and expensive

high-tech equipment.

vii) Hospital can maintain continuity of care.

Nursing Concepts and Approach

PPC system is based upon self-care concept where all nursing systems, i.e. wholly compensatory (acute care), partially compensatory (intermediate care), supportive educative (in all units/areas and especially long term, home care and OPDS). Assist the patient attain SELFCARE while continuity of care is maintained.

Challenges and Issues

Main challenges to make this system most effective are:

i) To improve quality of nursing practice in all its dimensions such as structure (resources), process (nursing care) and outcomes (patient satisfaction and nurses performance).

ii) Proper orientation, education and psychological preparation of client when they are shifted from one unit to another.

Primary Nursing

Primary nursing was developed in the 1980’s by Marie Manthey and the hallmark of this model is that one nurse cares for one group of patients with 24 hour accountability for planning their care. In other words, a Primary Nurse (PN) cares for her primary patients every time she works and for as long as the patient remains on her unit. An Associate Nurse cares for the patient in the PN’s absence and follows the PN’s individualized plan of care. This is a decentralized delivery model: more responsibility and authority is placed with each staff nurse. It has been debated whether PN is a cost-effective model. Some say it is because the RN has all the skills necessary to move the patient through the health care system quickly. Others say it is not cost effective because RNS spend time doing things that other, less expensive employees can do.

Primary nursing is a method of nursing practice which emphasizes continuity of care by having one nurse (often teamed with a nursing assistant) provide complete care for a small group of inpatients within a nursing unit of a hospital. The "primary nurse" is responsible for coordinating all aspects of care for the same group of patients throughout their stay in a given area.

This is distinguished from the practice of team nursing or functional nursing by dividing duties by patient rather than by function (i.e. passing medications, doing treatments, etc.)

Primary nursing concept was envisaged to promote individualized nursing care and to make qualified, registered nurses assume responsibilities for nursing care provided to patients.

Under traditional system of nursing, in a typical hospital ward, the patient is not assigned to nurse for the care that is provided to him during his hospitalization. Nurses carry out nursing functions and no nurse is specifically assigned to assume responsibility for care of patient on a 24-hour basis during hospitalization. Under this system it was difficult to promote accountability for nursing care provided to a patient. Primary nursing concept was developed as a solution to this problem.

Features

Started in 1960s, became popular in 1980s.

·         One registered nurse is responsible for patient care over 24 hour period 7 days a week from the time the patient is admitted to the hospital till the discharge.

·         Primary nurse is assigned the total care of a patient by the head nurse or nursing coordination for initiating and updating the nursing care plan.

·         An associated nurse works with the same patient on other shifts and on the primary nurses’ ‘day off’. The associate nurse carries out the plan established by the primary nurse.

·         Nurses mostly find greater job satisfaction because they have more autonomy and control over the care giver. They can enjoy extended and expanded roles along with traditional role of care giver.

Nursing Concept/Approach

Individualised (problem-oriented/need-based) patient-centred approach, and self care models can be incorporated in this system. Primary nurse can utilize nursing process for holistic assessment and care of clients.

Challeges and Issues

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.

·         Nurses may become possessive of their patients and may not delegate responsibilities when transferred from primary care setting to other settings.

·         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. Need for nursing care standards and protocols for quality assurance.

Advantages:	Increased satisfaction for patients and nurses More professional system: RN plans and communicates with all disciplines. RNs are seen as more knowledgeable and responsible. RNs more satisfied because they continue to learn as a function of the in-depth care they are required to deliver.
Disadvantages:	Intimidating for new graduates who are less skilled and knowledgeable. It may be costly Staffing pattern may necessitate a heavy client load. The nurse may be isolated from colleagues. There is little avenue for group planning of client care. Nurses must be mature and independently competent.

Case Management

Features

Currently used method of patient care:

·         The case manager (Registered nurse 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.

·         Case manager develops a critical pathway for care and treatment that include specific timelines and standard protocols. For example, case manager for cardiac surgery patients assists them go through diagnostic procedures, pre-operative preparations, surgical interventions (hospitalization), family counselling, post-operative care andrehabilitation.

·         The case manager identifies costly delays in diagnosis, hospital days and discusses these with doctors and patients.

·         Case managers are employed by third party payers (e.g. insurance companies) by the hospital authorities (e.g. for heart surgeries, renal transplant, reconstructive surgeries, etc.), by clubs, industrialists and associations or by individuals, e.g. geriatric, family or private patients case managers.

Nursing Concepts and Approach

No direct care by the manager whose main roles are of teaching, advocacy and coordinating with health care providers. Case manager (nurse) ensures quality care that is holistic (Considering patient as a biopsychosocial and spiritual being) and assisting the patient attain self care status according to his/her potential.

Challenges and Issues

There may be opposition from physicians who may see it as a threat on their historic rights of autonomy in decision-making.

Self-care Concept

Features

Orem (1971) developed this concept of nursing which focuses on the individual and his self-care needs. According to Orem, the special concern of nursing profession is man’s need for self-care action in order to sustain life and health, recover from disease or injury, and cope with their effects.

Self-care is the practice of activities that individuals personally initiate and perform on their own behalf to maintain life, health and well-being.

Nursing assistance is required to overcome self-care limitations of individuals, families, and communities.

 There are five methods or techniques of helping:

·         Acting for or doing for another.

·         Guiding another.

·         Supporting another

·         Providing an environment that promotes personal health and development.

·         Teaching another.

According to this concept, there are three basic types of nursing systems as follows:

·         Wholly compensatory nursing system.

·         Partly compensatory nursing system.

·         Supportive-educative system.

Nursing Concept/Appraisal

Basic nursing care (need-based or problem-oriented), utilization of nursing process by the individual nurse or team of nurses.

Challenges and Issues

The major area of concern or problem in self-care concept is the individual’s capabilities regarding complete and effective self-care or dependent care the source of this problem is any state or factor that imposes limitations on self-care or dependent care.

 Palliative Care Concept

The concept of palliative care grew out of pain relief and comfort measures for cancer patients. Since AIDS is a fatal disease with many curable manifestations, the distinction between active, curative treatment and palliation is blurred. As a result definitions of palliative care, define this medical care service as a more holistic one, that begins earlier in the course of a chronic, fatal medical condition.

Palliative care is defined by the ‘World Health Organization (WHO) as “the active total care of patients whose disease is not responsive to curative treatment. Control of  pain or other symptoms, and of psychological, social and spiritual problems, is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families palliative care affirms life and regards dying as a normal process neither hastens nor postpones death  provides relief from pain and other distressing symptoms integrates the psychological and spiritual aspects of care offers a support system to help family cope during the patient’s illness and in their own bereavement.”

Proper delivery of palliative care to the bedside not only is a public health strategy but also promotes the expression of the patient’s wants, needs, and thoughts, helps all to accept the reality of death; and encourages each person to find spiritual meaning in his or her life.

Palliative care can reverse the mechanization of death, achieve therapeutic consensus among patient, family and health professionals, minimize suffering induced by unwanted or futile therapies, balance a scientific outlook with the need to help a specific individual, enhance quality of life, humane the process of dying, and reconcile interpersonal differences. Palliative medicine matches perfectly with the hospice philosophy.

The focus of hospice care is palliative care, not curative treatment. A client entering a hospice has reached the terminal illness and the client, family and physician have agreed that no further treatment could reverse the disease process. An attempt is made to provide care that ensures death with dignity in the client’s home.

Hospice nurses work in institutional and community settings. They are committed to the philosophy and objectives of the facilities for which they work. They provide care and support for the client and family during the terminal phase and at the time of death and continue to offer bereavement counselling and follow-up to the family after the client’s death.

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Advanced Nursing Practice Models

Advanced Practice Nursing (APN) is a label used to describe Master’s prepared, licensed, registered nurses with nationally recognized clinical advanced certification. These professionals include Clinical

Nurse Specialists (CNS), Nurse Practitioners (NPs), nurse anesthetist, and nurse midwives. APNs practice in a variety of settings from community-based primary care clinics to surgical suites and critical care units in tertiary care referral centers. The role of the APN depends on their scope of practice and clinical privileges, which vary by state. Whereas Nurse Practitioners tend to work in

outpatient settings, Clinical Nurse Specialists play important roles in both inpatient and outpatient

environments. Central to the CNS role are core competencies that include clinical expertise,

collaboration, consultation, education, research, and management activities. There is evidence that CNS clinical intervention increases quality of patient care across settings and reduces costs over time by decreasing length of stay, reducing unnecessary tests and procedures, preventing complications, improving collaboration with physicians, and facilitating quality control. In its 1996 study on nurse staffing the IOM found that “high-quality, cost-effective care for certain types of patients, particularly those with complicated or serious conditions, will be fostered by the use of advanced practice nurses.” The IOM recommended that hospitals expand their use of RNs with advanced practice preparation to provide clinical leadership and cost-effective care.

Interprofessional Care Delivery Model

The Interprofessional Care Delivery Model integrates teams of nurse practitioners (NPs) and physicians to deliver care. Research regarding the impact of this model on patient care and outcomes is limited. Schmidt believes that interprofessional care delivery models are most useful in organizations concerned with care coordination, best practice thinking, continuity of efforts of multiple professions, and use of care protocols.

Shared Governance

Shared governance, a philosophy popularized by Porter-O’Grady, is designed to create organizational. Shared governance gives clinical nurses’ control over their practice and can extend their influence into administrative areas that are controlled only by managers. Shared governance structures are comprehensive and complete. In designing a shared governance structure utmost importance must be given to meet the demands of both groups by enhancing cost effective patient care.

Shared Governance in Nursing
Shared governance in nursing is a managerial innovation that legitimises nurses’ control over practice, while extending their influence into administrative areas previously controlled only by managers (Hess, 1998).
Shared governance is necessary to cultivate a professional practice environment for the nurses. Without it, organisations lack innovative and should be passed by majority vote of the entire nursing staff.

Goal of Shared Governance: The goal is to get more nurses involved in their work and profession and to strengthen nursing in the workplace in ways that would empower nursing as a profession and retain the interest of individual members (Porter O’ Grady, 2003).

Principles of Shared Governance: Shared governance is neither a form of participatory management nor management driven.

It has no locus of control. Models should be based on a clinical rather than an administrative organisation. Governance should be representative in nature. Further, the representatives should be elected, not selected. Bylaws should provide a system of checks and balanceshospitals from traditional organisations were nurses’ ability to exercise control over personnel in areas such as hiring, transferring, promoting, and firing personnel; performance appraisals and disciplinary actions; salaries and benefits; and the creation of new positions. Other significant area was nurses’ involvement in staffing, supplies, and budgets.

Increased autonomy, authority and accountability: A 1992 study identified the benefits of using a quality assurance council in shared governance as a method to increase nurse autonomy, authority and accountability.

Improvement in work environment: A 1993 study concluded that improvement in decision making style of managers, professional job satisfaction, and organisational job satisfaction and anticipated turnover was present when shared governance was implemented.

A 1994 study reported a perceived increase in autonomy, communication, decision making and team sense when shared governance was implemented on one intensive care unit

Nurses satisfaction: A 2001 multisite ex post facto co relational study found that nurses working on shared governance units had a more positive composite constructive culture, higher job satisfaction that reflected greater satisfaction with work, professional status, cohesion and administration but lower retention rate than traditional units

Models of Shared Governance

The Councilor model: It is the most frequently implemented model and is based on the decentralisation of professional accountability and an appropriate locus of control. It can be implemented at the departmental and unit levels. The model includes 5 areas of accountability i.e. Practice, Quality improvement, Education, Research and Management.

For each area of accountability a council (decision making body) is formed within the department of nursing with defined powers and accountabilities. Typically, four councils are clinical in nature and fifth is a management council. A majority of practicing staff nurses are members of the clinical councils with a management representative acting as an advisor.

The Management council, which includes the chief nursing officer, nursing service directors, nurse managers, and staff nurses, is chaired by a nurse manager. The manager’s role will move from motivation to empowerment.

The Administrative model : It splits the organisational chart into two tracks with either a management or clinical focus. The membership in both tracks often encompasses both managers and staff as implementation progresses.

Structures that ameliorate high turnover and dissatisfaction among nursing staff. Shared governance uses a decentralized participatory approach to management; staff nurses make decisions impacting their work and working environment, professional development, and personal fulfillment. This contrasts with the more hierarchical and bureaucratic traditional form of governance, under which a head nurse plans, organizes, and controls the administration of the unit and staff. The research is mixed regarding the effectiveness of this approach. Several studies found nurses working in a shared governance environment to have significantly higher job satisfaction than nurses working in a traditional environment. Another study, however, did not support this finding. Further, the sense of increased autonomy associated with greater influence in decision making was not sustained over time. No studies measuring the impact of shared governance on patient outcomes have been found.

Differentiated Nursing Practice

Differentiated nursing practice is a philosophy that focuses on the division of labor required to meet

patient needs, the value of complementary educational preparation and clinical experience, the need for collaboration to maximize effectiveness, and compensation based on academic preparation and

performance.

The goals of differentiated nursing practice include:

 (1) optimal nursing care matching patient’s needs with the nurse’s competencies;

 (2) effective and efficient use of scarce nursing resources;

(3) equitable compensation;

(4) increased career satisfaction among nurses;

(5) greater loyalty to employer; and (6) enhanced prestige of nursing profession.

The American Organization of Nurse Executives, the American Association of Colleges of Nursing, and the National Organization for Associate

Degree Nursing have all endorsed differentiated nursing practice as a way of maximizing scarce nursing resources. Published studies report increased in patient satisfaction, decreased length of stay, and decreased patient cost under differentiated nursing practice.

Most authors report positive or neutral effects on nurse satisfaction.

Journal review :

Bechtel GA, Printz V. conducted a study on Evaluating quality of care using modular nursing on a multispecialty unit. The purpose of this study was to examine performance outcome measures of nurses who work on a general medical unit and those who work on specialized or modular units. A sample of 82 nurses were reassigned to patients in either specialty modules or a general medical unit. Findings suggest that large nursing units staffed according to modular groups based on common diagnosis may improve nursing care quality. Modular nurses assigned to patients on a general medical unit made more medication errors, charted nursing interventions less frequently, and were less likely to provide prompt PRN medication administration. Of concern is the care provided to chronically ill; elderly clients not admitted to a predetermined specialty module received the poorest nursing care. We support development of specialty nursing modules to replace large, general medical units, it does not measure the impact of retention, cost, or other key variables on nurse staffing. We suggest that large medical units be divided into specialty modules and that staff rotation to general medical units be minimized.

Carruth AK, Steele S, Moffett B, Rehmeyer T, Cooper C, Burroughs R conducted on The impact of primary and modular nursing delivery systems on perceptions of caring behavior.using Descriptive, comparative, and correlational studies among Urban, inpatient, acute-care hospital. A convenience sample of 42 patients with cancer hospitalized for chemotherapy administration or complications arising from their diagnoses and 27 of their family members. Ninety-four data sets were collected--62 from the patients and 32 from the family members.  Patients' and family members' perception of caring.  Patient and nursing delivery characteristics were used to predict and explain variance in the dependent variable care. Number of days hospitalized accounted for 14% of the variance, with those patients hospitalized longer rating nurses as more caring. The longer a patient stays in the hospital, the greater the likelihood the patient and family members will feel nurses exceeded exceptions for caring. The findings support other studies that have compared quality care indicators across different types of delivery systems. Measures to evaluate quality care should be used when transitioning to new delivery models. Nurses need to recognize that not all patients value the same nurse qualities equally. When receiving care over an extended period of time from same nurse, patients and family members are more likely to rate the nurse as exceeding expectations.

Bibliography :

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