PATTERNS OF NURSING CARE

DELIVERY IN INDIA

ASSIGNMENTS,
ROTATIONS

ASSIGNMENTS

Nursing care delivery system -based on principles of

fundamental values.
clinical decision making,
Work allocation,
communication, and
management

GENERAL OBJECTIVES
To

provide the patient with the best possible

nursing care.
To plan assignment which are interesting to
nurses and stimulating to their professional
growth.
To run the unit smoothly and efficiently.

EVIDENCE BASED MANAGEMENT

PRACTICES
The efficiency and effectiveness of any system usually is
evaluated by measuring four factors

Quality patient care.

Patient satisfaction.

Nursing job satisfaction.

Cost effectiveness for the health care organization...

NURSE ROLES IN HEALTH CARE DELIVERY

SYSTEMS

Roles for registered nurses include

Advanced practice nurse.
Certified registered nurse anaesthetist.
Clinical nurse specialist.
Certified nurse midwife.
Nurse practitioner.
New role of clinical nurse leader.

NURSING CARE DELIVERY MODELS

The delivery of health care to the patient is a
multidisciplinary process that must take into account
based on:
availability of resources.
educational preparation of the nurse.
competencies of the staff.
needs of the patient.
cost implications for the institution or health system.

PATTERNS
CASE

METHOD OF NURSING
FUNCTIONAL NURSING
TEAM NURSING
PRIMARY NURSING
PROGRESSIVE NURSING
MODULAR NURSING

CASE METHOD OF NURSING

referred

to as total patient care.

The registered nurse is responsible for the patient
and
has total care responsibility for the patient during
the shift worked.
It is the oldest mode of organizing patient care.
The nurse is provided with high autonomy and
responsibility in this method.

Complete care including treatment, medication

administration and nursing care planning is the
assigned nurses responsibility.

WORK ALLOCATION
All patients have a registered nurse assigned to
them,
The case method is frequently practiced in
intensive care setting or in home health setting.

MERITS
Holistic and comprehensive care provided by a
registered nurse.
Co-ordination of all aspect of care
Continuity of care can be facilitated with care.
Client may feel more secure knowing that one
person is thoroughly familiar with the need and the
course of treatment

 Family

and friends become better known by nurse

and get more involved in the care of the client.

Work

load for the unit can be equally divided

among the available staff.

DEMERITS
The cost of registered nurses that is, cost
effectiveness.
Lack of continuity between the shifts.
Nurses are not enough to comply the demand of this
model.
The greatest disadvantage to case nursing occurs,
when the nurse is inadequately trained or prepared

CASE METHOD

STAFFING ASSIGNMENTS IN ICU

Charge nurse (RN)

RN

RN

RN

RN

RN

PATIENT (S)

PATIENT (S)

PATIENT (S)

PATIENT (S)

PATIENT (S)

FUNCTIONAL NURSING
A functional nursing care delivery system is defined
as a task-oriented system
in which individual care givers are not given patient
assignments,
but are expected to perform specific assigned tasks
within their capability for all patients in a given
care.

 This

method of providing care to the patients

involves both licensed nursing staff and unlicensed
assistive personnel.

 Here

nurses are assigned specific functions in the

ward
one group may do hygienic care of the patient,
another group may give medications and
one more group can give treatment like naso
gastric feeding, assisting a physician, changing
intravenous fluids of patients etc.

 Each

member of the working group is highly

depending on others for the completion of groups
total assignment.

The

only one person who has complete

responsibilities of the client is head nurse.

WORK ALLOCATION
The charge nurse (RN) may be responsible for both
administrative and clinical functions such as
taking orders,
contacting physicians for patient needs,
assisting personnel with difficult or emergent patient care
needs,
adjusting staffing schedules and
evaluating or orienting staff.

 The

task of medication administration is usually

assigned to an RN
where there is a shortage of RNs, a licensed
vocational or practical nurse (LVN/LPN) may be
assigned to administer oral and parental
medications
charge registered nurse administers the intra venous
medications.

FUNCTIONAL NURSING

MEDICAL OR SURGICAL
30 BED UNIT

CHARGE NURSE (RN)

MEDICATION NURSE
TREATMENT NURSE

1 LVN

VITAL SIGNS
COMFORT AND HYGIENE
ADLs

2 UAP

30
PATIENTS

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
experience and desires.
Less equipment is needed
The potential for development of technical skills is
amplified.
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 clients.
There is a little avenue for staff development

TEAM NURSING
In

team nursing care delivery system, patients are

assigned to a nursing team, which is usually led by a
registered nurse (RN).
The team may include RNs, LVNs, LPNs,
respiratory therapist etc. Team consists of 6
members and 15 to 25 patients.
Group of professional and non professional
personnel work together -comprehensive client
centred care. -common goal,

WORK ALLOCATION
30 patients -charge nurse or team leaders and
usually 2 to 4 members per team
The

team leader assigns all patients to team

members and may delegate additional tasks
according to the team members competence.

TEAM METHOD

MEDICAL SURGICAL UNIT

CHARGE NURSE (RN)

TEAM
LEADER (RN)

TEAM
LEADER (RN)

TEAM LEADER
(RN)

LVN

LVN

LVN

UAP

UAP

UAP

PATIENTS

PATIENTS

PATIENTS

SPECIFIC CHARACTERISTICS
Commonly agreed goals.
Supportive and co-operative interpersonal relationship.
Is always lead by nurse licensed to practice.
Include the patient in the development and
implementation of care plans where ever possible.
Is changeable and adaptable.
Recognizes and appropriately uses each individual

MERITS
Work load can be balanced and shared, especially when
more patients.
There is variety in the daily assignment.
Interests in clients well- being and care shared by
several people
All care is directed by a registered nurse.
Provides a range of service in an economical way.
Most cost effective

DEMERITS
Establishing the team concept takes time.
Unstable staffing patterns make team nursing difficult.
There is less individual responsibility.
Poor leadership may cause poor quality of nursing care.
Ineffective communication may affect on a quality of
care.
Interpersonal conflicts may affect a quality of care.
Fragmentation of nursing care due to division of work.

MODULAR NURSING
This

method is the modification of team nursing

and focuses on the patients geographic location
for staff assignments.

 The

patient unit is divided in to modules or district

and the same team of care givers 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 LVNs or LPNs and nursing assistants.

 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.

MERITS
Continuity of care is improved when staff members
are consistently assigned to the same module.
The RN as team leader is able to be more involved
in planning and coordinating care.
Geographic closeness and more efficient
communication saves staff time.

DEMERITS
Costs may be increased to stock each module with
the necessary patient care supplies (medication
chart, linens, and dressings)
Long

corridors, common in many hospitals, are not

conductive to modular nursing.

MODULAR NURSING MODEL

NURSE MANAGER

GEOGRAPHICAL
PATIENT UNIT
PATIENT CARE
TEAM
RNs
LVNs/LPNs
NURSE AIDES
MEDS SUPPLIES
LINENS

GEOGRAPHICAL
PATIENT UNIT
PATIENT CARE
TEAM
RNs
LVNs/LPNs
NURSE AIDES
MEDS SUPPLIES
LINENS

GEOGRAPHICAL
PATIENT UNIT
PATIENT CARE
TEAM
RNs
LVNs/LPNs
NURSE AIDES
MEDS SUPPLIES
LINENS

PRIMARY NURSING
a system in which each patient is assigned to a nurse
(registered nurse) who has 24 hour responsibility
for the nursing care delivered to the patient.
An

associate nurse cares for the patient by using

care plan developed by primary nurse, while the
primary nurse is on leave.

 The

associate nurse is excepted to contact

primary nurse regarding changes in the care
plan.

The

aim was to provide the patient and

family with continuous, coordinated and
comprehensive care.

WORK ALLOCATION
24 hour responsibility for the nursing care
The associate nurse (LVN/LPN or UAP.)
hours that the nurse is not present and is also
accountable for the coordination and continuity of
care from admission to discharge.

PRIMARY METHOD

MEDICAL OR SURGICAL 28 BED UNIT

EACH PATIENT
SOCIAL SERVICES
DIETICIAN

PHYSICIAN

PRIMARY NURSE-DAYS 24 HR
RESPONSIBILITY

ASSOCIATE WHEN
PRIMARY NURSE
OFF DUTY

ASSOCIATE NURSE
EVENING

ASSOCIATE NURSE
NIGHT

CHARGE NURSE

PRIMARY METHOD

DAY SHIFT 23 PATIENTS ON 30 BED UNIT

CHARGE NURSE (RN)

PRIMARY NURSE

PRIMARY
NURSE

ASSOCIATE NURSE

5 PATIENTS
5 PATIENTS +
NEW
ADMISSION

5 PATIENTS +
NEW
ADMISSION

PRIMARY
NURSE ON
VACATION

PRIMARY NURSE

3 PATIENTS
+
ACTING AS
ASSOCIATE FOR
2 OTHER
PATIENTS

PRIMARY
NURSE

5 PATIENTS

MERITS
Nursing
accountability,
responsibility
and
independence are increased.
The nurse is able to use a wide range of skills,
knowledge and expertise.
There is opportunity for the nurse to see the client
and family as one system.

MERITS
This method potentiates creativity by the nurse,
work satisfaction may increase significantly.
increased trust and satisfaction by the client
and nurse.
It assures more continuity of care.

DEMERITS
The nurse may be isolated from colleagues.
There is a little avenue for group planning a client care.
Nurses must be mature and independently competent.
It confines a nurses talent to a limited number of
patients so other patients cannot be benefitted.
An inadequately trained primary nurse may be
incapable of coordinating a multidisciplinary team or
complex patient.

PROGRESSIVE NURSING
concept is to organize hospital service in such a way
that the patient receives optimal care according to
his medical and nursing needs.
patients are placed in units on the basis of their needs
for care as determined by the degree of illness
rather than on the basis of medical speciality.

Progressive patient care has been defined as the right

patient, in the right bed, with the right services at the
right time.

GOAL
Primary goal is to raise the level of patient care.
By more effective use of nursing personnel and
facilities by grouping patients according to their
nursing needs.

PRINCIPLES ELEMENTS
Intensive care: this is for critically ill patients
Intermediate care: moderate amount of nursing care
Self care: this is for ambulatory and physically self-sufficient
patients
Long term care: this is for patients requiring skilled and
prolonged medical and nursing care -Eg: fracture cases,
cancer therapy cases.
Home care
Outpatient care

BENEFITS OF PROGRESSIVE PATIENT

CARE
PATIENT
Receive

specialized attention when they needed.

Get assistance in making adjustment to hospital
and later to home and community.

NURSING PERSONNEL
Can make effective use of special skills and
capabilities.
Placement can be made according to skills and
competencies of nursing services
Can deliver increased quantity and improved
quality of nursing services.

HOSPITAL
Can make efficient use of highly skilled personnel
and expensive high tech equipments.
Can enhance the quality of patient care as a result
of effective and efficient use of personnel beds,
physical facilities, supplies and funds.
Can maintain continuity of care and coordinate.

FACTORS TO BE CONSIDERED IN PROGRESSIVE

PATIENT CARE
Degree

of illness.
Time required in meeting the needs.
Degree of activity permitted.
The teaching, rehabilitation, required by each patient.

 The

knowledge and experience of the professional

and non- professional staff in the ward.
Proximity of the patients assigned to individual.
Orientation.
Job description.
Duration of patient care.

MERITS
Equipment and personnel can be used in efficiently.
Clients are in the best place to receive the care they
require.
patient can get better nursing care with minimum cost.
More utilization of medical and nursing skills in ICU

DEMERITS
Patient objected to being transferred between units.
Patient will not get continuous care.
Inadequate observation due to lack of nursing staff.

OTHER CONCEPTS OF NURSING

CARE
EXTENDED CARE
extended or continue care
Client often receives care after an initial crisis
period ends.
A broad continuum of care and assistance is
available.

EXPANDED ROLE OF NURSE

role

which goes beyond the traditional nursing role

to include additional responsibilities and a wide
range of function in the community and clinical care
settings.

This includes expanding their functions

advanced nurse practitioner
clinical nurse anaesthetist
clinical nurse midwives
nurse administration
researcher.
continued education and
Advanced nursing education

NURSE PRACTITIONER
assumes responsibilities of the expanded role to meet
the health care needs of a group in the community.
assumes

delegated medical responsibilities such as

diagnosis and treatment of minor ailments through
standing orders in addition to traditional nursing
responsibilities.

 She

provides a package of preventive, curative and

rehabilitative services for promotion, maintenance
and restoration of health of clients.

NURSE CLINICIAN
who was competent in care and knowledgeable
about cure.
Clinically competent in carrying out care function
and counselling functions.

ROTATIONS

 Clinical-important

to successfully apply the

concepts of nursing to clinical

theoretical
situations.
it is also a great learning opportunity.
There are several things to keep in mind in order to
excel during nursing clinical rotations.

The goals
to integrate skills and knowledge
to learn about the complex health issues of critically ill
patients,
practice selected technical skills, and
develop communication skills.
Employee's motivation
individual growth, involving improvement of employee
expertise and skills.
career development

to experience in a new area of work and to

develop new competencies and
to transfer fresh ideas from one clinical area to
another area.

 The

length of rotations varies.

The shift may also vary.
Some work day shift while others may to work
evening or night shift.
Shifts are usually either eight or 12 hours.
After you complete one rotation, you will be
assigned to your next one.

What to do during clinical rotations

Be

on time every shift

if any issues at a clinical site, talk with head
Adhere to the dress code
Prepare
Ask and answer questions
If dont know something, dont fake it
Ask what can do to help

What not to do during nursing rotations

Dont

shy away from procedures

Nobody likes a complainer
Stay out of hospital gossip
Dont forget manners

Rotation of staff will be based on the

following procedure :
To train,
update

the quality of nursing services in all

departments and
to be professionally skilled in the services of the
nurses in each stream.

Rotation of staff will be based on the

following procedure :
The rotational idea incorporates a number of
themes:
professional development,
continuing education,
support mechanisms,
rewards and incentives.

Rotation of staff will be based on the

following procedure :

Nursing

Supervisor of the concerned department

will orient / train the Staff Nurses who are on
rotation.

Rotation of staff will be based on the

following procedure :
The

Nursing Supervisor should be well organized

and be available with the staff to provide adequate
guidance.
The staff will be rotated departmental wise
The rotation will be planned based on the
individuals year of joining
Staff may be required to change shifts at short
notice to ensure safe staffing levels..

Rotation of staff will be based on the

following procedure :
The

size of the department,

bed occupancy,
work load of the particular area
will be considered for staff rotation. the duty
schedule.

Rotation of staff will be based on the

following procedure :
The

time schedule of the Staff Nurses will remain

the same
ex: for the shift duty 8:00 a.m. to 2:00 p.m.;
2:00 p.m. to 8:00 p.m. and
8:00 p.m. to 8:00 a.m. respectively.
The

hours and offs (deduction of leaves) will remain

same as per the cadre of the duty schedule.

Example
Team 1: DDOODDD-OODDOOO-NNOONNN-OONNOOO
Team 2: NNOONNN-OONNOOO-DDOODDD-OODDOOO
Team 3: OONNOOO-DDOODDD-OODDOOO-NNOONNN
Team 4: OODDOOO-NNOONNN-OONNOOO-DDOODDD
Where
D=Day shift,
N=Night shift, and
O=Off duty

Staff Welfare Activities

CNE-

Continuing Nursing Education

Annual Departmental Retreats
Counseling
Orientation - induction program.
Deputed for Workshops/ Conferences conducted
within the country and overseas.
Encouraged to participate in TNAI programs

Staff Welfare Activities

Rest

rooms are provided for the nursing staff to

rest after their second shift duties.
Staff children are sponsored for education for
various courses provided in our institution.
Medical benefits for staff and their family
members.