PATTERN

OF
NURSING
DELIVERY IN INDIA

CARE

INTRODUCTION:As nursing has evolved over a period, nursing is still focused on caring. Rapid
technologic advances , knowledge explosion, emphasis on quality cost effectivenessaccessibility of health care and increased demand by the patients for advanced alternative health
care modalities present many challenges for nursing profession.
How are nurses responding to these challenges? .So how can we best utilize professional
nurses across various practice settings? The answer for this question is that it is possible by
reshaping organizational (administrative) policies and developing such system of nursing care
delivery as best suited to client needs.
MEANING OF NURSING CARE DELIVERY SYSTEM:A system may be defined as a 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 out come.
The nursing care delivery system means 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.
There are various types of nursing care delivery system include case method, functional
method, team nursing, primary nursing, modular nursing, nursing care management, patient
focused care.

PRINCIPLES OF NURSING CARE DELIVERY :i)

ii)
iii)
iv)
v)
vi)

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 nursing care according to clients
needs
The aspect of patient care has to be initiated and controlled by nurse
There should be justification for selecting each delivery system
Before planning care organizational policies to be considered

Means of organizing nursing care(managing resources Tappen,page 252)

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I ) CASE METHOD
The case method or total patient care method of nursing care delivery is the oldest
method of providing care to a patient. The premise of the case method is that one
nurse provides total care to one patient during her entire work period of one shift.This
method was used in the era of Florence nightingale when patient received total care
in the home. That time nurses were hired and they lived with in the family of the
patient provided 24 hrs care to patient and even family including cooking and
cleaning. But the case method developed over the years to the specialty of private
duty nursing especially in critical care nursing where one nurse cared one or two
clients.
.
Model analysis:During an 8-12 hour shift the patient receives consistent care from one nurse. The
nurse , patient , family share mutual trust and work together toward specific goals.
Usually the care is patient centered, comprehensive, holistic and continuous

Areas where this method can be used:Community health agencies often use this method to assign cases to individual nurses
, intensive care agencies and also nurse educators often select this method of care
when students are assigned for caring patients
Organization of the case method-model(Leadership-A.Bernhard page-43)

REGISTERED
NURSE

PATIEN
T

IMPORTANT POINTS REGARDING CASE METHOD;

Oldest mode of organizing patient care

It involves the assignment of one or more patients to a nurse for a specific
period of time. Complete care including treatment, medication administration
etc
Nurses assume total responsibility for meeting all the needs of assigned
patients
Widely used in hospitals and in nursing homes
Students , private duty nurses and specialty units like icu,iccu etc make use of
this system
Merits:Nurse can see better and attend to the total needs of the patient
Continuity of care can be facilitated
Client or nurse interaction and rapport can be developed
Client may feel more secure
Family friends become more known by nurse and get more involved
Equal work load
Demerits;Many clients do not require the inherent care
Must be modified if non professional health workers are used
Great disadvantage when nurse is inadequately trained
Cost effectiveness

Nurse Manager role:-

o The nurse manager must consider the expense of the system

before arranging the staff
o Arrange skilled and qualified nurse so that she could manage all
the care of the person
o The manager also need to identify the level of education and
communication skills of all staff.
o Arrange for continuing education and in service education for the
personnel
Staff nurses role: Provide holistic care to assigned patient during a defined work period
Assessment and teaching the patient and family
FUNCTIONAL NURSING
This system emerged in 1930s in USA
Meaning:Individual care givers are assigned to specific tasks rather than being
assigned to certain patients or clients . It is based on a division of labour similar
to an assembly line
This model is also referred to as task method . Functional nursing evolved
during the depression when RNs went from being private practitioners to
becoming employees for the job security
Origin:Once world war II was broke out resulted in severe shortage of nurses in
US. Many nurses entered the military to care for the soldiers. To accommodate
this shortage, hospitals increased their usage of auxiliary personel.
Functional nursing is a method of providing patient care by which each
licensed and unlicensed staff members perform specific tasks for a large group of
patients. For example RN may administer all intravenous medications one
LPN /LVN may give treatments another LPN /LVN may give all oral
medications , One assistant may do all hygienic tasks, and another assistant may
take all vital signs. The nurse become expert in the particular task she is
performing.
A charge nurse co-ordinates care and assignments and may ultimately be
the only person familiar with all the needs of any individual patient.
The key idea was nurses to be assigned for tasks not to the patient

Functional method of nursing care delivery (Leadership-A.Bernhard page-44)

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Important points:

Merits:-

In 1930s when few registered nurses and only some practical nurses
available , much patient care was given by nursing aids.
RNs were keep busy with managerial and non-nursing duties and nurses aids
eliver the majority of patient care
The functional method of delivering nursing care evolved as a result of world
war II as the lack of graduate , registered nurses became critical
Auxiliary personnel were used to assist in patient care
Unskilled workers were trained and assigning persons to complete certain
tasks ,Eg; checking BP, changes linen, patients etc
As a whole the nurses were assigned for certain tasks, not to patients

Demerits:-

Person can become particularly skilled in performing assigned tasks

The best utilization of personnel can be done
Less equipment is needed
Saves time
Potential for development of technical skills is amplified
There is a sense of productivity for the task oriented nurse
It is easy to organize the work of the unit and staff
Task oriented and time saving
Reduced work load to the registered nurses.

o Client care become impersonal

o Diminishing continuity of care
o Staff may become bored and have little motivation to develop self and
others.
o Work may become monotonous
o Less accountability for the nurse
o Lack of professional development
o Client may tend to feel insecure and inconvenient
o Only parts of the nursing care plan are known to personal
Where the model is commonly used;
In certain hospital wards, nursing homes,nurse consultants,
operating rooms.
Nurse managers role: The nurse manager must be sensitive to the quality of patient care delivered
and the institutions budgetary constraints
Achieving patient outcome is her responsibility
Improve the staffs perception of their lack of independence
Rotate assignments among staff , to alleviate boredom with repetition
Conduct staff meeting frequently to encourage staff staff to communicate
about patient care And unit functions.
Staff nurses role:o They are skilled at the task which is assigned
o Complete the task in an efficient and economical manner
TEAM NURSING
Meaning:Team nursing is the delivery of nursing care by a designated groupof
staff members including both professional nurses and non-professional staff .
This method of nursing care was introduced in early 1950s . It was
designed by
Several elements are considered necessary;
1. Team leader is the delegated authority to make assignments for team members and
guide the work of the team. The leader of the team should be a registered nurse, not a
practical nurse
2. The leader is expected to use a democratic or participative style in interactions with
team members.
3. The team is responsible for the total care given to an assigned group of patients or
clients.
4. Communication among team members is essential to its success, and includes written
patient care assignments , nursing care plans, reports to and from
the
team
leader, team conferences in which patient care problems
and
team concerns
are discussed, and frequent informal feedback among team
members.
Team nursing was created at the end of World War II to make the best
use of the limited nursing staff available and alleviate the problems

created by the functional method . As more workers with minimum on

the- job training were hired in the healthcare field, it became
necessary to reorganize the delivery of care . It was also hoped that the
use of team nursing would increase both staff and patient satisfaction
and improve the quality of care.
In team nursing , a team leader is responsible for
coordinating the group of licensed and unlicensed personnel to provide
patient care to a small group of patients. The team leader is a highly
skilled leader , manager , and practitioner who assigns each member
specific responsibilities according to role , licensure , education,
ability, and the complexity of the care required.
The members of the team report directly to the team
leader , who then reports to the charge nurse or init manager . There
are several teams per unit , and patient assignments are made by each
team leader . 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 patient status
and formulate revision to the plan of care.

Model of a team nursing:(nursing leadership and managementTappen , page 252)

CHARGE NURSE RN

TEAM
LEADER RN

RN

LVN

GROUP OF
PATIENTS

TEAM
(RN)LEAD
ER

N
A

RN

LVN

RN

GROUP OF
PATIENTS

Important points
After the 2nd world war RN were still scarce , although the number of
auxiliary personal had increased.
It was introduced during the 1950s
To improve nursing service by giving the knowledge and skill of
professional nurses , and supervise the work of auxiliary nurses . the result
was an improvement in patient and self satisfaction.
Auxiliary personal collaborate in providing care to a group of patients
under the direction of a professional nurse.
Based on the philosophy that supports the achievement of goals through
group actions
Team is lead by a professional or technical nurse who plans , interprets,
co-ordinates , supervise and evaluates the nursing care
Responsibilities of team leader: Team leader assign team members to patients by matching patients needs
and staff knowledge and skill.

Advantages:-

Knowing condition and needs of all assigned patients

Duty vary according to work load, I,e assisting the members and giving
direct care to patients.
Planning and conducting the conference.
Improved patient satisfaction
Cost effectiveness for the agency
Care is less fragmented because of the increased
communication and extensive co-ordination efforts of team
leader
Allows comprehensive , holistic nursing care when the team
function best.
Good interpersonal relationships among staffs and with the
patients
Satisfaction to the patient and the nurses

Disadvantages:

Continuity of care is not given

Changing team membership makes it difficult for the team leader
to assign the patient.
Team nursing requires a great deal of co-operation communication
from all staff members
The large number of people attending the same patient is causing
some discomfort to the patient.

MODULAR NURSING
It is a modification of team nursing In modular nursing , staff are
geographically assigned to patients for whom they co-ordinate and provide comprehensive care.
It focuses on geographic location of patient rooms and assignment of staff members.
It was developed by Magargal in 1987
Delivery model:The total unit is divided in to modules or districts and the same team of staff is assigned
consistently to the module. Modular nursing is enhanced when nursing units are physically
designed and built with this nursing delivery system in mind but it can also be used in nursing
units that are not so designed. Each module has a modular, or team leader RN, who assigns the
patient to module staff
Each module ideally consists of at least one RN, one LPN/LVN and one nursing assistant.
A charge nurse will co-ordinate the work of all the modules in a unit. She expects the module

leaders to be accountable for patient care but assist in problem solving when necessary. Staff
nurses work independently or together, depending on the size of a modular districts . Modules
may have same or different number of patients

Responsibilities of charge nurse / head nurse; Assign patients to different modules

Co-ordinate the work schedule and supervises all care on the unit
Make patient care assignments, and there by maintain continuity of care.
Assist in problem solving when necessary
Responsibilities of modular or team leader: Assigns patient to module staff
Co-ordinate the module activity
Accountable for the care and to the charge nurse
Communicate with other modules
Model of modular nursing: nursing leadership and managementTappen , page 252)

Head
nurse

District
leader
(RN)with
patients
RN,LPN/LVN,

patients

District leader
(RN)with
RN,LPN/LVN,AN

Advantages: Increased continuity of care

Geographic closeness of the modular system saved nursing time
Better communication and co-operation among staff
Easier for less experienced nurses because they have other nurses directly
available to them for support
Patients are more secured
Disadvantages:
Less accountability

Less direct nurse-to-nurse communication and accountability

If patient changes room , he will also changes nurses , so patient satisfaction may be less

Its a costly method as it should have a redesign of the work environment to allow
medication cart , supplies and charts to be located in each module.

Primary nursing
Primary nursing developed by Manthey at al in 1970 as a method for
organizing patient care delivery in which one RN functions autonomously as the
patients primary nurse through out the hospital stay . This method is based on the
concept of my patient-my nurse In this nursing care delivery system, each
registered nurse is assigned to the care of group of patientfor which she plans
complete 24 hrs care and writes the nursing careplan.
The primary nurse cares for her patients every time she works for as long as
the patient stay on her unit.(ideally from admission to discharge) .When she is not
there , an associate nurse who will follow the primary nurses careplan is assigned
to the care of primary nurses patient . The primary nurse is intensively involved
with the patients. Licensed practical nurses function as associate nursesand are
supervised by the head nurse. When nursing assistants are used in primary nursing
system , they are generally assigned to assist primary and associate nursesby
doing specific tasks for each nurse they assist.

Model of primary nursing;- nursing leadership and managementTappen , page 252)

patient

Communicat
e Associate(days)
with
when
primary nurse
supervisers
is not available

Total patient
care
24hr/day
Associate
Primary nurse
(evenings)
when
primary nurse is

Associate
Consults
(nights)when
withphysicians
primary
nurse is
or other
health

Advantages:o Satisfaction for both patients and nurses

The relationship between nurses and patient is intimate
Autonomy for the nurses
Nurse is the person who is planning and providing complete care
She communicates with all other health team members involved in client care
Other health team members including physician tend to view her more knowledgable and
responsible
Patient receives quality and continuity of care
Reduces the number of errors than can result from a relay of orders
Increased satisfaction both to patients and nurses
Nurse can identify patient outcome as a result of their work
Demerits:Nurse may be isolated from colleagues
Nurses talent to a limited number of patients
Nursing care plan can be changed only with the permission of primary nurse
Creates separation anxiety in patients when nurse
Nurses should be well educated and trained in all area of patient care , most of the time
which may lack

CASE MANAGEMENT:Case management is considered as the newest type of nursing care delivery system
developed in 1985 as an outgrowth of primary care , nursing case management is a model
used to co-ordinate the care , maintain quality, and contain cost while focusing on the
outcomes of care

 Nursing case management is a collaborative activity that focuses on

comprehensive assessment and intervention and holistic care planning with appropriate
referrals to meet the health care needs of the patient and family.
The success of nursing case management models has been demonstrated in all
health care settings including acute, sub-acute or ambulatory settings long term care
facilities , in health insurance companies and in community.
Model of nurse case management:- nursing leadership and
management-Tappen , page 252)

Nursing administration

Medical
nurse
case
manage
All medical
pts

Pediatric
nurse
case
manager
Pediatric pts

OB nurse
case
manager
manager
All Ob
patients

Trauma nurse
case
manager

All trauma pts

Role of nurse case manager: Delivers client focused and outcome oriented care
Cost effective care through integration of clinical services in combination
with
financial services
Serves as an advocate for patient and family
More patient and nurse satisfaction is achieved through
intensive care
They attend to a specific high risk population
Advantages: Patient receives high standard care
Nurse is highly qualified and skilled in the particular area,
More satisfaction to the patient
Increased professional standards can be developed by the
nurses
Disadvantages: Sometimes discomfort to clients
Continuity care is difficult
Long time nurse patient relationships are difficult to arrange
Costly
Time consuming

 No proper attachment between nurses and patients

Factors influencing nursing care delivery system: Availability of adequate staff in wards or units
Patient census
Extend of staff deficiency
Organizational policies regarding its practice
Patients preferences for care
Availability of skilled staff
Opportunities for continuing and inservice education to the
staffs
Budget of the organization
Socio economical condition of the patient
The organizations mission
Patient and community needs
CONCLUSION:No single nursing care model works in all settings, or even necessarily
across a single multiservice settings. Before selecting a model nurse
manager must consider all the influencing facors.For a better care effective
selection and mixing of these methods are essential. All the models should
be evaluated periodically for its appropriateness to ensure safe and
effective nursing care.