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Organizing nursing services and patient care

  2. 2. “A hospital may be soundly organized, beautifully situated and well equipped, if the nursing care is not of high quality the hospital will fail in its responsibility”. Nursing service is the part of the total health organization which aims at satisfying the nursing needs of the patients/ community. In nursing services, the nurse works with the members of allied disciples such as dietetics, medical social service, pharmacy etc in supplying comprehensive program of patient care in hospital.
  3. 3.  The nursing service as the part of the total health organization which aims to satisfy major objective of the nursing services is to provide prevention of disease and promotion of health. -WHO expert committee on nursing –
  5. 5.  The quality in nursing care and management of nursing services is achieved through professional nurses who assist in the development of comprehensive programs of delivering nursing care. ♦ The quality of nursing care services is clearly and directly related to continuing growth and development of nursing personnel.
  6. 6.  High quality of nursing care can be best provided by a mixture of professional and non professional personnel who are organized into self directed work teams.  To ensure continuous improvement of nursing care quality, the role of professional nurse must include responsibility of nursing research and nursing education.
  7. 7.  Initiate a set of human relationships at all levels of nursing personnel to accomplish their job and responsibilities through systematic management process by establishing flexible organizational design.  Establish adequate staffing pattern for rendering efficient nursing service to clients and its management.
  8. 8.  Develop or revise proper job description for nursing personnel at all the levels and all units for proper delivery of nursing care.  Share nursing information system with other discipline functionaries in the hospital.
  9. 9.  Develop and implement proper communication system for communicating policies, procedures and updating advance knowledge.  Develop and initiate proper evaluation and periodic monitoring system for proper utilization of personnel.
  10. 10.  Assist the hospital authorities for preparation of budget by involvement.  Participate in interdepartmental programs and other programs conducted by other disciplinaries for improvement of hospital services.
  11. 11.  To assist the individual patient in performance of those activities contributing to his health or recovery that he would otherwise perform unaided has had the strength, will or knowledge.  To help and encourage the patient to carry out the therapeutic plan initiated by the physician.
  12. 12.  To assist other members of the team to plan and carry out the total programme of care. The organization of nursing care constitutes a subsystem for achieving the hospital’s overall objective. Nursing care of patients generally takes forms:  Technical  Educational  Trusting relationship
  13. 13. DIRECTOR (hospital) SERVICE Chief Nursing Officer Nursing Superintendent Assistant Nursing Superintendent Ward Sister - Clinical Supervisor Staff nurse- Student nurse
  14. 14. DIRECTOR OF HEALTH Asst. Director of Health Service Nursing Superintendent Grade-I Nursing Superintendent Grade-II Head Nurse Staff Nurse
  15. 15. ♠ Lack of adequate training. ♠ Problem of personnel management. ♠ Inadequate number of nursing staff. ♠ Shortage of trained manpower. ♠ Lack of motivation. ♠ No involvement in planning. ♠ No career mobility. ♠ Poor role model.
  16. 16. ♠ No research scope. ♠ Professional risk/hazards. ♠ No autonomy in nursing activities.
  17. 17.  Shortage of nurses.  Lack of motivation.  Negative attitude.  Lack of training.  Lack of team approach.  Inactive participation of program  Lack of interpersonal relationship  Less involvement in patients care by the nursing supervisors.  Lack of supervision.
  18. 18. DEFINITION OF PATIENT CARE o The services rendered by members of the health profession and non professionals under their supervision for the benefit of the patient o The prevention, treatment and management of illness and the preservation of mental and physical well-being through the services offered by the medical and allied health professions.
  19. 19.  Patient classification system (PCS), which quantifies the quality of the nursing care, is essential to staffing nursing units of hospitals and nursing homes. In selecting or implementing a PCS, a representative committee of nurse manager can include a representative of hospital administration. The primary aim of PCS is to be able to respond to constant variation in the care needs of patients.
  20. 20.  Differentiate intensity of care among definite classes.  Measure and quantify care to develop a management engineering standard.  Match nursing resources to patient care requirement.  Relate to time and effort spent on the associated activity.  Be economical and convenient to repot and use.
  21. 21.  Be mutually exclusive, continuing new item under more than one unit.  Be open to audit.  Be understood by those who plan, schedule and control the work.  Be individually standardized as to the procedure needed for accomplishment.  Separate requirement for registered nurse from those of other staff.
  22. 22.  The system will establish a unit of measure for nursing, that is, time, which will be used to determine numbers and kinds of staff needed.  Program costing and formulation of the nursing budget.  Tracking changes in patients care needs. It helps the nurse managers the ability to moderate and control delivery of nursing service
  23. 23.  Determining the values of the productivity equations  Determine the quality: once a standards time element has been established, staffing is adjusted to meet the aggregate times. A nurse manager can elect to staff below the standard time to reduce costs.
  24. 24.  Enhance staff satisfaction through stress free work environment.  Ensure that quality of nursing care is provided in safe environment
  25. 25.  The first component of a PCS is a method for grouping patient’s categories. Johnson indicates two methods of categorizing patients. Using categorizing method each patient is rated on independent elements of care, each element is scored, scores are summarized and the patient is placed in a category based on the total numerical value obtained.
  26. 26.  Johnson describes prototype evaluation with four basic categories for a typical patient requiring one –on- one care. Each category addresses activities of daily living, general health, teaching and emotional support, treatment and medications. Data are collected on average time spent on direct and indirect care.
  27. 27.  The second component of a PCS is a set of guidelines describing the way in which patient will be classified, the frequency of the classification, and the methods in each category  The third components of a PCS is the average amount of the time required for care of a patient in each category
  28. 28.  Administrative tool that aims to provide quality patient care and the degree of nursing care requirements. The PCS is referred as patient acuity system. Thus PCS is used to assist nurse administrators to determine workload of nurses and staffing needs.
  30. 30.  Descriptive System This is purely subjective system wherein the nurse selects which category the patient is best suited.  Checklist System Another subjective system, wherin the patient is assigned to a numerical value based on the level of activity in specific categories. The numerical values are added up to give the nurse an overall rating.
  31. 31.  Time Standards System This is the another method where the nurse assigns a time value based on the various activities needed to be completed for the patient. This time value is sum up and converted to an acuity level. Among these three, the most commonly used is the descriptive kind of PCS.
  32. 32.  DEFINITION OF ASSIGNMENT Assignment is defined as a written document of assigning of tasks to render patient care for a group of patients by trained nursing personnel working in that ward.
  33. 33.  To distribute the work to be done for patient care to nursing staff.  To ensure the cooperation of nursing personnel by knowing and accepting of the work to be done.
  34. 34.  Patient assignment should be done by the head nurse or nurse in charge for each individual nurse assigned in that unit.
  35. 35. Planning Assigning Leading Evaluating Reporting
  37. 37.  It is one of the oldest methods of organizing patient care.  It means the assignment of one or more patients to a particular nurse for a specific period of time  She is responsible for the complete care including assessing vital signs, general nursing measures, treatment, medication administration nourishments and imparting health education etc  Mostly used in hospital and in nursing homes, private duty nurses and specialty units etc.
  38. 38.  Ensure comprehensive care by meeting total needs of patients  More individualized nursing care is facilitated.  Continuity of care can be facilitated  Patient nurse interaction can be developed  Patient and family feel more safe and develop trust in nurse
  39. 39.  Equal workload for nurses is possible.  Better patient education  Patient receives totality of care  Enhance patient satisfaction  Enhance nurses satisfaction
  40. 40.  Many patient do not require the inherent care.  Qualified nurses are always not available.  cost-effective
  41. 41.  Emerged in 1930s in USA during world war II when there was a severe shortage of nurses in US  It is task focused, not patient focused.  In this model, the tasks are divided with one nurse assuming responsibility for specific tasks.  For e.g.: one nurse dose the hygiene and dressing changes, where as another nurse assumes responsibility for medication administration.
  42. 42.  Each person become very efficient at specific tasks and a great amount of work can be done in a short time (time saving).  It is easy to organize the work of the unit and staff.  The best utilization can be made of a person’s aptitudes, experience and desires.  The organization benefits financially from this strategy because patient care can be delivered to a large number of patients by mixing staff with a large number of unlicensed assistive personnel.
  43. 43.  Client care may become impersonal, compartmentalized and fragmented.  Continuity of care may not be possible.  Staff may become bored and have little motivation to develop self and others.  The staff members are accountable for the task.  Client may feel insecure.
  44. 44.  Developed in 1950s because the functional method received criticism, a new system of nursing was devised to improve patient satisfaction.  It is a method of nursing assignment that comprises of all personnel involvement in care of patient.  This method utilizes all professional, technical and nursing aids into small teams efficiently and effectively for patient care.
  45. 45.  Team nursing is based on philosophy in which groups of professional and non-professional personnel work together to identify, plan, implement and evaluate comprehensive client-centered care.  The charge nurse delegates authority to a team leader who must be a professional nurse.  This nurse leads the team usually of 4 to 6 members in the care of between 15 and 25 patients.  A conference is held at the beginning and end of each shift to allow team members to exchange information and the team leader to make changes in the nursing care plan for any patient.
  46. 46.  High quality comprehensive care is possible by team nursing by utilizing all members in the team.  Team members actively participate in decision- making for care and imparts their own expertise in improving patient care
  47. 47.  When the team assignment changes every day, it affects the continuity of care.  Team nursing fails when the team leader have inadequate leadership skills.  It becomes difficult for the team leader to assign the patient during changing team membership.
  48. 48.  Modular nursing is a modification of team nursing and focuses on the patient’s geographic location for staff assignments.  In modular nursing assignment, technical and nurse aides, as well as professional nurses are involved.  The concept of modular nursing calls for a smaller group of staff providing care for a smaller group of patients.
  49. 49.  The goal is to increase the involvement of the RN in planning and coordinating care.  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.  The team leader is accountable for all patient care and is responsible for providing leadership for team members and creating a cooperative work environment.
  50. 50.  Continuity of care is improved  Professional nurse become more responsible and engaged in planning, coordinating and collaborating care.  Develop leadership skill among professional nurse.  Nurses identify more opportunity to learn and to teach  Patients feels secure as they are well aware of the nurses under whom they are cared.  Work load can be balanced and shared. 
  51. 51.  Costs may be increased to stock each module with the necessary patient care supplies (medication cart, linens and dressings).  Establishing the team concepts takes time, effort, and constancy of personnel.  Unstable staffing pattern make team difficult.  The team leader must have complex skills and knowledge.
  52. 52.  It is a method in which client care areas provide various levels of care.  The central theme is better utilization of facilities, services and personnel for the better patient care.  Here the clients are evaluated with respect to all level (intensity) of care needed.
  54. 54.  Intensive Care Or Critical Care:  Patients who require close monitoring and intensive care round the clock.  These units have 9-15 numbers of beds, life-saving equipment and skilled personnel for assessment, revival, restoration and maintenance of vital functions of acutely ill patients
  55. 55.  Nursing approach in these units is patient-centered.  E.g. Patients with acute MI, fatal dysarythmias, those who need artificial ventilation, major burns, premature neonates, immediate post or cardiothoracic, renal transplant, neurosurgery patients.
  56. 56.  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.
  57. 57.  Convalescent and Self Care:  Although rehabilitation programme begins from acute care setting, yet patients in these areas 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.
  58. 58.  Long-term care:  Chronically ill, disabled and helpless patients are cared for in these units.  Nurses and other therapists help the patients and family members in coping, ambulation, physical therapy, occupational therapy along with activities of daily living.  Patients and family who need long-term care are, cancer patients, paralyzed and patients with ostomies.
  59. 59.  Home care:  Some hospital/centers have home care services.  A hospital based home care package provides staff, equipment and supplies for care of patient at home.  E.g. Paralyzed patients, post-operative, mentally retarded/spastic patient and patient on long chemotherapy.
  60. 60.  Ambulatory care:  Ambulatory patients visit hospital for follow up, diagnostic, curative rehabilitative and preventive services.  These areas are outpatient departments, clinics, diagnostic centers, day care centers etc.
  61. 61.  Efficient use is made of personnel and equipment.  Clients are in the best place to receive the care they require.  Use of nursing skills and expertise are maximized.
  62. 62.  Clients are moved towards self care, independence is fostered where indicated.  Efficient use and placement of equipment is possible.  Personnel have greater probability to function towards their fullest capacity.
  63. 63.  There may be discomfort to clients who are moved often.  Continuity care is difficult.  Long term nurse/client relationships are difficult to arrange.  Great emphasis is placed on comprehensive, written care plan.  There is often times difficulty in meeting administrative need of the organization, staffing evaluation and accreditation.
  64. 64.  It was developed in the 1960s with the aim of placing RNs at the bedside and improving the professional relationships among staff members.  The model became more popular in the 1970s and early 1980s as hospitals began to employ more RNs.  It supports a philosophy regarding nurse and patient relationship
  65. 65.  It is a system in which one nurse is caring for all the needs of a patient or more within a 24 hour from admission to discharge.  He or she is responsible for coordinating and implementing all the necessary nursing care that must be given to the patient during the shift.  If the nurse is not available, the associate nurse responsible for filling in for the nurse’s absence will provide hospital care to the patient based on the original plan of care made by the nurse.  In acute care the primary care nurse may be responsible for only one patient; in intermediate care the primary care nurse may be responsible for three or more patients This type of nursing care can also be used in hospice nursing, or home care nursing. 
  66. 66.  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.  Primary nurses are in a position to care for the entire person- physically, emotionally, socially and spiritually.
  67. 67.  High patient and family satisfaction  Promotes RN responsibility, authority, autonomy, accountability and courage.  Patient-centered care that is comprehensive, individualized, and coordinated; and the professional satisfaction of the nurse.  Increases coordination and continuity of care.
  68. 68.  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.
  69. 69.  May create conflict between primary and associate nurses.  Stress of round the clock responsibility.  Difficult hiring all RN staff  Confines nurse’s talent to his/her own patients
  70. 70.  It is a patient assignment method described as a process of monitoring an individual patients health care by the case manger, with the objective of optimizing positive patient care outcomes and cost effectiveness.  To become a case manager she or he should be graduate professional nurse or advance level prepared nurse practitioner.
  71. 71.  The case manager role warrants not only advanced nursing skills but also advanced managerial and communication skills  Case management is the coordination and collaboration of services rendered on behalf on an individual patient who is considered a case in different settings such as health care
  72. 72.  For the patient  A standards or expected nursing care is achieved for the patient.  The hospital length of stay of the patient is reduced.  Using the minimal resources, maximal healthy care outcome is achieved.  Enhance continuity of patient care through collaborative practice of diverse health professionals.  Patient are moved towards self-care, independence is fostered where indicated.
  73. 73.  For the nurse  Professional development and job satisfaction.  Facilitates the transfer of knowledge of expert clinical staff to novice staff.
  74. 74.  Continuity of care is difficult as case managers are not always available  Long term nurse patient relationship are difficult to arrange.
  75. 75.  Many variable factors influence the number of nurses needed on a ward in order to render a high quality of patient care.  The total number of patient to be nursed  The degree of illness of patients (physical dependency)  Type of service: medical, surgical, maternity, pediatrics and psychiatric
  76. 76.  The total needs of the patients  Methods of nursing care  Number of nursing aids and other non professional available, the amount and quality of supervision available  The amount, type and location of equipment and supplies  The acuteness of the service and the rate of turnover in patients according to the degree or period of illness.
  77. 77.  The physical facilities  The number of hours in the working week of nurses and other ward personnel and the flexibility in hours  Methods of performing nursing procedures  Affiliation of the hospital with the medical school  Methods of assignment-individual, team or functional method.  The standards of nursing care
  78. 78.  The experience of the nurses who are to give the patient care.  The number of non-nurses who involve in the patient care, the quality of their work, their stability in service.  The physical facilities  The number of hours in the working week of nurses and other ward personnel and the flexibility in hours
  79. 79.  Nursing is vital aspect of health care and needs to be properly organized. A nurse is in frequent contact with of the patients hence his/her role in educational aspect and service aspect in restoring health and confidence of the patient is of utmost importance. The quality of nursing care and the management of the nursing staff, reflects an image of the hospital/ nursing home. Many changes have taken place in the health care delivery system as it struggles with cost and providing care corresponding to changes in the education of health professionals and their function within the system.
  80. 80.  Basavanthappa B T;. Nursing administration. Ist edn. New Delhi: Jaypee brothers;2000.  Alamellu; Newer trends in management of nursing services and education. health science publishers first edition 2017; 92-104  Deepak. k et al; A comprehensive textbook on nursing management emmess publications;2013;125-144  Jogindra vati; principles and practice of nursing management and administration jaypee publications;256
  81. 81.  http://doi.org/10.1016/j.bi.2015.04.005  http://doi.org/10.1016/j.bi.2015.04.005  http://www.ncbi.nib.gov/pmc/articles/pmc1435388/
  82. 82.  Estimating Nursing Intensity and Direct Cost Using the Nurse-Patient Assignment  Welton, John M. PhD, RN; Zone-Smith, Laurie PhD, RN; Bandyopadhyay, Dipankar PhD  JONA: The Journal of Nursing Administration: June 2009 - Volume 39
  83. 83.  Background: This study examines the feasibility of using the nurse-patient assignment (NPA) to calculate direct nursing hours and costs for each inpatient-day. The NPA data are collected at every hospital and therefore represent a readily available information source that can establish the intensity and economic value of nursing care at US hospitals.  Method: Direct nursing care hours for each patient were collected twice a day using an existing nursing intensity database at a single university hospital between January 2004 and June 2005 for a total of 11,582 patient-days. Nursing intensity was also calculated for each shift using the NPA. Mean unit and hospital nursing hours were calculated and compared with the direct nursing care hours using ordinary least squares regression.
  84. 84.  Results: For the day shift, the NPA estimate explained 77.2% (r2 = 0.772) of the variance of patient-level nursing intensity. Unit and hospital mean estimates of nursing intensity had lower r2 of 0.574 and 0.456, respectively. The night-shift NPA, unit, and hospital r2 estimates were 0.824, 0.633, and 0.579, respectively.  Conclusion: The use of the NPA can provide a robust and easy method to calculate nursing intensity for individual patients using assignment data available in nearly all care settings. The NPA estimate can be used to allocate direct nursing time and costs for each patient within the hospital billing system and can also be used in pay-for- performance or for benchmarking nursing intensity within and across hospitals.
  85. 85.  Hospital staffing, organization, and quality of care: cross-national findings  LINDA H. AIKEN, SEAN P. CLARKE, DOUGLAS M. SLOANE
  86. 86.  Abstract  Objective. To examine the effects of nurse staffing and organizational support for nursing care on nurses’ dissatisfaction with their jobs, nurse burnout, and nurse reports of quality of patient care in an international sample of hospitals.  Design. Multisite cross-sectional survey.  Setting. Adult acute-care hospitals in the United States (Pennsylvania), Canada (Ontario and British Columbia), England, and Scotland.  Study participants. 10 319 nurses working on medical and surgical units in 303 hospitals across the five jurisdictions.
  87. 87.  Main outcome measures. Nurse job dissatisfaction, burnout, and nurse-rated quality of care.  Results. Dissatisfaction, burnout, and concerns about quality of care were common among hospital nurses in all five sites. Organizational/managerial support for nursing had a pronounced effect on nurse dissatisfaction and burnout, and both organizational support for nursing and nurse staffing were directly, and independently, related to nurse-assessed quality of care. Multivariate results imply that nurse reports of low quality care were three times as likely in hospitals with low staffing and support for nurses as in hospitals with high staffing and support.
  88. 88.  Conclusion. Adequate nurse staffing and organizational/managerial support for nursing are key to improving the quality of patient care, to diminishing nurse job dissatisfaction and burnout and, ultimately, to improving the nurse retention problem in hospital settings.  burnout, health care surve
  89. 89.  Knowledge Management: Organizing Nursing Care Knowledge  Anderson, Jane A. MSN, RN, FNP-BC; Willson, Pamela PhD, RN, FNP-BC  Critical Care Nursing Quarterly: January-March 2009 - Volume 32
  90. 90.  Almost everything we do in nursing is based on our knowledge. In 1984, Benner (From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley; 1984) described nursing knowledge as the culmination of practical experience and evidence from research, which over time becomes the “know-how” of clinical experience. This “know-how” knowledge asset is dynamic and initially develops in the novice critical care nurse, expands within competent and proficient nurses, and is actualized in the expert intensive care nurse.
  91. 91.  Collectively, practical “know-how” and investigational (evidence-based) knowledge culminate into the “knowledge of caring” that defines the profession of nursing. The purpose of this article is to examine the concept of knowledge management as a framework for identifying, organizing, analyzing, and translating nursing knowledge into daily practice. Knowledge management is described in a model case and implemented in a nursing research project.