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PATTERNS OF NURSING CARE DELIVERY IN INDIA

INTRODUCTION:-
Since the time of FLORENCE NIGHTINGALE there have been a variety of nursing care
delivery models, methods by which nursing care is provided for clients. Ideally, the vision & philosophy
nurses establish for the quality care of clients should drive the selection of a care delivery model. However,
too often the scarcity of nursing resources & business initiatives from the health care organization influence
the final decision. Care delivery must be effective in helping nurses achieve desirable outcomes for their
clients. Key factors contributing to success are decision-making authority for nurses who provide direct care,
autonomy, collaborative practice, & effective methods of communicating with colleagues, physicians, & other
health care providers.
DEFINITION:-
A nursing care model or the method or system of nursing care delivery is defined as a method of
organizing & delivering nursing care.
ELEMENTS OF NURSING CARE DELIVERY:-
MANTHEY identified the basic elements of nursing care delivery systems. There are four
fundamental elements namely:-
• Clinical decision-making.
• Work allocation.
• Communication &
• Management.
TYPES OF NURSING CARE DELIVERY:-
The major means organizing nursing care delivery are as follows:-
• Total patient care or case method nursing.
• Functional nursing.
• Team nursing.
• Modular nursing.
• Primary nursing.
• Case management.
• Progressive patient care or client care nursing.

TOTAL PATIENT CARE NURSING OR CASE METHOD NURSING:-

It is the oldest mode of organizing nursing care. It was the original care delivery model
developed during Florence Nightingale’s time. A Registered Nurse (R N) is responsible for all aspects of care
for one or more patients during an assigned shift.
DEFINITION:-
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• A total patient care is one in which the nurse is responsible for planning, organizing &performing all care,
including personal hygiene, medication, treatment, emotional support & education required for their
assigned group of patients during their assigned shift.
• The patient theoretically receives holistic & unfragmented care during the nurses time on duty. Each
nurses caring for the patient, can however modify the care regimen.
OBJECTIVES OF TOTAL PATIENT CARE:-
• To provide a high quality of therapeutic comprehensive care for each patient to meet immediate health
needs.
• To provide appropriate designed facilities with sufficient number of beds, trained staff & technical
personnels at a slightly lowest cost than that of traditional system.
• To provide different levels of medical & nursing care in the various units in accordance with nurse’s
skill in performing equipments & supplies to meet the patient’s needs.
• To dedicate a multi disciplinary group of professionals to frame appropriate policies, plans &
programmes & evaluate them periodically to assure that all patients are placed properly & receive
high quality care by trained personnels & technical workers.
• To initiate suitable hospital admission & transfer policies & procedures to that patient who can be
assigned to the appropriate unit in accordance with their medical & nursing care needs.
• To initiate & support the participant & management approach among physician & nurse towards
planning & giving care required to various units.
• To shorten the average length of patients hospitalization period.

• To help the patient & family to solve health problems in the hospital & home.
MEMBERS:-
The members are:-
• Charge nurse
• Registered nurse
• Student nurse
• Private duty nurses.
It is used commonly in speciality unit such as ICU, ICCU.
FUNCTION & MODEL:-
Each nurse caring for the patient can modify care regimen. If there are three shifts, the patient could
receive there different approaches to care.
MODEL-I
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MODEL-II

CHARGE NURSE

NURSING STAFF NURSING STAFF NURSING STAFF

PATIENTS PATIENTS PATIENTS

MERITS:-
• The nurse can see better & attend to the total needs of clients. Continuity of care can be facilitated
with care.
• Client / nurse interaction / rapport can be developed.
• Client may feel secure, knowing than one person is thoroughly familiar with the needs & the course of
treatment of his/ her disease.
• Educational needs of the clients can be closely monitored.
• Family & friends become better known by nurse & get more involved in the care of the client.
• Workload for the unit can be equally divided among the available staff.
• Nurse’s accountability for their function is built- in.
• The patient receives holistic unfragmented care by only one nurse per shift.
• The nurse maintains a high degree to practice autonomy.
• Lines of responsibility are clear.
• Centralization of skilled staff to take care of critically ill patients instead of nursing them to different
wards.
• Centralization of costly diagnostic & the therapeutic equipments instead of having such equipments in
every ward.
• There is greater likelihood of availability of skilled personnels on duty.
DEMERITS:-
 Many clients do not require the inherent care of intensity in this type of service.
 This method must be modified if non- professional health workers are to be used effectively.
 Nurses are not enough to comply the demand of this model; cost- effectiveness must be
considered.
 It is difficult for nurses to use this method to become involved in long- term planning &
evaluation of care.
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 The greatest disadvantage to case nursing occurs, when the nurse is inadequately trained or
operated to provide total care to the patient.
ASPECTS OF TOTAL PATIENT CARE:-
PHYSIOLOGICAL ASPECT:-
The client has one person who plans his care during the entire stay. The associate nurses on three
shifts are also kept consistent. If care is not given effectively by one person, the primary nurse is accountable.
Feedback both good & bad is bounded to the nurse.
SOCIAL ASPECT:
Communication facilitated by nurse improves the sense of responsibility for following the plan of care in
a better way by nurse & client.
EMOTIONAL ASPECT:-
The emotional support given by nurse adds to the client’s sense of worth.
FUNCTIONAL NURSING:-
Functional nursing is a model of care that evolved in the 1950s, when there was a severe shortage of
nurses during world war II. This system of assignment, which evolved from concepts of scientific
management used in the field of business administration, focuses on the jobs to be completed. In this task-
oriented approach, personnel with less preparation than the professional nurse fulfil less complex care
requirements.
DEFINITION:-
Functional nursing is a method of providing patient care by which each licensed & unlicensed staff
member performs specific tasks for a large group of patients.
Eg. RN administers IV medications.
Lower primary nurse gives oral medications.
Assistants perform hygiene tasks.
Another assistant checks vital signs.
MEMBERS:-
Charge nurse
Registered nurse
Lower primary nurse
Nursing assistants.
FUNCTION & MODEL:-
Here all the responsibilities of a unit are assigned to selected people in accordance with their expertise. A
charge nurse co-ordinates care & assignments & may ultimately be the only person familiar with all the needs
of the patient MODEL-I
CHARGE NURSE
LICENSED RN TREATMENT RN INTERVENOUS NA VITAL NA HYGIENE
PRACTICE ADMISSIONS MEDS SIGNS SUPPILES
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UNIT OF 30 PATIENTS
MODEL-II
HEAD NURSE

REGISTERED NURSE LICENSED PRACTICAL NURSE NURSING

AIDES

PATIENTS
MERITS:-
 The person can become particularly skilled in performing assigned tasks, it can be efficient &
economical.
 The best utilization can be made of a person’s aptitudes, experience & desires.
 Less equipment is needed & 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 a sense of productivity for the
task oriented nurse & this is an efficient method.
 It is easy to organize the work of the unit & staff & tasks are completed quickly.
 It is cost effective to mix staff.
 Unskilled person can be trained to one specific task.
DEMERITS:-
 Client care may become impersonal, compartmentalized & fragmented.
 There is a tremendous risk for diminishing continuity of care.
 Staff may become bored & have little motivation to develop self & others, work may become
monotonous.
 The staff members are accountable for the task; only the nurse incharge of the unit has accountability
for the individual, whole clientele.
 There is little avenue for staff development, except as it relates to tasks.
 Clients may tend to feel insecure, not knowing who is their own nurse.
 Only parts of the nursing care plan are known to personnel.
 It is difficult to establish client priorities & operationalise the care reflecting same.
 It is only safe when the head nurse can co-ordinate the activities of all members of the staff & make
certain that nothing essential in client care is overlooked or forgotten. This is a tremendous
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responsibility on one person who probably has to think of approximately thirty or more clients, plus
the staff.
 Poor staff development & involvement in framing care.
 Responsibilities of staff nurse are more.
TEAM NURSING:-
ORIGIN:-
In the early 1950s, Eleanor lamberston (1953) & her colleagues proposed a system of team nursing to
overcome the fragmentation of care resulting from the task-oriented functional approach & to meet increasing
demands for professional nurses created by advances in technological aspects of care.
DEFINITION:-
Team nursing is a method in which group of nursing personnels undr the leadership of a qualified nurse,
having the goal of comprehensive nursing care renders service to the patients.
A team made up of a registered nurse & other caregivers provides care to a designated group of patients on
a given shift. This is termed as team nursing.
“Care through others’’ is the hall-mark of team nursing.
PHILOSOPHY:-
In this a group of professional & non-professional personnels work together to identify, plan, implement
& evaluate comprehensive client-centered care.
MEMBERS & THEIR ROLES:-
• Nurse manager
• Team leader (registered nurse)
• Registered nurse

• Licensed practical nurseNursing aides.

CONCEPTS FOR PRACTISING TEAM NURSING:-
 Leadership by a registered nurse.
 Effective communication among team members.
 Leadership techniques by a team leader.
-Assess patient & determine nursing interventions.
-Co-ordinate medical & nursing care plan.
-Keeping nursing care plan up to date.
- Recording care & outcome of care.
Team members must accept the leadership of the team leader.
Head nurse is an important person in team nursing.
- Determine standards of work performance.
- Helping team members to develop leadership skills.
- Orientation of new employees.
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- Keeping channel of communication open with all.

- Encouraging staff to improve quality of care.
FUNCTION & MODEL:- Team leader is responsible for co-ordinating a group of licensed & unlicensed
personnel to provide patient care to a small group of patients. Team leader assigns each member specific
responsibilities according to role, licensure, education, ability & the complexity of the care required.
Communication is enhanced through written patient assignments, nursing care plans & team
conferences.
MODEL
HEAD NURSE

TEAM LEADER TEAM LEADER

RN LPN NA RN LPN NA

TEAM CONFERENCES:-
The heart of team concept is team conference. At some times during the day, after the patients have
received their morning care, the team members sit together in conference. It requires half to three fourth of an
hour. The team leader assumes the role of chairmen. It includes:-
-Reports by each team member.
-Planning care for new patients.
-Planning the next day assignment.
MERITS:-
• It includes all health care personnel in the groups functioning & goals.
• Feeling of participation & belonging are facilitated with team members.
• Workload can be balanced & shared.
• Division of labour allows members the opportunity to develop leadership skills.
• Every team members has the opportunity to learn from & teach colleagues.
• There is a variety in the daily assignment.

• Interest in client’s well-being & care shared by several people; reliability of decisions is increased.

• Nursing care hours are usually cost- effective.

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

• All care is directed by a registered nurse.

• Continuity care is facilitated, especially if teams are constant.

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• Barriers between professional & non- professional workers can be minimized; the group efforts
prevails.
• Everyone has the decision increased as clients’ well- being is shared by several people.

• Each member of team is able to participate in decision- making & problem-solving

DEMERITS:-
 Establishing the team concept takes time, effort & constancy of personnel. Merely assigning people to
a group does not make them a “group’’ or “team’’.
 Unstable staffing patterns make team nursing difficulty.
 All personnel must be client-centered.
 The team leader must have complex skills & knowledge. Ie. Communication, leadership
organization, nursing care, motivation & other skills.
 There is less individual responsibility & independence regarding nursing functions.
 Continuity of care may suffer.
 Team leader may not / have less leadership skills.
 Needs more nursing personnels.
MODULAR NURSING:-
DEFINITION:-
• Modular nursing uses the strengths of both teams. In modular nursing staff are geographically
assigned to patients for whom they co-ordinate & provide comprehensive care.
• Modular nursing is enhanced when nursing units are physically designed & built with the nursing
delivery system in mind.
MEMBERS & ROLES:-
• Head nurse
• Registered nurse-district leader.
• Licensed practical nurse.
• Nursing aides.
FUNCTION & MODEL:-
• Staff nurses work independently or together, depending on the size of a modular district.

• Each district has a district hospital whose responsibilities include giving & receiving shift report &
offering & receiving help from the district leader of the next module.
• The solid lines represent direct lines of communication & the broken lines represent indirect lines of
communication.
• The nursing aides may perform specific tasks or provide direct patient care.
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• The head nurse co-ordinates the work schedule & supervises all care in / on the unit. continuity of
care is maintained when the head nurse makes patient care assignments.
ADVANTAGES:-
 Better communication & co-operation among staff & less time is spent in walking between patients.
 Modular nursing is easier for less experienced nurses because they have other nurses directly
available to them for support.
MODEL
HEAD NURSE

RN-DISTRICT RN- DISTRICT RN- DISTRICT

LEADER LEADER LEADER & LPN
&
RN NA

PATIENT
DISADVANDAGES:-
• In modular nursing, there is an eight hour rather than twenty four accountability & much less direct
nurse-to-nurse communication & accountability for patient care.
• Patient satisfaction will be less; if the patient changes rooms, he will get a change in the nurses also.
PRIMARY NURSING:-
CONCEPT:-
• The primary nursing model of care delivery was developed in the 1960s with the aim of placing RNs
at the bedside & improving the professional relationship among staff nurses / members.
• The model became popular in the 1970s & early 1980s as hospitals began to employ more RNs.
• The aim of this method is to improve autonomy & quality care in professional nursing practice.
• In this a registered nurse or primary nurse assumes 24 hrs responsibility for planning, directing &
evaluating the patient’s care from admission through discharge.
DEFINITION:-
Primary method is a method of patient care delivery where one registered nurse functions autonomously as
the patient’s main nurse for 24 hrs day from admission till discharge.
A nurse is accountable for planning, evaluating & directing the care of patient 24 hrs a day throughout the
patient’s stay. This is a method of providing comprehensive, individualized & consistent care & it is also an
expensive method.
GOAL:-
Its goal is to achieve patient centered individualized care that is comprehensive in scope, coordinated &
continues from patient’s admission till discharge.
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BASIC CONCEPTS:-
• Fixed responsibility & accountability.
• Patient’s involvement in care & identification of patient’s goals.

• Patient’s assessment by primary nurse who plans the care to be given by secondary nurse.

• Complete communication of care.

• Discharge planning.
MEMBERS & ROLES:-
• The primary nurse & head nurse.
• Head nurse assign new patient to the primary nurse based on her assessment of patients’ need & her
knowledge of primary nurse. She communicates with them, but she delegates complete authority to
them for the care of their patients.
• Licensed practical nurses function as associate nurse & are supervised by the head nurse.
• Nursing assistants are also used but to assist primary & nurses.
PRIMARY NURSING SYSTEM & MODEL OF ORGANISATION:-
The primary nurse is responsible for 24 hrs a day total patient care from admission till discharge. While
on duty the nurse may provide care or delegate some patients’ care to an associate nurse. When the primary
nurse is off duty, care is provided by an associate nurse who follows the care plan established by the primary
nurse.
MODEL

PATIENT

TOTAL PATIENT CARE 24 HR / DAY

COMMUNICATES PRIMARY NURSE CONSULTES WITH

WITH SUPERVISIOR PHYSICIANS/ OTHER
HEALTH CARE PROVIDERS

ASSOCIATE (DAYS) ASSOCIATE (EVENINGS) ASSOCIATE (NIGHTS) WHEN

PRIMARY WHEN PRIMARY WHEN PRIMARY
NURSE NOT AVAILABLE NURSE NOT AVAILABLE NURSE NOT AVAILABLE
s MODEL
HEAD NURSE
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PRIMARYNURSES PATIENTS

ADVANTAGES:-
• There is opportunity for the nurse to see the client & family as one system.
• Nursing accountability, responsibility & independence are increased.
• The nurse is able to use a wide range of skills, knowledge & expertise.
• This method potentiates creativity by the nurse.
• Work satisfaction may increase significantly.
• The scene is set for increased trust & satisfaction by the client & nurse.
• Establishes good rapport between nurse & client & his /her family.
• Aims at providing holistic patient care.
DISADVANTAGES:-
• The nurse may be isolated from colleagues.
• There is little avenue for group planning of client care.
• Nurse must be mature & independently competent.
• Staffing patterns may necessitate a heavy client load.
• An inadequately prepared or educated primary nurse may be incapable of coordinating a
multidisciplinary team or identifying complex patient needs & condition changes.
CASE MANAGEMENT:-
ORIGIN:-
Case management is considered to be the newest type of nursing care delivery system. It is a care
management approach that co-ordinates & links health care services to clients & their families while
streamlining costs & maintaining quality.
DEFINITION:-
 The case management society of America (2003) defines case management as “a collaborative process
which assess, plans, implements, co-ordinates, monitors & evaluates the options & services required
to meet an individual’s health needs, using communications & available resources to promote quality,
cost- effective outcomes.”
 Case management is a set of logical steps & a process of interaction within a service network which
assure that a client receives needed services in a supportive, effective & cost- effective manner.
 Here one nurse is responsible for overseeing the quality & financial outcomes of patient care; the
nurse works collegially with physicians & other care givers as well as with payers to manage patients
along an agreed- on clinical pathway.
 The focus is on the individual patient & not population of patients.
 PURPOSES:-
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• Provision of services, care, treatment & opportunities to which a client is entitled.

• Accountability for cost of resources & use of funds.
MEMBERS & ROLES:-
The main member involved in giving care is the case manager. They handle each case individually,
identify cost- effective providers, treatment & care settings. Referrals begin from hospital & extend to
outpatient settings.
SERVICE ACCESS:-
• Case management is needed mainly for the following groups of patients:-

 Chronically disabled with functional or emotional impairments.

 Patients with long- term medically complex needs.
 Clients severely compromised with acute illness
FUNCTION & MODEL:-
The nurse case manager provides direct nursing care or delegate it to others, her role is the co-
ordination of services for quality & cost- effective care. She reports directly to her employer or in hospitals, a
head nurse or physician.
Her range of services include case finding, intake, assessment, direct care, provision, advocacy,
monitoring, cost containment & termination.
MODEL-I

NURSING ADMINISTRATION

MEDICAL PAEDIATRIC NURSE OB NURSE CASE TRAUMA NURSE

NURSE CASE CASE MANAGERS MANAGER CASE MANAGERS

ALL MEDICAL ALL PAEDIATRIC ALL OB PATIENTS ALL TRAUMA PATIENTS

PATIENTS PATIENTS

MODEL-II
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ADVANTAGES:-
 Clients receive more services.
 Enhanced personal satisfaction & increased autonomy.
 More efficient use of resources.
DISADVANTAGES:-
 Lack of clarity about its functions.
 Lack of research that clearly documents the outcomes of nursing case management.
 Duplication of services & possible “turf wars” of other professionals like i.e. social worker believe it
is their role to manage some of the services.
PROGRESSIVE PATIENT CARE OR CLIENT CARE:-
CONCEPT:-
It is a new concept where the patients are classified according to the degree of their illness &
according to their medical, physical & psychological need irrespective of their illness.
DEFINITION:-
It is the systematic classification of patients according to their medical needs & this method provides
better treatment & care by organizing hospital services around the individual patients.
Here the clients are evaluated with respect to all level ( intensity ) of care needed. As they
progress towards increased self care ( as they become less ethically ill or in need of intensive care or
monitoring ) they are marked to units / wards staffed to best provide the type of care needed.
PRINCIPLES & OBJECTIVES:-
 To provide a higher quality of care.
 To provide appropriately designed facilities.
 To provide different levels of medical & nursing care in different units.
 To delegate multi disciplinary group of professionals.
 To initiate suitable admission & transfer policies & procedures.
 Shortens the average length of patients’ hospitalization period.
 To provide the best nursing services under trained supervisors.
 To provide the community sources in an organized way.
ELEMENTS OR AREAS OR LEVELS OF CARE:-
 Intensive care unit.
 Intermediate care unit.
 Self care unit.
 Home care unit.
 Outpatient care.
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Intensive care unit:-

It is the unit where constant observation & interventions are provided to the critically ill patients with life
threatening health problems according to his / her needs.
Intermediate care unit:-
When the patients no longer need the close attention by the nurses, they are transferred to the intermediate
units.
Long term care unit:-
Patients who are under long term care are admitted in this unit. This unit serves.
• Chronically ill patients.
• Convalescent patients.
• Patients who are under rehabilitation.
Self care unit:-
Here ambulatory patients are given the nursing care needed & are encouraged to care for themselves in many
ways.
Home care unit:-
A follow-up home care plan becomes the last & final unit of hospital care. Here the family members give
care rather than the specially trained personnels.
Out patient care:-
It is for ambulatory patients. It renders diagnostic, curative, preventive & rehabilitative services.
ADVANTAGES:-
• Efficient use is made of personnel & equipment.
• Clients are in the best place to receive the care they require.
• Use of nursing skills & expertise are maximized due to different staffing patterns of each unit.
• Clients are moved towards self care, independence is fostered where indicated.
• Efficient use & placement of equipment is possible.
• Personnel have greater probability to function towards their fullest capacity.
• Helps in providing maximum care to the patient.
• Patients are given special attention & care according to need.
• It is cost-effective & infection is minimized.
• Nurse spends more time with the patient & can utilize her competencies effectively.
• Efficient use of personnels can be made.
• Nursing skills are maximized.
DISADVANTAGES:-
 There may be discomfort to clients mho are moved often.
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 Continuity care is difficult, even though possible.

 Long term nurse / client relationship are difficult to arrange.
 Great emphasis is placed on comprehensive, written care plan.
 There is often difficulty in meeting administrative need of the organization, staffing, evaluation &
accreditation.
 Requires skilled personnels in the team.
 Requires more number of nursing staff.
SUMMARY:-
In this seminar, we have discussed about the nursing care delivery system, various methods, their
principles, models, advantages & disadvantages in a detailed manner.
CONCLUSION:-
Nursing care delivery can be seen as the dynamic balance between routine resource management & the
structure, process & content of practice. Utilizing human resources decisions such as staffing & skills, the care
models form a network for the nursing staff & their assignments to client care.