nursing lecture in cairo university - faculty of nursing first term master - administration

1. Patient care delivery system
Under supervision
Prof .Dr Abeer Saeda

2. Prepared by:
1. Sabah Ali Mohamed
2. Hesham Hamdy
3. Nada Abdel Azeem

3. By the end of this lecture the audient will be able to:
oDefine Assignment
oIdentify purposes of Assignment
oExplain the principles of personnel Assignment
oApply characteristics of effective Assignment in his or her field of
specialty
oHow to apply the process of organizing patient care
oCompare and differentiate between the different methods of
Assignment.

4. Outlines
1. Introduction
2. Definition of Assignment
3. Purposes of assignment
4. Principles of personnel assignment
5. Characteristics of effective assignment
6. Process of organizing patient care

5. 7- Methods Of Patient Care Delivery (Methods Of Assignment)
1-Traditional Methods
a-Case Method b-Functional Method
c-Team Method d-Modular Method
e-Primary nursing Method
2-In Advanced Methods
a-Case Management b- PRACTICE PARTNERSHIPS
c- CRITICAL PATHWAYS d- DIFFERNTIATED PRACTICE

6. Introduction
One important function of the professional nurse
at the first-line management position of nursing service
department is organizing the activities of the staff into
a workable pattern to meet patient needs. She/he
should establish effective relationships between the
activities to be performed, the workers to perform them.

7. Definition of Assignment:
• Assignment refers to “a written delegation
of duties to care for a group of patients by
trained personnel assigned to the unit

8. Purposes of assignment:
1- To delegate the work to be done to the nursing personnel
2- To gain the cooperation of the nursing personnel by knowing
and accepting the acceptance of the work to be done
3-To produce high quality level of nursing care .
4-Improve stability of the environment
5-Minimize uncertainty.

9. Purposes of assignment:
6-To improve the communication skills between staff
Members , team spirit and responsibility And leadership
abilities
7-To know nursing roles or duties in advance .
8-To minimize the level of working over load .

10. Principles of personnel assignment:
1- Made by the head nurse or nurse in charge for each individual
nurse.
2- Based on :
a-Nursing needs of each patient and approximate time required to
care for him.
b-The capabilities, skill level, previous experience and the interest of
the staff members.
c-Job description.
3- Planned weekly, and revised daily if necessary to assure
continuity of care.

11. Cont,:
4- Take into account all the direct , indirect and unit activities
5-Consider the geographical location of the unit and the
assigned duties to save nurse’s time and effort.
6- Must be balanced among nursing staff.
7- Never to assign the same task to more than one nurse.

12. Characteristics of effective assignment:
1. Definite and easily understood.
2. Simple
3. Clear.
4. Signed.
5. Written.
6. Posted in advance.

13. Process of organizing patient care:
The head nurse or the nurse in charge should carry out their
duties and responsibilities through applying the following
steps:
Planning  Assigning  Leading  Evaluating 
Reporting

14. 1. Planning:
Is a process of developing a course of action for meeting the
needs of patients. In planning, the head nurse decides
what should be done, when, how, where, by whom and to
whom.

15. 2. Assigning:
Assignment of patient and nursing activities are written
in the assignment sheet by the head nurse/nurse in
charge, based on the principles of assignment.

16. 3. Leading:
Includes issuing instructions, motivation, and coordination of
activities, by making rounds, checking performance and
conducting conferences.

17. 4. Evaluating:
By reviewing nursing performance and patient progress
to be compared by the assignment and nursing care
plan.

18. 5. Reporting:
The head nurse prepares a nursing unit report “ e.g. shift report
” which includes patient’s needs, special observations,
census, bed number, all critically ill and post operative
patients, patients needs special preparation on the on-coming
shift, abnormal change in patient’s condition, data
concerning, admission, discharge, transfer and death.

19. Nursing care delivery models
• Is the method used to provide care to patients.
• Each model has advantages and disadvantages ,and
no single method is ideal.
• It is a method to evaluate patient care and save
money.

20. Managers must examine the following when
selecting model
Organizational
goals.
Budget.
Staff availability
Unit
objectives.
Patient
population

21. Nursing care delivery models
Traditional
Models of Care
TOTAL PATIENT CARE
PRIMARY NURSING
FUNCTIONAL
NURSING
Team nursing
MODULAR NURSING
INTEGRATED
MODELS OF CARE
PRACTICE
PARTNERSHIPS
CASE
MANAGEMENT
CRITICAL
PATHWAYS
DIFFERNTIATED
PRACTICE

22. Traditional Models of Care
1. TOTAL PATIENT CARE(Case Method )
2. TEAM NURSING
3. MODULAR NURSING
4. FUNCTIONAL NURSING
5. PRIMARY NURSING

23. KEY TERMS
• Registered Nurses (RNs)
• Unlicensed Assistive or nursing Personnel (UAPs)
• Licensed Practical Nurses (LPNs)
• Licensed vocational Nurses (LVNs)

24. TOTAL PATIENT CARE(CASE METHOD)
• Total patient care is the oldest
mode of organizing patient care.
• provided in the patient’s home,
and the nurse was responsible
for cooking, house cleaning, and
other activities specific to the
patient and family, in addition to
traditional nursing care

25. Great Depression of the 1930’s
people can no longer afford home
care and began using hospitals.
Nurses and students also became
caregivers in hospitals and in public
health agencies.
1930’s and 1940’s – hospitals grew
and provided total care continued as
the primary means of organizing
patient care.

26. wealthy and middle
class at Home
the poor and very
acutely ill At Hospitals
TOTAL PATIENT CARE(CASE METHOD)

27. TOTAL PATIENT CARE(CASE METHOD)
• the premise of the case method is that one nurse
provides total care for one patient during the entire
work period
• Is used in critical care setting where one nurse
provides total care to one or two critically ill patients.

28. Note
• Total patient care nursing is sometimes referred to as
the case method of assignment because patients
were assigned as cases

30. Nurse Manager’s role
• When using the case method the manager must
Consider the expense of system, weigh the expense of
RN versus( LPNS,UAPS).
• Decide if patient care required RN care or care
provided by (LPNS ,UAPS).

31. Direct care nurse’s role:-
•Provide Holistic care( physical , emotional ) to a group of
patients during defined work time.
•The nurse must complete the functions of care (
assessment, personal hygiene and teaching the patient
and family)
•No delegation of tasks.

32. Advantages
•provides nurses with high autonomy and responsibility.
•one nurse give all care to the same patient(s) for the entire
shift that lead to satisfaction of patients..
•Assigning patients is simple and direct and does not require
the planning.

33. Advantages
•Continuous, holistic, expert nursing care.
•Total accountability for the nursing care of the assigned
patient(s) for that shift.
•Continuity of communication with the patient, family,
physician(s), and staff from other departments

34. Advantages
•The lines of responsibility and accountability are clear.
•The nurse , patient , and family usually trust one another
and work together toward specific goal.
•Changes in the patient’s status can be easily noticed.
•Critical care units or Post anesthesia recovery areas.

35. Disadvantages
•RNs spend some time doing tasks that could be done more
cost-effectively by less skilled persons.
•To maintain quality care, this method requires highly
skilled personnel.
•There is little opportunity for Supervision or observation

36. Disadvantages
• The greatest disadvantage of total patient care delivery
occurs when the nurse is inadequately prepared to provide
total care to the patient.
• In the early history of nursing, only RNs provided care; now
a variety of nursing care personnel, many of who have no
license and limited education, work with patients.

37. Disadvantages
• During nursing shortages, many hospitals assign
healthcare workers who are not RNs to provide most
of the nursing care.
• Because the co-assigned RN may have a heavy patient
load, little opportunity for supervision exists. This
potentially could result in unsafe care.

38. evolved primarily as a result of World War II(1940)
and the rapid construction of hospitals. nursing
shortage developed and ancillary personnel were
needed to assist in patient care.
FUNCTIONAL NURSING (TASK )

39. • The number of registered nurses (RNs) serving in the
armed forces during World War II depleted the supply
of nurses at home. As a result of this loss of RNs, the
composition of nursing staffs in hospitals changed.
FUNCTIONAL NURSING (TASK )

40. • Staff that had been composed almost entirely of:
Licensed
Practical
Nurses
(LPNs)
Unlicensed
Assistive
Personnel
(UAPs)
Registered
Nurses
(RNs)
FUNCTIONAL NURSING (TASK )

41. Is a method by which staff member (licensed and
unlicensed) perform specific tasks for a large group of
patients rather than care for specific patients.
FUNCTIONAL NURSING (TASK )

43. Charge nurse
LPN
ORAL
MEDICATION
UAPs
VITAL SIGNS
HYGIENE
CARE
RN
Admissions
(IV)
Medication
• Coordinate care
• Assignments
• Familiar about all
patients ’ needs

44. Nurse manager’s role
•Must be sensitive to the quality of patient care delivered
and the institution’s budgetary constraints.
•Achieving patient outcomes.
•By using effective management and leadership skills, can
improve the staff’s perception of their lack of independence.

45. Nurse manager’s role
• Rotate assignments among staff.
• Staff meetings should be conducted frequently. This
encourage staff to express concerns and empowers them
with the ability to communicate about patient care and
functions.

46. Direct care nurse’s role
•Nurses are educated to care for the patient holistically, and
providing only a fragment of care to the patient.
•Do the tasks that are usually assigned by the charge nurse.

47. ADVANTAGES
•the staff become very efficient and effective at performing
their regular assigned tasks.
•tasks are completed quickly.
•Little confusion regarding responsibilities.
•Unskilled workers can be trained to perform specific tasks.

48. ADVANTAGES
• Allow care to be provided with a minimal number of
registered nurses(cost effective).
• Functions well in areas such as:
the Operating Room.
 Long -Term Care Facilities.
Ambulatory clinics.
In crises and emergencies situations.

49. DISADVANTAGES
•Fragmentation of care.
•Lack of holistic understanding of the patient(spiritual and
psychological needs).
•Problems with follow-up and patient progress.
•Use of unlicensed assistive personnel (UAPs) to deliver
nursing care.

50. DISADVANTAGES
• Because some workers feel unchallenged and under
stimulated in their roles, (low job satisfaction).
• Employees focus only on their own efforts, with less interest
in overall results.
• Patients become confused with many different care
providers

51. DISADVANTAGES
•Patient’s response to care is difficult to assess.
•Critical changes in patient status may go unnoticed.
•Can lead to Patient and family dissatisfaction and
frustration.

52. Economical means of providing care????
•Many nurse administrators believe that assigning low-skill
tasks to UAPs frees the professional nurse to perform more
highly skilled duties and is therefore more economical(This
is true if quality care and holistic care are not regarded as
essential)

53. Advantages
• Large number of tasks in
short period.
• Unskilled person can be
trained to one specific task
• Cost effective to mix staff.
Disadvantages
• Fragmented patient care.
• Poor communication among
staff members.
• Less control of quality.
• Professional nurse dissatisfaction

54. •Developed in the 1950s in an effort to
decrease the problems associated with the
functional organization of patient care.
•Developed that reduced the fragmented
care that accompanied functional nursing.
Team Nursing

55. Ancillary personnel collaborate in providing care to a
group of patients under the direction of a professional
nurse
Team Nursing

57. Nurse manager’s role
• Teaching, and coordinating patient activities.
• Responsible for more than one unit.
• Determine which nurse are competent and interested in becoming a
charge nurse or a team leader
• Provide an adequate staff mix.
• Orient team members to the team nursing system.
• Providing continuing education

58. •Act as a liaison between the team leaders and other
healthcare provider.
•Provide support for the teams on a shift by shift.
Charge nurse’s role

59. Team leader’s role
• Developing or updating nursing care plans.
• Delegate the work.
• supervise, and coordinate team members.
• Assisting team members.

60. Team leader’s role
•Resolving problems encountered by team members.
•Follow up with members to evaluate the quality of care the
patients assigned to their team.
•Facilitates patient care conferences.

61. Direct care nurse’s role
•Team nursing uses the strengths of each caregiver.
•Some nurses become known for their expertise in some
tasks (IV) ,will start IV for patients under the guidance and
supervision of the team leader.
•Direct patient care activities under the direction of the
team leader.

62. Direct care nurse’s role
• Nurse acts as a responsible for knowing the condition
and needs of all the patients assigned to the team and
for planning individual care.

63. Advantages
•Improve patient satisfaction.
•Cost effectiveness for the agency.
•Organizational decision making occurring at lower levels.
•Allows members to contribute their own special expertise
or skills.

64. Advantages
•It allows the use of LPNs and UAPs to carry out some functions
(e.g., making beds, transporting patients, collecting some data)
that do not require the expertise of an RN.
•It allows patient care needs requiring more than one staff
member, such as patient transfers from bed to chair, to be
easily coordinated.

65. Advantages
• Is usually associated with democratic leadership.
•Group members are given as much autonomy as possible
when performing assigned tasks,
• Although the team shares responsibility and accountability
collectively.
• High job satisfaction.

66. Disadvantages
• Assignments may not be equal if they are based on patient acuity
or may be monotonous if nurses continuously care for patients
with similar conditions (e.g., all patients with hip replacements).
• Problems in delegation and communication are the most
common reasons why team nursing is less effective than it
theoretically could be.

67. Disadvantages
• Are associated primarily with improper implementation rather
than with the philosophy itself.
• A great deal of time is needed for the team leader to
communicate, supervise, and coordinate team members.
• Continuity of care may suffer due to changes in team members,
leaders, and patient assignments.

68. Disadvantages
•No one person considers the total patient.
•There may be role confusion and resentment against the
team leader, who staff may view as more focused on
paperwork and less directed at the physical or real needs of
the patient.

69. • A mini-team (2-3 members approach).
• Members are sometimes called “care pairs”.
• A small team requires less communication, allowing
members better use of their time for direct patient
care activities.
MODULAR NURSING

70. Modular Nursing Method
Nurse manager
Geographic patient unit
Patient care team:
RNs
LPNs/LVNs
Nurse aides
Meds
Supplies linens
Geographic patient unit
Patient care team:
RNs
LPNs/LVNs
Nurse aides
Meds
Supplies linens
Geographic patient unit
Patient care team:
RNs
LPNs/LVNs
Nurse aides
Meds
Supplies linens

71. • A cultural revolution occurred in the
united states during the 1960s.the
revolution emphasized individual rights
.this revolution influenced the nursing
profession. Searching for quality of
patient care led to this model as a
method to increase RN accountability for
Primary nursing

72. • An adaptation of the case method, as a method for
organizing patient care delivery in which one RN
functions autonomously as the patient’s primary
nurse throughout the hospital stay
Primary nursing

73. • brought the nurses back to direct patient care.
• The primary nurse assumes 24-hour responsibility for
planning the care of one or more patients from
admission or the start of treatment to discharge or
the treatment’s end.
Primary nursing

74. • Provide the patient and the family with coordinated,
comprehensive, continuous care.
• Care is organized, using the nursing process.
• A nursing Staff comprised totally of RNs.
• clear communication among the patient, the physician, the
associate nurses, and other team members
Primary nursing

75. example
• A patient is admitted to a medical unit with
pulmonary edema .
• His primary nurse admits him and then provides a
written plan of care. When his primary nurse is not
working, an associate nurse implement the plan.

76. Associate nurses :
•Is an RN who has been delegated to provide care to the
patient according to the primary nurse’s specification .When
the primary nurse is not on duty.
•If the patient develops additional complications, the
associate nurse notifies the primary nurse.
•Provides input to the patient’s plan of care.

77. • Is the only type of patient care delivery that requires a one-
to one relationship between a nurse and a patient with
responsibility for planning and managing care clearly
established.
Primary nursing

79. Nurse manager’s role
•Unit quality manager.
•Delegation.
•Budget controller.
•Decision making.
•Ac as role model, consultant , coach.

80. Direct care nurse’s role
•Caregiver, Decision maker, Teacher, Care coordinate,
manager.
•Primary nurse depend on associate nurse.
•Changing in the plan can be made by the associate
nurse in coordination with the primary nurse.

81. Advantages
•Improved continuity, quality and coordination of care.
•Decentralization of nursing care decisions, authority,
and responsibility to the staff nurse.
•Patient and family are satisfied with the care.

82. Advantages
• nurses develop skill in primary nursing care delivery, they
feel challenged and rewarded.
• 24-hour accountability for nursing care activities by one
nurse
• High job satisfaction.

83. Advantages
• Decrease the number of unlicensed nurses.
• All staff are RN(professional staff)
• Motivation
• Autonomy

84. Disadvantages
• nurse may not have the experience or educational background.
• lie primarily in improper implementation.
• It requires excellent communication between the primary nurse
and associate nurses.
• Primary nurses must be able to hold associate nurses
accountable for implementing the nursing care as prescribed.

85. Disadvantages
• Because of transfers to different units, critically ill patients may
have several primary care nurses, disrupting the continuity of care
inherent in the model.
• This method is difficult to implement because of the degree of
responsibility and autonomy required of the primary nurse.

86. Disadvantages
•Many nurses may be uncomfortable in this role or initially
lack the experience and skills necessary for the role.
•It sometimes has been difficult to recruit and retain enough
RNs, especially in times of nursing shortages.
•In times of shortage (not be the model of choice).

87. II- The INTEGRATED MODEL OF CARE:-
1-Practice partnership:-
• Introduced by Marie Manthey in 1989.
• An RN and assistant (UAP,LPN or less experienced RN agree to
be practice partners.
• Work together with same schedule and the same group of
patients.

88. 1-Practice partnership:-

89. Con 1-Practice partnership:-
• Senior RN direct the work of the junior partner
according to partner’s abilities.
• Two partners work in concern with patients.
• Senior perform selected patient care activities and
delegates less ones to the junior.

90. Advantages
• Improved continuity of care .
• Offered an efficient way of nursing skills of a mix of
different levels of experiences.
• Less expensive for the organization.
• Satisfying professionally for the partners.

91. Disadvantages
• Increase number of UAP and decrease ratio of
professional nurses to non-professional .
• Potential for junior team members to assume too
much responsibility than appropriate.

92. II- The INTEGRATED MODEL OF CARE:-
2-CASE MANAGEMENT:
• is a process of coordinating healthcare by planning,
facilitating and evaluating interventions across levels of
care to achieve measurable cost and quality outcomes.
• It may be within the wall of hospitals or beyond the walls.

93. Con
2-CASE MANAGEMENT:-
• It became apopular and effectíve method to manage
shortened lengths of stay for patients while achieving
desired patient outcomes and to prevent expensive
hospital re-admissions.

94. Case management model
08/04/1439 94
Collaborates With Patient
& Family
Perform care, Evaluates Pt care To
Meet Pt Health
Onset Of
Illness
Resolution
Of illness
Collaborate with: Physician
,Physical Speech, Dietary
Coordinates Service :Homecare
Long Term goal

95. The case Manger:-
• The case manager may help the family to identify all the
options for care and treatment, ask questions to obtain
greater understanding of the overall problem, and work
with the family in the decision- making process. The private
case manger is paid by the client or family usually based on
the hours of service provided.

96. The case Manger’s:-
• The case manager role requires not only advanced nursing
skills but also managerial and communication skills
Professional nurse assigned responsibility for this process.
• Follow the patient from the diagnostic phase through
hospitalization, rehabilitation and back to home care.

97. Advantages
a) For the patient:
• Establishing and achieving a set of “expected” or standardized patient care outcomes for
each patient.
• Facilitating early patient discharge or discharge within an appropriate length of stay.
• Using the fewest possible appropriate health care resources to meet expected patient
care outcomes.
• Facilitating the continuity of patient care through collaborative practice of diverse health
professionals.

98. Advantages
b) For the nurse:
• Enhancing nurse’s professional development and job satisfaction.
• Facilitating the transfer of knowledge of expert clinical staff of novice staff.
• Assists with decision-making by ensuring that plans are made in advance for
the next needed step. and helps to ensure that the patient receives care that
will achieve the most positive outcomes in the most efficient manner. This
process helps to eliminate costly delays in progress.

99. Case manager’s approaches:-
1- Case mangers employed by the hospitals:-
follow a patient from the time admission is planned through
the time of discharge. This case manager might plan the admitting
process to ensure that all preadmission work-ups are completed
and that the patient is being admitted at the appropriate time to
facilitate follow-up through on problems.

100. Case manager’s approaches:-
2- Case mangers in private practice:-
focus on a particular group of client. For example, the
geriatric case manager focuses on managing care for
them

101. II- The INTEGRATED MODEL OF CARE:-
3-Critical pathway:-
• Successful case management relies on critical pathways to
guide care. The term critical path, also called a care map,
refers to the expected outcomes and care strategies
developed by the collaborative practice team.
• It provide direction for managing the care of a specific
patient during a specified time period.

102. Con
3-Critical pathway:-
• Comprehensive pre- printed standard plan reflecting ideal
course of treatment for diagnosis or procedure especially
with relatively predictable outcomes.
• The critical pathway may need to be revised or additional
data may be needed before changes are made .

103. Advantages :-
• Accommodate unique characters and conditions of
patients.
• Reduce costs and length of stay.
• Use appropriate sources

104. Disadvantages :-
• The critical pathway may need to be revised or additional
data may be needed before changes are made.
• The critical path must include a means to identify
variances easily and to determine whether the outcome
has been met.

105. II- The INTEGRATED MODEL OF CARE:-
4-Differentiated practice:-.
• is a method that sorting nursing practice roles, function and work based on
education, experience, and competence or some combination of them.
• Nursing competencies are generally measured in three areas:
technical skills, communication and management of care or leader
ship skills.

106. Advantages :-
• Nurses are allowed to work in specialized roles for
which they were educated, leading to greater career
satisfaction.

107. Disadvantages :-
• Nurses who have experience, knowledge and capability to
function beyond their original education may not
recognized.
• Organizations that have determined minimal educational
requirements for RN positions may have difficulty in
recruiting staff with the requisite credentials.

111. Reference
• ELEANORJ.SULLIVAN.EFFECTIVELEADERSHIP
• MANAGEMENT IN NURSING EHIGHT EDITION.