II.

Patient Care Delivery System

A. Nursing Process in the Delivery of Nursing Care Services
B. Patient Classification System
C. Modalities of Care

Group work:
1. What are the four categories of the patient classification system?
2. What are the different modalities of care?
3. Give the advantages and disadvantages of each modality of care

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Nursing Process in the Delivery of Nursing Care Services

Another problem-solving model not specifically designed for ethical analysis but appropriate for it is the
nursing process. Most nurses are aware of the nursing process and the cyclic nature of its components of
assessment, diagnosis, planning, implementation, and evaluation.

In 1958, Ida Jean Orlando started the nursing process that still guides nursing care today. Defined as a
systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to
treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition.

Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care.
The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are
assessment, diagnosis, planning, implementation, and evaluation.

Assessment

Assessment is the first step and involves critical thinking skills and data collection; subjective and objective.
Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable,
tangible data such as vital signs, intake and output, and height and weight.

Data may come from the patient directly or from primary caregivers who may or may not be direct relation
family members. Friends can play a role in data collection. Electronic health records may populate data in and
assist in assessment.

Critical thinking skills are essential to assessment, thus the need for concept-based curriculum changes.

Diagnosis

The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and
implementation of patient care.

The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing
diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to
actual or potential health problems on the part of the patient, family or community.
A nursing diagnosis encompasses Maslow's Hierarchy of Needs and helps to prioritize and plan care based on
patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental
needs innate for all individuals. Basic physiological needs/goals must be met before higher needs/goals can be
achieved such as self-esteem and self-actualization. Physiological and safety needs provide the basis for the
implementation of nursing care and nursing interventions. Thus, they are at the base of Maslow's pyramid,
laying the foundation for physical and emotional health.[4][5]

Maslow's Hierarchy of Needs

Basic Physiological needs: Nutrition (water and food), elimination (Toileting), airway (suction)-breathing
(oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABC's), sleep, sex, shelter, and exercise.
Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation, suicide precautions, fall
precautions, car seats, helmets, seat belts), fostering a climate of trust and safety (therapeutic relationship),
patient education (modifiable risk factors for stroke, heart disease).
Love and Belonging: Foster supportive relationships, methods to avoid social isolation (bullying), employ active
listening techniques, therapeutic communication, sexual intimacy.
Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of control or
empowerment, accepting one's physical appearance or body habitus.
Self-Actualization: Empowering environment, spiritual growth, ability to recognize the point of view of others,
reaching one's maximum potential.
Planning

The planning stage is where goals and outcomes are formulated that directly impact patient care based on
EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome.
Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for
personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a
role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement,
and continuity of care across the healthcare continuum.

Goals should be:

Specific
Measurable or Meaningful
Attainable or Action-Oriented
Realistic or Results-Oriented
Timely or Time-Oriented

Implementation

Implementation is the step which involves action or doing and the actual carrying out of nursing interventions
outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or
oxygen, direct or indirect care, medication administration, standard treatment protocols and EDP standards.

Evaluation

This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider
intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met.
Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be
adapted based on new assessment data.
What are the four categories of the patient classification system?

The Patient classification system (PCS), also known as the patient acuity system, is a tool used for managing
and planning the allocation of nursing staff in accordance with the nursing care needs. Thus, PCS is used to
assist nurse leaders to determine workload requirements and staffing needs.

There are different kinds of PCS available, but the three most commonly used are:

Descriptive - This is a purely subjective system wherein the nurse selects which category the patient is best
suited to.

Checklist - Another subjective system, wherein the patient is assigned to a numerical value based on the level
of activity in specific categories. The numerical value is added up to give the nurse an overall rating.

Time Standards – This is 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 Patient Classification System. These
are subdivided into four classifications namely:

Self-care / Minimal Care. The first classification of patients who are recovering and normally requires only
diagnostic studies, minimal therapy, less frequent observations, and daily care for minor conditions and are
awaiting elective surgery.

Moderate care. The patient in this category is moderately ill or under the recovery stage from a serious illness
or operation. They require nursing supervision or assistance that is related to ambulating and caring for their
own hygiene.

Maximum care. The patient needs close attention and complete care all through the shift. The nurses initiate,
supervise, and perform most of the patient's activities.

Intensive care. The last category or classification, wherein the patients are acutely ill and a high level of nurse
dependency is required. Intensive therapy and/or intensive nursing care are needed because of the unstable
condition of the patient. Frequent evaluation, observation, monitoring and adjustment of therapy is also
required. Patients in these levels include those in critical conditions or in life and death situations.

But whatever PCS is used, this will be applied to forecast staffing needs within each department. Nurses
should be informed of the patient care ratios that are relevant to each department and should understand how
to predict the staffing needs.

What are the different modalities of care?

Modalities of Nursing Care

This refers to the manner in which nursing care is organized and provided. It depends on the philosophy of the
organization, nurse staffing and client population.

Case Method/Total Patient Care

In case method, the nurse cares for one patient whom the nurse cares for exclusively. The Case Method
evolved into what we now call private duty nursing. It was the first type of nursing care delivery system.

In Total Patient Care, the nurse is responsible for the total care of the patient during the nurse’s working shift.
The RN is responsible for several patients.

Advantages:

Consistency in carrying out the nursing care plan

Patient needs are quickly met as high number of RN hours are spent on the patient
Relationship based on trust is developed between the RN and the patient’s family

Disadvantage:

It can be very costly

Functional Nursing

It is a task-oriented method wherein a particular nursing function is assigned to each staff member. The
medication nurse, treatment nurse and bedside nurse are all products of this system. For efficiency, nursing
was essentially divided into tasks, a model that proved very beneficial when staffing was poor. The key idea
was for nurses to be assigned to tasks, not to patients.

Advantages:

A very efficient way to delivery care.

Could accomplish a lot of tasks in a small amount of time
Staff members do only what they are capable of doing
Least costly as fewer RNs are required

Disadvantages:

Care of patients become fragmented and depersonalized

Patients do not have one identifiable nurse
Very narrow scope of practice for RNs
Leads to patient and nurse dissatisfaction

Team Nursing

This is the most commonly used model and is still in use today. It was developed in the 1950’s in order to
somewhat ameliorate the fragmentation that was inherent in the functional model. The goal of team nursing is
for a team to work democratically. In the ideal team, an RN is assigned as a Team Leader for a group of
patients. The Team Leader has a core of staff reporting to her, and together they work to disseminate the care
activities. The team member possessing the skill needed by the individual patient is assigned to that patient,
but the Team Leader still has accountability for all of the care. Team conferences occur in which the expertise
of every staff member is used to plan the care.

Advantages:

Each member’s capabilities are maximized so job satisfaction should be high

Patients have one nurse (the Team Leader) with immediate access to other health providers
Disadvantages:

Requires a team spirit and commitment to succeed

RN may be the Team Leader one day and a team member the next, thus continuity of patient care may suffer
Care is still fragmented with only 8 or 12 hour accountability
Primary Nursing

The hallmark of this modality is that one nurse cares for one group of patients with a 24-hour accountability for
planning their care. In other words, a Primary Nurse (PN) cares for her primary patients every time she works
and for as long as the patient remains on her unit. An Associate Nurse cares for the patient in the PN’s
absence and follows the PN’s individualized plan of care. This is a decentralized delivery model: more
responsibility and authority is placed with each staff nurse.

Advantages:

Increased satisfaction for patients and nurses

More professional system: RN plans and communicates with all healthcare members. RNs are seen as more
knowledgeable and responsible.
RNs more satisfied because they continue to learn as as part of the in-depth care they are required to deliver
to their patient
Disadvantage:

Only confines a nurse’s talents to a limited number of patients, so other patients cannot benefit if the RN is
competitive
Can be intimidating for RNs who are less skilled and knowledgeable

Modular Nursing (District Nursing)

This is a modification of team and primary nursing. It is a geographical assignment of patient that encourages
continuity of care by organizing a group of staff to work with a group of patients in the same locale.

Advantages:

Useful when there are a few Rns

RNs plan their care
Disadvantage:

Paraprofessionals do technical aspects of nursing care

SOURCES:

(1) Toney-Butler TJ, Thayer JM. Nursing Process. [Updated 2021 Jul 9]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK499937/

(2) https://www.nursingguide.ph/category-career-guides/the-patient-classification-system

(3) https://nursingcrib.com/nursing-notes-reviewer/fundamentals-of-nursing/modalities-of-nursing-care/
(4)