NURSING CARE

MODALITIES
KNH, SoN
 Lesson Outline

1. Introduction
2. Staffing
3. The Nursing Care Models
4. Other Nursing Care Delivery Concepts
5. Summary
Introduction
 Service Delivery

Health care Health

Financing Workforce

THE HEALTH SYSTEM

Medical Health
Products and Information
Technologies System

Leadership and
Governance
 Introduction

• Nursing care modalities/models are patient care

delivery systems
• A patient care delivery system is a template for
organizing and providing care to patients.
• The modalities/models focus on structure,
process and outcomes. OR
• Modalities of Nursing Care 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.
 Introduction

 The purpose of these models is to;

1. Provide high quality care, efficiently and
effectively
2. Ensure safety
3. Establishing a therapeutic relationship
between nurses and patients/families
4. Establishing a therapeutic relationship
between nurses to nurses/medical team
 Introduction

 The effectiveness of these care delivery models

depends on the organization's approach in
matching their;
 Available resources
 Patient characteristics
 Health care needs
 Introduction

 Before adopting any nursing care model, each

health institution must consider its;
1. Vision, Mission and Goals
2. Patient characteristics
3. Health care needs and demands
4. Cost of implementing the nursing model
(Manpower, Minutes, Money and Materials)
 Introduction

 The goal of successful patient care delivery

is high-quality and low-cost care with the
achievement of satisfactory patient
outcomes.
 Introduction

• Many studies have shown that nursing care is

the most important predictor of overall
patient satisfaction with their hospital care.

• Currently, there is movement from a task

based view of nursing care delivery to a
principles-based, holistic view of nursing
care.
Introduction
Task Based Care Principle Based Care
 Bureaucratic Nursing  Professional Nursing
 Tasks drive activities  Knowledge based
and cure of disease  Healing is the goal
 Focus is on physical and
 Focus is on holistic care
diagnosis-centered care
 Professional standards
 Policies and procedures
and current research
drive decision making
drive decision making
 Rules, habits and  Critical thinking and
routines determine innovation determine
nurse’s behavior
 Speed and
timeliness of
service
delivery
User friendly
Courtesy and
systems/less
Helpfulness
red tape

Characteristics
of Principle
Positive
based Nursing
attitude from Care Service
Reliability
staff

Accurate Consistency in
paper work Service delivery
Staffing
 Key Concepts in Staffing
1. Hours worked and available for patient care are
designated as productive hours.
2. Hours for benefits such as vacation/leave, sick time,
and education time are considered nonproductive
hours.
3. Direct care is time spent providing hands-on care to
patients.
4. Indirect care is time spent on activities that are
patient-related but are not done directly to the patient.
5. Full-time equivalents (FTEs) are a measure of the
work commitment/involvement of a full-time
employee.
6. Patient acuity is the measure of intensity of nursing
care/workload that is generated for each patient
 Establishing a Staffing Pattern
• A staffing pattern is a plan that articulates
how many and what kind/cadre of staff are
needed per shift to staff a unit or department.
• It can be generated by:
1. Determining the necessary ratio of staff to
patients, then calculating nursing hours and
total Full-time equivalents (FTEs)
2. Determining the nursing care hours needed for
a specific patient or patients, then generating
the FTEs and staff-to-patient ratio needed to
provide that care
3. Using a combination of both methods
 Considerations in Developing a
Staff Pattern
1. Skill mix is the ratio of different cadres of care
givers (MscN, BscN, KRCHN, ECN, Patient
attendants). The skill mix of a unit should vary
according to the care that is required and the
care delivery model being utilized.
2. Staff support – non-nursing staff must be in
place to support the operations of the unit or
department.
3. Historical information - What has worked in
the past
Nursing Care Delivery Models
Nursing Care Delivery Elements
The structure of a nursing care model has 4
elements which must be made clear.
These are;
1. Decision making: Who is responsible for
making decisions about patient care? How
long does that person’s decision remain in
effect?
2. Communication: How is patient care
communication handled? (patient to nurse
and nurse to nurse),(situation, background,
assessment and recommendation) SBAR
 Nursing Care Delivery
Elements….ctd

3. Work distribution: How is work allocated

among staff?
4. The setting of care delivery: Where will
the care be delivered? How is the whole unit
managed? What is the culture of care in the
unit? Ward? Outpatient clinic?
The Nursing Functional
Nursing
Care Models
Differentiated
Team Nursing

Total Patient
Care Delivery Care
Models
Primary
Nursing

Patient
Centered Case
Management

Clinical
Pathways
Differentiated Nursing Care Delivery
Models
 Differentiated Approach

• This care model sorts the roles, functions

and work of registered nurses according to
what needs to be accomplished
• Nurses mostly sorted according to;
1. Education
2. Clinical experience
3. Competence (Technical skills,
Communication skills, Management of
care, Leadership skills)
 Differentiated Approach
Advantage
1. Nurses are allowed to work in specialized
roles for which they are educated or
experienced in, leading to greater career
satisfaction.
.
 Differentiated Approach

Disadvantages
1. Nurses who have experience, knowledge,
and capability to function beyond their
original education may not be recognized.
2. Organizations that have determined
minimal educational requirements for RN
positions may have difficulty in recruiting
staff with the requisite/specialized
credentials
 Differentiated Approach

• Includes;
1. Functional Nursing
2. Team nursing
1. Functional Nursing
 Also called task nursing.
 an organization mode for assigning nursing
personnel tasks. It is activity oriented
 it is a nursing model in which the needs of
patients are broken down in to tasks. Each care
givers is assigned specific functions performed
for all patients in a given unit, and all report to
the head nurse.
 This ensures that the skills of each care giver
are utilized to the best advantage.
 E.g. a nurse can be giving bed baths, another
one carrying out observations, another one
 Nurse Manager

NURSE NURSE NURSE NURSE

PO Meds Assessments Vital signs Hygiene
Treatments Care Plans Hygiene Stocking

Assigned Patient Group

Functional Nursing Care Delivery Model

 1.Functional Nursing

 Functional nursing focuses on the skill mix of

the staff, hence tasks are allocated according
the skill levels of the staff.
 It was implemented in the 1940’s as a result of
shortages in nursing during the 2 nd world war.
Functional Nursing - Advantages

1. Large number of tasks are accomplished

within a short period of time
2. Assistant personnel are trained for specific
tasks
3. It is cost effective
4. All the employees become effective and
efficient in performing their regularly
assigned tasks
 Functional Nursing - Disadvantages
1. Patients receive fragmented care-uneven continuity
of care
2. No one has a direct responsibility of the patient
3. Fragmented communication between staff, which
may be time consuming
4. Staff become task oriented
5. Dissatisfaction of the professional nurse
6. Nurses may be less effective and efficient if they are
allocated a different task
7. Absence of holistic care of the patient
 TEAM NURSING
 2. Team Nursing
 Team nursing evolved from functional
nursing.
 A team of nurses provides total nursing care
to a group of patients under the direction of
a team leader.
 This model utilizes the diversity of skill,
education and qualification level of
each team member.
 A team of nurses are assigned certain
number of patients, while in other situations
patients may be grouped by diagnosis or
2. Team Nursing

 Modular nursing is a modification of team

nursing.
 It tries to enhance effectiveness of the team
concept by assigning a module to a confined
limited geographical area.
 The size of the module varies according to
physical layout of the unit , patient acuity and
nursing skill mix.
 2. Team Nursing

 The team members provide the care under

the leadership of a team leader.
 The team speaks for each patient, through
the team leader.
 With the team/modular nursing, the unit nurse
manager consults with team leaders,
supervises patient care teams and make
rounds with the physician.
 Nurse Manager

RN Team Leader RN Team Leader

NO-I NO-I
NO-II NO-II
NO-III NO-III

Assigned Patient Group Assigned Patient Group

Team Nursing Model

 Advantages of Team Nursing
1. Utilization of each member’s strength
2. The ‘team’ supports group productivity and
development
3. Organizational decisions are made closer to the
users
4. There is increased client satisfaction
5. It is cost effective.
6. It allows the use of less prepared staff
members to carry out some functions, that do
not require expertise through supervision
- Disadvantages of Team Nursing
1. Needs a skilled and experienced team leader
2. There has to be adequate staffing
3. There has to be a right skill mix
4. A large amount of time is required for the team
leader to maintain effective communication, team
planning, supervising, and coordinating the care
provided by all team members.
5. Continuity of care may be diminished due to
constant changes
6. Lack of holistic view of the patient by the staff
Patient Centered Nursing Care
Delivery Models
 Patient Centered Approach

• Designed to focus on patient needs rather

than staff needs.
• Necessary care and services are decentralized
and brought to patients; staff is kept close to
patients in decentralized workstations.
• Care teams are established for a group of
patients; within these teams, disciplines
collaborate to ensure that patients receive the
care they need.
 Patient Centered Approach

Advantages
1. Most convenient for patients
2. Expedites services to patients
Disadvantages
3. Can be extremely costly to decentralize
major services in an organization
 Patient Centered Approach

• Includes;
1. Total Patient Care
2. Primary Nursing
3. Case Management
4. Clinical Pathways
 1. Total Patient Care

 Involves the use of multi-skilled personnel

and nurses
 The nurse is responsible for all the care
given to one or more patients for the entire
shift
 Typically used in critical care units/NICU,
renal units,
Total Patient Care - Advantages

1. Continuous holistic expert nursing care

2. Total accountability for the nursing care of
the assigned patient for that shift
3. Continuity of communication with the
patient, family, physician and staff from
other departments
Total Patient Care - Disadvantages

1. Requires experienced personnel

2. Senior nurses spend some time doing tasks that
could be done more cost effectively by less
skilled persons
 2. Primary Nursing

 A nursing care delivery system in which one

nurse is responsible and accountable for the
nursing care of specific patients for the
duration of their stay/Admission.
 The primary nurse designs, implements and
is accountable for the nursing care of
patients in the patient load for the duration of
the patient’s stay in the unit.
 2. Primary Nursing

 The actual care is either given by the primary

nurse or associate nurse.
 Decision making is decentralized, from the
team leader to the bed side nurse.
 It focuses on the continuity of care beginning
with admission and ending with discharge.
 Primary Nurse
24-hour responsibility for
planning, directing &
other members evaluating patient care Associate Nurses

Patient

Primary Nursing Model

 Advantages of Primary Nursing
1. Focuses on client’s needs
2. There is increased autonomy for the nurse
3. Increased opportunity for development of
rapport between the nurse and the client/ family
4. Enhanced continuity and coordination of care
5. Increased accountability by the nurse
6. Increased nurse, patient and physician
satisfaction
 Disadvantages of Primary Nursing
1. There must be good communication between the
primary and the associate nurse
2. Some associate nurses may be unwilling to take
instructions from the primary nurse
3. It is costly- more expensive to hire highly skilled
nurses
4. It can not be practiced by less skilled nurses-
requires experienced nurses
5. Dependency of the patients on some nurses
 3. Case Management
 Historically used in the community/ public health
settings
 It is a model for identifying, coordinating and
monitoring the implementation of services
needed to achieve desired patient care outcomes
within a specified period of time
 Nursing case management organizes patient care
by major diagnoses or diagnosis related groups
and focuses on attaining predetermined patient
outcomes within the specified time frame and
resources
 Collaborates With Patient and Family

NURSE CASE MANAGER

Onset of Resolution of
Assesses, plans, implements, coordinates,
Illness Illness
monitors, and evaluates patient care
options and services to meet health needs

Collaborates with Nursing, Coordinates Services:

Physicians, Physical/Speech/ Home Care, Hospice,
Occupational Therapists, Dietary, Extended /Long-term Care
and Ancillary Services Ambulatory Care Services

Case Management
 Advantages of Case Management

1. There is collaboration of all health care

members
2. Identification of expected patient outcomes
with time frames
3. Promotion of professional practice
 Case Management - Disadvantages

1. For it to be successful, there has to be support

by key members of the organization
2. Needs skilled case managers
3. Its expensive in terms of time and manpower
 4. Clinical Pathways
• Clinical pathways are care management
tools that outline the expected clinical
course and outcomes for a specific patient
type.
• Typically they are pathways that outline the
normal course of care for a patient.
• Pathways are often done by day and for each
day expected outcomes are articulated.
• Patient progress is measured against the
expected outcomes.
Clinical Pathways - Advantages

1. Very instructive to new staff

2. Save a significant amount of time in the
process of care
3. In most cases, improve care and shorten
length of stay for the population on the
pathway
4. Allow for data collection of variances to the
pathway
 Clinical Pathways - Disadvantages

1. Some medical team members wrongly

perceive pathways and are reluctant to
participate in their development.
2. Development requires a significant
amount of work to gain consensus from
the various disciplines on the expected
plan of care.
3. Pathways are less effective for patient
populations that are nonstandard, since
they are constantly being modified to
reflect individual patient needs.
Other Nursing Care Delivery
Concepts
Preceptor nursing
 1. Practice Partnerships
 A nursing care delivery system in which senior
and junior staff members share patient care
responsibilities.
 The relationship between the senior and junior
partner is designed to create synergistic energy
as the two work in concert with patients
 The senior partner performs selected patient care
activities but delegates less specialized activities
to the junior partner.
 Practice Partnerships
Advantages
1. Less expensive for the organization
2. More satisfying professionally to the
partners.
Disadvantages
3. Organizations tend to increase the number
of un qualified nurses and reduce the
number of skilled nurses
 2. Preceptorship
 Preceptors help guide the transition and
integration of nursing students into the nursing
workforce.
 They support the development of clinical
competence and confidence in a way that allows
junior nurses to grow professionally.
 Management must offer support by allowing a
preceptor to balance this role with patient
responsibilities.
 The clinical team members must also be involved
so that the needs of patient continue to be met.
mentorship
NURSE MENTOR
 3. Mentorship
 Mentors provide information, advice and
support to less senior nurses over an
indefinite period of time.
 Both the mentor and mentee invest a
significant amount in the relationship
emotionally, allowing for self-directed
growth and learning.
- Advantages Mentorship
1. Bridge the gap between theory and nursing
practice.
2. Provide guidance for transformational
leadership.
3. Enhance critical thinking and career
development.
4. Increase self-esteem, job enrichment and
willingness to take risks.
5. Enhance productivity, managerial skills and a
sense of professionalism.
6. Recruitment and retention strategy.
 Mentorship - Challenges
1. There are fewer nurses in leadership positions
to act as mentors.
2. The high number of part-time and casual
nurses does not provide a supportive
environment for mentoring.
3. The emotional demand of mentorship also
makes it more difficult to recruit a nurse into a
mentorship role
4. Relationship Based Nursing Practice
 This is a new concept.
 RBNP is a care delivery model designed to
transition nursing care from task focused to
relationship based
 Focuses on 3 relationships; nurse to patient,
nurse to colleagues and nurse to self
 Principles guiding its use; team briefing and
debriefing, standardized handing over and
focus time.
Summary
• Nursing care modalities/models are patient
care delivery systems which are templates
for organizing and providing care to
patients.
• There is need to match available resources
with patient characteristics and health care
needs.
• Nursing care is the most important
predictor of overall patient satisfaction with
their hospital care.
• Care models can be differentiated
(Functional and Team nursing) or patient
centered (Total Patient Care, Primary
Nursing, Case Management and Clinical
Pathways).
• Other nursing care concepts include;
Practice Partnership, Preceptorship,
Mentorship and RBNP.
THANK
thank you
YOU

R.Amunga 76