ORGANIZING NURSING SERVICES AND PATIENT CARE

INTRODUCTION
Organization is the form of every human association for the attaintment of common purpose
and the process of relating specific duties or function in a whole. WHO expert committee on
nursing defines the nursing services 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.Nursing has a large, important and unique role in the health care delivery
system of a country. Nursing care is extremely important for good patient outcome. While the
physician plans the treatment and surgeon carries out the operation, it is the nurse who gives
24 hrs / round the clock nursing care and looks after the needs of the patient. The success of
the patient care depends upon the competence of the nursing staff. Organizing the high level of
nursing care is a big challenge for the nursing service administrator. Setting of standards and
goals for providing care to patients depends upon the philosophy of nursing in order to
organize the patient care.

ORGANIZING NURSING SERVICES

Meaning of nursing service and nursing service administration

Nursing Service
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 a comprehensive program of patient care in the hospital.
Nursing service administration
Nursing service administration is a complex of elements in interaction and is
organized to achieve the excellence in nursing care services. It results in output of clients
whose health is unavoidably deteriorating, maintained or improved through input of
personnel and material resources used in a process of nursing services.

DEFINITION OF NURSING SERVICE

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 WHO expert committee on nursing defines the nursing services 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.
OBJECTIVES OF NURSING SERVICE
The first component of nursing service administration is the planning and it should
be based on clearly defined objectives. The objectives of nursing service department are as
follows:
Objectives in relation to Patient care
The primary emphasis is on total patient care that is:
 To give highest possible quality care in terms of total patients need which include physical,
psychological, social, educational and spiritual needs by collaborating with other health tem
members.
 To assist the physician in providing medical care to the patients.
 To provide preventive and rehabilitative services.
 To provide round the clock nursing care to all the patients.
 To render timely and appropriate nursing service to emergency patients.
 To provide cost effective quality care as per the needs of patients.
 Confidentiality and privacy of each patient should be maintained.
 Constant monitoring and evaluating is of utmost importance to improve patient care
continuously.
Objectives in relation to Education
 Planning of education and training programme for nurses are must for professional growth
and development needs through in-service education and research support.
 To provide regular staff development, in-service education and guidance services for all
members of nursing staff.
 To conduct regular orientation programme for new entrants and for those have been on the
job for a long time.
 To conduct training for operating procedure of latest gadgets and on handling sophisticated
bio-medical equipment.
Objectives in relation to Administration and Organization
 To make regular supervision through rounds.

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 To ensure that the essential equipment is provided in functional status for nursing care
services.
 To provide regular flow of essential supplies to render quality nursingcare.
 To have a proper system of rotation of staff, provision for annual leave and days off for the
nursing staff without hampering patient care.
 Establish a communication system for nursing personnel, other health worker, patients,
health authorities, government authorities and public.
 Ensure that each nurse identifies her job responsibilities and accountability.
 Counseling for health personnel, patients and the public.
 The formulation of policies, standards, goals of nursing service, education and practice.
 Maintaining proper documentation of the personnel employed in nursing service.
Objectives in relation to Research
 Establish a system for collection of essential information, research and studies concerning
all aspects of nursing.
 To contribute in research programme conducted by hospitals and by other health personnel.
 To encourage and support the nurse to conduct research projects/ activities.

FUNCTIONS OF NURSING SERVICE

◘ 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.
◘ 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

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 The director of nursing service is delegated the authority and responsibilities for
organizing and administrating the nursing services in hospital. It is her duty to institute the
essential characteristics of good nursing services in her institute such as:

a. Plan of organization
b. Policy and administrative manuals
c. Nursing practice manual
d. Nursing service budget
e. Master staffing pattern
f. Nursing care appraisal plan
g. Nursing service administrative meetings
h. Adequate infrastructure facilities, supplies and equipment
i. Written job description & job specifications
j. Personnel records
k. Personnel policies
l. Health services
m. In–service education
n. Co-ordination
o. Advisory committee

a.Purposes and objectives of the nursing service:

The purposes should be in accordance with the hospital philosophy regarding patient
care and approved by administration. It must characterize the principles of excellence in
service, in practice and leadership. Objectives are specific, practical, attainable, measurable
and understandable to all the nursing staff.
b.Plan of organization:
Every hospital has the basic system of coordination of vast number of activities i.e.
the Director of Nursing service, she is responsible for maintaining standards for patient care
in terms of quality nursing service must be familiar with the formal organizational structure
of the hospital and its relationship in various department and their functions. The plan of
organization should indicate inter as well as intra-department relationship. The plan also

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should indicate area of responsibility and to whom and for whom each person is
accountable and the channels of communication.
c.Policy and administrative manuals:
The policy and procedure manual are required for the operation of the hospital. Policies
are established within the department to guide the nursing staff, which includes duty hrs,
rules and regulations etc. These are periodically revised and reviewed at regular intervals.
d.Nursing practice manual:
This the written procedure available as evidence of the standards of performance
established by nursing service organization for safe and effective practice after taking into
consideration the best use of available resources. Liberal use of diagram and precautions in
nursing manual helps to keep instruction direct and exact. The advantages are ensure
economy of time effort & material and provides basis for training for new personnel to
acquire knowledge and current skill.
e.Nursing service budget:
It is required for personnel budget, nurse’s welfare activities, staff development
programme, equipment and capital expenditure, supplies and expenses. Budget preparation
should includes analysis of past operation and anticipating the future revenue and expenses.
f.Master staffing pattern:
It is the number and composition of nursing personnel assigned to work in a hospital in
different department / wards at a given time. This helps the director to visualize the
equitable distribution of nursing personnel among various nursing unit. It serves as a guide
for planning daily, weekly and monthly schedules.
g.Nursing care appraisal plan:
Employing various techniques such as supervision, ward rounds, conference, anecdotal
record, rating scale, checklist, suggestion box and peer review can do performance
appraisal of nurses. This is done to improve the quality of service provided, determine the
job competence and to enhance staff development.
h.Nursing service administrative meetings:
This meeting gives opportunity for free communication, planning and evaluation of the
nursing service through regular meeting of the director of nursing with total nursing staff.
The purposes are regular exchange of view between management and nursing service for

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improving working condition, welfare of patient and improvement in methods and
organization of work.
i.Adequate infrastructure facilities, supplies and equipments:
The director of nursing evaluates periodically the adequate resources and arranges new
facilities needed for patient care in discussion with the hospital administrator.
j.Written job descriptions and job specifications:
In job description the responsibility are clearly spelt out as precisely including the job
content, activities to be performed, responsibility and result expected from various role
required by the organization. It is useful for reducing conflict, frustration, overlapping
duties and acts as a guide to direct and evaluate person.
k.Personnel records:
Personnel records include the information relating to the individual such as recruitment
and selection, medical records, training and development, transfer records, promotion,
disciplinary action records, performance records, absenteeism data, leave record and salary
records, etc.
l.Personnel policies:
It reflects an analysis of the total job of nursing in accordance with the types of
functions to be performed. It also indicates the qualitative and quantity of service to be
maintained and the purpose for which the hospital exist.
m.Health services:
Supervision of health of each employee by means of pre-employment physical
examination, periodic examination, immunization and provision of diagnostic, preventive
and therapeutic measures. The education of employee in the principle of health and hygiene
so that they may develop healthy habit of living and working.
n.In-service education:
It is the essential components of staff development programme, which aims at
augmenting, reinforcing nurse’s knowledge, skill and attitude. It includes orientation
programme, skill training, leadership and management training, on the job training, staff
development.

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 o.Co-ordination:
Regular consultation and discussion between the heads of departments and with
members of the medical staff could be an integral part of the administration.
p.Advisory committee:
Each committee has a clear statement and its membership is appropriate to the
purpose. After carefully weighing the advice of the committee, she makes the final decision
about the matter within her area of responsibility and becomes accountable for
implementation.
ORGANISATIONALSTRUCTURE IN NURSING

Organisation means the formal structure of authority calculated to define, distribute,

and provide for the co-ordination of tasks and contributions to the whole.Each organisation
has a formal and an informal structure that governs work flow and interpersonal relationship.
The formal structure is planned and publicised whereas the informal structure is unplanned
and covert.

An organisation's formal structure is the official management of positions into patterns

of working relationship that co-ordinate the efforts of workers with diverse tasks and
abilities. The formal structure of nursing department should be determined by the nurse
executive and nurse managers with input from various nurse specialists; should support
agency goals and nursing philosophy and objectives.

The informal organisation structure consists of unofficial relationships among workers

that influence work effectiveness. The formal structural diagram is a system of power and
control, a map of communication channels, and a scheme for assigning tasks to the most
qualified workers. The main purpose of the defining and updating diagram is essential to
clarify chain of command, span of control, official communication channel, and liaison links
for all department personnel.

Line Organisation Structure

A purely hierarchical chain of command in which each employee is supervised by and

is responsible to a single, clearly identified superior. Pure line structure operation analyses
the principles of classic or traditional, organisational theory, which are:

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 1. The organisation structure should be as simple as possible to facilitate understanding
of role relationship.
2. The organisation structure should provide clear-cut authority and responsibility for
each position.
3. The work of each employee should be confined to a single function, or group of
similar functions, because specialisation fosters efficiency.
4. The activities and functions of each employee should clearly contribute to
achievement of overall goals of organisation.
5. Related functions should be grouped under a single supervision.
6. Each worker should take orders from and be accountable to only one supervisor.
7. To ensure horizontal co-ordination, institutional rules and policies should be
formulated by the top administrator.

The line authority is a direct authority exercised by a supervisor over his subordinates
and the flow of authority is always downward. In its implicity, unity of control, better
discipline, fixed responsibility, flexibility and prompt decision will be possible.In practice, an
organisation's line functions sometimes we come across lack of specialisation, overloading of
works, inadequate communication and favouritism.

Line relationship exists between a superior and the subordinates immediately and
directly responsible to him. In nursing, staff nurses who perform the basic work of the

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nursing, that is direct patient care. The middle level manager, like head nurses supervisors
are responsible for programmed decision making and direction of day-to-day operation. The
nursing personnel at the top CNO or Directors are responsible for non-programmed decision
making such as goal setting, programme planning and performance evaluation.

Line and Staff Organisations

A staff function is an activity that is separated from the chain of command to permit a
high degree of specialisation. The staff authority is created for giving specialist advice to the
line superiors, and flow of authority is always upward. It has no power in the organisation.
Staff relations are those which arise where an individual is acting as the representative of a
superior. This individual is not vested with authority in her/his own rights but in acting for
and on behalf of the person who the authority is vested. A staff officer's specialisation
confers the status of expert in a narrower sphere of management. A cynical definition of a
staff specialist is one whose preparation and experience confer more and more knowledge
about fewer and fewer subjects. The staff officers serve one of these functions-service,
advisor, control, e.g. assistant nursing officer, (HN) incharge, in, service is a service
specialist, who serves line division by orienting and training of staff nurses. An assistant
nursing officer who is incharge of planning advises line manager/supervisor in setting goals
and planning of method to achieve goals. Like this, staff officer advises the line officers in
planning, organising, control and directing and other managerial affairs.

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 It is believed that the best system to adopt in any progressive and elite organisation is
the line and staff organisation. Here there is a provision for having experts, advice available
to management, which in turn increases efficiency of supervisors and also there is chance of
advancement to its employees. Here there is a scope for staff need to assume line authority
may lead to frictions, and if they do not give sound advice leads to problems, which hinders
the attainment of objectives properly.

Functional Organisation

Functional organisation is a system of organisation in which functional departments

are created at the institutional level to deal with the problems of concerned at each successful
level, e.g. in an hospital

Thus line and staff organisation is that key management functions that the chief
executive has neither skill or time to execute well, are delegated to functional experts who
can devote full time to the assigned function without being distracted by responsibilities of
day-to-day management of personnel and material.

A nursing organisation increases in size, it may evolve from a pure line, to a line and
staff and finally to the functionalised line and staff structure. In functional line and staff
organisation, the expert is responsible for a specified management function such as staffing,
policies, quality improvement, or staff development, has authority to command line
managers to implement needed actions that relate to the expert's specified functions.

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 ORGANISATION OF NURSING SERVICES:
An organizational structure for a division of nursing must meet the needs of that
division an written in the statements of mission, philosophy, vision, values, and objectives.
Before the structure. Before the structure is changed, the nurse mangers should engage in a
systematic analysis as well as do some sound thinking about altering the organization’s design
and structure, starting with objective and strate

AtNational level:-

Nurse are general no involved in making policies that govern their status and practice. Most
of the decisions concerning nurses and nursing care are made by other people i.e ministry of
health and family welfare. There is also a nursing advisor to the govt. of India.

Organizational set-up at directorate – general of health service,(recommended by high power

committee)and the institutions which come under the central government are given below:

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 DGHs

Addl DG(PH) AddlDDG(N) Addl DG(M)

DDG(N)

ADG ADG ADG

(Community Nsg. Services) (Nsg. Edu& research) (Hospital Nsg services)

DADG DADG DADG

(CommunityNsg. Services) (Nsg. Edu& Hospital) ( Nsg services)

CommunityNsg.officer Principal/Tutor school of Nsg Nsg suptd.

P.H.N Supervisor Senior Tutor Dy.Nsg Suptd.

P.H.N Tutor Asst.NsgSuptd.

LHV Clinical instructor Ward sister

ANM Staff

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At State Level:

Recommended organizational set-up at state /union territory level

Secretary Health

Director nursing services

Joint/Deputy director nursing services

ADNS ADNS ADNS

Community Nsg.Nsg. Educ. and Research Hospital Nsg Services

DADNS DADNS DADNS

Community nursing NsgEdu.and Res Nursing service

Dist.Nsg officer principal, school of Nsg. Nsg suptd.

P.H Nsg officer Senior Tutor Dy.NsgSuptd.

P.H.N and PHC Tutor Asst. Nsg Suptd.

LHV Clinical instructor Ward sister

ANM Staff nurse

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At district level
Recommended organizational set- up at the district level
Director nursing services

Deputy director nursing services

Asstt Director nursing services

DyAsstt Director nursing services

DMO DisttNsg Officer DHO

Officer
Asst Dist Nsg officer
AsstDistNsofficer Hosp and NsgEdu.
(Community)
principal Tutor

. Dist PNO
Nsgsuptd/ Dy.NsgSuptd
P.H Nsg officer
Asst.NsgSuptd Tutor PHN Supervisor(CHC)

Ward sister Clinical instructor PHN(PHC)

Staff nurse
LHV

ANM

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ROLE AND FUNCTION OF NURSE ADMINISTRATOR

The Principal Matron of the hospital will be responsible to the Commandant of the
hospital for the following duties:
1.Administration
a. Organizes, directs and supervises the nursing services both day and night.
b. Coordinates assignments of staff.
c. Establishes the general pattern of delegation of responsibilities and authority.
d. Formulates standing orders for the nursing care.
e. Ensures appropriate allocation of duties and responsibilities to all nursing staff
working under her.
f. Formulates nursing policies to ensure quality patient care and adequate attention at
all times.
g. Responsible for efficient functioning of the nursing staff.
h. Evaluates the personal performance of the nursing staff.
2.Discipline
a. Ensure that a standard of discipline of nursing staff is high at all times.
b. Maintain good order and discipline in wards/departments.
c. Makes daily rounds of the hospital wards/departments and also seriously ill patients.
In addition she will make unscheduled rounds in the hospital in the evenings.
d. Brings immediately to the notice of the medical superintendent all matters concerning
neglect of duty, insubordination either by nursing staff, patients or visitors or any un-
towards incident, which comes to her notice for taking suitable action as required as
per the orders on the subject.
3.Public Relations
a. Promotes and maintains harmonious and effective relationship with the various
administrative departments of the hospital and related community agencies.
b. Maintain cordial relationships with the patients and their families.
4.Confidential Reports
a. Initiates the confidential reports of nursing staff on due dates.
b. Responsible for the nursing budget.
5.Education
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 a. Carries out in-service training for all categories of nursing staff and paramedical
personnel and keeps the records of such trainings.
b. Conduct various update courses based on the needs.
c. Encourages the personnel to participate in the continuing education programme.
6.Welfare
a. Responsible for health and welfare of nursing staff.
b. Ensures annual and periodical health examination and maintenance of health records.
7.Conferences
a. Responsible for organizing and conducting staff meeting of the nursing staff once in
three months.
b. Holds conference in nursing care problems and discuss policies as regards to working
conditions, working hrs and other facilities.
8.Supervision
a. Supervises nursing care given to the patients and all nursing activities within the
nursing unit.
b. Supervises the work of all paramedical staff of the hospital.
9.Records and Reports
a. Maintains various records such as duty roster nursing staff, day off book, personal bio-
data, leave plan, staff conference book, courses file etc.
ORGANIZING PATIENT CARE
The overall goal of nursing is to meet the patient nursing needs with the available
resources for providing smooth day and night 24 hrs quality care to patients and to honor
his rights. To ensure that nursing care is provided to patients, the work must be organized.
A Nursing Care Delivery Model organizes the work of caring for patients. The decision of
which nursing care delivery model is used is based on the needs of the patients and the
availability of competent staff in the different skill levels. For organizing function to be
productive and facilitate meeting the organization’s needs, the leader must know the
organization and its members well.The top level manager who influence the philosophy and
resources necessary for any selected care delivery system to be effective.The first and
middle level managers generally have their greatest influence on the organizing phase of
the management process at the unit or departmental level. The managers organize how

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work is to be done, shape the organizational climate, and determine how patient care
delivery is organized. The unit leader-manager determines how best to plan work activities
so organizational goals are met effectively and efficiently, involves using resources wisely
and coordinating activities with other departments.
I.DEFINITION OF PATIENT CARE
The services rendered by members of the health profession and non-professionals under
their supervision for the benefit of the patient.
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.
II.MODES OF ORGANIZING PATIENT CARE / METHODS OF PATIENT
ASSIGNMENT
The most well known means of organizing nursing care for patient care delivery are,
a. Case method or Total patient care
b. Functional nursing
c. Team nursing
d. Modular or district nursing
e. Progressive patient care
f. Primary nursing
A. CASE METHOD
It was the first type of nursing care delivery system. In this method, nurses assume
total responsibility for meeting all the needs of assigned patients during their time on duty.
It involves assignment of one or more clients to a nurse for a specific period of time such as
shift. The patient has a different nurse each shift and no guarantee of having the same
nurses the next day. Nurse’s responsibility includes complete care including treatments,
medication and administration and planning of nursing care. This is the way most nursing
students were taught – take one patient and care for all of their needs. This model is used in
critical care areas, labor and delivery, or any area where one nurse cares for one patient’s
total needs. Here nurses were self-employed when the case method came into being,
because they were primarily practicing in homes. It lost much of that autonomy when

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healthcare became institutionalized in hospitals and clinics and now called as private duty
nursing.

Merits:
a. The nurse can attend to the total needs of clients due to the adequate time and proximity
of the interactions.
b. Good client nurse interaction and rapport can be developed.
c. Client may feel more secure.
d. RNs were self-employed.
e. Work load can be equally divided by the staff.
f. Nurse’s accountability for their function is built-it.
g. It is used in critical care settings where one nurse provides total care to a small group of
critically ill patients.
Demerits:
a. Cost-effectiveness.
b. The greater disadvantage to case nursing occurs, when the nurse is inadequately trained
or prepared to provide total care to the patient.
c. Nurse may feel overworked if most of her assigned patients are sick.
d. She/he may tend to ‘neglect’ the needs of patient when the other patients ‘problem’ or
‘need’ demands more time.

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 B.FUNCTIONAL NURSING
This system emerged in 1930s in U.S.A during WWII when there was a severe
shortage of nurses in US. A number of Licensed Practice Nurses (LPNs) and nurse aides
were employed to compensate for less number of registered nurses (RNs) who demanded
increased salaries. It is task focused, not patient-focused. In this model, the tasks are
divided with one nurse assuming responsibility for specific tasks. For example, one nurse
does the hygiene and dressing changes, whereas another nurse assumes responsibility for
medication administration. Typically a lead nurse responsible for a specific shift assigns
available nursing staff members according to their qualifications, their particular abilities,
and tasks to be completed

Charge Nurse

RN RN LPN UAP
Medication Treatment Vital signs Hygiene
Nurse Nurse Nurse Nurse

Patients assigned to the team

Merits:

a. Each person become very efficient at specific tasks and a great amount of work can be
done in a short time (time saving).
b. It is easy to organize the work of the unit and staff.
c. The best utilization can be made of a person’s aptitudes, experience and desires.
d. 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.
e. Nurses become highly competent with tasks that are repeatedly assigned to them.

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f. Less equipment is needed and what is available is usually better cared for when used only
by a few personnel.
Demerits:
a. Client care may become impersonal, compartmentalized and fragmented.
b. Continuity of care may not be possible.
c. Staff may become bored and have little motivation to develop self and others.
d. The staff members are accountable for the task.
e. Client may feel insecure.
f. Only parts of the nursing care plan are known to personnel.
g. Patients get confused as so many nurses attend to them, e.g. head nurse, medicine nurse,
dressing nurse, temperature nurse, etc.

C.TEAM NURSING

Developed in 1950s because the functional method received criticism, a new system of
nursing was devised to improve patient satisfaction. Care through others became the
hallmark of team nursing. 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. In team nursing an RN leads a team
composed of other RNs, LPNs or LVNs and nurse assistants or technicians. The team
members provide direct patient care to group of patients, under the direction of the RN
team leader in coordinated effort. 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. The team leader assigns tasks, schedules care, and
instructs team members in details of care. 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. The team leader also provides care
requiring complex nursing skills and assists the team in evaluating the effectiveness of their
care.

Charge Nurse RN

Team Leader RN Team Leader RN

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 RN LPN NA RN LPN NA

Group of Patients Group of Patients

Advantages:

a. High quality comprehensive care can be provided to the patient

b. Each member of the team is able to participate in decision making and problem solving.
c. Each team member is able to contribute his or her own special expertise or skills in
caring for the patient.
d. Improved patient satisfaction.
e. Feeling of participation and belonging are facilitated with team members.
f. Work load can be balanced and shared.
g. Division of labour allows members the opportunity to develop leadership skills.
h. There is a variety in the daily assignment.
i. Nursing care hours are usually cost effective.
j. The client is able to identify personnel who are responsible for his care.
k. Barriers between professional and non-professional workers can be minimized, the
group efforts prevail.

Disadvantages:
a. Establishing a team concept takes time, effort and constancy of personnel. Merely
assigning people to a group does not make them a ‘group’ or ‘team’.
b. Unstable staffing pattern make team nursing difficult.
c. All personnel must be client centered.
d. There is less individual responsibility and independence regarding nursing functions.
e. The team leader may not have the leadership skills required to effectively direct the
team and create a “team spirit”.
f. It is expensive because of the increased number of personnel needed.

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g. Nurses are not always assigned to the same patients each day, which causes lack of
continuity of care.
h. Task orientation of the model leads to fragmentation of patient care and the lack of time
the team leader spends with patients.

D.MODULAR NURSING
Modular nursing is a modification of team nursing and focuses on the patient’s
geographic location for staff assignments. The concept of modular nursing calls for a
smaller group of staff providing care for a smaller group of patients. 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 may include LVN/LPN or UAP. The team leader is
accountable for all patient care and is responsible for providing leadership for team
members and creating a cooperative work environment. The success of the modular nursing
depends greatly on the leadership abilities of the team leader.
Merits:
a. Nursing care hours are usually cost-effective.
b. The client is able to identify personnel who are responsible for his care.
c. All care is directed by a registered nurse.
d. Continuity of care is improved when staff members are consistently assigned to the
same module
e. The RN as team leader is able to be more involved in planning & coordinating care.
f. Geographic closeness and more efficient communication save staff time.
g. Feelings of participation and belonging are facilitated with team members.
h. Work load can be balanced and shared.
i. Division of labor allows members the opportunity to develop leadership skills
j. Continuity care is facilitated especially if teams are constant.
k. Everyone has the opportunity to contribute to the care plan.

Demerits:

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 a. Costs may be increased to stock each module with the necessary patient care supplies
(medication cart, linens and dressings).
b. Establishing the team concepts takes time, effort, and constancy of personnel.
c. Unstable staffing pattern make team difficult.
d. There is less individual responsibility and autonomy regarding nursing function.
e. All personnel must be client centered.
f. The team leader must have complex skills and knowledge.
g.
E.PROGRESSIVE PATIENT CARE:
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. As they
progress towards increased self care (as they become less ethically ill or in need of
intensive care or monitoring) they are marred to units/ wards staffed to best provide the
type of care needed.
Principal elements of PPC are:
i) Intensive care or critical care: Patients who require close monitoring and intensive care
round the clock, 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. 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. Nursing approach in these units is patient-centered.
ii) 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.
iii) 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.

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iv) 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.
v) 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.
vi) 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.
Merits:
a. Efficient use is made of personnel and equipment.
b. Clients are in the best place to receive the care they require.
c. Use of nursing skills and expertise are maximized.
d. Clients are moved towards self care, independence is fostered where indicated.
e. Efficient use and placement of equipment is possible.
f. Personnel have greater probability to function towards their fullest capacity.
Demerits:
a. There may be discomfort to clients who are moved often.
b. Continuity care is difficult.
c. Long term nurse/client relationships are difficult to arrange.
d. Great emphasis is placed on comprehensive, written care plan.
e. There is often times difficulty in meeting administrative need of the organization,
staffing evaluation and accreditation.

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 F.PRIMARY CARE NURSING
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.
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.

Patients

Total patient care 24 hrs/day

Communicates with Consults with physician

PRIMARY
supervisors or other healthcare
NURSE
providers

Associate (days) Associate (afternoon) Associate (evenings)

when primary nurse when primary nurse when primary nurse
is not available is not available is not available

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Advantages:
a. 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.
b. Primary nurses are in a position to care for the entire person-physically, emotionally,
socially and spiritually.
c. High patient and family satisfaction
d. Promotes RN responsibility, authority, autonomy, accountability and courage.
e. Patient-centered care that is comprehensive, individualized, and coordinated; and the
professional satisfaction of the nurse.
f. Increases coordination and continuity of care.
Disadvantages:

a. More nurses are required for this method of care delivery and it is more expensive than
other methods.
b. Level of expertise and commitment may vary from nurse to nurse which may affect
quality of patient care.
c. Associate nurse may find it difficult to follow the plans made by another if there is
disagreement or when patient’s condition changes.
d. It may be cost-effective especially in specialized units such as the ICU.
e. May create conflict between primary and associate nurses.
f. Stress of round the clock responsibility.
g. Difficult hiring all RN staff
h. Confines nurse’s talent to his/her own patients.

G.CASE MANAGEMENT
The case manager (RN or social worker with managerial qualification) is assigned
responsibility of following a patient’s care and progress from the diagnostic phase through
hospitalization, rehabilitation and back to home care. For eg; case manager for cardiac
surgery patients assists them go through diagnostic procedures, pre-operative preparations,
surgical interventions, family counseling, post-operative care and rehabilitation. Case
managers are employed by third party payers (e.g. insurance companies) by the hospital

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authorities (e.g. for heart surgeries, renal transplant, reconstructive surgeries, etc.), by
clubs, industrialists and associations or by individuals, e.g. geriatric, family or private
patients case managers. No direct care by the manager whose main roles are of teaching,
advocacy and coordinating with health care providers. Case manager (nurse) ensures
quality care that is holistic and assisting the patient to attain self care status according to
his/her potential. It emphasizes achievement of outcomes in designated time frames with
limited resources.
Case management involves critical paths, variation analysis, inter shift reports, case
consultation, health care team meetings, and quality assurance. Critical paths visualize
outcomes within a time frame. Variation analysis notes positive or negative changes from
the critical paths, the cause, and the corrective action taken. Case consultation may be
indicated when the client’s condition differs from the critical path as noted in the inter shift
report. Case consultation is conducted about once a week for a few minutes immediately
after inter shift report to deal with variations.
Health care team meetings provide an interdisciplinary approach to problem solving.
The case manager needs to identify no more than three priority goals and decide what team
members should be present after considering the patient, family physician, social service,
various therapists, and others involved. The case manager should set the time and place for
the meeting, make the arrangements, and post the date, time, place, and people to attend.
The case manager calls the meeting to order, states the goals, initiates discussion,
documents the plans, and sets time limits for follow through. The variance between what is
expected and what happened is assessed for quality assurance.
Responsibilities of case managers:
a. Assessing clients and their homes and communities.
b. Coordinating and planning client care.
c. Collaborating with other health professionals in the provision of care.
d. Monitoring client progress and client outcomes.
e. Advocating for clients moving through the services needed.
f. Serving as a liaison with third party payers in planning the client’s care.
Merits:
a. Case management provides a well coordinated care experience that can improve the

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 care outcome, decrease the length of stay, and use multiple disciplines and services
efficiently.
b. Provides comprehensive care for those with complex health problems.
c. It seeks the active involvement of the patient, family and diverse health care
professionals
Demerits:
a. Nurses identify major obstacles in the implementation of this service, financial barriers
and lack of administrative support.
b. Expensive
c. Nurse is client focused and outcome oriented
d. Facilitates and promotes co-ordination of cost effective care
e. Nursing case management is a professionally autonomous role that requires expert
clinical knowledge and decision making skills.

III.FACTORS INFLUENCING THE QUALITY PATIENT CARE

Many variable factors influence the number of nurses needed on a ward in order to
render a high quality of patient care.
a. The total number of patient to be nursed
b. The degree of illness of patients (physical dependency)
c. Type of service: medical, surgical, maternity, pediatrics and psychiatric
d. The total needs of the patients
e. Methods of nursing care
f. Number of nursing aids and other non professional available, the amount and quality
of supervision available
g. The amount, type and location of equipment and supplies
h. The acuteness of the service and the rate of turnover in patients according to the
degree or period of illness.
i. The experience of the nurses who are to give the patient care.
j. The number of non-nurses who involve in the patient care, the quality of their work,
their stability in service.
k. The physical facilities

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 l. The number of hours in the working week of nurses and other ward personnel and
the flexibility in hours
m. Methods of performing nursing procedures
n. Affiliation of the hospital with the medical school
o. Methods of assignment-individual, team or functional method
p. The standards of nursing care.
SUMMARY
As far we discussed about organizational nursing services and structure in nursing
services, its structure, organization of patient care,types of patient care and its merits and
demerits.
CONCLUSION
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. According to their educational
qualification and patient acuity they are delivering care to the patients throughout their
hospital stay. The structures of the delivery of care have taken many different formats.
BIBLIOGRAPHY:
1. Basavanthappa B T. Nursing administration. Ist edn. New Delhi: Jaypee brothers;
2000.
2. Chandra Ballabh. Encyclopedia of Hospital & Health Science Management. New
Delhi: Alfa Publishers; 2008.
3. Mary Lucita. Nursing: Practice and Public Health Administration. 2nd Ed. Philadelpia:
Elsevier Publishers; 2007..
4. Chavigny K, Lewis A. Team or Primary Nursing Care 1984; 32: (6) 322-7.
5. Basvanthappa B.T . Nursing administration.2nd ed. New Delhi: Jaypee brothers medical
publishers Pvt ltd;2009 p-64-85

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6. Goel S.L. Shalini Rajaneesh. Management technique principles and practices. New Delhi
:Deep&Deep publishers pvt ltd;2001 P-392-93

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Programme : MSc(N) II Year
Name of the student : Mrs.Jessy L
Subject : Nursing Management
Unit : IV
Topic : Organization of nursing and patient care
Hours Allotted : 2 hours
Name of the HOD : Mrs.Smitha Mohan
Name of the Evaluator : Mrs.Smitha Mohan
Submitted to : Prof V Mary Elizabeth
Submitted on : 28.06.2019

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