MODELS OF CARE DELIVERY SYSTEM

1.0 Introduction

Model of care delivery system is a method of delivering nursing care to achieve the optimum patient outcome. The structure of care delivery system is to enable the nurse to provide nursing care which include assessing care needs, formulating care plan, implementing and evaluate patient’s response to the intervention.

Manthey(1990)identified the element of nursing care delivery system as a clinical decision making, work allocation, communication and management. Since World War II, Models of Care Delivery System had undergone a lot of changes. Each of the nursing care delivery care system has an advantages and disadvantages. However, none of those systems is considered perfect. Critiqued heard and debates focused on perfectness of each model providing care considering patients, consumers’ and practitioners’ needs which include effectiveness, quality and cost effectiveness.

The goal of successful patient’s care delivery system includes high quality and the achievement of patients’ outcome and satisfaction level. The ability to reach the objective depends on the type of delivery system and how the care is delivered.

2.0 Type of Nursing Care Models.

There are old and new systems and models of care delivery applied but the priorities is in an environment where there is an increased of health care cost and health care errors. Huber,(2006) in her book stated 6 type of model of care delivery system which are, Private Duty Nursing, Group Nursing, Team Nursing, Modular Nursing, Primary Nursing, Case management, Mix model(Hybrid).However the most common model used are Functional Nursing, Team Nursing, Modular and Primary Nursing.

2.1 Functional Nursing.

Functional Nursing began in 1940’s due to the shortage of nurses. During World War ll, depletion of nurses is due to the moving of nurses to the armed forces. Also called task nurse whereby the staff nurses and care givers are used to the optimum advantage. The staff nurses will be working together with other health care provider performing task assigned .In Functional Nursing, different level of personnel worked side by side, each performing the assigned task. (Chitty, 2005).

The Staff Nurse will assess the patient and will assign other staff as medication nurse, dressing nurse, vital sign nurse. Nurse Aids are assigned to give bed bath to patient. The Functional Nursing of Delivery System is characterized by an assembly line approach to care, in which each staff member is assigned a set of tasks (Ringl, 1994).

The advantage of Functional Nursing is that it could accomplish a lot of tasks which they are capable and assigned to do efficiently in a small amount of time.

However the Functional Nursing has the disadvantages whereby there will be uneven continuity of care and absence of holistic view, poor follow up and poor communication with patient. Chitty. K. K (2005) said, they was no one person they could call, “my nurse”.

2.2 Team Nursing

Team Nursing is the most common model of care delivery system being practiced. It was developed in 1950’s to reduce the fragmented care that accompanied Functional Nursing despite the shortage of professional nursing staff. Team Nursing provides total nursing care to a group of patient. The goal is for the team uses a skill mix nursing staff to work together democratically, not as individuals, to provide total care to an assigned group of patients (Bertram, 1994; Sherman, 1990). Team nursing as said by (Kron 1978) 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 towards the common goal providing qualitative comprehensive nursing care.

Team Leader is accountable for all of the care activities and the team member possessing the skill needed by the individual patient. The most skillful team members will provide care for the most seriously ill patient and the least experience members will provide care for the patient who needs least care.

The Staff Nurse coordinates and leads the team in assigning, delegating, and supervising care. Job satisfaction should be high when the team member’s capabilities are maximized. Team member will support the group productivity and growth for the team. However, Team Nursing requires team spirit and commitment because the team leader will be changing, thus the continuity of patient care may differ.

Although Functional and Team Nursing were implemented in an effort to increase efficiency and cost effectiveness, they have been criticized as being strictly task oriented, increasing fragmentation of care, and reducing the amount of direct nursing care provided by the Staff Nurse (Bertram, 1994; Sherman, 1990).

2.3 Modular Nursing

Modular Nursing is modification of Team Nursing (Barbara Cherry, Susan R. Jacob. 2002) which requires less staff. The size of module or team is according to the physical layout of the ward, patient’s equity and skill mix nursing. The concept is for the smaller group of staff will be assigned to small group of patient and therefore the communication is more efficient.

Team leads by Staff Nurse and the team member will provide patient’s care as directed by her. The team leader’s activity will be developing, updating nursing care plans and solving problem encountered by the team members, communicate with physician regarding patient’s progress and other health care personnel. (Yoder Wise,2003) said that when staff consistently assigned to the same module, continuity of care and communication will improved and therefore the team leader will have time to participate in planning and coordinating care.

In Modular Nursing, team leader is accountable just like Team Nursing and the successful of this model is depending on the team leaders’ leadership.

2.4 Primary Nursing.

Primary Nursing is direct patient’s care which covers 24 hours, continuous accountability for planning and implementing patient’s care from admission till they discharge. The Staff Nurse will establish relationship with patient and family, making decision and coordinate the patient’s activities with other health personnel and seen as more knowledgeable and responsible. It increases the nurse satisfaction by learning in depth the care required. The primary nurse coordinates the plan of care throughout the patient’s hospitalization, and associate nurses carry will out the plan during the absence of the primary nurse. (Bertram, 1994; Shukla, 1983b).

Assignment will be allocated by the nurse leader according to the expertise and specialties of the staff and type of cases. The Staff Nurse coordinates and leads the team in assigning, delegating, and supervising care (Bertram, 1994). It has been debated saying that Primary Nursing is not cost effective because Staff Nurses spend time doing things that other, less expensive employees can do. However, during the shortage of staff, Primary Nursing cannot be implemented.

The advantages of the Primary Nursing are increased patient and family satisfaction when the nurse and patient knew each other well. Primary Nursing also promotes job satisfaction to nurses when they had autonomy to the decision making towards the patient’s care.

However, it is expensive to hire all staff nurses when Primary Nursing applied. The continues care for patient, heavy responsibility and conflict with the associate nurse might cause the nurse to suffer from stress.

3.0 Clinical Practice scenario

I am a Clinical Instructor for private Nursing College in Ipoh. When this assignment was started, my clinical posting was at Tapah District Hospital and therefore my observation was based on this hospital. Tapah Hospital is an old, small hospital with capacity of 100 beds. The hospital doesn’t provide advanced services and facilities to patient. The facilities are limited to minor cases among the population which covers small areas around the town. The wards and units are scattered at different location and at different building. The Male medical and Female Medical ward separated but shelters are attached to both wards to shelter from rain and hot sun.

The x ray, laboratory and pharmacy department located next to emergency department are up to 30 meters away from the ward. However, ambulance service is always available if any crisis arises. Patient will be accompanied by nursing staff if ever x-ray needed. If there is shortage of staff noted, additional staff will be called in. Nursing staff stayed at the hospital quarters or houses nearby and therefore staff is available at all time. They had an A&E and Outpatient clinic.

They are 3 Nursing Sisters. Each of them are assigned to Maternity, Pediatric and Medical ward. The Nursing Sisters will be on duty at 8.00a.m-5.00pm and taking turn to do On call. However, Emergency Department taken over by the Medical Assistant.

Patients’ populations are small. Occasionally the Male Medical Ward is having 8-12 patients and during the peak days they will be 16-20 patients. Patients are from different ethnic and mainly are from the local people and the Orang Asli (Indigenous People) nearby especially patient in the Maternity ward. Due to the distances, the discharge procedure delayed and longer stay in the ward noted compared to the other ethnic. The hospital provides Transit Ward for the convenience of the Orang Asli to stay especially to the pregnant mother awaiting for delivery.

Tapah Hospital is not equip with ventilator, central monitoring or invasive monitoring neither high tech equipment and therefore there does not require many highly skills staff. The allocated nurses are enough to maintain the well flow of care. The Staff Nurses are from the mix skill which could enhance high standard of patient’s outcome. Computer system is not in use in the ward. Tracing blood results from the laboratory and x-rays done manually by sending Nurse Aids to the particular department.

4.0 Model of Care Delivery System In Tapah Hospital.

I have observed Tapah Hospital practicing Functional Nursing which is also called task nurse. In the ward, there will be 2-3 Staff Nurses and 1 Community Nurse with an additional of 2 Nurse Aids will be assigned during the shift. It is also depend on the staff availability.1 Staff Nurse will be the leader or incharge nurse as assigned by the Nursing Sister. The nurse leader will follow ward rounds and communicate with physician or any other health care personnel, do changes in patients’ treatment and ensure all care are rendered .The other Staff Nurse will serve medication, attending new admission, ordering drugs and helping around if any of the staff need assistant.

The Community Nurse will be assigned for dressing and other procedures such as updating intake output chart, checking vital sign, checking blood sugar level and putting up IV fluids. Giving bath to patient, serving food and feeding done by the Nurse Aids. The Nurse Aids had limited scope of competencies. They are on job trained and able to do bed bath, bed making, positioning of patient, serving food, collecting trays, admitting and discharged of patient.

Delegation of assignment is according to the staff level. The activity of daily living will be done by Nurse Aid and procedure which requires high level of skills will be done by the Staff Nurses.

5.0 Discussion

Practically, Functional Nursing being practiced well in Tapah Hospital. However Primary Nursing is the most appropriate model with regards to environment, patients’ population and staff availability.

5.1 Environment

If Primary Nursing been practiced, greater competence in skill are optimized will enhance positive effect on quality patients’ outcome. The hospital could provide advanced equipment and invasive procedure could be performed. Critically ill patient will be taken cared well in view of the skill mix competencies of staff background and ensure continuity of patient care. Patient will be satisfied and complain will be less heard.

Transferring patient for further management can be avoided whereby it is occurred currently in this hospital. In the case of transferring intubated haemodynamically unstable patient to other centers for ventilation support, the patient might be at risk of accidental extubation in the ambulance and staff who accompanying the patient will be in stress.

Primary Nursing attract high quality nursing staff offering high quality of care which patient and family experiences increased satisfaction (Yoder-Wise, 2003). Staff satisfaction will be achieved when given an opportunity to nurse ill cases with advanced equipment, enable staff to maintained nursing skill to the optimum and able to use their education to provide holistic care. Furthermore, the staff will lost their skill in long period of time if the nursing skill is ignored. The “thank you” from patient is a big gift to the nurses. Kenneth J. Sellick, S. R. (2003, July) said a study was conducted in a large acute medical-surgical hospital incorporated a control group and quantitative measures of the variables under investigation showing significantly higher levels of patient and staff satisfaction were shown which support the philosophy of Primary Nursing.

In Primary Nursing features, staff will develop good communication, relationship and

responsibility towards patients through (Marriner-Tomey, 2000) continuity of care for 24 hours per day throughout the hospitalization. When staff: patient rapport buildup, health education can be emphasis in the sense of wellness which could changed patients’ and family towards healthy lifestyle.

5.2 Patient Population

Patient population at Hospital Tapah is small. Occasionally the Male Medical is having 8-10 patients and the peak days they will be 16-20 patient. Female Medical received 6-18 patients. Patients are from different ethnic and the Orang Asli (Indigenous People) nearby. I am focusing on the admission for the Orang Asli. Malays, Chinese and Indian doesn’t have so much problem for hospital admission, however for Orang Asli, admission to the hospital is a stressful experience. The advantages of primary nursing focus on clients need greater nurse autonomy and greater continuity care during the hospitalization (Huber, D. 1996). Language and culture barrier is very inconvenience to the Orang Asli.

If ever the Orang Asli were transferred to Ipoh or Teluk Intan Hospital for further management, the relative will be in dilemma due to the difficulties in life style, transportation and accommodation. Most of the Orang Asli stays far from the town and they cannot afford to spend a lot of money for transport and lodging. (Jeffrey R. Vincent, 2005) In their book said, “In 1999, half of the Orang Asli were poor, and one is approximately seven lived in extreme poverty”.

Due to the distances, the discharge procedure for Orang Asli always delayed and they will stay longer in the ward waiting for transport facilities compared to the other ethnic. However the hospital provides Transit Ward for the convenience of the Orang Asli to stay especially for the pregnant mothers awaiting for delivery.

5.3 Staff Availability

Primary Nursing requires Staff Nurses. Staff Nurses at Tapah Hospital comes from different specialties’. The Staff Nurses can provide all the care to the patient and therefore unlicensed or unprofessional staff will be decreased which reduced cost. Macdonald, M. (2006) in her descriptive literature in an attempt to decide whether primary nursing is worth trying, explored to determine whether the process of implementing primary nursing is worthwhile and finally agree there are staff and patient satisfaction, quality of care and the cost effective.

Staff Nurses at Hospital Tapah stays at the hospital quarters provided or at the housing area nearby and therefore if the need arises the staff is available to meet the requirement.

6.0 Critical analysis and critique

Nursing models constructed of theories and concept used by the nurses to assess, make plan, implementing and evaluating care. Caring is not unique in nursing. It is human behavior including cognitive, affective, psychomotor and administrative skills. Models of Care Delivery system gone through a lot of changes due to criticized in order to formulated another new system which results in better patient outcome and cost effective. However, there is a lack in the models often because of the lack on similarity of staffing, patient population on comparison unit cultural aspect and job satisfaction. The models could be better than the other in terms of cost, staffing and patient outcome.

Functional and Team Nursing are cost effective in view of reduced number of Staff Nurses but patient outcome is not as excellent as Primary Nursing. Compared to the pass, the patient now is acutely ill, but the Staff Nurses: patient ratio is declined. As mention by JoAnn Graham Zerwekh, Jo Carol Claborn (2003) increased acuity of patient results in increased of responsibilities and at the same time increases the nurses workload.

Primary nursing is expansive but reasonable. Patient is satisfied, complain not heard. Standard of care will remained excellent and the hospital will be well known. If the staff is competence and productive the cost might be equal and Primary Nursing will do better. Job satisfaction will motivate Staff Nurses to go for further study to the tertiary level and the will impact on positive patient outcome and increased nursing standard. The organization will be able to retained competence staff which will reduce cost on recruiting new staff.

Increased Nurse: patient ratio will have positive impact to patient good outcome whereby less error occurred such as medication error. Resources, J. C. (2004)did mention that lower staffing level are also associated with higher fall rates and medication error.Staff will be leaving to a better place when job satisfaction is poor due to stress at the work place, shortage of staff, low salary. According to Huber, D (2006), the shortage of nurses is due to 2 reasons for leaving their home country (1) for economic security, (2) professional opportunity.

Shortage of staff will increased overtime usage which is more expensive and restriction on admission whereby transferring of ill patient to another hospital for further management. The Unit manager will have problem in planning the staff on duty roster and end up with closing of wards. Huber,D (2006) said, staff shortage had a serious impact on nursing staffing and staff including increased overtime usage, higher stress, restricted expansion, changes in recruiting and hiring practices, decreased quality of care, and increased difficulty in scheduling coordination.

Considering the culture of indigenous people, they have got the right to get quality care from the health care organization and therefore I strongly emphasized that Primary Nursing should be taken into consideration to be practiced at the area like Tapah Hospital.

7.0 Conclusion

In this study, I have explored the care organized by nurses. I have discussed the advantages and disadvantages of the care delivery system in relation of how the models been managed and the impact of it. Currently patient seen to be demanding due to increased awareness of the quality care as the health care management are seen by the public as more concerned about controlling costs rather than protecting the rights of patient. Patient’s Right to the access to health care that is sufficient to provide access to appropriate high quality health care, receive treatment, emergency services whenever needed, consider to respectful and non - discriminatory care to be treated equally, irrespective of race, sex, age or disability as per the medical condition.

However, the nurses’ role is crucial in managing the care of delivery system to meet the need of health care outcome in the future. Model of Care Delivery System have changed by the cost control factor to meet the consumer expectation. The consumer concerned with the cost but at the same time they demand for competency and quality outcome.

Begin with the Functional Nursing, changes was done which the design formulated becoming Team Nursing to overcome the shortage of nurses. The Modular Nursing which requires less staff appeared when the Team Nursing model had been modified when nurses’ shortage become critical. Primary Nursing was designed for continues care which is more costly but ensure excellence quality outcome and satisfaction to consumer and staff. However the cost control appears to be the barrier. Primary Nursing requires more staff but study have shown that the cost comparison were inconclusive between the Team and Primary Nursing (Gardner, 1991; Lang &Clinton, 1984; Lee, 1993).

REFERENCES:

1) Huber, D. (2006). Leadership and nursing care management:Models of Care Delivery.(318-323)USA: Saunders Elsevier.Limited Preview(Online)

2) Rowland, B. L. (1997). Nursing administration handbook By Beatrice L. Rowland. Howard S. Rowland. United States of America: An Aspen Publication.Limited Preview(Online)

3) Chitty, K. K. (2005). Types Of Nursing Care Delivery System Hystorically Used In Acute Care Setting. In K. K. Chitty, Professional nursing: concepts & challenges (4th ed,pp. 361-362). USA: Elsevier Saunders.Limited Preview(Online)

4) Greta L. Krapohl, E. L. (1996). The impact of unlicensed assistive personnel on nursing care delivery. findarticles.com .(Online) http://findarticles.com

5) Basavanthappa, B. T. (2002).Hospital and its Routine. In B. T. Basavanthappa, Fundamentals of Nursing (pp. 134-135). India: Jaypee.Limited Preview.(Online)

6) Marriner-Tomey, A. (2000). Management. In A. Marriner-Tomey, Guide to nursing management and leadership (p. 383). USA: Mosby.Limited Preview(Online)

7) Macdonald, M. (2006). Primary nursing: is it worth it? Journal of Advanced Nursing , Journal compilation © 2009 Blackwell Publishing Ltd.(Online)

http://www3.interscience.wiley.com/journal.

8) Kenneth J. Sellick, Shirley Russell, Jacqueline L. Beckmann, (July 2003). Primary nursing: an evaluation of its effects on patient perception of care and staff satisfaction. International Journal Of Nursing Studies , 545-551.(Online)

http://www.journalofnursingstudies.com/article

9) Yoder-Wise (2003). Care delivery strategies. In . Yoder-Wise, Leading and managing in nursing By Patricia S. Yoder-Wise (pp. 262-263). USA: Mosby Elsevier.Limited Preview.(Online)

10) Huber, D. ( 2006). Model Of Care Delivery. In D. Huber, Leadership and nursing care management By Diane Huber (p. 323). USA: Saunder Elsevier.Limited Preview(Online)

11) Jeffrey R. Vincent, R. M. (2005). Natural Wealth:Depletion or Conservation? In R. M. Jeffrey R. Vincent, Managing natural wealth: environment and development in Malaysia (p. 383). USA: Recources For The Future.Limited Preview(Online)

12(Kowalski K,2009). Report: Nurses Are Key Components for Continuity of Care. Mosby's Nursing Consult .

http://www.nursingconsult.com.newdc.oum.edu.my

13) Huber, D. (2006). Nursing Shortage. In D. Huber, Leadership and nursing care management (p. 627). USA: Saunders Elsevier.Limited Preview(Online)

14) Resources, J. C. (2004). Problems In ICU Associated With Nursing Shortages. In J. C. Resources, Improving Care in the ICU (p. 101). USA: Joint Commission Resources.Limited Preview(Online)

15) JoAnn Graham Zerwekh, Jo Carol Claborn. (2003). The Health Care Organisation And Patterns Of Nursing Care Delivery. In J. C. JoAnn Graham Zerwekh, Nursing today: transition and trends (pp. 349-351(Chapter15)). Canada: Saunders Elsevier.Limited Preview(Online)

16)Huber, D. (2006). Models Of Care Delivery. In D. Huber, Leadership and nursing care management (p. 323). USA: Saunders Elsevier.Limited Preview(Online)

17)Barbara Cherry, Susan R. Jacob. (2002). Leadership And Management In Nursing. In S. R. Barbara Cherry, Contemporary nursing: issues, trends, & management (p. 452). USA: Mosby Elsevier.Limited Preview(Online)

18)Yoder-Wise (2003). Modular Nursing. In . Yoder-Wise, Leading and managing in nursing By Patricia S. Yoder-Wise (pp. 542). USA: Mosby Elsevier.Limited Preview.(Online)