This document discusses various patterns of nursing care delivery in India. It begins by introducing the challenges facing the nursing profession due to advances in technology, increased demand for healthcare, and emphasis on quality and cost-effectiveness. It then defines nursing care delivery systems as processes that combine nursing services to meet patient needs across various care settings. The main types of nursing care delivery discussed are case method, functional method, team nursing, primary nursing, modular nursing, and case management. For each type, the document outlines the basic principles and roles, benefits, and limitations. It emphasizes the importance of organizational policies, staffing, education, and addressing patient needs when selecting a nursing care delivery system.

1. Patterns of Nursing care
delivery in India
Raksha Yadav
1st Year M.SC nursing
Aiims rishikesh

2. INTRODUCTION
 As nursing has evolved over a period, nursing is still focused on caring. Rapid technologic
advances, knowledge explosion, emphasis on quality –cost effectiveness-accessibility of health care
and increased demand by the patients for advanced alternative health care modalities present
many challenges for nursing profession.
 How are nurses responding to these challenges? .So how can we best utilize professional nurses
across various practice settings? The answer for this question is that it is possible by reshaping
organizational (administrative) policies and developing such system of nursing care delivery as best
suited to client needs.

3. MEANING OF NURSING CARE DELIVERY SYSTEM
 A system may be defined as a whole made up of integrated or joined
and interrelated parts. Although each component of the system has its
specific function, yet all of them work harmoniously for common out
come.
 The nursing care delivery system means ‘the process of delivering care
to the client by combining various aspects of nursing service which will fit
to various patient care settings to produce a common outcome of
delivering quality care and meeting the needs of clients.’
 There are various types of nursing care delivery system include case
method, functional method, team nursing, primary nursing, modular
nursing, nursing care management, patient focused care.

4. PRINCIPLES OF NURSING CARE DELIVERY
 Holistic approach is used to identify nursing care needs:
 physical needs
 mental and social needs
 spiritual needs
 Nursing care is based on a helping relationship
 It is the unique function of the nurse to provide nursing care according to client’s needs
 The aspect of patient care has to be initiated and controlled by nurse
 There should be justification for selecting each delivery system
 Before planning care organizational policies to be considered

5. Factors influencing nursing care delivery system
 Availability of adequate staff in wards or units
 Patient census
 Extend of staff deficiency
 Organizational policies regarding it’s practice
 Patient’s preferences for care
 Availability of skilled staff
 Opportunities for continuing and in-service education to the staffs
 Budget of the organization
 Socio economical condition of the patient
 The organization’s mission
 Patient and community needs

6. Means of organizing nursing care
case method
team nursing
functional
method
primary
nursing
modular
nursing
case
management

7. 1. CASE METHOD
 The case method or total patient care method of nursing care delivery is the oldest method
of providing care to a patient.
 The premise of the case method is that one nurse provides total care to one patient during
her entire work period of one shift.
 This method was used in the era of Florence nightingale when patient received total care in
the home. That time nurses were ‘hired’ and they lived with in the family of the patient
provided 24 hrs care to patient and even family.
 But the case method developed over the years to the specialty of private duty nursing
especially in critical care nursing where one nurse cared one or two clients.

8.  During an 8-12 hour shift the patient receives consistent care from one nurse. The nurse ,
patient , family share mutual trust and work together toward specific goals. Usually the care is
patient centered, comprehensive, holistic and continuous
 Organization of the case method:
REGISTERED
NURSE
PATIENT

9. Nurse Manager’ role:-
 The nurse manager must consider the expense of the system before arranging the staff
 Arrange skilled and qualified nurse so that she could manage all the care of the person
 The manager also need to identify the level of education and communication skills of all
 Arrange for continuing education and in service education for the personnel
Staff nurse’s role:-
 Provide holistic care to assigned patient during a defined work period
 Assessment and teaching the patient and family

10. Merits:-
 Nurse can see better and attend to the total needs of the patient
 Continuity of care can be facilitated
 Client or nurse interaction and rapport can be developed
 Client may feel more secure
 Family friends become more known by nurse and get more involved
 Equal work load
Demerits:-
 Many clients do not require the inherent care
 Must be modified if non professional health workers are used
 Great disadvantage when nurse is inadequately trained
 Cost –effectiveness

11. 2. FUNCTIONAL NURSING
 This system emerged in 1930’s in USA
Meaning:-
 Individual care givers are assigned to specific tasks rather than being assigned to certain patients
or clients . It is based on a division of labour similar to an assembly line
 This model is also referred to as task method . Functional nursing evolved during the depression
when RNs went from being private practitioners to becoming employees for the job security
Origin:-
 Once world war II was broke out resulted in severe shortage of nurses in US. Many nurses
entered the military to care for the soldiers. To accommodate this shortage, hospitals increased
their usage of auxiliary personel.

12.  Functional nursing is a method of providing patient care by which each licensed and
unlicensed staff members perform specific tasks for a large group of patients. For example RN
may administer all intravenous medications one LPN /LVN may give treatments another LPN
/LVN may give all oral medications , One assistant may do all hygienic tasks, and another
assistant may take all vital signs. The nurse become expert in the particular task she is
performing.
 A charge nurse co-ordinates care and assignments and may ultimately be the only person
familiar with all the needs of any individual patient.
 ‘The key idea was nurses to be assigned for tasks not to the patient’

13.  Functional method of nursing care delivery:

14. Nurse managers role:-
 The nurse manager must be sensitive to the quality of patient care delivered and
the institution’s budgetary constraints
 Achieving patient outcome is her responsibility
 Improve the staff’s perception of their lack of independence
 Rotate assignments among staff , to alleviate boredom with repetition
 Conduct staff meeting frequently to encourage staff to communicate about
care And unit functions.
Staff nurse’s role:-
 They are skilled at the task which is assigned
 Complete the task in an efficient and economical manner

15. Merits:-
 Person can become particularly skilled in performing assigned tasks
 The best utilization of personnel can be done
 Less equipment is needed
 Saves time
 Potential for development of technical skills is amplified
 There is a sense of productivity for the task oriented nurse
 It is easy to organize the work of the unit and staff
 Task oriented and time saving
 Reduced work load to the registered nurses.

16. Demerits:-
 Client care become impersonal
 Diminishing continuity of care
 Staff may become bored and have little motivation to develop self and others.
 Work may become monotonous
 Less accountability for the nurse
 Lack of professional development
 Client may tend to feel insecure and inconvenient
 Only parts of the nursing care plan are known to personal
 Where the model is commonly used;

17. 3. TEAM NURSING
 Team nursing is the delivery of nursing care by a designated group of staff members including both
professional nurses and non-professional staff .
 This method of nursing care was introduced in early 1950’s.
 Several elements are considered necessary:
 Team leader is the delegated authority to make assignments for team members and guide the work
of the team. The leader of the team should be a registered nurse, not a practical nurse
 The leader is expected to use a democratic or participative style in interactions with team members.
 The team is responsible for the total care given to an assigned group of patients or clients.

18.  Communication among team members is essential to its success, and includes written patient
care assignments , nursing care plans, reports to and from the team leader, team conferences in
which patient care problems and team concerns are discussed, and frequent informal feedback
among team members.
 Team nursing was created at the end of World War II to make the best use of the limited nursing
staff available and alleviate the problems created by the functional method. As more workers
with minimum on –the- job training were hired in the healthcare field, it became necessary to
reorganize the delivery of care. It was also hoped that the use of team nursing would increase
both staff and patient satisfaction and improve the quality of care.

19.  In team nursing, a team leader is responsible for coordinating the group of licensed and
unlicensed personnel to provide patient care to a small group of patients. The team leader
is a highly skilled leader, manager, and practitioner who assigns each member specific
responsibilities according to role, licensure, education, ability, and the complexity of the
care required.
 The members of the team report directly to the team leader, who then reports to the
charge nurse or unit manager. There are several teams per unit, and patient assignments
are made by each team leader. Communication is enhanced through the use of written
patient assignments, the development of nursing care plans, and the use of regularly
scheduled team conferences to discuss patient status and formulate revision to the plan of
care.

20.  Model of a team nursing:

21. Responsibilities of team leader:
 Team leader assign team members to patients
by matching patient’s needs and staff
knowledge and skill.
 Knowing condition and needs of all assigned
patients
 Duty vary according to work load, i.e. assisting
the members and giving direct care to patients.
 Planning and conducting the conference.

22. Advantages:-
 Improved patient satisfaction
 Cost effectiveness for the agency
 Care is less fragmented because of the
increased communication and extensive
ordination efforts of team leader
 Allows comprehensive, holistic nursing care
when the team function best.
 Good interpersonal relationships among
staffs and with the patients
 Satisfaction to the patient and the nurses

23. Disadvantages:-
 Continuity of care is not given
 Changing team membership makes it difficult for the
team leader to assign the patient.
 Team nursing requires a great deal of co-operation
communication from all staff members
 The large number of people attending the same
is causing some discomfort to the patient.

24. 4.MODULAR NURSING
 It is a modification of team nursing In modular nursing, staff are geographically assigned to patients for
whom they co-ordinate and provide comprehensive care. It focuses on geographic location of patient
rooms and assignment of staff members.
 It was developed by Magargal in 1987
Delivery model:-
 The total unit is divided in to modules or districts and the same team of staff is assigned consistently to
the module. Modular nursing is enhanced when nursing units are physically designed and built with this
nursing delivery system in mind but it can also be used in nursing units that are not so designed. Each
module has a modular, or team leader RN, who assigns the patient to module staff
 Each module ideally consists of at least one RN, one LPN/LVN and one nursing assistant. A charge nurse
will co-ordinate the work of all the modules in a unit. She expects the module leaders to be accountable
for patient care but assist in problem solving when necessary. Staff nurses work independently or
together, depending on the size of a modular districts . Modules may have same or different number of
patients

26. Responsibilities of charge nurse / head nurse:
 Assign patients to different modules
 Co-ordinate the work schedule and supervises all care on the
 Make patient care assignments, and there by maintain continuity
of care.
 Assist in problem solving when necessary
Responsibilities of modular or team leader:
 Assigns patient to module staff
 Co-ordinate the module activity
 Accountable for the care and to the charge nurse
 Communicate with other modules

27. Advantages: -
 Increased continuity of care
 Geographic closeness of the modular system saved nursing time
 Better communication and co-operation among staff
 Easier for less experienced nurses because they have other nurses directly available to them for
support
 Patients are more secured
Disadvantages: -
 Less accountability
 Less direct nurse-to-nurse communication and accountability
 If patient changes room, he will also change nurses, so patient satisfaction may be less
 It’s a costly method as it should have a redesign of the work environment to allow medication
cart, supplies and charts to be located in each module.

28. 5. Primary nursing
 Primary nursing developed by Manthey Et al in
1970 as a method for organizing patient care
delivery in which one RN functions
autonomously as the patient’s primary nurse
throughout the hospital stay. This method is
based on the concept of ‘my patient-my nurse”
In this nursing care delivery system, each
registered nurse is assigned to the care of
group of patient for which she plans complete
24 hrs. care and writes the nursing care plan.

29.  The primary nurse cares for her patients every time she
works for as long as the patient stay on her unit.
(ideally from admission to discharge). When she is not
there, an associate nurse who will follow the primary
nurse’s care plan is assigned to the care of primary
nurse’s patient. The primary nurse is intensively
involved with the patients. Licensed practical nurses
function as associate nurse sand are supervised by the
head nurse. When nursing assistants are used in
primary nursing system, they are generally assigned to
assist primary and associate nurses by doing specific
tasks for each nurse they assist.

30. Model of primary nursing:-

31. Advantages: -
 Satisfaction for both patients and nurses
 The relationship between nurses and patient is intimate
 Autonomy for the nurses
 Nurse is the person who is planning and providing complete care
 She communicates with all other health team members involved in client care
 Other health team members including physician tend to view her more knowledgeable
and responsible
 Patient receives quality and continuity of care
 Reduces the number of errors than can result from a relay of orders
 Increased satisfaction both to patients and nurses
 Nurse can identify patient outcome as a result of their work

32. Demerits: -
 Nurse may be isolated from colleagues
 Nurses talent to a limited number of patients
 Nursing care plan can be changed only with the permission of primary nurse
 Creates separation anxiety in patients when nurse
 Nurses should be well educated and trained in all area of patient care, most of the
time which may lack

33. 6. CASE MANAGEMENT
 Case management is considered as the newest type of nursing care delivery system
developed in 1985 as an outgrowth of primary care, nursing case management is a model
used to co-ordinate the care, maintain quality, and contain cost while focusing on the
outcomes of care
 “Nursing case management is a collaborative activity that focuses on comprehensive
assessment and intervention and holistic care planning with appropriate referrals to meet the
health care needs of the patient and family”.
 The success of nursing case management models has been demonstrated in all health care
settings including acute, sub-acute or ambulatory settings long term care facilities, in health
insurance companies and in community.

34.  Model of nurse case management:

35. Role of nurse case manager:-
 Delivers client focused and outcome oriented care
 Cost effective care through integration of clinical services in combination with
financial services
 Serves as an advocate for patient and family
 More patient and nurse satisfaction is achieved through intensive care
 They attend to a specific high risk population

36. Advantages:-
 Patient receives high standard care
 Nurse is highly qualified and skilled in the particular area,
 More satisfaction to the patient
 Increased professional standards can be developed by the nurses
Disadvantages:-
 Sometimes discomfort to clients
 Continuity care is difficult
 Long time nurse patient relationships are difficult to arrange
 Costly
 Time consuming
 No proper attachment between nurses and patients

37. Research Input
A systematic review of several models of care has been undertaken with a predominance of team nursing
within the comparisons, suggestive of its popularity or longevity. Nurse satisfaction, absenteeism and role
clarity/confusion predominantly did not differ across model comparisons although the need for clear
definition of the role or tasks and accountability of specific nurses remains necessary. Similarly,
communication remains a key aspect of good patient care and nursing care delivery and should be
fundamental to any implementation of a new model of care. Surprisingly, little benefit was found within
primary nursing comparisons and the cost effectiveness of team nursing over other models remains
debatable. Nonetheless, team nursing does present a better model for inexperienced staff to develop, a key
aspect in units where skill mix or experience is diverse. Contexts such as day surgery may have relevance in
the choice of model and should be considered. This review has provided the best available evidence relating
to various models of nursing care on nurse sensitive indicators such as fall incidents, medication errors and
infection, with several studies showing no significant difference.These outcome measures are important
indicators of careand further studies should include these data.

38. CONCLUSION
No single nursing care model works in all settings, or even
necessarily across a single multiservice setting. Before
selecting a model nurse manager must consider all the
influencing factors. For a better care effective selection and
mixing of these methods are essential. All the models should
be evaluated periodically for its appropriateness to ensure
safe and effective nursing care.