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Nursing Delivery System 201 1

Introduction For these past hundred years the nursing community struggled to form a delivery system that can be used throughout the world without any time limit. However, none is found which can be relevant to be used at any place anywhere and also save the cost but not compromising with the quality of care delivers to the patients. The model of care of delivery system keeps evolving throughout the years. Nowadays, we have the different model which can be applied at different places. This assignment will e plain the types of nursing deliver system e ist in !alaysia and we will discuss the positive and negative effects of the different system those are used here. "e also will try to choose the best theory that is cost effective and improved both customer#s satisfaction and quality of care that will be applied in the Hospital $ that is facing problem regarding the low customer satisfaction and poor quality of the services given to the client. Theoretically, in Nursing we have two types of model of delivery system which is traditional and integrated. Traditional model of care can be further divided into % sub&types which are functional nursing model, team nursing, primary nursing, and patient centered care or patient focused care. The integrated model of care can be divided into ' sub&typed which are practice partnership, critical pathways, and case management. (et us e plore all these models one by one and see how there are applicable in !alaysia setting. Functional Nursing !odel The functional nursing model is a model which was invented in )*++ due to the shortage of nurse as a result from ,econd "orld "ar in the -nited ,tates of .merica /0aditch, 1++'2. The nursing work is divided into functional unit with one charge nurse and each functional unit is represented by one nurse which is speciali3ed in different areas. In this type of model, the nurses are not in charge of specific patients but they are bound to different task4 medication nurse, admission nurse, treatment nurse, vital signs nurse plus bathing nurse. Nowadays, the task might not be the same as the previous one, but the task is given based on the importance of the specific task /Tomey, 1++%2. If this model is used, the people who are delegating the 5ob must
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know the abilities of the nurses that they have. The tasks must be delegate according to the abilities of the registered nurse. If not, there are high chances of the nurses to make mistakes. To see the effectiveness of tasks delegation, the continuous evaluation should take place /6orbo, 1++72. The charge nurse is responsible to communicate the patient needs with other discipline like physician, dietitian, or physiotherapist. In the busy ward, these needs might be overlooked since the charge nurse is the only one who is responsible to rely the patient needs to the other discipline /Huber, 1++72. The charge nurse will also be the one who is responsible to make any decision /8obinson, 1++92. The advantages functional model is this model can cover a lot of patient and utili3es other type of health care workers when there is shortage of nurse /Heidental, 1++'2. :atient will also be having different people treating them in one shift and the one who is treating them is an e pert in what they are doing /Heidental, 1++'2. ;y this, the patient will not be seeing only one nurse for one shift. The disadvantage of this model is it is hard to deliver the holistic care to the patient because each nurse is bound to a specific task /8obinson, 1++92. The other disadvantage of using functional model of care is it will cause lack of satisfaction on both side4 patient < nurses /8obinson, 1++92. For the nurses they will absolutely feel boring and the will not see the effect of their tasks on the recovery of the patient. The patient will also has low satisfaction because they won#t receive holistic care, they only receive fragmented care due to the fragmented tasks perform by the different nurse. Team Nursing This model was developed )9=+ after "orld "ar 1 after a lot of complaint on the inefficient service delivered by functional model which created fragmented care causing nurses and clients dissatisfied on the care /!arquis < Huston, 1++72. In this model of care of delivery system, the staff was assigned to a group of patient. In a unit, there can be two divisions and each team is lead by one registered nurse. In one team, it might consist of licensed practical> vocational nurse, registered nurse, dietitian, respiratory physiotherapist or unlicensed assistive practitioner /8obinson, 1++92. The team leader is responsible to supervise and coordinate the members on the team and the care that was delivered by them. The team leader also responsible
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for giving professional direction to those on his team regarding the care provided. . typical unit govern by the team nursing system usually has '+ patients and was govern by 1 units one team usually has no more than = people /!arquis < Huston, 1++72. The team leader assigns all patients to team members and may delegate additional tasks according to the team members# competence /0aditch, 1++'2. The team assignments may sometimes mirror a functional approach to care when the team leader is the only 8N or licensed person on the team /!arquis < Huston, 1++72. The team leader is e pected to give the medications to the patient and delegates all others works to the others team members. The advantage of the team nursing is it requires good team leader that have a very good delegation and supervision skills /Heidental, 1++'2. If the nurse delegates the tasks wrongly and do not supervised well, chaos will happen in the world. -sing this model, we can also save up a lot of human resource because it used small portion of nurses to manage a lot of patient like what have been stated before this model can manage up to '+ patients. ?n the other hand, this model also can be comple because its require share responsibility and accountability in the communication which can cause confusion and lacked of accountability. Thus, the nurses will have low satisfaction and the patient will feel fragmented and feel they have depersonali3ed care. In this model, the team leader has to possess a good communication skill to make sure the tasks given to the staff nurse is not fragmented because it may cause the nurses to have low satisfaction in 5ob performance. To shape the nurses that have a high communication skill the higher authority must spent some money on the training of a nurse. :rimary Nursing This delivery system was developed in late )97+ or early )9@+ due to lack of satisfaction of nursing professional with the lack of autonomy of their side /0aditch, 1++'2. In the primary nursing, primary nurse is a registered nurse. :rimary nursing is defined as a system in which each patient is assigned to a nurse who has 1%&hour responsibility for the nursing care delivered to the patient /Tomey, 1++%2. The primary nurse is responsible for planning for the patient#s care and delegating the care during the hours that the nurse is not present and also is accountable for the coordination and continuity of care from admission to discharge. The nurse who assists the
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primary nurse during off&duty hours is called an associate nurse or associate caregiver. The associate nurse follows the plan of care, communicates pertinent information or changes in the patient status to the primary nurse, and provides direct patient care when the primary nurse is not present. .n associate caregiver may be a licensed vocational>practical nurse or unlicensed assistance practitioner /!anthey, 1++12. . nurse may be a primary nurse for a small caseload of patients and also may be an associate nurse for other patients. The three ma5or responsibilities of the primary nurse can be simplified into ' parts4 clear communication among all care disciplines, development of a plan of care using the nursing process, and discharge planning from the time of admission to discharge /!arquis < Huston, 1++72. The primary nurse is held accountable for collecting and communicating important patient information during the patient#s hospitali3ation. The primary nurse provides direct patient care because this nurse is in the best position to plan the care /!anthey, 1++14 8oussel, 1++72. Involving the patient in the collection of information, eliciting patient e pectations for the outcomes of care, and encouraging participation in the development of goals is a significant part of the process /0aditch, 1++'2. 6onsistent and accurate communication of information between shifts and appropriate delegation of care planning activities between associate nurses and primary nurses eliminate the charge nurse from the communication chain between physician and caregiver /8oussel, 1++74 ,wansburg < ,wansburg, 1++12. 0irect communication improves the rapport and trust between the primary nurse, the patient, and the physician, creating a therapeutic relationship. The charge nurse is then able to support the activities of the unit and provide consultation for the primary nurse. The use of an associate caregiver is not inconsistent with the intent of the primary nursing care delivery system,which is to provide patient&focused care in an environment where the professional nurse is held accountable for practice. The associate caregiver may be task focused, but the care continues to be coordinated and monitored on a 1%&hour basis by the primary nurse. The advantages of the primary nursing care delivery system are the increased nurse perception of autonomy, the continuity of care, and the patient focus. 8esearch also suggests that the outcomes of care are better and nurse satisfaction is higher /Tomey, 1++%2. .lthough the research does not support a specific patient care delivery model, many studies suggest that richer 8N staffing
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levels result in lower lengths of stay, fewer patient deaths, and lower failure&to&rescue rates /.iken, 6larke, < ,loane, 1+++4 Needleman et al., 1++14 ,ovie et al., 1+++2. :atient satisfaction has been correlated with nurse satisfaction and quality of care in several basic studies /Hegyvary < Haussman, )9@74 "eisman < Nathanson, )9*=2. 8ecent studies suggest a link between nurse burnout and decreased patient satisfaction /Aahey, .iken, ,loane, 6larke, < Aargas, 1++%2. ?ther research suggests that there are higher levels of nurse satisfaction, greater continuity of care, positive patient outcomes, and improved nurse retention with the use of primary nursing care delivery systems /Huber, 1++74 Bramer < ,chmalenberg, 1++12. The primary nursing care delivery system uses many hospital resources, but places the control and authori3ation of such resources in the hands of the primary nurse. The primary nurse is responsible for developing the plan of care and prioriti3ing the daily activities to achieve the mutually agreed&on goals in the plan. For instance, because the primary nurse understands the sleeping and eating preferences of a particular patient who has cancer, routines and treatments can be ad5usted to meet the patient#s basic needs. If the patient and family need comple information from the physicians or other members of the health careteam about the prognosis and treatment options of chemotherapy and radiation, the primary nurse may coordinate a care conference and identify the desired outcomes to reali3e a productive meeting. The primary nurse may advocate for scheduling placement of central lines for chemotherapy with patient and family schedules. 6hemotherapy treatments may be managed to coincide with family support. .ll of these activities are the responsibility of the primary nurse providing care at the bedside. Nurse practitioners can function within this system as physician e tenders and consultants to the primary nurse. 6linical nurse specialists are valuable in providing clinical e pertise and education to the primary nurse. The use of case managers may be redundant because of the primary nurse#s accountability for the entire patient e perience. This also may be true of the clinical nurse leader role, depending on the interpretation of primary nursing used, since the primary nurse is responsible for all of the functions that a clinical nurse leader normally would assume in one of the other types of nursing care delivery models. This may not be true in all agencies, depending again on the interpretation and usage of primary nursing. . primary nursing care delivery system may not be the preferred system during
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downturns in the economy and cyclical nursing shortages. There is a perception that labour costs are high because primary nursing requires a large number of 8Ns, although cost studies have disputed this perception /0aditch, 1++'2..dditional research is needed to determine whether a primary nursing care delivery system shields an institution from the impact of a nursing shortage by attracting and retaining nurses and improving patient outcomes. The clear advantage of this theory is the trusting relationship between the nurse, patient, and family will be developed well. There is also holistic approach to the patient care rather that shift to shift rotation focus. Nurses who practice this theory is will also have enough time to provide care because the decision making decision is done by the nurses themselves. The disadvantages of this theory are it requires a high cost because it needs a higher skill nurses and the nurses should be competence and possessing adequate knowledge. The patient and nurse care also should be realistic to make sure all the tasks are well done. :atient centered care This model is invented to fully meet the patient need and compromised with the other health care worker needs /Heidental, 1++'2. In this model the treatment is brought the client. ,o, all the services like rehabilitation and &ray service was decentrali3ed to meet the patient needs. The same thing also goes with the staffing when the staffing is based on the patient needs. "hen different unit is brought to the client it brings along the staffs in that particular unit. ,o, the staffing is multidisciplinary staffing. The advantage of this model is it will be convenient for the patient mostly because all the services are brought to them. This type of service will also be quite costly because if all unit need to be centrali3ed, it will involve a lot of money. For the disadvantages, some nurses perceive this model as a threat for them because it reduced the used of nurses. :ractice partnership This theory was introduced in )9*9 by !arie !anthey. This delivery system combined a less e perience nurse with the e perience nurse. It is like a mentoring programme. ,o, the senior will be looking after the 5unior and both of them work synergistically to improve the patient condition. The advantage of this theory is it will develop continuity of care and also
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create accountability for patient care. The disadvantage of this theory is the assumed e tra task by the 5unior staff nurse. The senior staff nurse to be aware with the ability of the new staff nurse and not to delegate the work that not suit the new nurse. 6linical pathways 6linical pathways are a power tools that give the nurse and physician the clinical routes and the e pected outcomes for the patient. The clinical pathways are done by daily basis and for each day, outcomes are articulated and patient progress is measured. This delivering system involves multidisciplinary orders of care. In this delivering system there are different group of people to manage the patient which are high volume, high risk, high cost, high length of stay and large variation of practice. .mong the advantages of this model are easier to manage the care, very instructive for the new staff, save a lot of time and will shorten the length of stay in the hospital. The highly anticipated challenge in this theory is it will take a long period to gain the consensus from the several of discipline on e pected plan of care. 6ase management The last but also an important model was a case management. 6ase management is a model that was created to improve patient care and on the same time reducing the cost through coordination of care. .s a case manage which is the registered nurse, he or she is responsible for coordinating care and establishing goals preadmission through discharge. This means that the case manager is responsible to the patient care from admission until the patient discharge. ,uggested delivery system for Hospital $ .ll the delivery systems e plained above have their own strengths and their own challenges if we want to apply them. However, those strengths and challenges can be face like a bulldo3er hit the wall and the wall can be a bridge that give advantages to people. . hospital which wants to apply one of those models needs to know what they want to achieve first before deciding to go with any delivery model. In Hospital $ case, Hospital $ already knew that.

Nursing Delivery System 201 1


"hat they want are the systems that are cost effective, improve both customer and nurse satisfaction and also increase quality of care. First let us define what is effective costing would means. Cffective costing would be the cost that is worth the amount of money that we spent on it. This is actually my personnel definition of effective costing. ,o, when you spent a lot of money and then have a high quality of care, it will be appropriate costing for me. .s stated before, each and every delivery models have the own strengths and challenges to apply them in clinical area. ,o, I would like to suggest different model to be used in different area and combining them to make them more comprehensive and suitable to be practiced in different area in the hospital producing a high quality of care, cost effective and also increase the both customer and nurse satisfaction. !y suggestion is mainly influenced by practice partnership, critical pathways, patient centered care and also some parts of other theories. The first area that I would like to cater is ward area. For the general medical ward, I would like to suggest the used of primary nursing mainly because it can infused the holistic care on the patient and also the nurse satisfaction. The other part that intrigues me was the decision making. The nurse is able to decide on him or herself on the bedside. ;y this, a lot of time will be saved and the nurse will have a lot of time doing another 5ob. -nlike the current situation in !alaysia, most of the general ward is using functional nursing model. This causing the client feels the services are unsatisfactory. In speciali3ed unit like I6-, this model is also useful due to time saving since in the unit like this, each second is valuable which can determine the life of the patient. :artnership model can be applied if the hospital is recruiting a new staff because new staff with lack of e perience needs a mentor to guide them to deliver a high quality of care. For the ne t unit which is the emergency department I would like to suggest the used of patient centered care where all of the patient needs are gather at one place. :eople might say that this delivery model costly but here is all the patient needs are necessary to be gathered at one place because in emergency period the patient requires the immediate attention from all the discipline. For the unit like ?T, I would like to suggest the used of partnership model of delivery. I had seen this theory being applied in ?T in one of the public hospital in Temerloh works tremendously. In ?T, the circulating nurse and scrub nurse always work together hand by
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hand so was like that in this model. Two nurses can be paired up together as scrub and circulating nurse and they will alternate their 5ob so that the one who was the new nurse can learn from the senior nurse and the senior nurse is always behind the 5unior nurse to teach and guide the new nurse and on the same time works as circulating nurse while he or she works as scrub nurse. "ith this, 5unior nurse will have the guidance, the old nurse can guide the 5unior nurse and the 5ob will be well done. It is a win&win situation for all. The last delivery model that I would think that will be fit to be used in most of the unit is the critical pathways. The one thing that made me interested in applying this model is it provides pathways for the health care workers to deliver the treatment to the patient. This model provides solution for every diseases and symptoms that is faced by the patient. "e will be also able to e pect the client#s length of stays in the hospital and also minimi3e it. This might be also used in the emergency department by altering the length of stay in the ward to length of stay in the red, yellow, green or observation 3one. ?n the same time, case management can model can be used by the case manager is managing the treatment from admission to discharge whether to the ward or to straight back to the home. The main challenge in applying clinical pathway is to make the guidelines for every disease, ward or symptom that is e perienced by the client. However, we can duplicate and modify the clinical pathways which have been applied in the overseas. "e might need to change here and there to make it relevant to our setting especially Hospital $. The other problem is this might be a bless for the new nurse but it be hard for the e perience nurse because they get used to use their own usual pathway. However, if we give them sometimes, it might works. :lus, their own usual pathway should not be much different with the written clinical pathways. These guidelines for clinical pathways should be easily accessible for all health care providers and the number of copies is enough to cater all of them. -sing the method is also cost saving because we will not do procedure as we like because we are following the guideline as well as time saving. I believe there is no one theory that can cater all the needs of the patient or the target of the hospital. Hospital $ is trying to improve the quality of care, client and nurse satisfaction and

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on the time it is cost effective. I think by combining all the theories above we can cater the entire target above. 6onclusion In conclusion, all the models have their own strengths and weaknesses. ,o, in order to achieve the hospital goals, these theories need to be integrated. ,o, if the hospital is having cost problem, they can cut the nurse and the functional model and save some money. In my personnel opinion, I don#t think money is an issue for a hospital. ;efore building a hospital, the one who build the hospital should have a lot of money in the first place. In !alaysia, most of the hospitals run by the government and I don#t think cutting the budget and use the model that can save the budget is a wise move since i don#t think it is worth it to compromise the money with the safety and health.

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"orks 6ited Heidental, :. B. /1++'2. Nursing Leadership & Management. -,.D Thomson>0elmar (earning. 8obinson, 6. /1++92. Nursing care delvery system. In B. ,. ?sborn, 6. C. "raa, < .. "atson, Medical Surgical Nursing Preparation for Practice /pp. *=&9=2. New EerseyD :earson. 6orbo, ,. .. /1++72. 0elegation definedD C amining the principles of this tool as both an art and a science. .dvance for Nurses, * /)72, 1). 0aditch, B. /1++'2. 6are delivery strategies. In :. ,. Foder&"ise /Cd.2, (eading and managing in nursing /'rd ed.2. ,t. (ouisD !osby. Huber, 0. /1++72. (eadership and nursing care management /'rd ed.2. :hiladelphiaD ". ;. ,aunders. Tomey, .. !. /1++%2. Guide to nursing management and leadership /7th ed.2. ,t. (ouisD !osby !anthey, !. /1++12. The practice of primary nursing /1nd ed.2. ;ostonD ;lackwell ,cientific :ublications. !arquis, ;. (., < Huston, 6. E. /1++72. (eadership roles and management functions in nursing /=th ed.2. :hiladelphiaD (ippincott "illiams < "ilkins. 8oussel, (. /1++72. 6onceptuali3ation of nursing administrationD Theory and concepts. In (. 8oussel /Cd.2 with 8. 6. ,wansburg < 8. E. ,wansburg, !anagement and leadership for nurse administrators. ,udbury, !.D Eones and ;artlett. ,wansburg, 8. 6., < ,wansburg 8. E. /1++12. Introduction to management and leadership for nurse managers /'rd ed.2. ,udbury, !.D Eones and ;artlett.

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.iken, (. H., 6larke, ,. :., < ,loane, 0. !. /1+++2. Hospital restructuringD 0oes it adversely affect care and outcomesH Eournal of Nursing .dministration, '+, %=@I%7=. Needleman, E., ;uerhaus, :. I., !attke, ,., ,tewart, !., Jelevinsky, B. /1++12. Nurse staffing levels and the quality of care in hospitals. New Cngland Eournal of !edicine, '%7, )@)=I 1@11. Hegyvary, ,. T., < Haussman, 8. B. /)9@72. 6orrelates of the quality of nursing care. Eournal of Nursing .dministration, 7 /92, 11I1@. ,ovie, !. 0., Gift, .., Eawad, .. F., ,tratton, (., "allace, :(., .iken, (. /1+++2. Hospital restructuring#s impact on outcomes. Final report /NIH Grant = 8?) N8+%1*=&+'2. ;ethesda, !0D National Institute of Nursing 8esearch. Aahey, 0. 6., .iken, (. H., ,loane, 0. !., 6lark ,. :., < Aargas, 0. /1++%2. Nurse burnout and patient satisfaction. !edical 6are, %1 /12, ))&=@I))&77. Aahey, 0. 6., .iken, (. H., ,loane, 0. !., 6lark ,. :., < Aargas, 0. /1++%2. and patient satisfaction. !edical 6are, %1 /12, ))&=@I))&77. Nurse burnout

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