ORGANIZING NURSING

SERVICES

DEEPTHY P. THOMAS
II YEAR M.Sc. NURSING
GOVT. COLLEGE OF NURSING
ALAPPUZHA

Nursing Service
Nursing service is the part of the total
health organization which aims at
satisfying the nursing needs of the
patients/community.

Nursing service administration

Nursing service administration is a
complex of elements in interaction and is
organized to achieve the excellence in
nursing care services.

DEFINITION OF NURSING SERVICE

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 SERIVCE IN

HOSPITAL

Management of nursing service and care

Initiate a set of human relationships at all
levels of nursing personnel.
Establish adequate staffing pattern.
Develop and implement proper
communication system.
Develop and initiate proper evaluation and
periodic monitoring system.

proper job description for nursing

personnel.
Assist hospital authorities for effective
personnel management.
Share nursing information system with
other discipline.
Formulate and interpret nursing service
policies.
Assist hospital authorities for preparation
of budget.
Participate in inter departmental programs
and other programs.

Education training and staff developments

Encourage

a stimulating environment in which the

personnel have opportunities to be creating
innovators.
Develop and initiate orientation and training
programs.
Create an atmosphere that conducive to give
proper learning experiences for students.

 Assist

in the development of a sound, constructive

program of leadership in nursing.
Initiate programs to improve the practice of
nursing in keeping with advances in the relative
areas and disciplines affecting the quality of
nursing.

Research
Participate in identifying the areas of
research.
Participate in the application of data and
research.
Produce conducive environment for
research.

Community health program

Participate in community health programs,
associated with hospital.
Interpret the roles and responsibilities in
community health programs.
Participate in extramural health programs
of the hospital and other related
organizations.

FUNCTIONS OF NURSING SERVICES

to

assist the individual patient in

performance of those activities contributing
to his health or recovery.
To help and encourage the patient to carry
out the therapeutic plan initiated by the
physician.
To assist other members of the health team,
to assist other members of the team to plan
and carry out the total program of care

SOUND ORGANISATIONAL PLANNING

FOR HOSPITAL NURSING SERVICES
A written

statement of the purpose and

objectives of the nursing service
A plan of organization
Policy and administrative manuals
Nursing practice manuals

 Nursing

service budget
A master staff planning
Plans of appraisal of nursing
Nursing service administrative meetings
Advisory committees:

 Adequate

facilities, supplies and

equipments
Written job descriptions and job
specifications
Personnel records
Health services
In-service education of nursing personnel
Meeting with personnel from other
departments

ORGANIZATION AND MANAGEMENT

OF NURSING SERVICE UNIT
factors influencing patient care
The type of service.
The acuteness of the service and the rate of
turnover in patients.
The experience of the nurse.
The number of non-nurses

 The

amount and quality of teaching.

The amount and quality of supervision and
ward teaching.
The method of appointment of the medical
staff.
The plan of ward floor plan.
The physical facilities.

 The

amount, type and location of equipments

and supplies.
The number of working hours
The morale of the worker.
Methods of performing nursing procedures.
The time required for hospital routines
The method of assignment.
The standards of nursing care.
Good ward management.

Management
Assessment or data gathering.
Implementation-directing groups of nurses
to implement planned actions.
Evaluation step in management process,
includes the action of multiple care givers,
patient outcomes and costs.

DETERMINING THE NURSING STAFF

REQUIREMENT
Calculating

staff needs based on the

number of beds in the hospitals.
Estimating the number of staff according to
the degree of dependency of the patients as
determined on a scale.
This method relies on observations of
nursing activity.

ORGANISATION OF NURSING
SERVICES
Chief nursing officer
Nursing Superintendent
Deputy Nursing Superintendent
Deputy Nursing Superintendent
Ward Sister - Clinical Supervisor
Staff nurse Student nurse

Organizational set-up at Directorate General

of Health Services

 Organizational

set-up of Nursing Service at

Central Level
Organizational

Level

set-up of Nursing Service at State

ROLE AND FUNCTION OF NURSE ADMINISTRATOR

Administration

Organizes, directs and supervises the nursing

services both day and night.
Coordinates assignments of staff.
Establishes the general pattern of delegation of
responsibilities and authority.
Formulates standing orders for the nursing care.

 Ensures appropriate allocation of duties and

responsibilities to all nursing staff working under
her.
Formulates nursing policies to ensure quality
patient care and adequate attention at all times.
Responsible for efficient functioning of the
nursing staff.
Evaluates the personal performance of the nursing
staff.

Discipline
Ensure that a standard of discipline of nursing
staff is high at all times.
Maintain good order and discipline in wards /
departments.
Makes daily rounds of the hospital wards /
departments and also seriously ill patients.
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 untowards incident.

Public Relations
Promotes and maintains harmonious and effective
relationship with the various administrative
departments of the hospital and related community
agencies.
Maintain cordial relationships with the patients and
their families.
Office duties
Scrutinizes the reports and returns and submits in
accordance with existing orders.

Confidential Reports
Initiates the confidential reports of nursing staff
on due dates.
Responsible for the nursing budget.
Education
Carries out in-service training for all categories of
nursing staff and paramedical personnel and keeps
the records of such trainings.
Conduct various update courses based on the
needs.
Encourages the personnel to participate in the
continuing education program.

Welfare
Responsible for health and welfare of nursing
staff.
Ensures annual and periodical health examination
and maintenance of health records.
Conferences
Responsible for organizing and conducting staff
meeting of the nursing staff once in three months.
Holds conference in nursing care problems and
discuss policies as regards to working conditions,
working hrs and other facilities.

 Supervision

Supervises nursing care given to the patients and

all nursing activities within the nursing unit.
Supervises the work of all paramedical staff of the
hospital.
Records and Reports
Maintains various records such as duty roster
nursing staff, day off book, personal bio-data,
leave plan, staff conference book, courses file etc.

PROBLEMS AND CHALLENGES FACED

BY THE NURSE ADMINISTRATOR

Lack of adequate training.

Problem of personnel management.
Inadequate number of nursing staff.
Shortage of trained manpower.
Lack of motivation.
No involvement in planning.

 Poor role model.

No research scope.
Professional risk/hazards.
No autonomy in nursing activities.

Day to day problem in nursing services

Shortage of nurses.
Lack of motivation.
Negative attitude.
Lack of training.
Lack of team approach.
Inactive participation of program
Lack of interpersonal relationship
Less involvement in patients care by nursing supervisors.
Lack of supervision.

ORGANIZING PATIENT CARE

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.

PATIENT CLASSIFICATION SYSTEMS

Patient classification system (PCS), which
quantifies the quality of the nursing care, is
essential to staffing nursing units of hospitals and
nursing homes. In selecting or implementing a
PCS, a representative committee of nurse manager
can include a representative of hospital
administration. The primary aim of PCS is to be
able to respond to constant variation in the care
needs of patients.

Characteristics
Differentiate intensity of care among definite
classes.
Measure and quantify care to develop a
management engineering standard.
Match nursing resources to patient care
requirement.
Relate to time and effort spent on the associated
activity.
Be economical and convenient to repot and use.

 Be mutually exclusive, continuing new item

under more than one unit.
Be open to audit.
Be understood by those who plan, schedule and
control the work.
Be individually standardized as to the procedure
needed for accomplishment.
Separate requirement for registered nurse from
those of other staff.

Purposes
The system will establish a unit of measure for
nursing.
Program costing and formulation of the nursing
budget.
Tracking changes in patients care needs.
Determining the values of the productivity
equations
Determine the quality

LEADERHIP ROLES AND MANAGEMENT

FUNCTION ASSOCIATED WITH
ORGANIZING PATIENT CARE
Leadership roles:
evaluate the effectiveness of the organizational
structure
Determines adequacy of resources and support
Examines the human element
Inspires the work group towards a team effort.
Inspires subordinates to achieve higher.
Ensures that chosen nursing care delivery models
advance the practice of professional nursing.

Management functions:
Examines the philosophy.
Select nursing delivery system.
Use scientific research and current literature.
Uses patient care delivery system that maximizes
human and physical resources as well as time.
Ensure that non- professional staff are
appropriately trained and supervised.

 Organizes

work activities to attain organizational

goals.
Groups activities in a manner that facilitates
communication and co-ordination
Organizes work so that it is cost- effective
possible.
Makes changes in the work design
Clearly delineate criteria to be used for
differentiated practice roles

 Organizes

work activities to attain organizational

goals.
Groups activities in a manner that facilitates
communication and co-ordination
Organizes work so that it is cost- effective
possible.
Makes changes in the work design
Clearly delineate criteria to be used for
differentiated practice roles

MODES OF ORGANIZING PATIENT CARE

Case

method nursing or total patient care.

Functional nursing
Team nursing or modular nursing
Primary nursing
Case management or managed care

Case method
In

this method, nurses assume total responsibility

for meeting all the needs of assigned patients
during their time on duty.

Characteristics:
Complete care.
nurses with high autonomy and
responsibility.
It is developed and communicated through
written sources, its usage remains in
contemporary practice.
The lines of authority and accountability
are clear.

Merits:
The nurses attend to total needs of clients
Continuity of care.
Client/ nurse interaction/rapport can be developed.
Client may feel more comfortable
Educational needs of the client can be closely
monitored.
Family and friends became better known by the
nurse
Workload of the patient can be equally divided.
Nurses accountability for their function is built-in.

Demerits:
Many clients do not require the inherent care of
intensity in this type of service.
This method need to be modified if professional
workers are to be involved effectively.
It is difficult for the nurses to use this method to
become involved in long term planning and
evaluation of care.
It is not possible if the nurses are not adequately
trained for the total care of the patient.

Functional method:
In

this, persons were assigned to complete certain

tasks rather than care of specific patients. Eg.
Checking BP, administering medications

Characteristics:
Afunctional method is a technical approach of
nursing care.
The available staff in the unit, for a particular
period of time, are assigned selected functions of
nursing practice such as vital signs, treatments,
medications.
All the responsibilities are assigned in accordance
with the expertise.
The only person who has responsibility of the
client is the head nurse or nurse acting the role.

Merits:
person become specifically skilled in performing
certain assigned task.
best utilization of a persons aptitudes,
experiences and desires.
Less equipment is needed.
saves time.
development of technical skill
sense of productivity for the task oriented nurse
easy to organize the work of the unit and staff

Demerits:
Client care become impersonal,
compartmentalized and fragmented.
diminishing continuity of care.
Staff may become bored and have little
motivation.
only the nurse in-charge has accountability for the
client.

 little

avenue for the staff development.

Client may tend to feel insecure.
Only parts of the nursing care plan are known
difficult to establish the client priorities.
only safe when the head nurse co-ordinate all the
activities of the members.

Team nursing:
Team

nursing is based in the philosophy in which

a group of professional and non- professional
personnel work together who identify, plan,
implement and evaluate comprehensive centered
care.

Characteristics:
ancillary personnel collaborate in providing care.
Team nursing involves decentralization of nursing
unit and professional head nurse authority.
Each team composed of a team leader, team
members and patients.
Comprehensive care is the responsibility of the
entire team.

 The

head nurse has the responsibility to know the

conditions of all patients assigned to the team and
planning individual care.
democratic leadership.
Group members are given as much as autonomy

Merits:
includes all health care personnel in the group
functioning and goals.
Feelings of participation and belonging
Workload can be balanced and shared.
Division of labour allows members the
opportunity to develop leadership skills
Every team members has the opportunity to learn
from and teach collegues.

Demerits:
Establishing the team concept takes time, effort
and constancy of personnel.
Unstable staffing patterns make team nursing
skills patterns make team nursing difficult.
All personnel must be client centered.
This leads to blurred lines of responsibility,
errors, and fragmented care.
For the team nursing to be effective the leader
must be excellent practitioner and have good
communication, organizational, management,
and leadership skills.

Primary nursing:
It

is also called relationship based nursing. It

involves total nursing care, directed by a nurse on
24 hour basis as long as the client is under the
care.

Characteristics:
The RN primary nurse assumes 24-hour
responsibility from admission or start of treatment
to discharge or the treatments end.
During work hours, primary nurse provides total
direct care for that patient.

 When

the primary nurse is not on duty, care is

provided by other junior nurses.
An integral responsibility of the primary nurse is
to establish a good communication
The combination of clear interdisciplinary group
communication and consistent, direct patient care
by relatively few nursing staff allows for holistic,
high quality patient care.

Merits:
opportunity for the nurse to see the client and
family as one system.
Nursing accountability, responsibility and
independence are increased.
The nurse is able to use wide range of skills,
knowledge and expertise.
potentiates creativity by the nurse and thereby
work satisfaction increases
increased trust and satisfaction for both

Demerits:
The

nurse may be isolated from the colleagues.

Little avenue for group planning of care.
Nurse must be mature and independently
competent.
It must be cost effective.

 Staffing

patterns may necessitate a heavy client

load.
It may be difficult to recruit and retain enough
staff, especially in times of nursing shortage.
An inadequately prepared or incompetent primary
nurse may be incapable of coordinating a
multidisciplinary team or identifying complex
patient needs and condition changes.

Case management:
Case management is defined as a collaborative
process that assesses, plans, implements,
coordinates, monitors and evaluates opinions and
services to meet an individual health needs
through communication and available resources to
promote quality, cost-effective outcomes.
Case management society of America

Characteristics:
Case mangers handle each case individually.
In general case manger can handle a load of 25
patients [smith, 2003].
Case mangers use critical pathways and
multidisciplinary action plans to plan patient
care.

Responsibilities of case managers:

Assessing

clients and their homes and

communities.
Coordinating and planning client care.
Collaborating with other health
Monitoring client progress and client outcomes.
Advocating for clients
Serving as a liaison with third party

Merit:
additional

work efficiency due to geographical

proximity.
Establishes solid relationships with nursing and
ancillary staff working on the unit.
Case management provides a well coordinated
care.
Provides comprehensive care
It seeks the active involvement of the patient,
family and diverse health care professionals

Demerits:
Some

experts are argued that this role should be

reserved for the advance practitioner nurse or an
RN with advanced training or need 3 to 5 year
experience.
The case manger should also be extremely bright,
have well developed interpersonal skills, be able to
multitask, have a strong foundation in utilization
review, and understand payer-patient specifics and
hospital reimbursement mechanisms.

 Nurses

identify major obstacles in the

implementation of this service, financial barriers
and lack of administrative support.
Expensive
Nurse is client focused and outcome oriented
Facilitates and promotes co-ordination of cost
effective care
Nursing case management is a professionally
autonomous role that requires expert clinical
knowledge and decision making skills.

Modular nursing

Modular nursing is a modification of team

nursing and focuses on the patients 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.

Characteristics:
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:
Nursing care hours are usually cost-effective.
The client is able to identify personnel who are
responsible for his care.
All care is directed by a registered nurse.
Continuity of care is improved
The RN as team leader is able to be more involved
in planning & coordinating care.

 save staff time.

Feelings of participation and belonging
Work load can be balanced and shared.
develop leadership skills
Continuity care is facilitated
Everyone has the opportunity to contribute to the
care plan.

Demerits:
Costs may be increased to stock each
takes time, effort, and constancy of personnel.
Unstable staffing pattern make team difficult.
There is less individual responsibility and
autonomy regarding nursing function.
All personnel must be client centered.
The team leader must have complex skills and
knowledge.

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.

Principal elements of PPC are:

Intensive

care or critical care

Intermediate care
Convalescent and Self Care
Long-term care
Home care
Ambulatory care

Merits:
Efficient use is made of personnel and equipment.
Clients are in the best place to receive the care .
Use of nursing skills and expertise are maximized.
Clients are moved towards self care, independence
is fostered where indicated.
Efficient use and placement of equipment is
possible.
Personnel have greater probability to function
towards their fullest capacity.

Demerits:
discomfort to clients who are moved often.
Continuity care is difficult.
nurse/client relationships are difficult to arrange.
Great emphasis is placed on comprehensive,
written care plan.
There is often times difficulty in meeting
administrative need of the organization, staffing
evaluation and accreditation.

DIFFERNTIATED NURSING
PRACTICE
Differentiated

nursing practice refers to an attempt

to separate nursing practice roles based on
education or experience or some combination of
both.

 Education

model:
Role differentiation based upon type of
educational preparation [BSN, MSN etc]
Competency model:
Role differentiation based on individual nursing
skills, expertise, experience etc.

Merits:
match patients needs with nursing
competencies.
efficient use of nursing resources.
Provide equitable compensation
It increase nurse satisfaction, built loyalty
and increase the prestige of the nursing
profession.

a prominent characteristic among the new models

being tried is the nurse as a clinical expert
leading other members of the team partners.

THANK YOU