system approach in nursing service

2. PRESENTEDBY
:-
•JASPREET KAUR SODHI

3. INTRODUCTION
•The systems approach integrates
the analytic and the synthetic
method, encompassing both holism
and reductionism. It was first
proposed under the name of "
General System Theory" by the
biologist Ludwig von Bertalanffy

4. System approach to nursing
service
A system approach is useful in determining
the optimal numbers and types of nursing
personnel's for each patient care unit in
health care agency.the basic components
of any system are:-
•Input
•Process
•Output
•Controls
•Feedback loops

5. INPUTS TO SYSTEM

6. PROCESS
•It would Consist of those calculations
undertaken to determine the correct
number and types of personnels to be
budgeted and assigned to specific care
units.

7. OUTCOME
•It consists of recommended numbers of
each type of personnel's needed for each
unit given a certain census and a specified
workload.)

8. CONTROL
•It includes Joint Commission on
accreditation of hospital or state
department of health regulations either
nurse –patient ratios or workers
qualification, contractual agreements and
so on.

9. FEEDBACK LOOP
•It consists of information concerning the
time lapsed between duty shifts of
employyes ,patient assignment and so on.

10. Patient Classification System
“The greatest asset of a man’s business is his pride in
work."
•Rapid and dynamic changes in healthcare
delivery have placed the issues of patient
safety and quality of care at the center of
healthcare. The American Nursing
Association’s Nursing Safety and Quality
Initiative, highlighted the strong linkage
between nursing actions and patient
outcomes. Developing a fair, objective, and
reliable way to predict the required number
and skill level of staff to meet patient needs
and staffing assignments is a continuous
challenge to healthcare leaders.

11. WHAT IS PCS?
•The PCS is a scheme that group patients
according to the amount and complexity of
their nursing care requirements. It serves
as a tool to measure patient needs,
caregiver interventions, and the skill levels
required to meet those needs.

12. PURPOSES OF PCS:-
•Determine the required nursing hours
needed to provide safe and efficient patient
care based on standards of care and
practice.
•Determine the number and category of staff
(skill mix) needed for providing quality
patient care.
•Monitor changes in patient demographics
and care needs.

13. PURPOSES OF PCS:-
•Provide data on each patient care unit that
directs and supports staffing decision-
making.
•Ensure that quality nursing care is provided
in a safe environment.
•Assess the level and support services
required.
•Enhance staff satisfaction through a stress
free work environment

14. USES OF PCS:-
•The PCS data generated is used to:
•Improve patient satisfaction by providing
required time to the patient according to
his/her needs.
•Enhance staff satisfaction by determining
staffing needs and thus decreasing
workload.
•Monitor the provision of quality nursing care
according to international standards in a
safe work environment

15. Five major concepts
•were identified and became the framework
around which the new system was
designed and developed:
•1. The care management team is the focal
point.
•2. Classification and staffing are separate.
•3. Classification is based on professional
judgment.
•4. The system is self-auditing.
•5. Staffing is based on informed
professional judgment.

16. No. of personnel's required
Daily hours of average daily census days per year
Nursing care * *
Needed /pt/day
Days per
year
-
Expected off duty
days/employees
*Duty daily hours
per employees

17. HOURS OF NURSING CARE
NEEDED PER YEAR
HOURS OF CARE DELIVERED
BY EACH EMPLOYEE PER
YEAR
=
NUMBER OF
EMPLOYEES
TO BE
BUDGETED
FOR THE UNIT

18. QUESTION ?
•suppose that for an adult medical-surgical ward it
has been established that an average of 5 hours of
nursing care per day is to be provided each patient;
that there will be an average of 20 patients per day
on the unit; and that an all-registered nurse staff is
to be assigned to the unit, Suppose further that in
the same agency, nursing contract calls for each
nurse to work a 40-hour, five-day week, to have 20
day of vacation each year, to be given 10 paid
holidays each year, and to be allowed 12 paid sick
days per year. If a review of personnel attendance
records shows nurse uses an average of six paid
sick leaves with 140 off leaves

19. TYPES OF PATIENT CLASSIFICATION
SYSTEM
•PROTOTYPE EVALUATION SYSTEM
•FACTOR EVALUATION SYSTEM

20. PROTOTYPE EVALUATION SYSTEM
•In the prototype system
,characteristics of patient typical of
each care category are listed, and
patients are classified on the basis
of their resemblance to a typical
patient in the list.

21. FACTOR EVALUATION SYSTEM
•In the factor system, a number of critical
care descriptors are identified, against
each of which the patient’s need for care
is measured to yield a subscore.this
subscore,when combined with other
subscores,yields a total score that
designates the patient’s dependency
category.

22. FUNCTIONAL CLASSIFICATION
SYSTEM
•Most patient classification systems are of
the factor type, in which a number of care
elements or descriptors are identified, each
of these elements is broken down into
component sub elements, and a standard
time is set for accomplishment of each sub
element (each of which represents a
different level of patient dependency).

23. FUNCTIONAL EVALUATION SYSTEM
•In one system the descriptors used to
assign patients to care categories are the
activities of daily living - feeding, grooming,
toileting, comfort measures, and mobility.
The amount of time required to assist the
patient with each of these is then quantified
from least possible time required (as "feeds
self or needs little help") to most possible
time required (as "cannot feed self at all
and may have difficulty chewing and
swallowing food").

25. PROTOTYPE EVALAUATION
SYSTEM
•Category I: Patients with acute, non chronic, episodic
disease or disability who will return to their pre-illness level
of functioning and for whom the care goal is complete
elimination of the existing health problems.
•Category II: Patients with chronic disease on which is
superimposed an acute episode of illness, who have the
potential to return to the pre-episodic level of functioning,
and for whom the care goal is management of the chronic
health problem by the patient and family without ongoing
support from the agency.
•Category III: Patients with chronic disease or disability,
where return to pre-illness level of functioning is not
possible but there is potential to increase the level of
functioning, and for whom the care goal is rehabilitation to
a maximum level of functioning through continuing agency
support.
•Category IV: Patients with a chronic disease or disability
who can't be maintained at home without ongoing agency
support, for whom the care goal is maintenance at home at
a maximum level of functioning through ongoing agency
support.
•Category V: Patients with end stage illness for whom the
care goal is assurance of comfort and dignity throughout
the terminal stage of illness.

26. MODES OF ORGANISING PATIENT CARE
/ NURSING CARE DELIVERY SYSTEM

27. There are five primary means of organizing
nursing care for patients namely
•1. Case method nursing or total patient
care
•2. Functional nursing
•3. Team nursing or modular nursing
•4. Primary nursing
•5. Case management or managed care

28. Case Method:
•oldest mode of organizing patient care.
• In this method, nurses assume total
responsibility for meeting all the needs of
assigned patients during their time on duty.

29. •It involves the assignment of one or more
clients to a nurse for a specific period of
time, such as shift. Complete care,
including treatments, medication
administration and nursing planning, is the
assigned nurse's responsibility.

30. •Even though the case method is one of the earliest
methods of nursing care delivery, it is still widely
used in hospitals and in home health agencies.
•Students most frequently learn within this model,
private duty nurses practice with this design, and
speciality units such as ICU, ICCU etc most often
use this model.I

31. •Case method nursing provides nurses with high
autonomy and responsibility.
•Assigning patient is simple and direct and does not
require the planning that other methods of patient care
delivery do.
•The lines of authority and accountability are clear.
•The patient theoretically receives holistic and
unfragmented care during the nurses time on duty. Each
nurse caring for the patient can, however modify the care
regimen. The merits and demerits of this method are as
follows.

32. •The patient theoretically receives holistic
and unfragmented care during the nurses
time on duty. Each nurse caring for the
patient can, however modify the care
regimen.

33. Merits:
•The nurse can see better attend to the total needs
of clients due to the time and proximity of
interactors. Co-ordination of all aspects of care is
the main responsibility of the nurse; which includes
physical, emotional, medical regimen, teaching and
all other aspects related to it.
•Continuity of care can be facilitated with care.
•Client /nurse interaction / rapport can be developed
by virtue of intensity of time and proximity of those
involved.

34. •Client may feel more secure, knowing that one person is
thoroughly familiar with the needs and the course of
treatment of his/her disease.
•Educational needs of the clients can be closely
monitored.
•Family and friends become better known by nurse and
get more involved in the care of the client.
•Work load for the unit can be equally divided among the
available staff.
•Nurse's accountability for their function is built-in.

35. •Family and friends become better known by
nurse and get more involved in the care of
the client.
•Work load for the unit can be equally
divided among the available staff.
•Nurse's accountability for their function is
built-in.

36. Demerits:
•Many clients do not require the inherent
care of intensity in this type of service.
•This method must be modified if non-
professional heal1h workers are to be used
effectively.
•Nurses are not enough to comply the
demand of this model; cost-effectiveness
must be considered.

37. •It is difficult for nurses to use this method to
become involved in long-term planning and
evaluation of care.
•The greatest disadvantage to case nursing
occurs, when the nurse is inadequately
trained or prepared to provide total care to
the patient.

38. Functional Method:
•The functional method is a technical approach to
nursing care that emphasizes the dependent
functions of nursing practice.
•It consists of separating nursing tasks and
assigning each nursing staff member available on
a unit to perform selected functions such as vital
signs, treatments, medications for all the patients in
a unit or for a large number of patients in the unit.

39. •The responsibilities of the unit are assigned
to selected people in accordance with their
expertise. The only person who has
complete responsibility of the client is the
head nurse or nurse acting in that role. The
following are merits and demerits of
functional nursing.

40. Merits:
•The person can become particularly skilled in
performing assigned tasks, it can be efficient and
economical.
•The best utilization can be made of a person's
aptitudes, experience and desires.
•Less equipment is needed and what is available is
usually better cared for when used only by a few
personnel.
•This method saves time because it lends itself to
strict organizational protocol

41. •The potential for development of technical
skills is amplified.
•There is a sense of productivity for the task
oriented nurse.
•It is easy to organise the work of the unit
and staff as small number of nurses can
care for a large number of patients in a
relatively short period of time.

42. Demerits:
•Client care may become impersonal,
compartmentalized and fragmented.
•There is a tremendous risk for diminishing
continuity of care.
• Staff may become bored and have little motivation
to develop self and others, work may become
monotonous.
•The staff members are accountable for the task;
only the nurse in charge of the unit has the
accountability for the individual.

43. •There is little avenue for staff development, except
as it relates to tasks.
•Clients may tend to feel insecure, not knowing who
is their own nurse.
•Only parts of the nursing care plan are known to
personnel.
•It is difficult to establish client priorities and
operationalise the care plan reflecting same.

44. •It is only safe when the head nurse can co-ordinate
the activities of all members of the
•staff and make certain that nothing essential in
client care is overlooked or forgotten. This is a
tremendous responsibility on one person who
probably has to think of approximately thirty or
more clients, plus the staff.

45. •Majority of them viewed this functional nursing as an executed
economical means of providing care. Major advantage of this
method is its efficiency, tasks are completed quickly, with little
confusion regarding responsibility, e.g. in many areas such as
operating room, labour room; etc the functional nursing works well
end is still very much in evidence. But may lead to fragmented care
and the responsibility of overlooking priority needs and may lead to
low job satisfaction.

46. Team Nursing /Modular Nursing:
•Team nursing was designed to
accommodate several categories of
personnel in meeting the comprehensive
nursing needs of a group of clients
(Donovan 1975).

47. •Team nursing is based on a philosophy (Kron ,
1978) in which a group of professional and non-
professional personnel work together who identify,
plan, implement and evaluate comprehensive client
centered care. The key concept is a group that
works together towards a common goal, providing
qualitative comprehensive nursing care.

48. •In team nursing ancillary personnel
collaborate in providing care to a group of
patients under the direction of a
professional nurse. Actually the team
nursing involves decentralization of a
nursing unit and professional head nurses
authority, in which the unit is divided into
teams.

49. •Each team composed of team leader, team
members and patients. In comprehensive care, the
client is the responsibility of the entire team, but is
led by the team leader who should be a registered
nurse.
• Assignments are made according to the capability
of the members and respond to the needs of the
group of clients.

50. •In team nursing, team leader or the head nurse is
responsible for knowing the conditions and needs
of all the patients assigned to the team and
planning individual care. The team leader duties
vary depending on the patient needs and workload.
These duties may include assisting team members,
giving direct personal care to patients, teaching
and coordinating patient care activities.

51. Merits
•It includes all health care personnel in the groups
functioning and goals.
•Feelings of participation and belonging are
facilitated with team members.
•Workload can be balanced and shared.
•Division of labour al1ows members the opportunity
to develop leadership skills.
•Every team member has the opportunity to learn
from and teach colleagues.

52. •There is a variety in the daily assignment.
•Interest in client's well-being and care
shared by several people; reliability of
decisions is increased.
•Nursing care hours are usually cost-
effective.
•The client is able to identity personnel who
are responsible for his care.

53. •All care is directed by a registered nurse.
•Continuity of care is facilitated, especially if
teams are constant.
•Barriers between professional and non-
professional workers can be minimized.
•Everyone has the opportunity to contribute
to the care plan.

54. Demerits:
•Establishing the team concept takes time,
effort and constancy of personnel. Merely
assigning people to a group does not make
them a group or "team".
•Unstable staffing patterns make team
nursing difficult.
•All personnel must be client centered.

55. •The team leader must have complex skills
and knowledge, i.e. communication,
leadership, organisation, nursing care,
motivation and other skills.
•There is less individual responsibility and
independence regarding nursing functions.

56. Progressive Patient /Client Care:
•Progressive client care is a method in
which client care areas or units provide
various levels of care, e.g.
• intensive care unit for the critically ill,
• post intensive care unit,
• regular care units,
• convalescent unit, and
• self care unit.

57. • 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
mared to units/wards staffed to best provide
the type of care needed. The merits and
demerits of progressive patient care are as
follows

58. Merits:
•Efficient use is made of personnel and
equipment.
•Clients are in the best place to receive the
care they require.
•Use of nursing skills and expertise are
maximized due to different staffing patterns
of each unit.

59. •Clients are moved towards self care,
independence is fostered where indicated.
•Personnel have greater probability to
function towards their fullest capacity.

60. Demerits:
•There may be discomfort to clients who are
moved often.
•Continuity care is difficult, even though
possible.
•Long term nurse/client relationships are
difficult to arrange.

61. •Great emphasis is placed on
comprehensive, written care plan.
•There is often times difficulty in meeting
administrative need of the organisation,
staffing evaluation and accreditation.

62. Primary Nursing
Primary nursing involves total nursing care, directed
by a nurse on a 24 hours basis as long as the
client is under care. As originally designed, this
method requires a nursing staff comprising totally
of registered staff nurses. Here one specific nurse
is the client's nurse, at all times directing, planning,
evaluating and teaching. The primary nurse is
essentially, on call all the time and arranged
coverage when away.

63. •Actually, the primary nurse assumes 24
hours responsibility for planning the care or
more patients from admittance or the start
of treatment to discharge or the treatment’s
end.

64. •During working hours the primary nurse
provides total direct care for that patient,
when the primary nurse is not on duty, care
is provided by other junior nurses who
follow the care plan established by the
primary nurse, that means, even though the
primary nurse is the director of care for
clients, segments of care are often
delegated.

65. •Although this method is designed for use in
hospitals, this structure lends itself well to home
health nursing, hospice nursing and other health
care delivery enterprises.
•An integral responsibility of the primary nurse is to
establish clear communication between the patient,
the doctor, the associate nurses and other team
members.
•Although the primary nurse establishes the nursing
care plan, feedback is sought from others in
coordinating the patient care.

66. Merits:
•There is 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 a wide range of
skills, knowledge and expertise.

67. •This method potentiates creativity by the
nurse; work satisfaction may increase
significantly.
•The scene is set for increased trust and
satisfaction by the client and nurse.

68. Demerits
•The nurse may be isolated from colleagues.
•There is little avenue for group planning of
client care.
•Nurses must be mature and independently
competent.
•It may be cost-effective

69. •Staffing patterns may necessitate a heavy
client load.
•An inadequately prepared or educated
primary nurse may be incapable of
coordinating a
•multidisciplinary team or identifying
complex patient needs and condition
changes.

71. SYSTEMS APPROACH
INTRODUCTION :-
The system approach is an important tool in both
planning and control functions of management.
A system can be simply defined as a set of objects or
elements in interaction to achieve a specific goal.
A system is not just a logical and orderly arrangement
of parts but an ongoing process or state of change
that consists of diverse elements and their
relationships to each other.
Further, each system consists of interconnected and
interrelated subsytems, each of which has its own
objective that contributes positively towards the
goals of the larger system.

72. FUNCTION OF SYSTEM
The function of any system is to convert or
process information, energy, or materials
into a planned outcome or product for use
within the system, outside the system, or
both.
Thus, nursing process is system the function
of which I to convert the knowledge and
skills of the nurse, the patient, and the
patient’s family into supportive and
therapeutic interventions against illness,
debility and loss.

73. DEFINITION OF SELECTION
Selection is the process of choosing the most
suitable persons out of all the applicants. In
this process relevant information about
applicants is collected through a series of
steps so as to evaluate their suitability for the
job requirements.

74. SELECTION PROCESS:
The selection process can be
successful if the following
conditions are satisfied:
•Some one should have the
authority to select. This authority
comes from the employment
requisition as developed through
an analysis of the workload and
workforce.

75. SELECTION PROCESS :
•There must be some standard of
human resource with which
applicant can be compared. In
other words, a comprehensive job
description and job specification
should be available beforehand.
•There must be a sufficient
number of applicants from whom
the required number of
employees may be selected.

76. Steps in Selection Process
•Preliminary Interview
•Application Bank
•Selection Test.
•Employment Interview.
•Medical examination
•Reference checks
•Final approval

77. SELECTION TESTING
(PSYCHOLOGICAL
TESTS)

78. TYPES OF TESTS:
Aptitude or Potential Ability Tests.
• Mental or Intelligence Tests
• Mechanical Aptitude Tests
• Psycho-motor or Skill Tests

79. 2. Achievement or Proficiency Tests:
a) Job Knowledge Tests.
b) Work sample Test

80. 3. Personality Test:
•Objective Tests
(b) Projective Tests
(c) Situation Tests

81. Selection
Interviewing

82. Types of Interview
a)Informal Interview
b)Formal Interview
c)Patterned or Structured Interview
d)Non directed or unstructured interview

83. Types of Interview
Depth interview
Group interview
Stress interview
Panel or board interview

84. STEPS IN INTERVIEW PROCESS:
•Preparation for the interview
•The physical set up
•Conducting the interview
•Closing the interview
•Evaluation of results

85. SELECTION

PROCEDURESYSTEM

APPROACHINCMC

86. CLASSIFICATION OF STAFF
In hospital, posts are classified
belonging to one or other of the
following three groups:-
Group -1
Group- II
Group -III

87. GROUP -I
Appointments are made by the
governing body on the
recommendations of the
director, Internal Management
committee or the senior
Academic staff appointment
and promotion committee.

88. GROUP -II
Appointment are made by the
following employing officers :-
•Personnel officer
•Nursing superintendent
•Medical superintendent
•Principal ,medical college.
•Principal, dental college.
•Principal ,college of nursing.

89. GROUP-III
•Appointment are made
by the personal officer.

90. TYPES OF APPOINTMENTS
•Confirmed appointment.
•Term appointment

91. CONFIRMED APPOINTMENT
All employees are appointed to
confined position shall serve 12
months on the probation .if
satisfactory reports received at the
end of this time ,such staff may be
considered for the confirmation . If
the reports are not satisfactory
,either the probationary period ,may
be terminated as provided by rules
and regualtion of hospital.

92. TERM APPOINTMENT
•A term appointment is an employment
offered for fixed duration and the
termination date is stated on the
appointment agreement .It ends
automatically on due date and no notice on
either side is necessary.

93. SELECTION CRITERIA EMPLOYED IN
hospital
•Initially recruitment is done (it may be
either external or internal ).
•No pre made question bank is available.
•Speciality wise ,each member
formulates 20 questions
•Written test is conducted
•Interview of qualifying candidates
•Selection is based on contract basis.

94. Obtaining Additional personnel

95. SCHEDULING

96. STEPS OF SCHEDULING
Following analysis of the unit’s work
schedules and routines, she must
determine hours of maximum and minimum
workload so as to decide hours of peak
need and least need workers of all
categories.
Positions budgeted and filled, she must
determine what pattern of on and off-duty
hours would provide desired numbers and
types of personnel to the unit for each day.

97. Manager must assign on and off duty time for workers for a
span of days so as to group the total staff into desired
congratulations.
 She must check the completed schedule for errors such as
names omitted, promised holidays or vacations not provided,
inadequate numbers of personnel during certain periods, and
improper mix of personnel on certain days or shifts.
 She must secure approval of the proposed schedule from
appropriate nursing mangers or directors.
She must post schedules to notify staff members of assigned
duty hours for several weeks in advance
She must review and analyze schedules and policies on a
regular basis to identify staffing problems that necessitate
scheduling changes.

98. SCHEDULING POLICIES
Person, by title, who is to prepare time schedules for personnel in each
unit
Time period to be covered by each on/off duty schedule.
Amount of advanced notice to be given worker concerning on/off duty
schedule
Total required on and off duty time for each worker per day, week, or
month
Day that starts the duty week
Beginning and ending time for each duty shift
Number of shifts to which each worker must rotate
Required frequency of shifts to which rotation
Necessity of rotating from one unit to another and of frequency of
such rotation
Necessity of scheduling two days off each week or an average of two
days off per week

99. Frequency of weekends off for each category of personnel
Definition of “weekend off” for night duty personnel
Required incidence of sequential and nonsequential days off
Maximum sequential duty days allowable
Minimum interval required between sequential duty shifts
Number of paid holidays to be granted each employee
Required number of holidays per year on which employee must
be scheduled off duty
Length of advanced notice to be given employee regarding
holiday on/off duty schedule

100. Procedure to be followed in requesting to be off duty
on a specific vacation time
Restrictions on vacation scheduling during during
Thanks-Christmas-New Year holidays
Number of personnel of each category to be
scheduled for vacation or holiday at one time
Procedure for resolving conflicts among personnel in
regard to vacation and holiday time requests
Procedure for processing “emergency” requests for
adjustment of time schedules

101. Scheduling Responsibility
The supervisor or head nurse has been
responsible for scheduling on duty time for unit
nursing personnel.
Scheduling must be prepared several weeks in
advanced, and then modified to accommodate
changes in patient census, worker illness and
emergency time-off requests, much valuable
supervisory time spent in preparing and adjusting
time schedules

102. CYCLICAL SCHEDULING
It consists of assigning work days
and shifts for unit staff members
according to a predictable and
repeating pattern, makes available
desired numbers and mix of
personnel and facilitates continuity
of patient care and constancy of
primary work groups

103. PRINCIPLES OF CYCLICAL SCHEDULING
 The cycle of personnel assignment should
represent a balance between the institution’s
need for labour coverage and the employee’s
need for balanced work and recreation
The assignment cycle should distribute “good”
and “bad” duty days and hours equitably among
all employees
All employees should be assigned according to
the cyclical pattern

104. oOnce the cyclical schedule has been established, individual
deviations from the schedule should be rare and granted
o only for following written request for a change of schedule
oThe cyclical method of scheduling should be well publicized
oand implemented so that employees do not perceive the schedule as
unduly controlling
oThe cyclical pattern used should ensure adequate numbers desired
mix of employees to each unit for all shifts
oThe cyclical pattern used promote continuity of patient care by
minimizing “floating” of personnel and by prolongating contact
between each patient and his composition of the primary work group
oEach worker should be notified of her on and off duty days and shift
rotations far enough in advance to permit reasonable planning of
personnel, business and educational activities

105. Causes of overstaffing
 Frequent and unpredictable variations in
patients census
The tendency of many nurse managers to
compensate for census variations by
staffing for maximum or peak census
rather than for average or minimum
census

106. Obtaining Additional personnel

107.  In some hospitals and clinics a pool of “float”
personnel is assigned to the central nursing office
Each “float” nurse is oriented to the several similar
units.
Float personnel are assigned daily by a nurse
administrator to one or another nursing nursing unit to
assist with increased workload