System Approach

PRESENTED BY :• JASPREET KAUR SODHI

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

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

INPUTS TO SYSTEM

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.

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

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.

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

“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.

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.

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.

PURPOSES OF PCS:• Provide data on each patient care unit that directs and supports staffing decisionmaking. • 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

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

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.

No. of personnel's required Daily hours of average daily census Nursing care * * Needed /pt/day

Days per year

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Expected off duty * days/employees

days per year

Duty daily hours per employees

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

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

TYPES OF PATIENT CLASSIFICATION SYSTEM

• PROTOTYPE EVALUATION SYSTEM

• FACTOR EVALUATION SYSTEM

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.

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.

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).

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").

PROTOTYPE EVALAUATION SYSTEM •

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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.

MODES OF ORGANISING PATIENT CARE / NURSING CARE DELIVERY SYSTEM

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

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.

• 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.

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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

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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.

• 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.

Merits: •

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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.

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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.

• 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.

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

• 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.

Functional Method: •

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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.

• 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.

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

• 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.

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.

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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.

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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.

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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.

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).

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Team nursing is based on a philosophy (Kron ,1978) in which a group of professional and nonprofessional 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.

• 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.

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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.

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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.

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.

• 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 costeffective. • The client is able to identity personnel who are responsible for his care.

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

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.

• 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.

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.

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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

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.

• Clients are moved towards self care, independence is fostered where indicated.

• Personnel have greater probability to function towards their fullest capacity.

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.

• 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.

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.

• 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.

• 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.

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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.

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.

• 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.

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

• 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.

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.

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.

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.

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.

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.

Steps in Selection Process • • • • • • •

Preliminary Interview Application Bank Selection Test. Employment Interview. Medical examination Reference checks Final approval

SELECTION TESTING (PSYCHOLOGICAL TESTS)

TYPES OF TESTS: Aptitude or Potential Ability Tests. • • •

Mental or Intelligence Tests Mechanical Aptitude Tests Psycho-motor or Skill Tests

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

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

Selection Interviewing

Types of Interview a) b) c) d)

Informal Interview Formal Interview Patterned or Structured Interview Non directed or unstructured interview

Types of Interview    

Depth interview Group interview Stress interview Panel or board interview

STEPS IN INTERVIEW PROCESS: • • • • •

Preparation for the interview The physical set up Conducting the interview Closing the interview Evaluation of results

SELECTION PROCEDURE SYSTEM APPROACH IN CMC

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

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.

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.

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

TYPES OF APPOINTMENTS

• Confirmed appointment. • Term appointment

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.

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.

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.

Obtaining Additional personnel

SCHEDULING

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.

 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. 

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

 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      

 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

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

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

PRINCIPLES OF SCHEDULING  CYCLICAL The cycle of personnel assignment should

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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

o Once 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 o The cyclical method of scheduling should be well publicized o and implemented so that employees do not perceive the schedule as unduly controlling o The cyclical pattern used should ensure adequate numbers desired mix of employees to each unit for all shifts o The 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 o Each 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

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

Obtaining Additional personnel

 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