PRINCE SULTAN MILITARY COLLEGE OF HEALTH SCIENCES Nursing Diploma Department PSMCHS, Dhahran

COURSE CODE: NURS 112

TITLE:

FUNDAMENTALS
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NURSING

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DATE REVISED: DEC 2003 DATE DEVISED: DEC 2004 N.

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LECTURE NOTES N. NURS 112.005

THE HEALTH CARE DELIVERY SYSTEM

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OBJECTIVES
At the completion of this lecture, the trainee should be able to:

1.
2. 3. 4. 5. 6.

Explain the major forces that influence change in the health care system. State the gaps between client needs and services offered. Outline the various component of the current health care system. Identify the various component of the current health care system. Express strategies professional nurses could use to thrive in the current and future health care delivery system. Explore the ethical issues surrounding current changes in health care delivery.

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FORCES INFLUENCING CHANGES IN THE HEALTH CARE SYSTEM

When nurses understand how health care delivery occurs, they can help people in using the system. Numerous forces influence recent and future changes within the health care system. Humans have control over some and remain powerless against others. Developing a health care system that effectively provides access, cost and quality seems to be the greatest challenge confronted by the health care system. One of the most significant influences affecting health care delivery is the increasing population of older people. Worldwide, the population of those older than 65 years is expected to grow from 10% in 1975 to 18% to 20% by 2030. Because older persons often have chronic conditions that require treatment and care, their increasing numbers will exert a continuing upward pressure on health care costs. Other demographic influences include changes in geographic distribution and composition. Urban midsize cities are experiencing rapid growth in the need for health care delivery services for the very young and the elderly.

1.

Age-Related Factors

The increasing numbers of older adults means a greater need for acute care hospitalization for diseases of the heart, malignant neoplasms and chronic incurable diseases with multisystem failures and functional decline. Chronic disorders such as diabetes and osteoarthritis, cognitive impairment and the increased fragility of advancing age are of major concern. Mental health and dental needs also will increase. Health promotion, illness prevention and rehabilitative services are needed to enhance the quality of life for the elderly. Older adult caregivers (primarily women) of their frail elderly parents will need support and assistance. The increasing need for coordination and continuity of care provides an opportunity for managed care by professional nurses. Infant mortality continues to be of major concern. There is evidence that primary care directed at high-risk mothers can be effective. Good prenatal care can prevent prematurity and low birth weight in infants. Health promotion efforts aimed at influencing high-risk behaviors among adolescents are especially needed.
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2.

Impact of HIV

Acquired immune deficiency syndrome (AIDS) is now a world pandemic. It is estimated that in 2000, an estimated 40 million people worldwide had HIV, with 90% them in developing countries (WHO, 2001). A number of therapies have been developed, but no cure is known. There will be an increasing need for acute and community care, education and counseling regarding HIV prevention and nurses will need to lead programs for HIV and other infectious diseases.

3.

Drug and Alcohol Abuse

Abuse of alcohol and other drugs is a causative factor in various severe health and social problems, including: traffic accidents transmission of hiv through contaminated needles lost wages and productivity increased homelessness, disability, poverty and crime Community health nurses, in particular, provide essential for prevention, detection referral for treatment and education.

4.

ENVIRONMENT FACTORS

Our industrial age is associated with numerous environmental problems that have an impact on health, including: air pollution the greenhouse effect acid rain deforestation increased ultraviolet radiation (associated with depletion of the ozone layer) toxic and nuclear wastes lead-based paints and asbestos

Science and Technology

During the 20th Century, medical science has focused on expanding the length of the human life span. Therapies for once fatal illnesses and injuries are prolonged life. As scientific knowledge and technology expand, even longer life spans can be predicted for those with access to these new therapies. However, scientific advances and
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increased used of technology add to the cost of health care delivery. advances in medical therapies are expensive.

Scientific

Within the last few years, pharmaceutical firms have begun directly advertising new products to consumers using various media formats. Pharmaceutical companies expect to profit from newly developed medications.

Changing Attitudes
During the last two decades, the public has become increasingly aware of and interested in promoting health. People are more aware of the relationship between lifestyle and the incidence of stress-related disease, chemical and drug dependencies and the predisposition to other diseases. To prevent illness and promote health, people have focused attention on moderating stressful aspects of their lifestyles; developing good nutrition, adequate exercise, rest and relaxation; and controlling the use of abusive substances, such as alcohol and other drugs. People begin to accept increased responsibility for personal health and self-care, and need increased health education. As clients have requested and received information, they have begun to question the advantage that the the doctor knows best. Evidence suggests a shift in attitudes toward personal involvement in choices affecting health status. As informed clients become more involved in health-related decision-making, the emphasis on ethics, research and noninvasive procedures increases. Clients are becoming more aware of preventive and therapeutic interventions and want mutuality, rather than paternalism, by health care professionals. Collaborative care has created opportunities for nursing to: distribute information and promote an educated public strengthen nursings influence on health promotion promote associations with clients and collaborative relationships with physicians become accepted as primary care providers for long-term care

Declining Enrollment in Nursing Programs

In 1994, overall enrollments in basic Registered Nurse Programs in the United States decreased for the first time in 6 years. This decrease is continuing, with 1996 enrollment in entry levels bachelors programs decreasing 6.2% from the previous year. The decrease in supply is in response to a number of factors including:

a decrease in the population of people 18 to 24 years of age a shift in interest from a career in nursing
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an increase in the number of career choices available to women (who comprise 97% of the nursing work force) limited salary and promotion increases throughout a nursing career

image problems, including an emphasis on hard technical work, low entry, salaries and limited career financial potential limited return for increased education and low status increased labor intensity of acute illness in hospitals understaffing in acute and extended care facilities

Jobs Satisfaction among Nurses

Job satisfaction is an issue - nurses express dissatisfaction with basic working conditions such as scheduling, inadequate numbers of staff and the correct mix of nursing and support personnel. Nurses also express concern about the profession, including control over nursing practice, adequate autonomy for client care, respect from others (especially physicians and administrators) and opportunities for growth and promotion. The number of nurses, stating that they are going to leave the profession, is increasing.

Physician Surplus
Nursing supply and demand is affected by the supply of physicians. There is a growing oversupply of physicians in urban areas and specialties and a shortage in family practice and in rural and impoverished areas. The surplus of available physicians will have a significant impact on nursing practice and on other aspects of the health care delivery system. Physicians have become more active in pension, elderly ambulatory and community settings that previously were less appealing.

Advanced Practice Nursing

Some physicians view advanced practice nurses as a threat to medical practice. Registered nurses in advanced nursing practice have the knowledge base and practice experience to prepare them for specialization, expansion and advancement. Unfortunately, some physicians view advanced practice nurses as competitive providers of health care, rather than professional colleagues.

Nurses Entrepreneurs
Nurses also can assume more control and accountability when they become entrepreneurs. Nurse entrepreneurs offers interactive video health education, case
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management, facility planning, foot care, enterostomal therapy, legal consultation, quality assurance, aromatherapy, massage, organization reinvention and general health counseling service programs.

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CHANGES IN THE HEALTH CARE DELIVERY SYSTEM: NURSING IMPLICATIONS

STRUCTURE AND ORGANIZATION
Health care delivery system provides:

Primary care:

health promotion prevention of illness treatment toward the cure of illness

Secondary care: Tertiary care:

technologically complex diagnostic, treatment and rehabilitative service.

Although hospitals have been the dominant provider care, alternative structures have been developed recently. Various categories and classifications designate the purpose of health care providing organizations.

ALTERNATIVE DELIVERY SYSTEMS Alternative delivery systems, particularly for ambulatory secondary care, have developed during the past few years, providing care at a lower cost than is possible through hospital admittance. ALTERNATIVE AMBULATORY CARE SYSTEMS Diagnostic centers Minor emergency Surgery centers Birthing centers Substance abuse facilities Rehabilitation centers

Although occupancy rates have been decreasing, the severity of illness of clients who are admitted to the hospital has been increasing.

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INTEGRATED HEALTH CARE DELIVERY SYSTEMS

Health care delivery within the next few years may differ greatly. The requirement will be for a very integrated health care delivery system that provides clients with a high continuity of care. These integrated services need to be near an urban health care that offers comprehensive, sophisticated, technological medical therapies and offer complementary therapies. Clients will receive less expensive follow-up care at home or in extended care facilities. Clients will see nurse practitioners, physician assistants or primary care physicians for routine health care maintenance whilst clients will see specialists only when advanced diagnostic services or complicated disease management need arise. Under this integrated system, care will be managed and emphasis placed on health promotion.

NURSING CARE DELIVERY MODELS

On a daily basis, nurses make decisions related to organizing and managing client care. Nurses consider a variety of factors when selecting the best way to deliver care to a group of clients.

Factors considered include: acuity level of clients specialized needs of clients availability of registered nurses to meet special care needs numbers of available staff nursing care delivery system used by the health care organization

When nursing shortages occur, nurses accommodate for them by selecting from a variety of available nursing care delivery models.

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The following is an overview of currently used nursing care delivery models. NURSING CARE DELIVERY MODELS Case Method or Total Clinic Care Functional Nursing Team Nursing District Nursing Client-Focused Care Nursing Interdisciplinary Care Delivery Model Case Management

1.

Case Method or Total Client Care

Nurses assume the responsibilities for meeting the care need of a single client or group of clients. In Victorian times, case nursing was the only model for care delivery. Currently, nurses use the case method in home, private duty and intensive care nursing settings. Nursing Instructors assign nursing students using the case method for initial clinical nursing experiences.

2.

Functional Nursing
Functional nursing developed in response to a nursing shortage in the 1940s. Functional nursing divides tasks among nursing staff members based on registration and tasks. Because the least skilled and lowest paid workers assume routine care tasks that require no special skills or license, functional nursing promotes efficiency in care delivery. But because of the division of client care tasks, care becomes fragmented. Clients may receive care without regard for their sleep or rest needs. Example of functional nursing pattern:

One professional nurse assumes the role of charge nurse, who makes staff assignments, develops client care plans and directs all unit activities. Another nurse assumes the tasks of administering intravenous therapy, doing client assessments and documenting care for all clients. Another nurse receives the assignment to administer oral medications, perform treatment such as dressing changes and deliver eneteral feedings. A nurse aide
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assumes responsibility for monitoring vital signs and performing hygiene measures for all clients.

3.

Team Nursing
Team nursing started during the end of World War II in response to the nursing shortage and to fix problems created by the functional nursing care delivery system. Extended care facilities, home health agencies and acute care hospital use team nursing. In team nursing a group of nursing staff personnel with varying skills and registration status care for the needs of a group of clients. The registered nurse serves as the team leader, who divides client care duties for one shift focuses on client needs and supervises team members. The team assumes responsibility for the total care given to its assigned client group. Team conferences are held to discuss the daily nursing care needs for the client group. A team of nursing staff would provide care for a limited number of clients on an acute care nursing unit. Large nursing units may have multiple teams to care for clients. With team nursing, each team cares for approximately the same number of clients with a similar client acuity. Success relies on effective written and verbal communication skills.

4.

Client-Focused Care Nursing

Care delivery systems were redesigned in the 1990s because of rising costs of acute care facilities. Various terms have been given to the most newly developed nursing care delivery systems, such as work redesign, client-focused care, client-focused care or modular nursing. Improved efficiency of nursing care delivery has provided the force for the development and implementation of a new care delivery system for acute care settings. The goal of client-centered care is to cross-train unlicensed and other ancillary workers to be capable of performing multiple client care functions to improve productivity levels.

5.

Interdisciplinary Care Delivery Model

Because the client-centered approach includes more than nursing care, some nursing experts consider this an interdisciplinary care delivery model. With the client-centered care approach, satellite pharmacies or unit computerized medication supply units enable professional nurses to acquire ordered mediations immediately. Satellite laboratories also may be present on a unit.
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Client care units store client care supplies close to client rooms. Some institutions keep the client medical record at the bedside or in a holder directly outside the client room. The central nursing station is eliminated and client care documentation is done by staff at the bedside or in small nursing stations located in close proximity to client rooms. As hospitals and health care agencies merge as for-profit organizations, costeffective health care is the main aim.

6.

Case Management
Case management provides a system of client care delivery that focuses on the achievement of outcomes within effective time frames and with appropriate use of resources. Case management tries to reduce the use of the emergency department for treatment of symptoms of chronic disease because such care is not costeffective and does not provide continuity of care. Client populations, such as the frail elderly; clients with transplants, diabetes or multisystem failure; and infants with low birth weights, may benefit from the service of a nurse case manager.

TASKS OF THE CASE MANAGER

Assessment: clients home environment client and family teaching requirement need for long-term treatment and procedures

Collect clinical data: health history information physical examination findings

Evaluate: needs after discharge abuse of alcohol or drugs referrals after discharge (such as for physical therapy or diabetic education) prescription medicine need for long-term care need for long-lasting medical equipment

The case manager in the acute care setting integrates nursing processes with management processes to achieve client outcomes.
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Implementation of the plan of care requires observation and time management. The clients progress is compared daily to the goals of the plan of care. The case manager assertively coordinates procedures and referrals. Team meetings are held to identify the possibility of early discharge to home or the unexpected need for a skilled nursing facility after discharge from the hospital. The case manager acts as the clients advocate in getting benefits and services from health care payers. The nurse providing client care reports client progress and abilities during team meetings.

Evaluation of the clients progress is compared to the length of stay. This comparison may identify new goals or require goals revision. Deviation from expected outcomes may be observed, identifying trends in the hospitals delivery or performance of services. Any delays or repeated procedures compromise efficient and optimum care. The case manager monitors the clients progress in terms of recovery, cost and efficiency of the facility.

PRIMARY ROLES OF THE CASE MANAGER

1. 2. 3. Clinician Manager Financial communicates effectively with a multidisciplinary health care team. clients care consultants. is coordinated among professionals and

ensures economic care but does not compromise quality.

No one single nursing care delivery system model can provide comprehensive, holistic care of high quality in a cost-effective manner in all health care settings. In all settings, the nurse manager assumes responsibility for determining the effectiveness of the currently used nursing care delivery system. Selection of a nursing care delivery system depends on the health care organizations mission, philosophy and values, as well as the availability of professional nurses. Professional nurses must exercise care when delegating professional nursing tasks to technical and unlicensed staff members.

7.

Cost of Health Care

Many changes in society have increased the cost of health care delivery. Most of the time, health care clients rely on health care professionals for sound advice to maximize their health potential. Within the past 20 years, health care delivery shifted from being an altruistic service to a business. Some societal changes have contributed to the escalation of health care costs.
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8.

Economic Forces
In this century health care costs have rapidly increased. Inflation in health care costs also has increased at a rate higher than that of general inflation.

Health care expenditures fall into the following categories: 1. 2. health-related research and facilities construction payment for personal health care services and supplies

Payment for individual health care services and supplies costs more than new construction or research. Of the personal health care services, hospital costs constitute the greatest single health care expense.

9.

Hospital Costs
Hospital costs have been a major component of increasing health care costs. Several factors have influenced hospital costs. The development and intense use of advanced technology was encouraged for medical research. Specialization of knowledge promoted the growth of medical specialties supported by a complex network of nonphysician health care workers. In the past, physicians and third-party reimbursers urged consumers to expect extensive use of hospital resources for diagnosis and treatment. Sometimes hospital admittances were unnecessary; costs were increased by multiple unnecessary laboratory tests, by procedures performed to avoid the threat of a lawsuit and by excessive lengths of stay. Although these practices have been changing, the costs of hospital care have continued to increase. New technologies, such as magnetic resonance imaging (MRI), genetic engineering, the artificial heart, monoclonal antibodies for the treatment of cancer and organ transplantation, create pressures on health care costs, just as hip replacement, long-term dialysis, coronary bypass grafts and computed tomography (CT) scans did in earlier years.

10.

Ethical Concerns
Ethical concerns have been raised by an increasing life span, the development of health care technology and the increasing cost of delivering care. Because it is not possible to meet all goals of accessibility, equity and quality given available resources, difficult choices must be made. One basic issue is the relative valuing of predictability and containment of the costs of health care versus the access to health care for all persons.

Ethical questions raised by these choices include:

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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Who will cover the costs to make the system affordable, acceptable and available to all? How much is health care a basic right? If there are limits on access to health care, who should have priority? What is an acceptable level of health care? Should technology be available to all, regardless of cost or should it be rationed? What should be the criteria for rationing? Who should determine the criteria? How much is the prolongation of life worth? Does reducing costs reduce the quality of care? What rights do clients have? Is cure of all disease possible? Is cure of all disease desirable at any cost?

It is critical that the voice of the nursing profession be added to that of the public in discussions of the philosophic considerations and values that will shape the decision concerning the size, shape and direction of the health care system.

CONCLUSION
As a result of significant demographic, economic, attitudinal and available manpower forces, the health care delivery system is in the process of structural change and reorganization, raising multiple ethical considerations. Health care providers can use historical events to prevent repeating past mistakes. The nursing professional has the opportunity to influence the direction of change to ensure the improvement of health and health care.

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