TRADITIONAL APPROACHES AND TRENDS IN NURSING CARE DELIVERY SYSTEM

Nakul S Babu

Introduction:What is nursing?. How has it emerged as a profession? Is it a profession? What is the position of the nurse in relationship to other members of the health care team? Is the nurse a professional? If so what education is required for professional standing? What is the exclusive role of nurse? These are numerous questions face nurses and nursing today. Many of the questions remain unanswered. In this seminar Intend you to expose some trends that surround nursing to day

TERMS:
1. TRADITIONAL: - Beliefs or customs taught by the generation to the next.

2. APPROACHES:- To begins to deal with or work on.

HEALTH CARE IN ANCIENT CULTURES

Primitive societies and ancient cultures were nomadic out of necessity. They are well- defined groups, built around the nucleus of family relationships, wandered in search of food, warmth and an environment that supported life. Solidarity among these scattered groups, organized for the convenient management of human affairs; existed for purposes of mutual protection. Anthropologists believe that primitive groups originated in Africa and migrated across the world. Ice ages in the northern latitudes may have driven these groups back to the warmer climates found around the Medeitarenian Sea, in India and in China, where civilizations developed.

SUMMARY OF HEALTH CARE PRACTICES OF SELECTED EARLY CIVILIZATIONS

1. Egypt 3000 B.C.

Provided the earliest medical records, dating back as far as 3000 B.C, with included more than 700 classified drugs. Developed a system of community planning that helped avoid public health problems Established strict rules regarding cleanliness, food, drink exercise, and sexual relations Was credited with being one of the healthiest of the ancient civilizations

2. Ancient Israel 1900 B.C

Isolated people with communicable diseases, differentiated clean from unclean , and established rules that forbade eating meat past the 3rd day after slaughter, monitored by priest- physicians who functioned as health inspectors Shared knowledge with other cultures.

3. Greece 800 B.C 300 B.C

The home of Hippocrates, born about 400 B.C., who became known as the Father of Modern Medicine. Hippocrates stressed natural causes for disease, a patient centered approach ; and the necessity of accurate observations and record keeping.

4. Rome 800 B.C 476 A.D

Borrowed medical practices from the countries they conquered.

5. India (3000 1500B.C)

Early civilizations highly developed, with systems of sanitation, Vedic age ( 1500 B.C) characterized by worship of Brahma , which resulted in segregation of society into four caste

6. China 3000 B.C 249 B.C

Developed concept of yin and yang and had elaborate material many drugs still used today. Developed acupuncture skills in practice today, studies circulation. Baths used for reduction of fever, bloodletting to release evil spirits.

7. Mayan and Aztec civilizations 2000 1000 B.C

Sun god of particular significance; health viewed as a balance between nature, and the supernatural Rites, ceremonies herbal treatments charms and perhaps human sacrifice contributed to healing practices.

EARLY IMAGE OF NURSE

1. The Folk Image of the Nurse:

Since the time of the first mother, women have carried the major responsibility and nurturing children, caring for elderly and ageing members of the family. It is reasonable to assume that early tribes and civilization had need for health. Superstition and magic played a significant role in treatment and a close relationship existed between religion and the healing hearts. 2. The Religious Image of the Nurse:The first continuity in the history of nursing began with Christianity. Christ admonish people to love and care for their neighbours. Christs precepts placed women and men on a charity and church. Unmarried women were selected for service.
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3.

Servant Image of the Nurse:

From the middle ages to the 19th century nursing was often left to uncommon women, a group comprising prisoners, prostitutes and drunks.

THE NIGHTINGALE INFLUENCE

In the letter half of the 18th century, one women dramatically changed the form and direction of nursing and succeeded in establishing it as a respected field of endeavor. This outstanding woman was Florence Nightingale. Florence Nightingale born in May 12, 1820. By the age of 17, as the result of tutoring from her father, she had mastered several languages and Mathematics. However, she wanted to become a nurse, but this aspiration was unthinkable to her family because of the terrible conditions of the hospital at that time. In 1850 she began to practice at Paster Fliedners institute at Kaiserweath . After the Crimean war began in March 1854, was correspondents wrote about the abominable manners in which the British Army used for STCK and wounded Soldiers. Florence Nightingale along with 38 nurses were appointed at was site. Her tireless effort in the Crimea resulted in greatly reduced morality rates among the stick and wounded. When the war ended in 1856, Florence Nightingale returned to England as a national heroine. Throughout her lifetime, Florence Nightingale wrote extensively about hospitals, sanitation, health and health statistics. Among her most popular book is Notes on Nursing, published in 1859. She for and brought about great reform in nursing education. In 1860, she started a school of nursing at St. Thomas Hospital in London.

THE BASIC PRINCIPLES ON WHICH MISS NIGHTINGALE ESTABLISHED HER SCHOOL INCLUDED THE FOLLOWING: Nurses would be trained in teaching hospitals associated with medical schools and organized for that purpose. Nurses would be selected carefully and would reside in nurses houses designed to encourage discipline and from character. The school matron would here final authority over the curriculum, living arrangements and all others aspects of the school. The curriculum would include both theoretic material and practical experience Teachers would be paid for their instructions. Florence Nightingale died in her sleep at the age of 90 on August 13, 1910.

THE MILITARY INFLUENCE

Through the experience in the Crimean war, Florence Nightingale first brought attention to nursing as a career and profession and to needed changes in health care delivery. Similarly other wars have brought advances in how care is provided. Like wise, in war after war, nurses have provided care, expanded the role of nursing and created new nursing techniques.

1. The American Revolution:The nuns of the Catholic church nursed the wounded soldiers. Woman who had followed their husbands to the battle field often nursed soldiers. Homes and barns near the battles were turned into hospitals. After the war new types of institution evolved, which is perhaps the forerunner of todays clinic or hospital outpatient department.
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2.

The Civil War:-

The civil war broke out in the United States in 1861. Although Social reforms was in the rise, the nursing profession was still in an embryonic unorganized stage. There was neither on army nurse corps nor an organized medical corps. There were no ambulance services or hospital units. 6,18,000 man died due to lack of props treatment. A steamer, captured from the confederates, was converted into a floating hospital, which is the first navy hospital ship, named Red Rover was staffed through the volunteer efforts of the catholic sisters of mercy who became the first nurses.

3.

World War I:-

First world was started when Austria declared war on Serbia when the united States joined the conflict, nurses from the Army and navy were ready to provide care to the wounded. Experienced nurses were recruited. The influence epidemic of 1918 was a major problem and claimed many lives, including those of doctors and nurses. Recognizing the demand for a long term supply of military nurses, the Army School of Nursing was organized in 1918. England founded the Royal college of Nursing in 1916.

4.

World War II: In response to Germanys invasion of Austria and Poland, England declared

war against Germany and Italy in September 1939. The United States entered the war after Japan attacked Pearl Harbor on December 7, 1941. During this period United States Recruited 1,24,065 women graduated from the Cadet Nurse corps. It provided funds for tuition, a monthly allowance , uniforms and other expenses for women who would enter nursing. In world War II , nurses were given commissions as officers and had military rank.
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5.

Vietnam War:-

Learning from the experiences of World War II, treatment centers located close to the front lines were established. Triage care evolved, made more effective by advances in antibiotics and medical technology. Flight nursing saw a significant resurgence.

THE BEGINNING OF NURSING EDUCATION

After the establishment of the Nightingale School in England, nursing programs flourished and the Nightingale system spread to other countries. In the United States, much of the push for nursing education occurred shortly after the civil war during which the lack of trained nurses presented a serious concerns.

ESTABLISHMENT OF EARLY SCHOOLS As with many other significant events that have evolved from a variety of influences, it is difficult to pinpoint the first nursing program. As early as 1798, a pioneer physician , Dr. Valentine Seaman, is said to have initiated the first system of instruction for nurses at New York Hospital . A society was formed in 1839 under Quaker influence, called The nurses society of Philadelphia and a combined Home and school, were opened . Womens hospital of Philadelphia which operated under the direction of two female physicians opened a training school in 1861. In 1869, the American Medical Association established a committee to study the issue of training for nurses. In 1872 The New England Hospital for women and children is often credited with being the first hospital to establish a formed one year programme to train nurses. In 1873, Linda Richards became Americas first trained nurse. In 1888, the Mills School of Nursing at Bellevne Hospital opened to train male nurses for patient care.

CHARACTRISTICS OF THE EARLY SCHOOLS

The life of the nursing student at the turn of the century was not an easy one. The strong militarists and religious influences over nursing were embodied in the expectations held for nursing student. The typical nursing student was about 21 years of age, single and female. The first weeks or month of their education were spent as probationers. Although helping with the operation of the hospital for example they spent much of their time Washing, scrubbing , polishing, folding, stacking etc. Rules of the conduct were rigid and for giving , Nursing students were expected to be unselfish, thinking not of themselves but of the happiness and well being of others. Initially, nursing education was largely an apprenticeship and resulted in students providing much of the work force of hospitals. The workday was long and arduous often starting at 5.30AM and ending very late at night. There was no standardization of curriculum and no accreditation. The few lectures that were part of the program were usually given by physicians and scheduled at 8 or 9 Pm, after a long day of work. Lectures were cancelled if students were needed to care for patients. Although there were some changes in the curriculum work hours were decreased, The length of study was increased and the theory component was organized into a specific areas of care such as medical, surgical,obstetric nursing. In 1921, a nurse was discharged for Cigarette Habit skirts of nurses uniform were getting shorter but there was periodic measurement to be sure some were not too short. In 1924 there were first student protest. Student nurses were required to wear their hair long in those days.

DEVELOPING A DEFINITION FOR NURSING Defining nursing is difficult . Nurses themselves cannot agree on a single definition, partly because of the history of nursing. EARLY DEFITNITIONS OF NURSING: A nurse is a person who nourishes fosters and protects a person who is prepared to care for the sick , injured and aged in this sense, nurse is used as a noun and is derivered from the Latin word nutrix which means nursing mother. INFLUENCES ON THE DEFINITION OF NURSING A number of factors have influenced the definition of nursing. One might first think of technologic advances that have significantly affected the definition of nursing and the role of the nurse. Today recovery is anticipated after careful evaluation and treatment that can require diagnostic imaging, sophisticated laboratory tests, delicate medical procedures and specialized critical care nursing. Critical thinking skills are essential to the successful performance of the diverse tasks expected of a nurse. Nurse in many positions have been required to assume ever greater levels of responsibility. Only recently are nurses beginning to receive the official authority, autonomy and recognition that should accompany those responsibilities. Another factor influencing the definition of nursing is the work of nursing theorists.

DEFINITIONS OF NURSING BY MAJOR THEORISTS:1. Florence Nightingale (1860):The goal of nursing is to put the patient in the best condition for nature to act upon him, primarily by altering the environment.

2. Hildegord Peplau (1952):-

Nursing is viewed as an interpersonal process involving interaction between two or more individual , which has as its common goal assisting the individual who is sick or in need of health care. 3. Virginia Henderson (1996):-

Nursing is role is to assist the individual sick or well to carry out those activities contributing to health or its recovery or peaceful death that he would perform if he had the necessary strength, will or knowledge.

4.

Katharine Y Kolcaban (1992):-

The immediate desirable outcome of nursing care is enhanced comfort. This comfort positively correlates with desirable health seeking behaviors.

Defining Nursing for the Future:As the profession grows and responsibilities change, undoubtedly we will continue to refine the definition of nursing. By being responsive to changes, nursing has become more closely aligned with profession such as law, theology and education.

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EVOLUTION OF NURSING EDUCATION IN THE WORLD

1.

1862

Florence Nightingale established school of nursing at St. Thomas Hospital, London Miss. Melinda Ann Richards become Americas first trained nurse.

2.

1874

3.

1885

Japanese school of nursing at Kyoto by Linda Richards

4. 1909 Minnesota 5. 1914 6. 1917

First Collegiate programme at university of

College of nursing started at London Curriculum committee of national league of nursing Education was formed Revision of curriculum addition of sociology and public health

7. 1927

8. 1934 university. 9. 1938

Ph.D and EdD in nursing started at New York

45 universities all over the world having nursing programmes.

10.1954 11.1980 of

Ph.D in nursing at university of Ittusburgh. Nursing diagnosis evolved as a separate component

nursing practice. 12.1980 onwards Nursing education flourished all over the world.

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EVOLUTION OF NURSING EDUCATION IN INDIA

1. 1871 Madras 2. 1886

School of nursing started in general hospital,

School of nursing in a fullfleged from was started in J.J.Hospital, Bombay

3. 1908 4. 1909 5. 1913 6. 1926 7. 1942 8. 1943 9. 1943 started in

TNAI established. Bombay presidency nursing association was formed. South India Board was organized. First nurses registration act passed in Madras ANM programme started School of Nursing at RAK college, New Delhi. Diploma programme in nursing administration

New Delhi 10.1946 RAK College and CMC, Vellore. 11.1947 12.1949 13.1959 14.1963 INC act was passed INC was Established Msc Nursing started in RAK College Post basic B.Sc programme started in various Institutions. 15.1968 16.1972 17.1985 18.1986 M.Sc nursing at CMC, Vellore Basic degree programme started in Kerala IGNOU established Curriculum change for GNM programme from three
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Four year B.Sc nursing administration started in

and a half years to three years

19.1986 20.1987 21.1988 22.1992 23.1992 24.1994 25.1996 26.2001

M.Phil programme stated in RAK , Delhi M.Sc Nursing Started in Kerala M.Sc Nursing at NIMHANS Ph.D in RAK, Delhi Post basic programme started under IGNOU M.Sc nursing at Mahe, Manipal M. Phil and Ph. D at Mahe, Manipal Ph.D at NIMHANS

TRADITIONAL MODELS OF NURSING CARE DELIVERY SYSTEM;1. CASE METHOD The case method evolved into what we now call private duty nursing. It was the first type of nursing care delivery system. This is the way most nursing students were taught take one patient and care for all of this needs. We still see this model used in critical care areas, labor and delivery etc. Advantages a. b. Patient needs were quickly met Close relationship between the patient and nurse.

Disadvantages a. 2. Cost! RNs are expensive FUNCTIONAL METHOD

This model is also referred to as the task method. Once world War II broke out, the nurses left to care for the soldiers which left the hospitals short staffed. To accommodate this shortage hospital increases their use of ancillary personnel. The key idea was for nurses to be assigned to TASKS, not to patients. For example,

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one nurse would be responsible for all the treatments, another nurse for all the medications and so on. Advantages a. A very efficient way to delivery care b. Could accomplish a lot of tasks in a small amount of time. c. Staff did what only they were capable to do Disadvantages; a. Care of persons became fragmented b. Patients did not have one identifiable nurses. c. The nurse had not accountability. 3. TEAM METHOD

This is the most commonly used model and is still in use today. It was developed in the 1950s . The goal of the team method is for a team to work democratically. In the ideal team, an RN is assigned as a team Leader for a group of patients. The team Leader has a cadre of staff reporting to her and together they work to disseminate the care activities. Team Leader must be both a skilled clinician and an effective group leader. Advantages: a. Each members capabilities are maximized

Disadvantages: a. b. Requires a team spirit and commitment to succeed Care is still fragmented with only 8 or 12 hours accountability.

4.

PRIMARY METHOD:-

Primary nursing was developed in the 1980s by Marie Manthey and the hallmark of this model is that one nurse care for one group of patients with 24 hours
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accountability of planning their care. In other words, a primary nurse (PN) cares for we primary patients every time she works and for as long as the patient remains on her unit. An associate nurse cares for the patient in the primary nurses absence and follows the PNs individualized plan of care. Advantages: a. b. Increased satisfaction for patients and nurse. RNs are seen as more knowledgeable and responsible.

Disadvantages :a. Intimidating for new graduates who are less skilled and knowledgeable.

ROLE OF CODE OF ETHICS IN NURISNG CARE DELIVERY SYSTEM: According to the code of Ethics for nursing, Primary Nursing Valves involve task like:1. 2. 3. 4. 5. 6. 7. Providing competent, compassionate, safe and right care to all the patients. Promoting and respecting informed decision making of every patient. Promoting health and well being of all the patients Preserving dignity Promoting Justice Maintaining confidentiality and privacy Being accountable for their actions.

ROLE OF INC FOR IMPROVING NURSING CARE DELIVERY SYSTEM: 1. To establish and monitor a uniform standard of nursing education for nurses

midwife, A Nurse midwives by doing inspection of the institutions. 2. To recognize the qualifications enders section 10 (2) (4) of the Indian

Nursing Council Act, 1947 for the purpose of registration and employment in India and abroad.

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3.

To give approval for registration of Indian and foreign nurses possessing

foreign qualification under section 11 (2) a of the Indian Nursing council Act, 1947. 4. 5. To prescribe the syllabus and regulations for Nursing programs. Power to withdraw the recognition of qualification in case the institution

fails to maintain its standards. 6. To advise the state Nursing Council, Examining Boards, State Governments

and Central Government in various important items regarding nursing education and service in the country. ROLE OF KNC IN NURSING CARE DELIVERY SYSTEM 1. Regulation of training programme of the diploma, Graduate and Post

Graduate courses . 2. 3. 4. Supervision of the practice of the profession by its members. Granting recognition to the training institutions and periodical inspection. Prescribing syllabus and curriculum for various nursing courses and

conducting qualifying examinations. 5. Registration and granting certificate to qualified persons to practice their

profession.

ADCANCED PRACTICE ROLE OF NURSES:1. Nurses Practitioners (NP):-

NP is an advanced practice Nurse (APN) who had masters or a Doctoral degree. Practitioners hold national certification is an area of specialty (Obstetrics , Gynecology, Pediatrics, adult care acute care etc.) Nurses Practitioners Job:a. Diagnosing, treating, evaluating and managing acute and chronic illness. b. Obtaining medical histories and conducting physical examination. c. Ordering , performing and interpreting diagnostic studies.
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d. Prescribing drugs for acute and chronic illness. e. Providing prenatal care and family planning services f. Providing well-child care, including screening and immunizations g. Providing care for patients in acute ant critical care settings. h. Performing or assisting in minor surgeries and procedures. i. Counseling and e patients on health behaviors, self care skills, and treatment options.

2.

Nurse Anesthetist:-

Certified registered nurse Anesthetist (CRNA) , is a licensed professional nurse who provide the same anesthesia services as an anesthesiologist.

Education: Nurse Anesthetists must first complete a bachelors degree in nursing Must be licensed registered nurse Minimum of one year of full time nursing experience in acute care settings Applicants apply program of anesthesia education and study for 24 to 36

months.

3.

Clinical Nurse Specialist: (CNS):-

CNS is an advanced practice nurse, with masters or doctorate from a program that prepares CNSs. CNSs are clinical experts in the diagnosis and treatment of illness and delivery of evidence based nursing interventions. The primary goal of the CNS is continuous improvement of patient outcomes and nursing care.

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According to Sparacinio (2005) the role of CNS are:-

1.

Direct Clinical Practice Includes expertise in advanced assessment

implementing nursing care and evaluating outcomes.

2.

Expert Coaching and Guidance encompasses modeling clinical expertise

while helping nurses integrate new evidence into practice. It also means providing education or teaching skills to patients and family. 3. 4. Collaboration focuses on multidisciplinary team building Consultation Involves reviewing alternative approaches and Implementing

planned change. 5. Research involves interpreting and nursing research evaluating practice and

collaborating in research 6. Clinical and professional leadership involves responsibility for innovation Ethical decision making involves influence in negotiating moral dilemmas

and change in patient care system. 7.

allocating resources, directing patient care and access to care.

4.

Certified Nurse Midwife (CNM):CNM is an Advanced practice Nurse who has specified education and training

in birth Nursing and Midwifery. CNM possess Master of Science in Nursing. They are able to prescribe some medications, treatments , medical devices, therapeutic and diagnostic.

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ROLE OF CNM Provide medical care o women from puberty through menopause Care of the newborn Ante partum , intra partum, Post partum and non surgical gynecological care. CNM also provide care to the male partner in areas of STD of their female

patients

5.

Nurse Care Manager:-

Nurses in this field coordinate care for patients receiving long term therapy in all aspects of treatment. For cancer patients, for example, they coordinate primary care visits. Surgery, radiation and chemotherapy Nurse care Manager usually specializes in on specific area such as AIDS, geriatrics , children etc.

CONCLUSION
However, after all our discussion, we return to our initial questions and restate that there are no clear cut answers for many of the other concerns. The definition of nursing is continuing to evolve. The differences over the use of the words p[profession and professional continue to exist. Nurses for many years have been continuing to deliver health care in the best way they are able without waiting for definitive answers to question about nursing itself. Perhaps part of the strength of nursing is that whatever our personal philosophical concerns. We continue to see the patient, or client, as the appropriate focus for our major efforts.

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BIBLIOGRAPHY
1. 161 2. 3. 4. TNAI (2001) History and Trends in Nursing in India page 22 59 B. Sankaranarayan (2003) learning and Teaching Nursing Page 1-2 Julia . M. Leahy, Palriica E kizikyFountations of Nursing practice , Burnner and Suddarths Text book of medical surgical Nursing Lippinvott Janice Rides Ellis (2008) Nursing in Todays World IX edn page 125-

Samudras, (1998); page 3-6. 5. Wiiliams and Walkins , 10th Edn ; (2003) page 5-8. 6. 7. 8. 9. 10. NJI, Sep 2000, Vol. L xxxxi, no.9, page 198-199 The Hindu @ vsnl.com www.INC.org www.KNC.org http://en.wikipedia.org/wiki/nursingeducation

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