Nursing MSc Solved Question Papers for 2nd Year (2009-2014) Elakkuvana Bhaskara Raj D
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Based on Rajiv Gandhi University of Health Sciences1

Nursing Management
Paper 2014 May
  1. Discuss the philosophy, principles and scope of administration.
    1. Define nursing audit.
    2. Describe the steps of auditing procedure.
  2. As a principal plan and organize staffing pattern for college of nursing.
    1. Define Law. Discuss briefly legal issues related to negligence and malpractice in nursing.
    2. Explain the role of regulatory bodies in licensure and accreditation.
  1. Step in decision-making.
  2. ABC analysis in material management.
  3. Quality assurance in nursing services.
  4. Organizing nursing services and patient care.
  1. Discuss the philosophy, principles and scope of administration.
Administration is the organization and direction of human and material resources to achieve of desired ends.
Pfiffner and Pres Thus
Administration is the direction, co-ordination and control of many person to achieve some purposes or objectives.
White LD
Administration has to do with getting things done. With the accomplishment of defined objectives.
Luther Gullick
Cost Effectiveness
In management or administration of any enterprises for organization, the quality, quantity, timing and cost of the necessary to reach the objective of the enterprises are interrelated factor, which must be given constant attention. If the recourses of health work, in trained persons and in financiers were unlimited, the need for constant attention to these factors would be not great.
Execution and Control of Work Plan
One of the greatest possible contributors to wastage of our precious recourses, whether at the local or national level, is the failure of the those at any level of administration and at 2all stages in the management of the activity, to base all decision on verifiable facts. There should be no tolerating errors in administration action, which occur, because someone failed to get all these facts in the evolution, execution and control of work plans, obtaining the factual evidence should always be the first step.
Delegation of Responsibility and Authority
The delegation of responsibility and authority is an important aspect of successful administration, to place the responsibility for decision at the lowest possible organizational level in order to attain decision as speedily as possible. No administration can do in detail all the work he/she is administrating for; by definition of an administration managers the work of others. Therefore, with principles of delegation of responsibilities should be followed to the utmost extent, consistent with efficiency and coordination of policy. the responsibility and authority placed in each position must correspond to the responsibility, which the position carries.
Human Relation and Good Morale
Since, the function of administration is to attain an established objective through the management of people, administration if deeply concerned with human relation. How the individual worker in any enterprise, including health work, feel about a situation. One of the fact of the situation, which administrator must take in to account assessing the total situation. Good morale of the staff is essential to the success of any undertaking and that morale is affected by both financial and non-financial factors contributing to good morale is a personal satisfaction in working that a job is well done and the satisfaction of being associated with an institutions of which one can be proud of.
Effective Communications
Effective communications are essential for all aspect of effective administration. Staff must be adequately and correctly informed about plan, methods, schedules, problems events and progress. It is necessary that instructions, knowledge and information be passed on for practical application to all concerned and that they be so clearly presented as to rule any misinterpretation or misunderstanding. Proper and adequate communication is not just one direction, it requires two way passages. Administration must be certain that they know and understand the problem of workers for whom they are responsible. Communications must flow from the bottom upwards, as well as from top to down.
Administrators must be completely flexible to meet the changing needs of the situation.
Meaning of management principles:
  1. Management principles are statements of fundamental truth, which acts as guidelines for taking managerial action.
  2. Management principles are derived and developed in the following two steps:
    • 3Deep observations
    • Repeated experiments.
  3. Management principles serve as guidelines for the managers to manage with different situations. It helps in understanding of nature of management.
  4. Management principles aimed at influencing human behavior.
  5. Management principles improve the manager's efficiency who will work for social objectives.
  6. Management principles provide new ideas, imagination and visions to the managers and the organization.
  7. Guide to research.
Fayol's 14 Principles of Management
  1. Division of work: Specialization allows the individual to build up experience, and to continuously improve his/her skills. There by he can be more productive.
  2. Authority: The right to issue commands, along with which must go the balanced responsibility for its function.
  3. Discipline: Employees must obey, but this is two-sided; employees will only obey orders if management play their part by providing good leadership.
  4. Unity of command: Each worker should have only one boss with no other conflicting lines of command.
  5. Unity of direction: People engaged in the same kind of activities must have the same objectives in a single plan. This is essential to ensure unity and coordination in the enterprise. Unity of command does not exist without unity of direction but does not necessarily flows from it.
  6. Subordination of individual interest (to the general interest): Management must see that the goals of the firms are always paramount.
  7. Remuneration: Payment is an important motivator although by analyzing a number of possibilities, Fayol points out that there is no such thing as a perfect system.
  8. Centralization (or decentralization): This is a matter of degree depending on the condition of the business and the quality of its personnel.
  9. Scalar chain (line of authority): A hierarchy is necessary for unity of direction. But lateral communication is also fundamental, as long as superiors know that such communication is taking place. Scalar chain refers to the number of levels in the hierarchy from the ultimate authority to the lowest level in the organization. It should not be over-stretched and consist of too-many levels.
  10. Order: Both material order and social order are necessary. The former minimizes lost time and useless handling of materials. The latter is achieved through organization and selection.
  11. Equity: In running a business a ‘combination of kindliness and justice’ is needed. Treating employees well is important to achieve equity.
  12. Stability of tenure of personnel. Employees work better if job security and career progress are assured to them. An insecure tenure and a high rate of employee turnover will affect the organization adversely.
  13. Initiative: Allowing all personnel to show their initiative in some way is a source of strength for the organization. Even though it may well involve a sacrifice of ‘personal vanity’ on the part of many managers.
  14. 4Esprit de corps: Management must foster the morale of its employees. He further suggests that “real talent is needed to coordinate effort, encourage keenness, use each person's abilities and reward each one's merit without arouzing possible jealousies and disturbing harmonious relations.”
  1. Political: A function of the administration includes the executive—legislative relationship.
  2. Defensive: It covers the hospital protective functions.
  3. Economic: Concerns with the waste area of the health care activities.
  4. Foreign.
  5. Educational: It involves educational administration in its broadest senses.
  6. Legislative: It includes most not mealy delegated legislation, but the preparatory work done by the administrative officials.
  7. Financial: It includes the whole of financial, budget and inventory control managements.
  8. Social: It includes the activities of the departments concerned with food and social factors.
  9. Local: It concerned with the activities of the local bodies.
Issues In Nursing Administration
Profession of nursing
The issue related to nursing are:
  • Status of nursing in society in the healthcare delivery system
  • Values reflected in our nursing performances
  • Attitude, human approach
  • Quality in nursing vis-a-vis education and practice
  • Unique function of nursing
  • Different levels of nurses that we need in our country
  • Define and delineation of nursing functions at the different level.
Nursing education
  • Taken in to consideration the national health policy goals and programs
  • Shifted its emphasis from traditional to community health-oriented approach and re-oriented nursing circular accordingly
  • Be making sincere efforts to prepare nurses for the job they are accepted to perform in their work field in terms of appropriate skills, knowledge and right attitude and the desired behavior patterns reflecting the values for caring and at the level of
  • Been preparing nurses keeping in the status and countries health needs in minds
  • Made studies on our west countries nursing training needs and training load
  • Worked out continuing education plans accordingly
  • Been implementing the same in the realistic manner and giving the due to emphasis on nursing research.
Nursing practice
  • In the community setting
  • In the institutional setting at the level of primary, secondary and tertiary levels of care
  • 5Are nurses as matter of policy conceited in all matters related decisions area for nursing practice?
  • Can it be said that, nursing service rendered reflect quality of nursing care, do there have the necessary back up support from the system for performing the way they are required to perform
  • Are the nurses aware of the shift of emphasis on the primary healthcare approach
  • Is there an going evaluation program for the nurses available.
Nurse themselves
  • Long hours of duties with very little time for recreation
  • Nonavailability of healthcare program of nurses
  • Pressure from influence people
  • Noninvolvement of nurses in nursing matters
  • Poor pay structures
  • Lack of security and safety
  • Nonavailability of basic communities like toilet facility, in residential accommodation of community nurses
  • Death of effective performance appraisal systems; nonavailability of transport of community nursing services.
Nursing in Different Prospectives
Traditional Nurse Role
The traditional roles of nursing revolve round sick individual, who are hospitalized. Here the nurses work by large in the shadow of the physician and very few independent decision making area left to them.
Community Nurse Role
  • Health maintenance and promotion
  • Specific protection
  • Disease prevention
  • Rehabilitation
  • Treatment of minor ailments
  • Referral appropriate contumely
  • Community mobilization
  • MCH and family welfare services covering
  • Child survival and safe motherhood program
  • School health services.
Expanded Nurse Role
  1. Performs not only the basic nursing care activities.
  2. To have sound knowledge of operating the equipment to adopt appropriate emergency measures.
  3. To the patterns and coordinators giving patients care services in the hospitals.
  4. To act managers, teachers and supervisors, while rendering patient care services.
Role of Nurse Administration
  • Provide visibility for organization goal
  • Provide resources and define constraints
  • Mediate conflict
  • Serve as a coach
  • Monitor result.
    1. Define nursing audit.
    2. Describe the steps of auditing procedure.
    1. Define nursing audit.
  1. According to Elision: “Nursing audit refers to assessment of the quality of clinical nursing.”
  2. According to Goster Welfare:
    • Nursing audit is an exercise to find out whether good nursing practices are followed
    • The audit is a means by which nurses themselves can define standards from their point of view and describe the actual practice of nursing
    • A nursing audit is a method of evaluating care that evolve reviewing patient records to assess the outcomes were achieved.
  3. Nursing audit is defined as:
    • Nursing audit is the part of the cycle of quality assurance; it incorporates the systematic and critical analysis by nurses, midwives and health visitors, in conjunction with other staff, of the planning, delivery and evaluation of nursing and midwifery care, in terms of their use of resources and the outcomes for patients/clients, and introduces appropriate change in response to that analysis (NHS ME, 1991 Framework for Audit for Nursing Services).
  1. Describe the steps of auditing procedure.
Procedure for Nursing Audit
  1. Formulation of nursing audit committee consisting of chairman (e.g. senior nurse) and 3–4 members (supervisors/head nurse).
  2. Committee should meet once a month to audit records of patients discharge during that time.
  3. Chairman should assign the number of charts each members will audit. Steps out lined for evaluation/auditing care:
    • Visit the unit to complete the evaluation form
    • Compile the score for each patients
    • Meet the committee to discuss the findings.
  4. Members should be very honest and impartial in their judgment. A confidential note should be sent to the individual if something very outstanding has been recorded.
  5. 7Review of audit is done by the members of the committee, compiled and submitted to the authorities with recommendations for future action.
Steps of Development of Nursing Audit Tool
Nursing audit tool as an instrumental is designed to measure the quality of care received by a patient during a particular cycle of care. The audit is useful in evaluating the quality of the care provided in any program and setting in which a record is an integral part of providing comprehensive and continuing nursing care. The steps given below may be followed in the development of nursing audit tool:
  1. Review with the nursing staff the steps in evolution to provide some common base for understanding.
  2. Develop a list of criteria statements for high quality care and ensure concerns on the final criteria used for evolution.
  3. The criteria finally derived are grouped in broad area and stated as questions which could be answered ‘Yes’ or ‘No’ (a criteria either met or not met). Example for broad group may include:
    • Standard physical needs
    • Safety
    • Medication and treatment
    • Emotional needs
    • Spiritual needs
    • Teaching
    • Posthospital care
    • Environmental
    • Recording.
Identify Problem or Issue
  1. Select a topic that is important or significant.
  2. This may come from personal experience.
  3. A problem may be identified from every day practice or a feeling that something could or should have been done better.
Problems can be identified in three basic areas of practice work.
Structure-what you need: This refers to the resources required, for example, the number of staff and the skills they require, space and equipment.
Process-what you do: This refers to actions and decisions taken by practitioners, such as communication, assessment, education, investigations, prescribing, interventions, evaluation and documentation.
Outcome-what you expect: This refers to the outcome of interventions such as health levels, patient knowledge or satisfaction.
zoom view
Figure 1: Nursing audit cycle
Problem Priorities
  1. 8Is the topic concerned of high cost, volume or risk to staff or users.
  2. Is there evidence of a serious quality problem, e.g. patient complaint or high complication risk.
  3. Is good evidence available to inform standards, e.g. systematic review or national clinical guidance.
Set Criteria and Standards
  1. A criterion is an item of care or an aspect of practice that can be used to assess quality.
  2. This is where you can say what should be happening.
  3. The criterion is written as a statement defining what you want to measure.
  4. Criteria are the way you should be doing things in an ideal world.
  5. To make the criteria (statement) useful the standard needs to be defined.
Standards—setting Targets
For each criterion you will need to set targets for something you should always do (100%) and/or something that should never happen (0%).
Remember to be valid follow:
  1. S: Specific, standards should relate to a specific area of care and should give specific boundaries. They should be unambiguous.
  2. M: Measurable, If standards are vague and woolly how can you compare your practice against them. You need to be able to physically measure aspects of the standard to allow comparison.
  3. A: Achievable, there is no point writing standards that are not achievable either due to resource or clinical limitations.
  4. R: Research based, peer reviewed research evidence will have shown the best available treatment/method for your topic area.
  5. T: Timely, standards should reflect current practice not what you thought you did two years ago.
Who should write criteria and standards?
Recent government publications state that health professionals will be expected to develop standards that measure a wide range of features of quality in healthcare.
What if no standards are available?
You will need to develop and write your own in conjunction with the clinical team.
Who needs to be involved?
You can write standards alone, but if you are going to use them to measure practice other than your own, you must involve the relevant people.
Collecting Data on Performance
Identify what data needs to be collected, how and in what form it needs to be collected, and who is going to collect it. Remember only collect information that is absolutely essential.
Assess Performance Against Criteria and Standards
With the information collected analysis is possible, and identification of any area of care below the predetermined standard of the criteria can be made. The results can then be used to develop an action plan, i.e. what needs to be done, how it needs to be done, who is going to do it and when is it going to be done?
Identify Need for Change/Implementing Change
The audit cycle is now almost complete, but without re-evaluating the care the practice is giving it is impossible to see if recommendations have been implemented and the level of care improved.
Audit as a Tool for Quality Control
An audit is a systematic and official examination of a record, process or account to evaluate performance. Auditing in health care organization provide managers with a means of applying control process to determine the quality of service rendered. Nursing audit is the process of analyzing data about the nursing process of patient outcomes to evaluate the effectiveness of nursing interventions. The audits most frequently used in quality control include outcome, process and structure audits.
Outcome Audit
Outcomes are the end results of care; the changes in the patients health status and can be attributed to delivery of health care services. Outcome audits determine what results if any occurred as result of specific nursing intervention for clients. These audits assume the outcome accurately and demonstrate the quality of care that was provided. Examples of outcomes traditionally used to measure quality of hospital care include mortality, its morbidity, and length of hospital stay.
Process Audit
Process audits are used to measure the process of care or how the care was carried out. Process audit is task oriented and focuses on whether or not practice standards are being fulfilled. These audits assumed that a relationship exists between the quality of the nurse and quality of care provided.
Structure Audit
Structure audit monitors the structure or setting in which patient care occurs, such as the finances, nursing service, medical records and environment. This audit assumes that a relationship exists between quality care and appropriate structure. These above audits can occur retrospectively, concurrently and prospectively.
Advantages of nursing audit
  1. Can be used as a method of measurement in all areas of nursing.
  2. Seven functions are easily understood.
  3. 10Scoring system is fairly simple.
  4. Results easily understood.
  5. Assesses the work of all those involved in recording care.
  6. May be a useful tool as part of a quality assurance program in areas where accurate records of care are kept.
Disadvantages of the nursing audit
  1. Appraises the outcomes of the nursing process, so it is not so useful in areas where the nursing process has not been implemented.
  2. Many of the components overlap making analysis difficult.
  3. Is time consuming.
  4. Requires a team of trained auditors.
  5. Deals with a large amount of information.
  6. Only evaluates record keeping. It only serves to improve documentation, not nursing care.
  1. As a principal plan and organize staffing pattern for college of nursing.
Staffing Pattern
Staffing in Educational Setting
Staffing of colleges of nursing at university level and schools of nursing at hospital level with handful of nurse teachers for clinical and public health nursing practice much is to be desired. Due to lack of trained nurse teachers majority of the classes are taken by the doctors or other nonteachers, who cannot relate their subject to the practice. Every subject taught in nursing must be taught by nurses only to that extent, which can be translated into practice. As per Indian Nursing Council (INC) staffing norms to the nursing institution.
BSc (N) and MSc (N)
  1. Annual intake of 60 students in BSc (N) and 25 students for MSc(N) program:
    Professor-cum-Vice Principal
    Reader/Associate Professor
    Tutor/Clinical Instructor
  2. One in each specialty and the entire MSc (N) qualified teaching faculty will participate in all collegiate programs.
  3. Teacher/Student Ratio = 1:10 for MSc (N) Program.
  4. Other staff (minimum requirements).
To be reviewed and revised and rationalized keeping in mind the mechanization and contract service.
Administrative Officer
Office Superintendent
PA to Principal
  • Upper Division Clerk
  • Lower Division Clerk
  • Store Keeper
  • Maintenance of stores
  • Classroom attendants
  • Sanitary staff
As per the physical space
Security staff
As per the requirement
  • Peons/Office attendants
  • Librarian
  • Library attendants
As per the requirement
  • Wardens
  • Cooks, bearers
As per the requirement sanitary staff
  • Ayas/Peons
As per the requirement
  • Security staff
As per the requirement
  • Gardeners and Dhobi
Depends on structural facilities (desirable)
Basic BSc Nursing
Teaching Faculty
Admission capacity:
  • Annual Intake
  • Professor-cum-Principal
  • Professor-cum-Vice Principal
  • Reader/Associate Professor
  • Lecturer
  • Tutor/Clinical Instructor
  • Total = Teacher/Student Ratio = 1:10
Staffing in Hospital Setting
Most of the hospitals have the chief nurse, but not in an executive position. He/She acts more like a middle level manager and he/she may be assisted by one, two or eight assistants to look after a hospitals. The existing norm stipulated by INC with regard to nursing staff for wards and special units (excluding outpatient department).12
Table 1   Staffing in hospital setting
Hospital setting
Staff nurse
Staff (each shift)
Department sister/Assistant Nursing Superintendent
Medical ward
1 for 3–4 week
Surgical ward
1 for 3–4 week
Orthopedic ward
1 for 3–4 week
Pediatric ward
1 for 3–4 week
1 for 3–4 week
Maternity ward
1 for 3–4 week
Intensive care unit
1:1 (24 hour)
Coronary care unit
1:1 (24 hour)
1:1 (24 hour)
1 department sister/Assistant Nursing, Superintendent for 3–4 units clubbed together
Special wards –eye, ear, nose and throat (ENT), etc.
1:1 (24 hour)
Operation theater
3 for 24 hour per table
1 departmental sister/Assistant Nursing Superintendent for 4–5 operating rooms
Causality and emergency unit
2–3 staff nurses depending on the number of beds
1 departmental sister/ assistant nursing, superintendent for emergency, causality, etc.
    1. Define Law. Discuss briefly legal issues related to negligence and malpractice in nursing.
    2. Explain the role of regulatory bodies in licensure and accreditation.
    1. Define Law. Discuss briefly legal issues related to negligence and malpractice in nursing.
Definition of Law
  1. The law is a system of rights and obligations which the state enforces.
  2. The law is the body of principles recognized and applies by the state and the administration of justice.
Legal Issues Related to Negligence and Malpractice in Nursing
Legal Issues in Nursing
Some legal issues recur frequently in nursing practice. It is wise for the nurse to try to understand these particular issues as they relate to individual practice.
Personal Liability
As an educated professional, nurses are always legally responsible or liable for their action. Thus, if a physician or supervisor asks you to do something that is contrary to your best professional judgement and says, ‘I’ll take responsibility that person is acting unwisely. The physician and supervisor giving the directions may be liable if harm results, but that would not remove your liability. Although each person is legally responsible for his or her own actions, there are also situations in which a person or organization may be held liable for actions taken by others.
Employer Liability
The most common situation in which a person or organization is held responsible for the actions of another is in the employer-employee relationship. In many instances, an employer can be held responsible for torts committed by an employee. This is called the doctrine of respondent superior(let the master respond). The law holds the employer responsible for hiring qualified personnel, for establishing an appropriate environment for correct functioning and for providing supervision or direction as needed to avoid errors or harm. Therefore if a nurse, as an employee of a hospital, is guilty of malpractice, the hospital may be named in the suit. The employers liability may exist even if the employer appears to have taken precautions to prevent error. It is important to understand that this doctrine does not remove any responsibility from the individual nurse, but it extends responsibility to the employer in addition to the nurse.
Informed Consent
Every person has the right to either consent to or refuse medical treatment. The law requires that a person give voluntary and informed consent to treatment. This consent may be either verbal or written. Written consent usually is preferred in health care to ensure that a record of consent exists. The form should state the specific proposed medical procedure or test.
A nurse may present a form for a patient to sign and the nurse may sign the form as a witness to the signature. This does not transfer the legal responsibility for informed consent for medical care to the nurse. If the patient does not seem well informed, the nurse should notify the physician so that further information can be provided to the patient. The nurse has ethical obligations to assist the patient in exercising his or her rights and to assist the physician in providing appropriate care.
Consent and Minors
The consent of minor is usually given by a parent or legal guardian. You should also obtain the minor consent when he/she is able to give it. Increasingly, courts are emphasizing that minors be allowed a voice when it concerns matters that they are capable of understanding. This is especially true for adolescent, but this consideration should be given to any child who is seven years of age or older. When the minor refuses care and the legal guardian have authorized that care, you should not proceed until legal clarification is given. Your nursing supervisor should be consulted.
Fraud is deliberate deception for the purpose of personal gain and is usually prosecuted as crime situations of fraud in nursing are not common. One example would be trying to obtain a better position by giving incorrect information to a prospective employer. By deliberately stating (falsly) that you had completed a nurse practitioner program to obtain a position for which you would otherwise be ineligible, you are defrauding the employer.
This may be prosecuted as a crime because you are also placing members of the community in danger of receiving substandard care. You may also commit fraud by trying to cover up a nursing error to avoid legal action. Courts tend to be more harsh in decision regarding fraud represents a deliberate attempt to mislead others for your own gain and could result in harm to those assigned to your care.
Medication Errors
Some errors results from drugs with similar names, look alike medication containers, poor systems for communication in which hand writing problems may contribute to lack of clarity. When medications errors do occur, fraud or intentional concealment may be charged and may contribute to the awarding of punitive damages as well as ordinary damages.
Torts are civil wrongs committed by one person against another. The wrong may be physical harm, psychological harm or harm to reputation, livelihood or some other less tangible value.
Classification of Torts
  • Intentional torts
  • Quasi-intentional torts
  • Unintentional torts.
Intentional torts
Assault is any intentional threat to bring about harmful or offensive contact. No actual contact is necessary. The law protects clients who afraid of harmful contact. It is an assault for a nurse to threaten to give a client for an X-ray procedure when the client has refused consent. The key issue is the client consent. In an assault lawsuit, if the clients gives consent, the nurse is not responsible.
Battery is unconsented or unlawful touching of a person. For battery to occur, the touching must occur without consent. Remember that consent may be implied rather than specifically stated. Therefore, if the patient extends an arm for injection, he/she cannot later charge battery, saying that he/she was not asked. But if the patient agreed because of a thread (assault), the touching would still be considered battery because the consent was not freely given.
False imprisonment
The tort of false imprisonment occurs with unjustified restraining of a person without legal warrant. For example, this occurs when nurses restrain a client in a bounded area to keep 15the person from freedom but when it occurs in health care it is most often the basis of a civil suit rather than a criminal case. Any time a patient needs to be confined for his or her own safety or well being, it is best to help the understand and agree to that course of action. If the patient is not responsible, the guardian or legal representative may give permission. The third alternative is to objectively document the need in the patients record and obtain a physicians order as soon as possible. Be sure to follow the policies of the facility. All persons who have the right to make decisions for themselves, regardless of consequences you protect yourself by recording your efforts to teach the patient the need for restrictions and by reporting the patients behavior to your supervisor and the physician.
Quasi-intentional torts
Invasion of privacy: Invasion of privacy is the intrusion into the personal life of another, without just cause, which can give the person whose privacy has been invaded a right to bring a lawsuit for damages against the person or entity that intruded. However, public personages are not protected in most situations, since they have placed themselves already within the public eye, and their activities (even personal and sometimes intimate) are considered newsworthy, i.e. of legitimate public interest. However, an otherwise non-public individual has a right to privacy.
Defamation of character: Defamation is a false statement that can cause harm to a person's reputation and make him/her vulnerable to public contempt, derision, hatred or censure.
Defamation communication that is false or made with a careless disregard for the truth and results in injury to the reputation of a person.
Unintentional torts
Definition: Negligence refers to the act of doing something or refraining from doing something that any other reasonable medical professional would do or refrain from doing in a similar situation. It goes without saying that every situation is different, and that is where the law becomes somewhat cloudy. However, when reviewing a nursing negligence case, assumptions and circumstantial evidence are taken into account to determine if there was negligence.
The basic and legal definition of negligence means breach of duty or injury. Standards of care in nursing generally mean those practices that “a reasonably prudent nurses would use.” So a good nurse knows and understands ethics in the medical field and strives to provide excellent quality of care in order to avoid negligence. However, mistakes, which will happen, do not necessarily mean negligence has occurred.
Breach of duty: Examples of breach of duty, which may be considered negligent under certain circumstances may include “doing something which a reasonably prudent person would not do, or the failure to do something which a reasonably prudent person would do, under circumstances similar to those shown by the evidence. It is the failure to use ordinary or reasonable care,” according to critical care nurse, a journal for high acuity, progressive and critical care.
Injury: For an injury to be considered caused by negligence, records must show that the nurse failed to perform his/her duties with the patient in question. In such cases, the failure of duty must then be proven as directly related to the injury of the patient. For example, if a nurse fails to give medications as directed then the patient's condition worsens or he dies, the nurse may be found negligent.
16Performance failures
Inadequate nursing skills or attention to tasks may result in a suit of negligence against a nurse who chronically fails to provide approved standards of care. Such incidents include, but are not limited to, habitual medication errors, failure to follow protocol or orders and improper use of equipment.
Examples of Nursing Negligence
Common examples of nursing negligence include malnutrition, inadequate hydration, physical abuse, medication errors, and mental and emotional abuse. In nursing homes or other places of long-term care, there are also often injuries due to bedsores, infections and falls. Malnutrition and dehydration cases come from leaving a patient unattended for too long, ignoring his needs, or simply refusing to feed and provide water. Abuse comes in a variety of forms and, in many cases, nurses do not feel they will be reported, especially if the patient is mentally handicapped. Medication errors, bedsores, infections and falls are most frequently the result of carelessness and lack of paying attention to their patients as necessary.
The legal review of a nursing negligence case requires proof that injury was done, and that it was the result of the nurse's care or lack thereof. There are five main elements in a nursing negligence case, and all elements must be proven in order for a case to be valid. If one or more of the elements is not present, the case may be difficult to pursue:
  1. The nurse had a duty to perform.
  2. The appropriate care was apparent in the situation.
  3. There was a breach or violation of care.
  4. There was an injury proven to result from the nurse's negligence.
  5. There is proof that damages occurred as a direct result of the situation.
Avoiding Negligence
It is important for nurses to document their actions very closely and accurately at the time because sometimes negligence cases come about later when details are difficult to remember. Charting everything makes it easy to determine the details surrounding each action or inaction and to find a logical reason as to why it was done. This, in combination with a nurse who follows the proper scope of practice, will likely keep a nurse from being prosecuted for nursing negligence.
Malpractice is defined as improper or negligent practice by a lawyer, physician, or other professional who injures a client or patient. The fields in which a judgment of malpractice can be made are those that require training and skills beyond the level of most people's abilities. Medical malpractice is defined as a wrongful act by a physician, nurse, or other medical professional in the administration of treatment— or at times, the omission of medical treatment, to a patient under his or her care. Although dentists, architects, 17accountants, and engineers are also liable to malpractice suits, most lawsuits of this type in the United States involve medical malpractice.
Medical malpractice is professional negligence by act or omission by a healthcare provider in which care provided deviates from accepted standards of practice in the medical community and causes injury or death to the patient. Standards and regulations for medical malpractice vary by country and jurisdiction within countries. Medical professionals are required to maintain professional liability insurance to offset the risk and costs of lawsuits based on medical malpractice.
Why Nursing Malpractice is Increasing?
Nursing is a profession that's critical to the administration of health care, and it's a profession that's in high demand. But there are not enough qualified nurses (for instance, registered nurses and licensed practical nurses) to keep up with this demand, and the result is chronic understaffing and a population of overworked nurses. While nursing shortages are not a direct cause of nursing malpractice, it does cause a couple of serious issues:
  1. Nurses who work excessively long shifts may suffer from fatigue, making them more prone to commit an error. In fact, a 2004 report showed that nurses who worked a shift longer than 12.5 hours were three times more likely to make a mistake.
  2. Hospitals and other healthcare facilities may hire inadequately trained nurses or unlicensed nurse aides to fill a need. The less training a nurse has, the greater the risk of a medical error.
In addition, miscommunication and carelessness are not uncommon in the healthcare setting and may directly cause a potentially life-threatening complication or mistake.
Types of Nursing Malpractice
Nursing malpractice takes many forms, including:
  1. Medication errors giving a patient the wrong medication or the wrong dose, or dispensing medication to the wrong patient.
  2. Failure to follow a physician's orders.
  3. Delaying patient care and/or failure to monitor a patient.
  4. Incorrectly performing a procedure, or trying to perform a procedure without training.
  5. Documentation error.
  6. Failure to get informed patient consent.
Consequences of Nursing Malpractice
The consequences of nursing malpractice can range from minor to potentially fatal and may include:
  • Medication overdose
  • Adverse drug reaction
  • Coma
  • Brain, heart, kidney or other organ damage
  • Infection
  • Death.
How Can Malpractice Actions Be Avoided?
The simple answer is that they cannot be avoided. However, by utilizing the nursing process and employing critical thinking, bad outcomes that commonly lead to malpractice claims can be reduced.
The steps of the nursing process are described as follows:
  • Assessment
  • Problem/Need identification
  • Planning
  • Implementation
  • Evaluation.
By ensuring that each step is taken and that reflection is given by using critical thinking, the likelihood of an avoidable adverse medical event occurring is less likely. In medication administration, the 5 ‘R's are often cited—right patient, right drug, right route, right dose, and right time. All too often 1 or more of these ‘rights’ are violated and a patient is injured. As with any order, guideline, directive, or principle within the nursing process, following these steps is only the beginning. To ensure that the clinical circumstances warrant implementation of the order, critical thinking is essential when administering any drug. Legal responsibilities of nurse:
  • Responsibility of appointing and assigning
  • Responsibility in quality control
  • Responsibility for equipment
  • Responsibility for observation and reporting
  • Responsibility to protect public
  • Responsibility for record keeping and reporting
  • Responsibility for death and dying.
b. Explain the role of regulatory bodies in licensure and accreditation.
Health professionals such as nurse's doctors, Pharmacist and many others are regulated and licensed by regulatory bodies as required by provincial legislation. All nurses are required to be licensed to practice with their designated provincial nursing regulatory body. Legal responsibility in nursing practice is becoming of greater importance as each year passes. In order to provide safe and competent nursing care an understanding of legal boundaries is very essential. It is important to know the law in one state and the authorities enforcing these laws.
Vital Role of Regulatory Bodies
  • To ensure the public's light to quality healthcare service
  • To support and assist professional members
  • Set and enforce standards of nursing practice
  • Monitor and enforce standards for nursing education
  • Set the requirements for Monitor and enforce standards of nursing practice
  • Set the requirements for registration of nursing professionals
  • Nursing regulatory bodies also known as colleges or associations, are responsible for the licensing of nurses with in their respective provinces territory
  • The Nursing Regulatory bodies receive their authority from legislation.
Major Types of Regulatory Bodies
  • Trained nurses association of India
  • Institutional rules
  • The state government
  • Canadian nurses association
  • American nurses association
  • International council for nurses
  • National league for nursing.
Indian Nursing Council Act
The Indian Nursing Council, which was authorized by the Indian Nursing Council Act of 1947, was established in 1949 for the purpose providing uniform standards in nursing education and reciprocity in nursing registration throughout the country. The only national legislation directly related to nursing practice, also provides a basis from which rules for nursing practice can be developed. Among other responsibilities, this Act gives authority to the Indian Nursing Council for prescribing curricula for nursing education and recognizing qualifications of institutions with teaching programs for nursing. This means that the INC has authority to control nursing education and what the nurse is prepared to do. It is important because legal responsibility does finally depend upon what you should be able to do and how you should do it as well as what you are not prepared to do. The INC uses this authority in nursing education, but it delegates authority for control of nursing practice to the State Nurses' Registration Councils.
Indian Nursing Council
The Indian Nursing Council was authorized by the Indian Nursing Act of 1947. It was established in 1949 to providing uniform standards in nursing education and reciprocity in nursing registration throughout the country. Nurses registered in one state were not necessarily recognized for registration in another state before this time. The condition of mutual recognition by the state Nurses Registration Councils, which is called reciprocity, was possible only if uniform standards of nursing education were maintained.
Functions of INC
  1. It provides uniform standards of in nursing education and reciprocity in nursing registration.
  2. It has authority to prescribe curriculum for nursing education in all states.
  3. It has authority to recognize program for nursing education or to refuse recognition of a program if it did not meet the standards required by the council.
  4. To provide the registration of foreign nurses and for the maintenance of the Indian Nurses Register.
  5. The INC authorizes State Nurses Registration Council and Examining Board to issue qualifying certificates.
The INC has been given heavy responsibilities for nursing practice and nursing education, but it has not been able to exert enough power to support high standards in nursing.
Trained Nurses Association of India (TNAI)
Trained Nurses Association of India, is a national professional association of nurses. The level of organization moves to the district, state and national levels. Members of TNAI are usually most active on the level of the local unit. Activities and conference however are planned regularly by the state branches and provide opportunities for valuable professional participation and development of the individual member. Functions are:
  1. Up grading development and standardization of nursing education.
  2. Registration for qualified nurses.
  3. Improvement of living and working condition for nurses in India.
  4. It has promoted the development of courses in higher education for nurses.
  5. It gives scholarships for nurses who wish to go on for advanced study.
  6. Helps to develop leadership ability.
  7. Helped to organize the State Nurse and Midwives Registration Council.
  8. Helps to share and solve professional problems.
  9. Helped to improve economic conditions for nurses.
  10. Helped to remove discrimination against male nurses.
  11. The official organ of TNAI is the Nursing journal of conditions for nurses India, which is published monthly.
International Council of Nurse (ICN)
The International council of nurses, founded in 1899 by Mrs. Bedford Fenwick, is a federation of non-political and self- governing national nurses association. The headquarters are in Geneva, Switzerland.
The main purpose of the ICN is to provide a mean through which the national associations can share their interest in the promotion of health and care of the sick. Functions are:
  1. To promote the development of strong national nurses associations.
  2. To assist National Nurses Association to improve the standards of nursing and the competencies of nurses.
  3. To assist National Nurses Associations to improve the status of nurses within their countries.
  4. To serve as the authoritative voice for nurse and nursing internationally.
The ICN is the global voice of nursing. The governing body of the ICN is the council of national representative, which is made up of the ICN honorary officers and the presidents of the national members associations. The ICN code of ethics for nurses has four principles elements.
State Registration Councils
Since the INC works in co-operation and coordination with the State Nursing Councils it is necessary that one must say a few words about the State Nursing councils. There are present eighteen State Nursing Councils—Andhra Pradesh, Assam, Bihar, Gujarat, Haryana, Himachal Pradesh, and Kerala, Karnataka, Maharashtra, Madhya Pradesh, Orissa, Punjab, Rajasthan, Tamil Nadu, Tripura, Uttar Pradesh and West Bengal.
Delhi Nursing Council Bill has been recently passed by the assembly. Manipur registration council is in the process of being constituted. The training of nurses, midwives, 21health visitors and ANMs is to a large extent controlled by Nurses' Registration Councils in the respective states. State nursing council serves as a legal protection to the nurse and protects the public from incompetent nursing practices or poor nursing care. The functions of the councils are to:
  • Inspect and accredit schools of nursing in their state
  • Conduct examinations
  • Prescribe rules of conduct, take disciplinary actions, etc.
  • Maintain register of nurses, midwives, ANMs and health visitors in the state.
The State Registration Councils are autonomous to a great extent except that they do not have powers to prescribe syllabi for the various training courses, recognize examining bodies and to negotiate reciprocity. These powers are vested with the INC and State Councils ensure that the prescribed syllabi are followed and standards are maintained.
Karnataka State Nursing Council
The Karnataka State Nursing Council was constituted in the year 1971 under the authority of Karnataka Nurses, Midwives and Health Visitors Act of 1961. The first council was nominated by Government with different members representing various constituencies under section 3 of the Act, all together consisting of 22 members. The Council is an Autonomous Statutory Registration body for qualified nurses, midwives, ANM's and Health Visitors. Its function include besides others:
  1. Regulation of training program of the diploma, graduate and postgraduate courses.
  2. Supervision of the practice of the profession by its member.
  3. Granting recognition to the training institutions and periodical inspection there on, as the council is governing authority of physical and clinical facilities in almost all the nursing courses conducted in the institution.
  4. Proscribing syllabus and curriculum for various nursing courses and conducting qualifying examination there for.
  5. Registration and granting certificate to qualified persons to practice their profession and to watch and take action against practice of profession by quacks and check malpractice as well and to take action.
The council is as per the Act headed by President and Vice-President of the Council and both are duly elected by the members of the council under section 5 of the Act. The council meets under the chairmanship of, and takes decision on the matters covered by its statutory functions as enumerated above. The expenditure of the council will be met with the fees charged for registration and renewal.
  1. Step in decision-making.
Refer April 2012, Question No. 4.
  1. ABC analysis in material management.
It is concerned with providing the drugs, supplies and equipment needed by the health personnel to deliver health services.
22The right drugs, supplies and equipment must be at right place, at right time and in right quantity in order that health personnel deliver health services. Without proper material, health personnel cannot work effectively, they feel frustrated and the community lacks confidence in the health services and unless appropriate materials are provided in proper time and is required quantity, productivity of personnel will not be up to expectation.
ABC is the analysis of stores items on cost criteria. It has been seen that a large number of items consume only a small percentage of resources and vice versa:
  • A items- Represents high cost center
  • B items- intermediate cost center
  • C items- low cost center
  • It helps in economizing ones effort to achieve greater results
  • It helps to segregating those items which ought to be given priority to maximize results.
ABC analysis tells us that 5–10% of all items(called A category) accounts for 70% of annual consumption costs, another 10–20% of items (B category) account for 20–30% of the costs, while the balance 70% of items (C category) account for about 5–10% of costs.
  1. The usefulness of this management tool is that, by focusing on the ‘A’ category items, 70% results can be achieved with just 5% effort.
  2. Once A category items are identified, it is possible to devote more attention to these items to minimize purchase costs and exercise control over consumption in a more effective manner.
  3. Other strategies in material management:
    • Purchase planning
    • Forecasting
    • Negotiating prices
    • Minimizing inventory carrying costs
    • Minimizing unofficial inventory
    • Restricting usage
    • Controlling wastage
    • Managing closing stock
    • Audit.
These show greatest results when applied with emphasis on ‘A’ category.
A Items
  • Tight controls
  • Rigid estimates
  • Strict and close watch
  • Safety stocks should be low
  • Management of items should be done at top management level.
B Items
  • Moderate controls
  • Purchase based on rigid requirement
  • 23Reasonably strict watch and control
  • Safety stocks moderate
  • Management be done at middle level.
C Items
  • Ordinarily control measures
  • Purchased based on usage estimates
  • Controls exercises by store keeper
  • Safety stocks high
  • Management be done at lower levels.
  1. Quality assurance in nursing services.
April 2012, Question No. 4.
  1. Organizing nursing services and patient care.
Definition of Nursing Services
WHO expert committee on nursing defines the nursing services as the part of the total health organization, which aims to satisfy major objective of the nursing services is to provide prevention of disease and promotion of health.
Nursing service is the part of the total health organization, which aims at satisfying the nursing needs of the patients/community. In nursing services, the nurse works with the members of allied disciples such as dietetics, medical social service, pharmacy, etc. In supplying a comprehensive program of patient care in the hospital.
Functions of Nursing Services
  1. Establishment of object for the department of nursing and organizational structure to achieve the objectives.
  2. Formulation of nursing service policies and procedures, and for keeping them up to date.
  3. Putting in to effect and interpreting the administrative policies established by the governing board.
  4. Maintenance of stable staffing pattern.
  5. Selecting and assigning nursing personnel.
  6. Planning and directing orientation and in-service training programs for professional and non–professional nursing staff.
  7. Constantly evaluating and improving nursing care of patients and establishing nursing standards.
    zoom view
    Figure 2: Organization chart of nursing services
  8. 24Maintenance of proper nursing records for clinical and administrative purposes.
  9. Assisting in the preparation of and administering the budget for the department.
  10. Coordination the activities of various nursing units.
  11. Promotion and maintaining effective and harmonious relationships among nursing personnel, and between the nursing service department and medical staff patients and public.
  12. Participating in community health education programs.
Organization Chart of Nursing Service
The usual way of illustrating a formal organization is by means of an organization chart. The basic organization of all services, their relationship to one another, lines of authority, responsibility and communication among various departments, which are located at different levels of hierarchy are illustrated by an organization chart. There is no stereotyped organization chart suitable for every hospital. Such a chart should come as a result of the consideration made on the objectives, responsibilities and feasible program of a specific hospital.
The organization char illustrates the formal structures in two dimensions—horizontal and vertical. The horizontal dimension depicts differentiation of the total organizational job into different departments. The vertical dimension refers to the hierarchy of authority relationship with a number of levels from top to bottom authority flows downwards along these lines.
The organization chart illustrates the various levels of authority from the higher to the lower levels. The different levels are:
  1. At the top level is the policy making body (e.g. governing body).
  2. At the next level is operating authority (e.g. administrator or superintendent of the organization).
  3. At the next level are broad areas of services with their departmental heads (e.g. medical service, nursing service, dietary service, etc.).
  4. At the next level are the supervisory manager (from line managers) who supervises the front line workers (e.g. ward sister/head nurse).
  5. At the lowest level are the personnel delegated with responsibility for the performance of specific functions (front line workers).
Various Types of Relationships Existing Between Positions
Line relationship: This exists between a superior and the subordinates immediately and directly responsible for certain functions through which the formal communications flow, e.g. the relationship of nursing superintendent to the head nurse. This is represented by continuous lines.
Later relationship: These types of relationship exist between positions in various parts of organization, where no direct authority is involved, e.g. relationship of the nursing superintendent in nursing service with the principal (nursing education).
Functional relationship: Functional relationship exists whenever an individual has the right to control certain activities in other departments outside his formal chain of command, e.g. the in-charge of the laundry department controls the supply of linen in a medical ward. 25Therefore, a functional relationship exists between the in-charge of the laundry department and the in-charge of the medical ward.
Staff relationship: Literally, the word ‘staff’ means the stick carried in the hands for support. The nature of the staff authority is merely advisory. The staff cannot take decisions on behalf of and issue commands to the line managers. Staff authority consists of experts and specialists in various fields who give support to the executives who hold the line authority.
Methods of Patient Assignment
There are five methods of nursing assignment, i.e. functional, team, primary, modular and case:
  1. Functional method of nursing assignment consists of separating the task involved in each patient's care and assigning each staff member to perform one or two care tasks or functions for all patients in the unit. It is suitable only for short-term use. If continued it fragments the nursing functions, e.g. bed making nurse, bed bath nurse, IV nurse, etc.
  2. Team nursing is a method of nursing assignments that binds professional, technical and auxiliary nursing personnel into small teams to mutually suppressive workers, there by combining the superior knowledge and skill of professional workers with lower personnel costs of technical and auxiliary workers. It is common, two graduate nurses, two diploma nurses and two auxiliary nurses, and two attendants to be assigned as a team to provide total nursing care for a defined group of students.
  3. Primary nursing method is a method of nursing assignment, in which each nurse is given total responsibility of planning, executing and evaluating nursing care for a small case load of four to six patients.
  4. Modular nursing is a combination of team nursing and primary nursing because her professionals are cooperatively taking care of the patients and each pair of nursing personnel is responsible for the care of the patients in their case load from admission to discharge.
  5. Case method is a method of nursing assignment otherwise known as nursing care management. It is the set of activities undertaken by a single nurse to mobilize, monitor, and evaluate all resources used by a patient during the total course of an illness.
Important objectives in methods of patient assignment
  1. Establishing and achieving a set of ‘expected’ or standardized patient care outcomes for each patient.
  2. Using the fewest possible appropriate healthcare resources to meet expected patient care outcomes.
  3. Facilitating early patient discharge or discharge within an appropriate length of stay.
  4. Facilitating the continuity of diverse health professionals.
  5. Enhancing nurses professional developments and job satisfaction.
  6. Facilitating the transfer of knowledge of expert clinical staff.
Factors influencing ward management in providing nursing care
  • Knowledge of the ward duties
  • Planning schedule—time plan
  • 26Arrangements of duty according to priority
  • Preventing interruptions
  • Delegation of duties
  • Follow the policy manual of the institution
  • Maintain good coordination with other supportive department
  • Orientation of new personnel
  • Orientation of the hospital
  • Orientation of the ward
  • Maintenance of suitable environment
  • Providing supplies in the hospital
  • Follow the doctor's order
  • Doctors orders must be clear, legible
  • Record keeping
  • Reporting
  • Maintenance of high morale
  • Delegating responsibility
  • Well-planned assignments
  • Good teaching
  • Good supervision.
27Nursing Management
Paper 2013 November
    1. Define supervision.
    2. Explain the principles of supervision.
    3. Discuss the role of a nurse as a ward supervisor.
    1. Identify the factors influencing in in-service education.
    2. Plan for an in-service education for the staff nurses working in intensive care unit.
  1. Discuss briefly the theories of management.
    1. Explain the communication process and its strategies.
    2. Role of a nurse to overwhelm the barriers of communication.
  1. Role of a nurse in disaster management.
  2. Consumer Protection Act.
  3. Leadership theories.
  4. Staff development program.
    1. Define supervision.
    2. Explain the principles of supervision.
    3. Discuss the role of a nurse as a ward supervisor.
    1. Define supervision.
  1. It is been defined as the authoritative direction of the work of one's subordinates.
  2. Supervision is defined as “guiding and directing efforts of the employees and other resources to accomplish stated work outputs”.
    Terry and Franklin
  3. Supervision is defined as a process by which workers are helped by a designated staff member to learn according to their needs, to make the best use of their knowledge and skills, and to improve their abilities so that they do their jobs more effectively and with increasing satisfaction to themselves and the agency.
  1. 28Explain the principles of supervision.
Principles of Supervision
  • Supervision should not be overburned to any individual or group
  • Supervision causing unreasonable pressure for achievement results in low performance and low confidence in the supervisor
  • Supervise diagnosis; do not overestimate his understanding and memory
  • Human behavior with due consideration to human weakness. This should be kept in minds of supervisors
  • Supervisors should create atmosphere of cordiality and mutual trust
  • Supervision should be planned and adopted to the changing conditions; it calls for good planning and organization
  • Supervisors must possess sound professional knowledge
  • Supervision must be exercised without giving the subordinate a sense that they are being supervised
  • It strives to make the unit a good learning situation and it should be a teaching-learning process
  • It should foster the ability of each staff member to think and act for himself/herself
  • Supervision should encourage workers' participation in decision-making
  • Supervision needs good communication
  • It should have strength to influence downwards depends on capacity to influence upwards
  • It is a process of cooperation and coordination
  • Supervision should create suitable climate for productive work
  • Supervision should give autonomy to workers depending from personality, competence and characteristics
  • Supervision should respect the personality of the staff
  • Supervision should stimulate the workers/staff ambitions to grow in effectiveness
  • Supervision should focus on continued staff growth and development
  • Supervision is responsible for checking and guidance
  • Good leadership is part of good supervision.
  1. Discuss the role of a nurse as ward supervisor.
A supervisor is called upon to assume many roles and responsibilities in the course of their work. They are often called as a coach, an educator or a resource person.
Orientation of newly posted staff: All newcomers should be informed about their functions, methods that they should use, the personnel with whom they will work and the community where in they will work that needs an orientation.
Assessment of the workload of the individuals and groups: A supervisor should not expect from workers a level of effort that is beyond them.
Arranging for the flow of materials: A supervisor must find out the needs or supplies and equipment and arrange for their supply in good time.
Coordination of the efforts: A supervisor coordinates the work of his/her workers and agencies and promotes team work.
29Promotion of effectiveness of workers: This may be done through performance evaluation and introducing concepts of staff development.
Promotion of effectiveness of workers: Social contacts help to bring the staff together and increase group cohesiveness. A good supervision should provide opportunity for it.
Helping individuals to cope with their personnel problems: Personnel problems are likely to come up while dealing with workers. Those may be outside the supervisor's duties, but a sympathetic understanding on his/her part improves the individual morale.
Facilitating the flow of communication: A free flow of communication among members is necessary for team work. Supervisor should encourage free communication among peer, team members.
Raising the level of motivation: All good work should be given due credit through recognition. Supervisor must provide opportunities for growth and achievements.
Establishment of control: Supervision is a control measure as well as leadership technique. The supervisor must know what work is being done and with what effectiveness.
Development of confidence: Supervisor must know the background of the workers and try to develop mutual confidence.
Emphasis on achievement: It has been proved that, the development of a smooth work routine and the improvement of human relations without corresponding emphasis on goal achievement are not likely to increase productivity.
Record keeping: The supervisor should maintain good record system for many purposes. In addition, supervisor's role is to:
  • Develop and maintain team spirit
  • Improve the knowledge and skill of the workers
  • Maintain interpersonal relationship
  • Allocation of specific work plan
  • Assess training needs of the staff and do needful
  • Have knowledge of rules and regulations of agency
  • Identify problems and help subordinates to find out solution
  • Maintain his image
  • Forcefulness, integrity and firmness
  • Full awareness of the job and the rules and regulations
  • Full awareness of existing situation
  • Intelligence and willingness to grow
  • Good judgment
  • Ability to delegate duties and responsibilities
  • Non-interference unless indicated
  • Continuous guidance, cooperation and coordination
  • Sympathetic attitude and good listening
  • Willingness to adopt new policies and accept changes according to good health, enthusiasm for work and human interests
  • Approachability and fair (treat individual impartially)
  • Ability to communicate information tactfully and skillfully
  • Ability to work with others
  • 30Knowledge of the activities, techniques and procedures
  • Objectivity, impartiality and fairness in dealing.
    1. Identify the factors influencing in in-service education.
    2. Plan for an in-service education for the staff nurses working in intensive care unit.
    1. Identify the factors influencing in in-service education.
In-service education is defined on continued program of education provided by the employing authority, with the purpose of developing the competence of personnel in their functions appropriate to the position they hold or to which they will be appointed in-service.
  • Developing the ability for efficient working capacity with continuous learning
  • To develop professional growth
  • To update with current knowledge
  • Provide qualitative nursing service in all programs.
The educational program for the nursing department includes three phases:
  1. Orientation.
  2. In-service.
  3. Continuum of education.
Factors Affecting In-service Education
The economic, social, medical and technological sciences, which affect that society will affect nursing in-service education programs are:
Cost of health care: In-service education program may increase the efficiency of nursing services, but it adds additional expenditure on health care delivery system.
Manpower: In-service education requires need qualified human resources, leads to increase human resources.
Changes in nursing practice: Lead to frequent changes in the programs and in-service education.
Standards: It should fallow for nursing practice.
Organization of nursing departmental planned approaches is regular.
  1. Plan for an in-service education for the staff nurses working in intensive care unit.
Approaches to In-service Education
31Whether the pattern of in-service education desired to be centralized, decentralized or coordinated approach will directly affect the organization policies and practices.
Centralized Approach
The centralized approach has its origin in the belief that the in-service curriculum ought to emanate from and be conducted by nursing personnel in the central administration of the agency. None of the learners are consulted or participate learning experiences and yet are expected to attend an in-service offering.
Decentralized Approach
The decentralized approach is based on a conviction that the in-service curriculum for all nursing personnel should be the responsibility, in large measure, of the practicing nurse, with whom the personnel work.
Decentralized in-service education is planned by and conducted for the employees of one or more units. The employees may be expected to keep administration informed of their activities and possibly consult with administration when help is wanted, but the employees are expected to develop and direct their own learning experiences. With a decentralized approach, control in planning for in-service is a responsibility of employees. If self-direction, initiation and participation are qualities, which are valued and they may be fostered by decentralized approach.
Coordinated Approach
  • The coordinated approach is compromise between the centralized and decentralized pattern
  • While the practicing nurse does indeed carry a large measures of responsibility for the in-service curriculum
  • The central administration of nursing personnel of the agency is responsible for broad program, which is of importance to all nursing personnel
  • Coordinated is improved, duplication is avoided and unity of efforts is maintained
  • Coordinated approach provides for mutual cooperation and assistance to central administration and unit personnel in the agency
  • An advantage of coordinated approach is that realistically, people will tend to lend support to an effort in which they personally participate or contribute.
  1. Discuss briefly the theories of management.
  1. Management is the process and agency, which directs and guides the operations of an organization in realizing, established aims.
  2. Management is defined as the process by which a cooperative group direct action towards common goals.
    Joseph messie (1973)
  3. Management is principally the task of planning, cocoordinating, motivating and controlling the efforts of others toward a specific objective.
    James lunde (1968)
There are several theories of administration and management. Although strictly speaking the word ‘theory’ may not be correct word to use at the present stage. Since the term ‘theory’ is used because of its popularity. Actually the systematic study and analysis of 32organization started in later part of 19th century and early 20th centuries. Few prominent figures who attempted to study the organization as mentioned below.
The five important theories focused for nurse managers are:
  • Scientific management theory
  • Classic organizational theory
  • Human relations theory
  • Behavioral science theory
  • Modern management theory
Scientific Management Theory
Principles of scientific management focuses on:
  • Observation
  • The measurement of outcome.
The pioneers of scientific management are:
  • Frederick W Taylor (1856–1915)
  • Gantt Henry I Gantt (1861–1910)
  • Emerson (1853–1936)
Frederick W Taylor (1856–1915)
Taylor is recognized as father of scientific management. He conducted Time-And- Motion studies to time the workers, analyze their movements and set their standards. He used stop watches. He applied the principles of observation, measurement and scientific comparison to determine the most effective way to accomplish a task.
Achievements of Taylor
  • He trained his workers to follow the time to complete the task given; the most productive workers were hired even when they were paid an incentive or wage
  • Labor costs per unit were reduced as a result
  • Responsibilities of management were separated from the functions of the workers
  • Developed systematic approach to determine the most efficient means of production
  • He considered management function is to plan
  • Working conditions and methods to be standardized to maximize the production
  • It was the management's responsibility to select and train the workers rather than allow them to choose their own jobs and train by themselves
  • He introduced an incentive plan to pay the workers according to the rate of production to minimize workers dissent and reduce resistance to improved methods
  • Increased production and produce higher profits.
The effect of time-motion study of Taylor:
  • Reduced wasted efforts
  • Set standards of performance
  • Encouraged specialization and stressed on the selection of qualified workers who could be developed for a particular job.
Gantt Henry I Gantt (1861–1910)
Gantt was concerned with problems related to efficiency. He contributed to scientific management by refining the previous work of Taylor than introducing new concepts:
  • He studied the amount of work planned or completed on one axis to the time needed or taken to complete a task on the other axis
  • 33Gantt also developed a task and bonus remuneration plan whereby workers received a guaranteed day's wages plus a bonus for production above the standard to stimulate higher performance
  • Gantt recommended to select workers scientifically and provided with detailed instructions for their tasks
  • He argued for a more Humanitarian approach by management, placing emphasis on service rather than profit objectives
  • He recognized useful non–monetary incentives such as job security and encouraging staff development.
Emerson (1853–1936)
Emerson emphasis was on conservation and organizational goals and objectives. He defined principles of efficiency related to:
  1. Interpersonal relations and to system in management.
  2. Goals and ideas should be clear and well defined as the primary objective is to produce the best product as quickly as possible at minimal expense.
  3. Changes should be evaluated-management should not ignore ‘commonsense’ by assuming that big is necessarily better.
  4. ‘Competent counsel’ is essential.
His theory explains about:
  1. Management can strengthen discipline or adherence to the rules by justice, or equal enforcement on all records, including adequate, reliable and immediate information about the expenses of equipment and personnel should be available as a basis for decisions.
  2. Dispatching or production scheduling is recommended.
  3. Standardized schedules, conditions and written instructions should be there to facilitate performance.
  4. ‘Efficiency rewards’ should be given for successful completion of tasks.
  5. Emerson moved further beyond scientific management to classic organizational theory.
  6. Charles Babbage (1792–1871): Charles Babbage, a scientist mainly interested in mathematics, contributed to the management theory by developing the principles of cost accounting and the nature of relationship between various disciplines. Charles Babbage laid the foundation for much of the work that later come to be known as scientific management. He concentrated on production problems and stressed the importance.
  7. Division and assignment of work on the basis of skill.
  8. The means of determining the feasibility of replacing manual operations with automatic machinery.
Classic Organizational Theory
Importance of classic organization theory:
  1. The classic administration-organization thinking began to receive attention in 1930.
  2. Organization is viewed as whole rather than focusing solely in production.
  3. The concepts of scalar levels, span of control, authority, responsibility, 34accountability, line staff relationships, decentralization and departmentalization become prevalent.
Table 1   Six aspects of administration
Three pioneers of Classic organizational theory:
Henry Fayol (1841–1925)
Fayol was a French industrialist known as Father of the management process school concerned with management of production shops. He studied the functions of managers and concluded that management is universal.
All the managers regardless of the type of organization or their level in organization have essentially the same tasks such as planning, organizing, issuing orders, coordinating and controlling. These six aspects of administration, falling into two main groups related as to process and effect as follows:
These six aspects of administration follow each other in logical sequences. The plan needs organization, which in turn needs coordination of the effort of the person involved. In this sense, the schematic representation of the elements of administration can be shown as follows.
Table 2   Elements of administration
Coordination of control
Functions of Management
  • Planning policies, programs and procedures
  • Organization based on hierarchy of authority
  • Directing the business in order to gain optimum return from all workers
  • Coordination, signifying harmony in activities of the organization and to facilitate its working
  • Control, the errors of the functionaries of organization and ensure that such errors do not occurs.
Fayol divided all the work carried out in a business enterprise into the following categories:
  • Technical activities (production, manufacture, etc)
  • Commercial activities (buying, selling, personnel, and industrial relations)
  • Financial activities (to have optimum use of capitals)
  • Security activities (production of property and persons)
  • Managerial activities (planning organizing, commanding, directing, coordination control, communication, motivation, leadership).
He derived general principles of management:
  • Division of work
  • Authority and responsibility
  • Discipline
  • Unity of command
  • Unity of management
  • 35Subordination of industrial interests to the common good
  • Remunerative
  • Centralization
  • Hierarchy
  • Order of team members justice
  • Justice
  • Stability of tenure
  • Initiative
  • Sense of union.
The requirements listed above, there, are still more principles by which good organization can be recognized. They are as follows:
  • The number of organization units should be the minimum needed to cover the major enterprise functions
  • All related functions should be combined within one unit
  • The number of levels of authority should be kept to a minimum
  • There should be room for initiative with the limit of his assigned authority
  • Functions should be assigned so as to minimize cross relations between organizational units
  • No more employees should report to a superior than he can effectively direct and coordinate.
Fayol also stressed that managers should possess physical, mental, moral, educational and technical qualities to conduct the multifaceted operations of business enterprise.
Fayol desired that management training should be provided to imbibe the principle and qualities essential for management. Technical ability is most important and managerial ability becomes more significant and quality to be cultivated for top-level executives. Fayol advocated some valuable concepts in management, which can be incorporated usefully in present day analysis of management science. His emphasis on unity of command and direction, non-financial incentive, decentralization, coordination has greater relevance even today:
  1. Division of work: There should be division of work and task specialization than different workers consistently carrying out different job responsibilities.
  2. Authority: Each worker should be given authority to commensurate with the amount of his responsibility.
  3. Discipline: Each worker and management should maintain proper discipline, voluntarily according to their placement.
  4. Unity of command: Each employee should receive orders from one supervisor only.
  5. Unity of direction: One person should direct all activities that support a single objective.
  6. Subordination of individual interest to general interest, i.e. the interest of the individual work, should be subordinated to the interest of the total work group.
  7. Remuneration: Proper remuneration, which includes salaries, allowance and other incentives to be given to all employees according to their level of performance and responsibility by the management or employee.
  8. Centralization or decentralization: Certain power and functions reserved with top level authorities and other power and functions are distributed to executives and co- executives and workers also to some extent.
  9. Scalar chain: There should be an unbroken scalar chain/hierarchy of authority extending from the top executive to the lowest level worker.
  10. 36Order: There should be proper policies, rules and regulations to maintain an orderly situation in the organization.
  11. Equity: All employees should be treated with equity and justice.
  12. Stability and tenure: There should be prescribed tenure, which is needed for all employees.
  13. Initiative: All employees and management should take proper initiative to achieve the objectives of the organization.
  14. Esprit de corps: The group spirit and group morale can be cultivated among employees and employer to accomplish objectives.
Fayol recognized the tentative and flexible nature of these principles, stressing that effective management result from basing each action on the appropriate principle.
Max Webber theory (1864–1920)
Max webber is German psychologist. He earned the title of Father of organizational theory. His emphasis was on rules instead of individuals and on competencies over favoritism. His conceptualization was on bureaucracy, structure of authority that would facilitate the accomplishment of organizational objectives:
The three basis for authority:
  1. Traditional authority, which is accepted because it seems things have always been that way such as the rule of a king in a monarchy.
  2. Charisma, having a strong influential personality.
  3. Rational legal authority which is considered rational in formal organizations because the person has demonstrated the knowledge, skills and ability to fulfil the position.
James Mooney Theory (1884–1957)
Mooney believed that management to be the technique of directing people and organization the technique of relating functions. Organization is managements responsibility.
Four universal principles:
  • Coordination and synchronization of activities for the accomplishment of goal
  • Functional affects the performance of one's job description
  • Scalar process organizes level of commands
  • Arrange authority in to a hierarchy.
Consequently people get their right to command from their position in the organization.
Human Relation Theory
The human relations movement began in 1940s:
  • Focused on the effect that the individuals have on the success or failure of an organization
  • Classic organization and management theory concentrated on the physical environment fail to analyze the human element.
Instead of concentrating on the organizations structure, managers encourage workers to develop their potentials and help them meet their needs for:
  • 37Recognition
  • Accomplishment
  • Sense of belonging.
Follett Theory (1868–1933)
  1. Follett stressed the importance of coordinating the psychological and sociological aspects of management in 1920s.
  2. She perceived the organization s a social system and management as a social process.
  3. Indicated that legitimate power is produced by a circular behavior where by superiors and subordinates mutually influence one another.
  4. The law of the situation dictates that a person does not take orders from another person but from the situation.
Lewin theory (1890–1947)
  • Lewin focused on the group dynamics
  • He maintained that groups have personalities of their own—composites of the member's personalities
  • He showed that group forces can overcome individual interests.
Behavioral Science Theory
Emphasis is on:
  • Use of scientific procedures to study the psychological
  • Sociological
  • Anthropological aspects of human behavior in organization.
  • The importance of maintaining a positive attitude toward people
  • Training managers
  • Fitting supervisory actions to the situation
  • Meeting employees needs
  • Promoting employees sense of achievement
  • Obtaining commitment through participation in planning and decision-making.
Douglas McGregor's Theory (1932)
McGregor's is the Father of the classical theory of management, which termed the theory. He developed the managerial implications of Maslow's theory. He noted that one's style of management is dependent on ones philosophy of humans and categorized those assumptions as theory X and theory Y.
Theory X
  • The manager's emphasis is on the goal of organization
  • The theory assumes that people dislike work and avoid it.
Consequence of theory X
  • Workers must be directed
  • Controlled
  • Coerced
  • Threatened.
So that organizational goals can be met.
According to theory X:
  • Most people want to be directed and to avoid responsibility because they have little ambition
  • They desire security.
Managers who accept the assumption of theory X:
  • Will do the thinking and planning with little input from staff associates
  • They will delegate little, supervise closely
  • Motivate workers through fear ad threats
  • Failing to make use of the workers potentials.
Theory Y
It is focuses on goal:
  • People do not inherently dislike the work and that work can be a source of satisfaction
  • Workers have the self-direction and self-control necessary for meeting their objectives
  • Will respond to the rewards for the accomplishment of those goals.
Managers who believe in this Y theory:
  • Will allow participation
  • They will delegate
  • Give general supervision than close supervision
  • Support job enlargement
  • Use positive incentives such as praise and recognition.
They believe that under favorable conditions: people seek responsibility and display imagination, unity and creativity. According to theory Y human potentials are only partially used.
Rensis Likert's Theory
Rensis Likert has studied human behavior within many organizations. After extensive research, Dr Rensis Likert concluded that there are four systems of management. According to Likert, the efficiency of an organization or its departments is influenced by their system of management. His theory of management is based on his work at the University of Michigan's institute for social research. Likert categorized his four management systems as follows.
He identified three variables in organizations:
  • The casual variable includes leadership behavior
  • The intervening variables are perceptions, attitudes and motivations
  • The end results variables are measures of profits, costs and productivity.
39Likert believes that the managers may act in ways harmful to the organization because they evaluate end results to the exclusion of intervening variables.
So, he developed a Likert scale questionnaire that includes measures of casual and intervention variables.
Factors measured by Likert scale
The scale measures several factors related to leadership behavior process:
  • Motivation
  • Managerial
  • Communication
  • Decision making process
  • Goal setting
  • Staff development.
Four types management system
Four types of management system according to Likert's effects on the management systems.
  • He associates the first system with the least effective in performance
  • Managers show less confidence in staff associates and ignore their ideas
  • Consequently staff associates do not feel free to discuss their jobs with their managers
  • Staff associates ideas are sometimes sought, but they do not feel free to discuss their jobs with the manager
  • Top and middle management are responsible for setting goals
  • There is minimal communication, mostly downward and received with suspicion
  • Decisions are made at the top with some delegation.
Consultative system
  • The manager has substantial confidence in staff associates
  • Their ideas are usually sought
  • They fell free to discuss their job with the manager
  • Goal setting is fairly general
  • It has limited accuracy and accepted with some caution
  • Broad policy is set at the top level
  • There are decisions-making throughout organization
  • Control functions are delegated to lower level where reward and self-guidance are used
  • There is some resistance from informal groups in the organization.
Participative group
Group participative is the most effective performance. Managers have complete confidence in their staff associates. Their ideas are always sought and they feel completely free to discuss their jobs with the manager. Goals are set at all levels. There is a great deal communication—upward, downward, and later that is accurate and received with open mind.
He is strong believer of participative management and supportive relationships. His linking–pin concept is based on studies about the differences between good and poor managers as measured by their level of productivity. Good mangers found to have more influence on their own managers than did poor managers. Their managerial abilities and procedures were better received by their staff associates. When middle managers have the opportunity for interaction with their manager, workers can have input and there is a chance for the individuals and the organizational goal to become similar.40
Modern Management Theories
The modern era is characterized by trends in the management through:
  1. Microanalysis of human behavior, motivation, group dynamics leadership leading to many theories of organization.
  2. The macro search for fusion of the many systems in business organization-economic social technical political and quantitative methods in decision-making.
  3. Modern management theories era can be further classified as the three streams:
    • Quantitative approach
    • System approach
    • Contingency approach.
Indicating further refinement, extension and synthesis of all the classical and neoclassical approaches to management.
Quantitative approach: Management science refers to the application of quantitative methods to management. Management science has an interdisciplinary basis in other words management science is a combination and interaction of different scientists.
System approach: According to system approach the organization is the unified, purposeful systems composed of interrelated parts and also interrelated with its environment. Each unit must mesh/interact with the organization as a whole, each manager most interact/ communicate and deal with executives of other unites and the organization itself must also interact with other organizations and society as whole.
Ludwig Von Bertalanffy
Bertalanffy, a biologist is credited with coining the general system theory. His contention were that it was possible to develop a theoretical framework for describing relationship in the real world and different disciplines with similarities could be developed into a general systems model. The similarities were:
  • Study of organization
  • State of equilibrium
  • Openness of all systems and their influence on the environment and environment influence on the system.
Contingency approach: The contingency approach can be described as the behavioral approach.
Luther Gulick
He was influenced by Taylor and Fayol. He used Fayal's five elements of administration, i.e. Planning, organizing, command, coordination and control as a frame work for his neutral principles. He condensed the duties of administration into a famous acronym ’POSDCORB’. Each letter in the acronym stands for one of the seven activities of the administrator as given below:
  1. Planning (P): Working out the things that need to be done and the methods for doing them to accomplish the purpose set for the enterprise.
  2. Organizing (O): Establishment of the formal structure of authority through which work subdivisions are arranged, designed and coordinated for the defined objective.
  3. 41Staffing (S): The whole personnel function of bringing in and training the staff, and maintaining favorable conditions of work.
  4. Directing (D): Continuous task of making decisions and embodying them in specific and general orders and instructions, and serving as the leader of the enterprise.
  5. Coordinating (CO): All important duties of interrelating the various parts of the work.
  6. Reporting (R): Keeping the executive informed as to what is going on, which includes keeping himself and his subordinates informed through records, research and inspection.
  7. Budgeting (B): All that goes with budgeting in the form of fiscal planning, accounting and control.
Luther Gulick was very much influenced by Fayol's 14 basic elements of administration in expressing his principles of administration as follows:
  • Davison of work or specialization
  • Bases of departmental organization
  • Coordination though hierarchy
  • Deliberate coordination
  • Decentralization
  • Unity of command
  • Staff and line
  • Delegation
  • Span of control.
Lyndal Urwick
Lyndal Urwick also one among the classical theorist, attached more important to the structure of organization than the role of the people in the organization.
Lyndal Urwick concentrated his efforts on the discovery of principles and identified eight principles of administration applicable to all organization as given below:
  1. The ‘principle of objective’-that all organizations should be an expression of a purpose.
  2. The ‘principle of correspondence’—that authority and responsibility must be coequal
  3. The ‘principle of responsibility’—that the responsibility of higher authorities of the work of subordinates is absolute.
  4. The ‘scalar principle’—that a paramedical type of structure is build up in an.
  5. The ‘principle of span control’.
  6. The ‘principle of specialization’—limiting ones work to single function.
  7. The ‘principle of coordination’.
  8. The ‘principle of definition’—clear prescription of every duty.
Critical Theory Versus Critical Thinking
Steffy and Grimes note that a strict natural science approach to social science is native, since subjective or qualitative analysis is important to quantitative research. This holds true for management and consequently for nursing management. The authors suggest a critical theory approach to organizational science rather than a phenomenological or hermeneutic approach.
42Phenomenological approach uses second order constructs “interpretations of interpretation. “The nurse manager would interpret the meaning of nursing of nursing management experience or observations and arrive at a nursing management theory from aggregate of meanings.
Hermeneutic approach is the art of textual interpretation. She would consider the specific context and historic dimensions of data collected, and would reflect on the relationship between theory and history.
Critical theory
Critical theory is an empirical philosophy of social institutions. It is translated into practice by decision makers, in these case nurse managers. It includes organizational development, management by objectives or results, performance appraisal, and other practice-oriented activities performed by managers.
  1. To critique the ideology of scientism, “the institutionalized form of reasoning, which accepts the idea that the meaning of knowledge is defined what the sciences do and thus can be adequately explicated through analysis of scientific producers.
  2. ‘To develop an organizational science capable of changing organizational processes. “it is used the practice of clinical nursing and nursing management.
Critical thinking
Concept analysis is advocated as a strategy for promoting critical thinking. The rudiments of critical thinking are recalling facts, principles, theories and abstractions to make deductions, interpretations, and evaluations in solving problems, making decisions, and implementing changes. Concept analysis uses critical thinking to advance the knowledge base of nursing management as well as nursing practice.
Definition: Are as follows:
  1. Critical thinking is reflecting on a situation, a plan an event under the rule of standards and antecedent to making a decision.
  2. Critical thinking is both a philosophical orientation toward thinking and a cognitive process characterized by reasoned judgment and reflective thinking.
    Jones and Brown
Abraham Maslow
Abraham Maslow an American psychologist has given best known classification of human needs as ‘Need Hierarchy’.
Abraham Maslow arranges individual needs in a Hierarchical manner:
  1. Physiological needs: The basic things necessary for human survival, e.g. hunger thirst, shelter, etc.
  2. Security needs: Include job security or safety and the work place, thus giving psychological security to human being.
  3. Social needs: Represent the relationship between and among groups of people working in the organization.
  4. Self-esteem needs: Represent higher level needs of human being.
  5. Self-actualization: Is a higher level need represents culmination of all other needs.
Abraham Maslow's hierarchy of needs motivational model
Abraham Maslow developed the hierarchy of needs model in 1940–1950 in USA, and the hierarchy of needs theory remains valid today for understanding human motivation, management training, and personal development. Indeed, Maslow's ideas surrounding the hierarchy of needs concerning the responsibility of employers to provide a workplace environment that encourages and enables employees to fulfill their own unique potential (self-actualization) are today more relevant than ever. Abraham Maslow's book Motivation and Personality, published in 1954 (second edition in 1970) introduced the ‘hierarchy of needs’, and Maslow extended his ideas in other work, notably his later book toward a psychology of being, a significant and relevant commentary, which has been revised in recent times by Richard Lowry, who is in his own right a leading academic in the field of motivational psychology.
Abraham Maslow was born in New York in 1908 and died in 1970, although various publications appear in Maslow's name in later years. Maslow's PhD in psychology in 1934 at the University of Wisconsin formed the basis of his motivational research, initially studying rhesus monkeys. Maslow later moved to New York's Brooklyn College.
The Maslow's hierarchy of needs five-stage model below (structure and terminology— not the precise pyramid diagram itself) is clearly and directly attributable to Maslow; later versions of the theory with added motivational stages are not so clearly attributable to Maslow. These extended models have instead been inferred by others from Maslow's work. Specifically Maslow refers to the needs cognitive, aesthetic and transcendence (subsequently shown as distinct needs levels in some interpretations of his theory) as additional aspects of motivation, but not as distinct levels in the hierarchy of needs.
Where Maslow's hierarchy of needs is shown with more than five levels these models have been extended through interpretation of Maslow's work by other people. These augmented models and diagrams are shown as the adapted seven and eight-stage hierarchy of Needs pyramid diagrams and models below.
There have been very many interpretations of Maslow's hierarchy of Needs in the form of pyramid diagrams. The diagrams on this page are my own interpretations and are not offered as Maslow's original work. Interestingly in Maslow's book Motivation and Personality, which first introduced the hierarchy of needs, there is not a pyramid to be seen.
Herzberg's Two Factor Theory
Two factor theory was developed in 1959. It is based on realization that work motivation and job-satisfaction are two dimensions that influence the productivity of an employee. Herzberg's finding that good working conditions, adequate salary, good physical facilities, good human relation, quality of supervision might contribute to job satisfaction of employees, which are ‘hygiene’ factors. Whereas factors like recognition of work done, status, opportunities for growth, challenging task, play an important role in creating work motivation for employees, which are the motivation factors. Later, many authors interpreted that all the motivation factors described by Herzberg do not give equal amount of satisfaction to all employees.44
zoom view
Figure 1: Abraham Maslow's hierarchy of needs motivational model
Implications of management theories in nursing:
  1. Taylor's theory can be implemented in nursing to study complexity of care and determine staffing needs and observe efficiency and nursing care.
  2. Nurses can utilize Emerson's theory of early notion of the importance of objectives setting in an organization.
  3. Nurses should be aware of the managerial tasks as defined by Fayol: Planning, organizing, directing, coordinating and controlling.
  4. The theory of human relations of Follett and Lewin emphasize the importance for nurse managers to develop staff to their full potential and meeting their needs for recognition, accomplishment and sense of belonging.
  5. Mc Gregon and Likert support the benefits of positive attitudes towards people, development of workers, satisfaction of their needs and commitment through participation.
    1. Explain the communication process and its strategies.
    2. Role of a nurse to overwhelm the barriers of communication.
    1. Explain the communication process and its strategies.
Communication is a process of change. In order to achieve the desired result, the communication necessarily be effective and purposive.
Definition of Communication
Communication is a process in which a message is transferred from one person to other person through a suitable media and the intended message is received and understood by the receiver.
Importance of Communication
Promotes Motivation
Communication promotes motivation by informing and clarifying the employees about the task to be done, the manner they are performing the task, and how to improve their performance if it is not up to the mark.
Source of information: Communication is a source of information to the organizational members for decision-making process as it helps identifying and assessing alternative course of actions.
Altering individual's attitudes: Communication also plays a crucial role in altering individual's attitudes, i.e. a well-informed individual will have better attitude than a less-informed individual. Organizational magazines, journals, meetings and various other forms of oral and written communication help in molding employee's attitudes.
Helps in socializing: Communication also helps in socializing. In today's life the only presence of another individual fosters communication. It is also said that one cannot survive without communication.
Controlling process: Communication also assists in controlling process. It helps controlling organizational member's behavior in various ways. There are various levels of hierarchy and certain principles and guidelines that employees must follow in an organization. They must comply with organizational policies, perform their job role efficiently and communicate any work problem and grievance to their superiors. Thus, communication helps in controlling function of management.
Process of Communication
  1. All of the manager's functions involve communication. The communication process involves six steps.
  2. Ideation encoding transmission receiving decoding response.
  3. Response decoding receiving transmission encoding.
The first step, ideation, begins when the sender decides to share the content of her message with someone, senses a need to communicate, develops an idea or selects information to share. The purpose of communication may be inform, persuade, command, inquire or entertain.
Encoding is the second step, involves putting meaning into symbolic forms. Speaking, writing or non-verbal behavior. One's personal, cultural and professional biases affect the goals and encoding process. Use of clearly understood symbols and communication of all the receiver needs to know are important.46
zoom view
Figure 2: Communication process
The third step, transmission of the message, must overcome interference such as garbled speech, unintelligible use of words, long complex sentences and distortion from recording devices, noise and illegible handwriting.
The receiver's senses of seeing and hearing are activated as the transmitted message is received. People tend to have selective attention (hear the message of interest to them, but not others) and selective perception (hear the parts of the message that conform with what they want to hear) that cause incomplete and distorted interpretation of the communication. Sometimes people tune out the message because they anticipate the content and think they know what is going to be said. The receiver may preoccupied with other activities and consequently not be ready to listen.
Decoding of the message by the receiver is the critical fifth step. Written messages allow more time for decoding, as the receiver assesses the explicit meaning and implications of the message based on what the symbols mean to her. The communication process is depending on the receiver's understanding of the information.
Response or Feedback
Response or feedback is the final step. It is important for the manager or sender to know that the message has been received and accurately interpreted.
Strategies of Communication
Mainly there are two types of communication, i.e. verbal communication and non-verbal communication.
Verbal Communication
Verbal communication involves spoken or written words. Words are tools or symbols used to express ideas or feelings arouse emotional responses, describe objects, observations, memories or interferences. To make a message clear nurses use effective verbal communication technique such as:
Clarity and brevity: Clarity can be achieved by speaking slowly and clearly. Using examples can make explanation easier to understand. Brevity is best achieved by using words that express an idea simply, i.e. “Tell me what is your problem?”
47Vocabulary: Instead of using purely technical words use, local words synonyms to technical words for better understanding.
Denotative and connotative meaning: A denotative meaning is one shared by individuals who use a common language that is used to define a word so that it means the same to everyone. The connotative meaning of a word is the thoughts, feelings or ideals that people have about the word.
Pacing: Verbal communication is successful when expressed at an appropriate speed or pace.
Timing and relevance: Timing is critical to reception. For example if the supervisor/manager is in bad mood, the timing is wrong to ask for a raise. And relevance is also important, i.e. that communication is most likely to have an impact when message pertain to an individual interest and needs.
Humor: It can be a powerful tool in promoting all aspects in management and also for well- being. Laughter is the best medicine. When it is used in good sense according to circumstances and events.
The written communication must be based on four essential ‘C's – clear, correct, complete, and concise.
Non-verbal Communication
Non-verbal communication is transmission of messages without the use of words. To compensate for the inadequacy of verbal message information, people unconsciously use facial expression, gesture, touch and vocal tone to amplify the meaning of spoken communication. It is one of the powerful ways people convey messages to others.
Metacommunication: It is the message that conveys the sender's attitudes, feelings, and intentions towards listener. It may be verbal or non-verbal. Non–verbal shows genuine feelings or may be an attempt to hide feeling, for example, smiling when angry.
Personal appearance: The general impression formed of another person influences the response to that person. It is often leads to impressions about personality and self-concept.
Intonation: The tone of the speaker's voice can have a dramatic impact on a message's meaning. A person's emotion can directly influence tone of voice.
Facial expression: The face is rich in communication potential. The face and eyes send overt and subtle clues that assist in interpretation of messages, e.g. surprise, fear, anger, disgust, happiness and sadness.
Posture and gait: It reflects attitudes emotions, self- concept and physical wellness.
Gestures: It identifies 3 functions such as an illustrating an idea, expressing an emotional state and signaling by use of sign.
Touch: It is a personal form of non-verbal communication. Persons engaged in communication must be close to each other when touch is used.
Techniques to improve the communication
  • Listening
  • Broad openings
  • 48Restating
  • Clarification
  • Reflection
  • Focusing
  • Sharing perceptions
  • Silence
  • Humor
  • Informing
  • Suggesting.
Listening: It an active process of receiving information. The complete attention of the nurse is required and there should be no preoccupation with oneself. Listening is a sign of respect for the person who is talking and a powerful reinforce of relationships. It allows the patients to talk more, without which the relationship cannot progress.
Broad Openings: These encourage the patient to select topics for discussion, and indicate that nurse is there, listening to him and following him. For example, questions such as what shall we discuss today? “Can you tell me more about that”? “And then what happened?” From the part of the nurse encourages the patient to talk.
Restating: The nurse repeats to the patient the main thought he has expressed. It indicates that the nurses are listening. It also brings attention to something important.
Clarification: The person's verbalization, especially when he is disturbed or feeling deeply, is not always clear. The patients' remarks may be confused, incomplete or disordered due to their illness. So, the nurses need to clarify the feelings and ideas expressed by the patients. The nurses need to provide correlation between the patient's feeling and action. For example, “I am not sure what you mean“? “Could you tell me once again?” Clarifies the unintelligible ideas of the patients.
Reflection: This means directing back to the patient his ideas, feeling questions and content. Reflection of content is also called validation. Reflection of feeling consists of responses to the patient's feeling about the content.
Focusing: It means expanding the discussion on a topic of importance. It helps the patient to become more specific, move from vagueness to clarity and focus on reality.
Sharing Perceptions: These are the techniques of asking the patient to verify the nurse understands of what he is thinking or feeling. For example, the nurse could ask the patient, as “you are smiling, but I sense that you are really very angry with me.”
Theme Identification: This involves identifying the underlying issues or problem experienced by the patient that emerges repeatedly during the course of the nurse-patient interaction. Once we identify the basis themes, it becomes easy to decide, which of the patient's feeling and thoughts to respond to and pursue.
Silence: This is lack of verbal communication for a therapeutic reason. Then the nurse's silence prompts patient to talk. For example, just sitting with a patient without talking, non-verbally communicates our interest in the patient better.
Humor: This is the discharge of energy through the comic enjoyment of the imperfect. It is a socially acceptable form of sublimation. It is a part of nurse client relationship. It is constructive coping behavior, and by learning to express humor, a patient learns to express how others feel.
49Informing: This is the skill of giving information. The nurse shares simple facts with the patient.
Suggesting: This is the presentation of alternative ideas related to problem solving. It is the most useful communication technique when the patient has analyzed his problem area, and is ready to explore alternative coping mechanisms. At that time suggesting technique increase the patient's choices.
  1. Role of a nurse to overwhelm the barriers of communication.
Barriers of Communication
Communication barriers create problem of misunderstanding and conflict between men who live together in the same community, who work together on the same job and even between men living in the distinct parts of the world who have never seen one another. Following are the main barriers to overcome.
Due to Organization Structure
The breakdown or distribution in communication sometimes arises due to:
  • Several layers of management
  • Long lines of communication
  • Special distance of subordinates from top management
  • Lack of instructions for passing information to the subordinates
  • Heavy pressures of work at certain levels of authority.
Due to Status and Position
  1. The attitude exhibited by the supervisor is sometimes a hurdle in two way communication. One common illustration is non listening habit. A supervisor may guard information for:
    • Consideration of prestige, ego and strategy
    • Underrating the understanding and intelligence of subordinates.
  2. Prejudice among the supervisors and subordinates may stand in the way of a free flow of information and understanding.
  3. The supervisors particularly at the middle level may sometimes like to be in good books of top management by:
    • Not seeking clarification on instructions which are subject to different interpretations
    • Acting as screen for passing only such information which may please the boss.
Semantic Barriers
Semantic is the science of meaning. Words seldom mean same thing to two people. Symbols or words usually have a variety of meaning arid the sender and the receiver have to choose one meaning from among many. If both of them choose the same meaning, communication will be perfect. But this is not so always because of differences in formal education and specific situations of the people. Strictly one cannot convey meaning, only one can do it to convey words. But the same words may suggest quite different meaning to different people, e.g. ‘profits’ may mean to management efficiency and growth, whereas to employees it may suggest excess funds piled up through paying inadequate wages.
Tendency to Evaluate
A major barrier to the communication is the natural tendency to judge the statement of the person or other group. Everyone tries to evaluate others from his own point of view or experience. Communication requires an open mind and willingness to see things through the eyes of others. Some intelligent brains even complimented him on his excellent style of imagination.
Heightened Emotions
Barriers may also arise but in specific situations, e.g. emotional reactions, physical conditions like noise or insufficient light, past experience, etc. when emotions are strong, it is most difficult to know the frame of mind of the other person or group.
Lack of Ability to Communicate
All persons do not have the skill to communicate. Skill in communication may come naturally to some, but an average man may need some sort of training and practice by way of interviewing and public speaking, etc.
The simple failure to read bulletins, notices, minutes and reports is a common feature. With regard to failure to listen to oral communications, it has been seen that non listeners are often turned off while they are preoccupied with other affairs, like their family problems.
Unclarified Assumptions
This can be clarified by an illustration. A customer sends a message that he will visit a vendor's plant at particular time on some particular date. Then he may assume that vendor will receive him and arrange for his lunch, etc. whereas vendor may assume that the customer was arriving in the city to attend some personal work and would make a routine call at the plant. This is an unclarified assumption with possible loss of goodwill.
Resistance to Change
It is the general tendency of human-being to maintain status quo. When new ideas are being communicated, the listening apparatus may act as a filter in rejecting new ideas. Thus, resistance to change is an important obstacle to effective communication.
Sometimes, organizations announce changes which seriously affect the employees, e.g. shifts in timings, place and order of work, installation of new plant, etc. changes affect people in different ways and it may take some time to think through the full meaning of the message. Hence, it is important for the management not to force changes before people are in a position to adjust to their implications.
Closed Minds
Certain people who think that they know everything about a particular subject also create obstacles in the way of effective communication.51
  1. Role of a nurse in disaster management
Refer November 2012, Question No. 7
  1. Consumer Protection Act
Refer November 2012, Question No. 6
  1. Leadership theories
Refer May 2011, Question No. 2 b
  1. Staff Development Program
Refer October 2011, Question No. 10
52Nursing Management
Paper 2013 May
    1. Elaborate principle of organization.
    2. Explain job responsibilities of Principal of ‘college of nursing’.
    1. Enumerate principles of budget.
    2. Explain the essential requisition of budget preparation.
  1. Discuss in detail about recruitment and selection procedure for teaching staff in college of nursing.
  2. Discuss Indian health services administration system at national, state and local level.
  1. Standard safety measures.
  2. Performance appraisal in nursing.
  3. Inventory control.
  4. Innovation in nursing.
    1. Elaborate principle of organization.
    2. Explain job responsibilities of Principal of ‘college of nursing’.
    1. Elaborate principle of organization.
Organization is “a group of people working together with each other toward the achievement of the common goals.”
According to Koontz and O’Donnell, organization is a ‘essentially as the creation and maintenance of an intentional structure of role’.
Principle of Chain of Command
  1. Communication flows through the chain of command or channel of communication tends to be one-way downward.
  2. In a modern nursing organization, the chain of command is flat with line managers, technical, clerical staffs that support the clinical staff. The communication flows freely in all directions with authority and responsibility delegated to the lowest operational level.
  3. This principle supports a centralized authority that aligns authority and responsibility.
  4. 53The organizations are established with hierarchical relationships, within which the authority flows from top to bottom in order to be satisfying to members, economically effective and successful in achieving the goals.
Principle of Unity of Command
  1. An employee has one supervisor/one leader and one plan for a group of activities with the same objective, also called principle of responsibility. The organizational set up should be arranged in such a way that a subordinate should receive the instruction or direction from one authority or boss.
  2. Primary nursing and case management modality support this principle (many professional nurses engage in matrix organizations in which they answer to more than one supervisor).
  3. In the absence of unity of command:
    • The subordinate may neglect his duties. It will result in the noncompletion of any work
    • There is no guidance available to the subordinates and there is no controlling power for the top executives of the organization
    • Further some subordinates will have to do more work and some others will not do any work at all.
Principle of Span of Control
  1. Span of control refers to the maximum number of members effectively supervised by a single individual. The number of members may be increased or decreased according to the nature of work done by the subordinates or the ability of the supervisor.
  2. The span of control enables smooth functioning of the organization.
  3. Person should be a supervisor of a group that he/she can manage in terms of numbers, functions and geography. The more highly trained the employee, the less supervision is needed.
  4. Employees in training need more supervision to prevent blunders.
  5. When different levels of nursing employees are used, the Nurse Manager has more to coordinate.
  6. In the past, the nurse managers had a narrow span of control. They were responsible for one nursing unit and a limited number of staff.
  7. Recently the span of control has increased to the point that the nurse managers have to cover several nursing units and departments with a large number of employees.
  8. This is also called span of management or span of supervision. This principle is based on the principle of relationship.
Principle of Specialization or Division of Work
  1. Each person should perform a single leading function.
  2. There is a division of labor, a differentiation among kinds of duties.
  3. Specialization is the best way to use individuals and groups.
  4. Division of work means that the entire activities of the organization are suitably grouped into departments and sections (the department and sections may be further divided into several such units so as to ensure maximum efficiency.
  5. 54This will help to fix up the right man to the right job and reduce waste of time and resources.
  6. The work is assigned to each person according to educational qualification, experience, skill and interests.
  7. He should be mentally and physically fit for performing the work assigned to him. The required training may be provided to the needy persons.
  8. It will result in attaining specialization in a particular work or area.
Hierarchy or Scalar Chain
  1. Scalar chain is the order of rank from top to bottom in an organization.
  2. This is also called chain of command or line authority (normally, the line of authority flows from the top level to bottom level. It also establishes the line of communication).
  3. Each and every person should know who is his supervisor and to whom he is answerable.
Centrality relates to the position or distance the person has on the organizational chart from other workers.
Unity of Objectives
  1. An establishment or enterprise exists to achieve certain laid down objectives. The organization requires to be geared toward fulfillment of these objectives.
  2. Hence, this principle dictates that it is essential for the organizational objectives to be formulated in clear, unambiguous, achievable and measurable terms, which should be understood by all concerned.
Definition of jobs/Principle of Definition
  1. It is necessary to define and fix duties, responsibilities and authority of each worker.
  2. In addition to that, the organizational relationship of each worker with others should be clearly defined in the organizational setup.
Principle of Balance
There are several units functioning separately under one organizational set up. The work of one unit might have been commenced after the completion of the work by another unit. So, it is essential that the sequence of work should be arranged scientifically.
Principle of Equilibrium Balance
In certain periods, some sections or departments are overloaded and some departments are underloaded. During this period, due weightage should be given on the basis of the new workload. The overloaded sections or departments can be further divided into subsections or subdepartments. It would entail in the effective control over all the organizational activities.55
Principle of Continuity
  1. Administration is a continuing or ongoing process, recycling the structure of the organization based on the economic, environmental and sociopolitical changes.
  2. There should be a reoperation of objectives, readjustments of plans and provision of opportunities for the development of future management. This process is taken over by every organization periodically.
Principle of Exception
  1. Implies routine decision-making should rest with lower levels of management within the policy framework and only unusual or exceptional matters should be referred to the higher levels of management for taking decisions.
  2. The junior officers are disturbed by the seniors only when the work is not done according to the plans laid down. It automatically reduces the work of middle level officers and top level officers. So, the top level officers may use the time gained by reduction in workload for framing the policies and chalking out the plans of organization.
Principle of Unity of Direction
  1. Also called principle of coordination.
  2. The major plan is divided into subplans. Each subplan is taken up by a particular group or department. All the group or departments are requested to cooperate, to attain the main objectives or in implementing major plan of the organization.
Principle of Communication
A two-way communication flow from top to bottom levels and from bottom to top levels is a prerequisite to obtain an effective organizational setup.
Principle of Flexibility
To meet the challenges of the increasing and changing demands of the environment, an organization structure is subjected to change. As such rigidity has to be avoided and flexibility is essential in the organization structure, so that changes can be brought about without disrupting basic design of the structure.
  1. Explain job responsibilities of Principal of ‘college of nursing’.
Principal (College of Nursing)
Job Summary
Principal of ‘college of nursing’ is the administrative head of the ‘college of nursing’, will be directly responsible to the Director of the Medical Education/Director of Health and Family Welfare services and responsible for implementation, and revision of curriculum for various courses and research activities of the college of nursing.56
Duties and Responsibilities
  • Planning
  • Develops philosophy and objectives for educational program
  • Identifies the present needs related to educational program
  • Investigates, evaluates and secures resources
  • Formulates the plan of action
  • Selects and organizes learning experience.
  • Determines the number of position and scope, and responsibility of each faculty and staff
  • Analysis the job to be done in terms of needs of education program
  • Prepares the job description, indicate line of authority, responsibility in the relationship and channels of communication by means of organizational chart and other methods
  • Considers preparation, ability and interest personally in equating responsibility
  • Delegates authority commensurate with responsibility
  • Maintains a plan of workload among staff members
  • Provides an organizational framework for effective staff functioning such as meeting of the staff, etc.
  • Recommends appointment and promotion based on qualification, and experience of the individual staff, scope of job and total staff composition
  • Subscribes and encourages developmental aspects with reference to welfare of staff and students
  • Directs activities of staff working under
  • Provides adequate orientation of staff members
  • Guides and encourages staff members in their job activities
  • Consistently makes administrative decision based on established policies
  • Facilitates participation in community, professional and institutional activities by providing time, opportunity for support such participation
  • Creates involvement in designing educationally sound program
  • Maintenance of attitude rightly acceptable to staff and learners
  • Provides for utilization in the development of total program and encourages their contribution
  • Provides freedom for staff to develop active training course within the framework for curriculum
  • Promotes staff participation in research
  • Procures and maintains physical facilities, which are of a standard.
  • Coordinates activities relating to the programs such as regular meetings, time schedule, maintaining effective communication, etc.
  • Initiates ways of cooperation
  • Interpretes nursing education to other related disciplines and to the public.
  • Provides for continuous follow-up and revision of education program
  • Maintains recognition of the educational program by accrediting bodies such as university, Karnataka State Nursing Council (KSNC), Indian Nursing Council (INC), etc.
  • 57Maintains a comprehensive system of records
  • Prepares periodic report, which revives the progress and problems of the entire program, and presents plans for its continuous development
  • Prepares, secures approval and administrates the budget
  • Instruction (teaching)
  • Plans for participating in educational programs for further development
  • Recognizes the needs for continuing education for self and staff provide stimulation of opportunities for such development
  • Participate as a teacher in the educational program.
  • Provides for systematic guidance program for staff members and students
  • Encourages studies, research and writing for publication
  • Provides and maintains a program for recruitment, selection and promotion of students.
    1. Enumerate principles of budget.
    2. Explain the essential requisition of budget preparation.
    1. Enumerate principles of budget.
Steps in Budgeting
zoom view
Figure 1: Steps in budgeting
Principles of Budgeting
A budget is an operational plan for a definite period, usually a year, expressed in financial terms and based on expected income and expenditure. A budget needs certain principles as given below:
  • Budget should provide sound financial management by focusing on requirement of the organization
  • 58Budget should focus on certain objectives and policies of organization
  • Budget requires a planned schedule
  • Budgetary process requires delegation of duties
  • Budget needs coordination
  • Budget should have a fixed time period
  • Budget should appropriate to the nature of service
  • Budget should be prepared under the direction and supervision
  • Budget requires continues evaluation.
  1. Explain the essential requisition of budget preparation.
Feature of Budget
  • Budget should be simple in design and oriented to those who use it
  • It should be flexible; it should be adjust various needs and conditions of the institution
  • It should be synthesis of past, present and future
  • It should be product of joint venture and cooperation of executives/department heads at different levels of management
  • Budget is composed of two segment; that are income and expenditure. Income limits expenditure; hence, income should be estimated prior to the estimation expenditure
  • A budget reflects the goals and aspirations of the faculty
  • Budget making involves the whole situation
  • Budget is forward planning. Planned activities are vital for efficient and successful functioning
  • A budget gives direction–it is more than the list of the desired and approved expenditure; it is also the instrument of administration and management
  • It should have support of top management throughout the period of its planning and supplementation
  • Budget has a time period usually, annual; it is important to secure the maximum participation of organization in preparation on of budget.
Essential Requisition of Budget Preparation
These are:
  • Accounts for the 3 or more years for arriving at the average figures for the respective income or expenditure
  • Original revised budget for the previous year
  • Schedules of budget figures of receipts and payments for the current period after considering proposals of expansion or detracting of activities, or services and expense
  • Letters of sanction from various authorizes communicating sanction of the grants for the current or for the next year
  • A record of all the votes taken during the course of the year for the purpose.
  1. 59Discuss in detail about recruitment and selection procedure for teaching staff in college of nursing.
Recruitment is a process in which the right people for the right post is procured. It is a source of manpower to meet the requirements of the staffing schedule and to employ effective measures for attracting that manpower in adequate numbers to facilitate effective selection of an efficient student.
It is the process of actively seeking out qualified applicants for existing position in organization in a cost-effective manner.
Steps in Recruitment Process
  1. Planning.
  2. Strategy development.
  3. Searching.
  4. Screening.
  5. Evaluation and control:
    • Organizational policies regarding recruitment should prior to the advertisement of a job position
    • All possible source of potential applicant must be identified
    • The optimum mode of publicizing seats
    • The recruitment need and qualification required must be used
    • The response to the recruitment effort should be evaluated and adjusted as needed.
Sources of Recruitment
The sources of recruitment are as follows.
Internal sources: These include present employees, employee referrals, former employee and former applicants.
Present employees
Promotion and transfers from among the present employees can be good source of recruitment. Promotions to higher positions have several advantages. They are:
  • It is good for improving public relations
  • It builds morale
  • It encourages competent individuals who are ambitious
  • It improves the probability of a good selection, since information of the candidate is readily available
  • It is less costly
  • Those chosen internally are familiar with the organization.
However, promotions can be dysfunctional to the organization as the advantage of hiring outsiders, who may be better qualified and skill is denied. Promotions also results in breeding, which is not good for the organization.
Another way to recruit from among present employees is the transfer without promotion. Transfers are often important in providing employees with a broad based view of the organization, necessary for the future.60
Employee referrals
This is the good source of internal recruitment. Employees can develop good prospects for their families and friends by acquainting with the advantages of a job with the company, furnishing cards introduction and even encouraging them to apply. This is very effective, because many qualified are reached at very low cost. Most employees known from their own experience about the recruitments for the job what sort of person is looking for? A major concern with the employee recommendation is that referred individuals are likely to be similar type (e.g. race and sex) to those who are already working for company.
Former employees
Some retired employees may be willing to come back to work on a part-time basis or may recommend someone who would be interested in working for the company. An advantage with these sources is that the performance of these people is already known.
Former applicants
Although not truly an internal source, those who have previously applied for jobs can be contacted by mail, a quick and inexpensive way to fill an unexpected opening.
Evaluation of internal recruitment
  • It is less costly
  • Organizations typically have a better knowledge of the internal candidate's skills and abilities than the ones acquired through external recruiting
  • An organizational policy of promoting from within can enhance employee's morale, organizational commitment and job satisfaction.
  • Creative problem solving may be hindered by the lack of new talents
  • Divisions complete for the same people
  • Politics probably has a greater impact on internal recruiting and selection than does external recruiting.
External sources: Sources external to an organization are professional or trade associations, advertisements, employment exchanges, college/university/institute placement services, walk-ins and writer-ins, consultants, contractors.
Professional or trade associations
Many associations provide placement services for their members. These services may consist of compiling seekers' lists and providing access to members during regional or national conventions.
These constitute a popular method of seeking recruits as many recruiters prefer advertisements because of their wide reach. For highly specialized recruits, advertisements may be placed in professional/business journals. Newspaper is the most common medium.
General Recruitment for Nursing
The fact that a person decides to apply to a particular course in nursing shows that he/she must have become interested in nursing as a carrier. At this stage, he/she will have been influenced by his/her parents, teachers or friends, by her personal experience of nursing care and by the image of the nurse, which she/he buildup. The way to attract suitable 61persons to the profession, therefore, is to ensure that a good impression and correct information are conveying to the public in general:
  • The public awareness can be done through talks and plays on the radio, by publishing articles in journals and by publication and wide distribution of pamphlets
  • Pamphlets should be attractive and cheap, and written in all the languages of the region
  • Pamphlets should contain information about different type of courses and opportunities for employment, and promotion after qualification.
Selection is the process of choosing from among applicants the best qualified individuals. Selection may be carried out centrally or locally, but in either case certain policies or methods are adopted.
Selection Policies
Application forms: The issue and receipt of application forms is the administrative responsibility and much of the preliminary work is handled by the clerical staff under the supervision of the administrative head of the college. The information contained in the application form and reports received in connection with them should be systematically tabulated and filed as they are useful for evaluating the effectiveness of the form, assessing academic achievement with subsequent performance and knowing from which parts of the state or country the faculty are most frequently admitted or apply for admission.
The application form should elicit the following information:
  • Name
  • Address
  • Age of the candidate
  • Name of parents or guardians
  • Occupation of father
  • Details of education
  • Details of employment
  • Particular aptitudes or abilities.
Selection Committee
Usually the selection occurs in the college itself. Otherwise, if the selection is carried outside the college, it is important that at least representatives of the college should be a part of committee and as far as possible students be selected for a specific college according to its individual admission policies and the program it offers.
The members of the selection committee should include:
  • Head of the college of nursing
  • Professor
  • Representative of the local controlling authority
  • Representative of the nursing division of the state.
The procedure for selection should consist of a personal interview of the candidate and possibly a separate interview. It may also include tests of previous achievements, both written and oral, to assess knowledge of various subjects such as arithmetic, English, the 62regional language and general science, and his/her ability to express orally and in writing. If psychological tests are given, only those devised by experts in their field should be used.
It should be made clear to them that final acceptance for the course will be subject to a satisfactory medical report and assessment during the preliminary training period.
Orientation Program
After selection, an orientation program is to be conducted to make the students aware of the college rules, hostel rules and the hospital and the college building, and associated parallel medical education departments. Orientation should be given by a senior faculty of the college of nursing. Orientation program may take 3–5 days.
Development of Master Plan
When a particular batch is admitted, the class teacher may draw a master plan according to which the whole program is planned, i.e. date of examinations and periodic evaluation measures, etc. are formulated.
Nursing care is extremely for good patient outcome. So, recruitment and selection of faculty into the nursing profession is an important aspect.
  1. Discuss Indian health services administration system at national, state and local level.
Organization and Administration of Health Services in India at Different Levels
India is a union of 29 states and seven union territories. Under the constitution states are largely independent in matters relating to the delivery of health care to the people. Each state, therefore, as developed its own system of healthcare delivery, independent of the Central Government. Central responsibility consists mainly of policy making, planning, guiding, assisting, evaluating and coordinating the work of the State Health Ministries, so that no state lags behind in health services.
Health system in India has three links:
  1. Central level.
  2. State level.
  3. District level.
Central Level
Health is a state subject under the constitution of India. The health centers are mainly with international, national and interstate health matters. The center is also responsible for execution of health programs in the centrally administered areas. It advises and helps the states on all health matters.
Official organs of the health system at the national level consist of:
  1. The Ministry of Health and Family Welfare.
  2. The Directorate General of Health Services.
  3. The Central Council of Health and Family Welfare.
  4. The Ministry of Health and Family Welfare.63
Ministry of Health and Family Welfare
The responsibilities of the central and state governments in the area of health are defined under Article 246 of the Constitution as follows:
  • Union list
  • International obligations such as International Sanitary Regulations regarding port quarantine
  • Administration of central institutes such as All India Institute of Hygiene and Public Health, Kolkata, National Institute of Communicable Diseases, Delhi, National Institute of Health and Family Welfare, Delhi
  • Promotion of research through bodies such as the Indian Council of Medical Research
  • Regulation and development of medical, dental, pharmaceutical, and nursing education and professionals through their respective councils
  • Regulation of manufacture and sale of biological products, and drugs including drug standards
  • Undertaking census, collecting and publishing health, and vital statistics data
  • Coordination with state in their health programs, giving them technical and financial assistance and procuring for them facilities from international agencies
  • Coordination with other ministries in matters related to health
  • Health regulations regarding labor in general and mines and oil fields in particular
  • Concurrent list.
Both center and states have simultaneous power of legislation in relation to subjects in concurrent list:
  • Interstate spread of disease
  • Prevention of adulteration of foods
  • Control of drugs and poisons
  • Vital statistics
  • Labor welfare
  • Minor ports
  • Population control and family planning
  • Social and economic planning.
Directorate General of Health Services
  • Conducting various national health programs
  • Organizing health services in the form of Central Government Health Scheme
  • Providing medical education through the colleges and institutions under its control, e.g. Rajkumari Amrit Kaur College of Nursing, Delhi, All India Institute of Hygiene and Public Health, Kolkata, Jawaharlal Institute of Postgraduate Medical Education and Research (JPMER), Puducherry, etc.
  • Medical research through Indian Council of Medical Research and the institutes under it, as also other institutions such as the Central Research Institute, Kasauli
  • International health and quarantile at major ports and international airports.
  • Drug control
  • Medical stores and supplies
  • Health education through Central Health Education Bureau
  • Health intelligence, through Central Health Intelligence Bureau.
Central Council of Health and Family Welfare
  • To consider and recommend broad outlines of policy in regard to matters concerning health in all its aspects such as the provision of remedial and preventive care, environmental hygiene, nutrition, health education and the promotion of facilities for training and research
  • To make proposals for legislation in fields of activity relating to medical and public health matters and to lay down patterns of development for the country as a whole
  • To make recommendations to the Central Government regarding distribution of available grants-in-aid for health purposes to the states and to review periodically the work accomplished in different areas through the utilization of these grants-in-aid
  • To establish any organization or organizations invested with appropriate functions for promoting and maintaining cooperation between the central and state health administrations.
State Level
There are 29 states in the country. Health, as states earlier is a state subject. Therefore, the pattern of organization, state of integration, level of health services, public health laws and scales of pay differ from state to state. The aim, however of all states and their public health administration is the same health, happiness and longevity for all the people.
State Ministry of Health: The ministry has a Minister and Deputy Minister of Health. The secretary and Joint secretary, etc. held by the Indian Administrative service (IAS) cadre.
State Health Directorate: The process of integration has now been completed in most states. The usual pattern now is that the State Health Directorate is headed by a Director, usually known as Director of Health Services, he is assisted by a suitable number of deputies to look after various health and medical health services. Some states also have a separate Director Medical Education.
District Level
Each state in Indian union is divided into districts. Total population in each district, urban as well as rural, varies from 1-3 million. Just as in case of states, some autonomy has been given to urban and rural areas in the district as well. The autonomous bodies or local self-government are called Corporation and Municipal Committees in the cities, Zilla Panchayats or Zilla Parishads in rural districts, Taluka Panchayat or Taluka Parishats in taluka level and Grama Panchayat and Nagara Panchayats in villages and small towns.
Health organizations in urban areas
There are three types of self-government in urban areas of district, depending upon the size of population:
  1. Town areas committees (5,000–100,000).
  2. Muncipal Board or Municipality (10–2,000,000).
  3. Corporation (above 200,000).
Town areas committees: Its functions primarily limited to provision of sanitary services.
Muncipal board or Muncipality: Its functions are more diverse. These include regulation regarding construction of houses, latrines and urinals, hotels and markets; provision of 65water supply, drainage and disposal of refuse and excreta, disposal of the dead, registration of births and deaths, keeping of dogs, and control of communicable diseases.
Corporation: It provides essentially the same services as the municipality, but on a larger scale. It also maintains hospitals and dispensaries.
Health organization in rural areas
Under Panchayat Act 1961, the district administration was reorganized into three levels, self-governing autonomous bodies were formed at different levels as follows:
  1. For each villages or group of villages with population from 1,000 to 10,000 there is a gram panchayat. If the population is over 10,000–30,000 there is a Nagar Panchayat. The gram panchayat in constituted by 15–30 elected members, who in turn elect a Sarpanch or President, Vice President, and Panchayat Secretary is recruited by government.
  2. For each block: There is a Panchayat Samiti or Taluka Panchayat, which is an elected body.
  3. For each district: There is a Zilla Panchayat or Parishad, which is an autonomous body for district as well as a whole, responsible to the State Assembly. It is constituted by elected members, MLAs, MPs.
In all above provision has been made for reservation for schedule caste, schedule tribes and women to ensure their active participation in all round development of the village.
Primary Health Care in India
  • In 1977, the Government of India launched a rural health scheme, based on the principles of ‘placing people's health in people's hands'
  • As a signatory to Alma-Ata Declaration, the Government of India is committed to achieving the goal of healthcare approach, which seeks to provide universal health care at a cost, which is affordable
  • Keeping in view the World Health Organization (WHO) goal of ‘Health for All’ by 2000 AD, the Government of India evolved a National Health Policy in 1983
  • Keeping in view the Millennium Developmental Goals, the Government of India revised the draft of National Health Policy in 2001.
Principles of Primary Health Care
  • Equitable distribution
  • Community participation
  • Intersectoral coordination
  • Appropriate technology
  • Preventive in nature
  • Man power development.
Comparison of Infrastructure in India and Karnataka
Primary Health Center
Primary health centers (PHC) are the cornerstone of rural health services, a first port of call to a qualified doctor of the public sector in rural areas for the sick and those who 66directly report or referred from sub centers for curative, preventive and promotive health care.
A typical primary health center covers a population of 20,000 in hilly, tribal or difficult areas and 30,000 populations in plain areas with four to six indoor/observation beds. It acts as a referral unit for six subcenters and refer out cases to community health center (CHC) (30-bedded hospital) and higher order public hospitals located at sub-district and district level.
Table 1   Comparison of infrastructure in India and Karnataka
District hospitals
Community health center (CHC)
Primary health center (PHC)
In order to provide optimal level of quality health care, a set of standards are being recommended for PHC to be called Indian Public Health Standards (IPHS) for PHCs. The launching of National Rural Health Mission (NRHM) has provided this opportunity.
Assured services or functions of primary health centers
Assured services cover all the essential elements of preventive, promotive, curative and rehabilitative primary health care. This implies a wide range of services that include:
  • Medical care:
    • Outpatient department (OPD) services: Minimum 4 hours in the morning and 2 hours in the evening
    • 24-hour emergency services
    • Referral services
    • Inpatient services (six beds).
  • Maternal and child health care including family planning:
    • Antenatal care: Early diagnosis, minimum three antenatal check-up, identification and management of high-risk pregnancies, nutrition and health counseling, minimum laboratory investigation such as urine albumin, test for syphilis, chemoprophylaxis for malaria in high endemic area as per National Vector Borne Disease Control Programe (NVBDCP)
    • Intranatal care (24-hour delivery services, both normal and assisted)
    • Postnatal care such as Janani Suraksha Yojana (JSY), minimum two postpartum visits, initiation of breastfeeding, health education on hygiene, contraception, etc.
    • Newborn care
    • Care of the child
    • Family planning.
  • Medical termination of pregnancies using manual vacuum aspiration (MVA) technique (wherever trained personnel and facility exists)
  • Management of reproductive tract infections/sexually transmitted infections
  • Nutrition services (coordinated with Integrated Child Development Service (ICDS)
  • School health
  • Adolescent health care
  • Promotion of safe drinking water and basic sanitation
  • Prevention and control of locally endemic diseases such as malaria, kala-azar,
  • Japanese encephalitis, etc.
  • Disease surveillance and control of epidemics
  • 67Collection and reporting of vital events
  • Education about health/behavior change communication (BCC)
  • National Health Programs including Reproductive and Child Health Program (RCH), National HIV/AIDS Control Program, Non-communicable Disease Control Program, etc.
  • Referral services
  • Training: Accredited social health activists (ASHA), auxiliary nurse midwives (ANM), lady health visitors (LHV)
  • Basic laboratory services
  • Monitoring and supervision
  • Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) services as per local people's preference (mainstreaming of AYUSH)
  • Rehabilitation
  • Selected surgical procedures.
Table 2   Manpower in primary health center
Medical Officer
2 (one may be from AYUSH* or lady Medical Officer)
Nurse-midwife (staff nurse)
Health worker (F)
Health educator
Health assistant (M and F)
Lady home visitor (LHV) and health assistant male
Laboratory technician
Class IV
*AYUSH, Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy
In the public sector, a subcenter is the most peripheral and first contact point between the primary healthcare system and the community. As per the population norms, one subcenter is established for every 5,000 population in plain areas and for every 3,000 population in hilly/tribal/desert areas. A subcenter provides interface with the community at the grass-root level, providing all the primary healthcare services. As subcenters are the first contact point with the community, the success of any nationwide program would depend largely on well-functioning subcenters providing services of acceptable standard to the people. The current levels of functioning of the subcenters are much below the expectations.
There is a need felt for quality management and quality assurance in healthcare delivery system so as to make the same more effective, economical and accountable. No concerted effort has been made so far to prepare comprehensive standards for the subcenters. The launching of National Rural Health Mission (NRHM) has provided the opportunity for framing Indian Public Health Standards.
68Objectives of subcenters
  1. To provide basic primary health care to the community.
  2. To achieve and maintain an acceptable standard of quality of care.
  3. To make the services more responsive and sensitive to the needs of the community.
The staff of the subcenter will have the support of ASHA wherever, the ASHA scheme is implemented/similar functionaries at village level in other areas. ASHA is primarily a trained woman volunteer, resident of the village-married/widow/divorced with formal education up to VIIIth standard preferably in the age group of 25–45 years. The general norm is one ASHA per 1,000 populations. The job functions of ANM, male health worker, ASHA and anganwadi worker (AWW) in the context of coordinated functions under NRHM.
Table 3   Manpower division in subcenter
Health worker (female)
Auxiliary nurse midwife
Health worker (male)
Multipurpose worker
Voluntary worker (paid ₹100 per month as honorarium)
Assured services or functions of primary health centers
Assured services cover all the essential elements of preventive, promotive, curative and rehabilitative primary health care. This implies a wide range of services that include:
  1. Maternal and child health care including family planning:
    1. Antenatal care: Early diagnosis, minimum three antenatal check up, identification and management of high-risk pregnancies, nutrition and health counseling, minimum laboratory investigation urin albumin, test for syphilis, chemoprophylaxis for malaria in high endemic area as per NVBDCP.
    2. Intranatal care: Promotion of institutional deliveries, skilled reference at home deliveries. Minimum two postpartum visit, initiation of breastfeeding, health education on hygiene, contraception, etc.
    3. Others: Provision of facilities under Janani Suraksha Yojna and NRHM.
    4. Postnatal care.
    5. Child health: Essential newborn care, promotion of exclusive breastfeeding, immunization of all children, prevention and control of all childhood disease.
  2. Family planning and contraception: Education, motivation and counseling to adopt family planning motheds, provision of contraception.
  3. Counseling and appropriate referral for safe abortion services for those in need.
  4. Adolescent health care.
  5. Assistance to school health services.
  6. Control local endemic diseases such as malaria, filariasis, etc.
  7. Disease surveillance.
  8. Water quality monitoring: Disinfection of water sources.
  9. Promotion of sanitation including use of toilets and appropriate garbage disposal.
  10. Field visits.
  11. Community needs assessment.
  12. Curative services: Provide treatment for minor ailments, referral service, organizing health day once in month at anganwadi.
  13. 69Training coordination and monitoring: Training of traditional birth attendants ASHA community health volunteers, monitoring of water quality.
  14. National Health Programs.
  15. Record of vital events.
Community Health Centers
Healthcare delivery in India has been envisaged at three levels namely primary, secondary and tertiary. The secondary level of health care essentially includes community health centers (CHCs), constituting the first referral units (FRUs) and the district hospitals. The CHCs were designed to provide referral health care for cases from the primary level and for cases in need of specialist care approaching the center directly. Four PHCs are included under each CHC, thus catering to approximately 80,000 populations in tribal/hilly areas and 1, 20,000 populations in plain areas. CHC is a 30-bedded hospitals providing specialist care in medicine, obstetrics and gynecology, surgery and pediatrics. These centers are however fulfilling the tasks entrusted to them only to a limited extent. The launch of the NRHM gives us the opportunity to have a fresh look at their functioning.
National Rural Health Mission (NRHM) envisages bringing up the CHC services to the level of Indian Public Health Standards. Although, there are already existing standards as prescribed by the Bureau of Indian Standards for 30 bedded hospital, these are at present not achievable as they are very resource intensive. Under the NRHM, the ASHA is being envisaged in each village to promote the health activities. With ASHA in place, there is bound to be a groundswell of demands for health services and the system needs to be geared to face the challenge. Not only does the system require upgradation to handle higher patient load, but emphasis also needs to be given to quality aspects to increase the level of patient satisfaction.
Objectives of Indian Public Health Standards (IPHS) for CHCs
  • To provide optimal expert care to the community
  • To achieve and maintain an acceptable standard of quality of care
  • To make the services more responsive and sensitive to the needs of the community.
Every CHC has to provide the following services, which can be known as the assured services:
  • Care of routine and emergency cases in surgery:
    • This includes incision and drainage, and surgery for hernia, hydrocele, appendicitis, hemorrhoids, fistula, etc.
    • Handling of emergencies such as intestinal obstruction, hemorrhage, etc.
  • Care of routine and emergency cases in medicine:
    • Specific mention is being made of handling of all emergencies in relation to the National Health Programs as per guidelines like dengue hemorrhagic fever, cerebral malaria, etc. Appropriate guidelines are already available under each program, which should be compiled in a single manual.
  • 24-hour delivery services including normal and assisted deliveries
  • Essential and emergency obstetric care including surgical interventions like cesarean sections and other medical interventions
  • Full range of family planning services including laparoscopic services
  • 70Safe abortion services
  • Newborn care
  • Routine and emergency care of sick children
  • Other management including nasal packing, tracheostomy, foreign body removal, etc.
  • All the National Health Programs (NHP) should be delivered through the CHCs
  • Others: Blood storage facility, essential laboratory services, referral (transport).
Table 4   Manpower at community health center
General surgeon
1 (proposed)
Public health program manager
1 (proposed)
1 (proposed)
Nurse-mid wife
Dresser (certified by Red Cross/St Johns Ambulance)
Laboratory technician
Ophthalmic assistant
1 (optional)
Ward boys
Outpatient department (OPD) attendant
Statistical assistant/Data entry operator
Operation theatre (OT) attendant
Registration clerk
India's public health system has been developed over the years as a three tier system, namely primary, secondary and tertiary level of health care. District health system is the fundamental basis for implementing various health policies and delivery of health care, management of health services for defined geographic area. District hospital is an essential component of the district health system and functions as a secondary level of health care, which provides curative, preventive and promotive healthcare services to the people in the district.
Every district is expected to have a district hospital linked with the public hospital/health centers down below the district such as subdistrict/subdivisional hospitals, community health centers, primary health centers and subcenters. However, some of the 71medical college hospitals or a subdivisional hospital is found to serve as a district hospital where a district hospital as such (particularly the newly created district) has not been established. Few districts have also more than one district hospital.
Objectives for District Hospitals
The overall objective of Indian Public Health Standards (IPHS) is to provide health care that is quality oriented and sensitive to the needs of the people of the district. The specific objectives of IPHS for District hospital (DHs) are:
  1. To provide comprehensive secondary health care (specialist and referral services) to the community through the district hospital.
  2. To achieve and maintain an acceptable standard of quality of care.
  3. To make the services more responsive and sensitive to the needs of the people of the district and the hospitals/centers from which the cases are referred to the district hospitals.
The term district hospital is used here to mean a hospital at the secondary referral level responsible for a district of a defined geographical area containing a defined population.
Grading of district hospitals
The size of a district hospital is a function of the hospital bed requirement, which in turn is a function of the size of the population it serves. In India the population size of a district varies from 35,000 to 3,000,000 (Census, 2001). Based on the assumptions of the annual rate of admission as 1 per 50 populations and average length of stay in a hospital as 5 days, the number of beds required for a district having a population of 10 lakhs will be around 300 beds. However, as the population of the district varies a lot, it would be prudent to prescribe norms by grading the size of the hospital as per the number of beds:
  • Grade I: District hospitals norms for 500 beds
  • Grade II: District hospitals norms for 300 beds
  • Grade III: District hospitals norms for 200 beds
  • Grade IV: District hospitals norms for 100 beds.
The disease prevalence in a district varies widely in type and complexities. It is not possible to treat all of them at district hospitals. Some may require the intervention of highly specialist services and use of sophisticated expensive medical equipments. Patients with such diseases can be transferred to tertiary and other specialized hospitals. A district hospital should however be able to serve 85–95% of the medical needs in the districts. It is expected that the hospital bed occupancy rate should be at least 80%.
  1. It provides effective, affordable healthcare services (curative including specialist services, preventive and promotive) for a defined population, with their full participation and in cooperation with agencies in the district that have similar concern. It covers both urban population (district headquarter town) and the rural population in the district.
  2. Function as a secondary level referral center for the public health institutions below the district level such as subdivisional hospitals, CHCs, PHCs and subcenter.
  3. To provide wide ranging technical and administrative support and education, and training for primary health care.
Essential services
Services include OPD, indoor and emergency services. Secondary level healthcare services regarding following specialties will be assured at hospital:
Consultation services with following specialists:
  • General medicine
  • General surgery
  • Obstetrics and gynecology
  • Pediatrics including neonatology
  • Emergency (accident and other emergency such as casualty)
  • Intensive care unit (ICU)
  • Anesthesia
  • Ophthalmology
  • Ear, nose, tongue (ENT)
  • Orthopedics
  • Radiology
  • Dental care
  • Public health management.
Paraclinical services:
  • Laboratory services
  • X-ray facility
  • Echocardiogram (ECG)
  • Blood transfusion and storage facilities
  • Physiotherapy
  • Dental technology (dental hygiene)
  • Drugs
  • Pharmacy.
Support services
  • Medicolegal/Postmortem
  • Ambulance services
  • Dietary services
  • Security services
  • Waste management
  • Warehousing/Central store
  • Maintenance and repair
  • Electric supply (power generation and stabilization)
  • Water supply (plumbing)
  • Heating, ventilation and air conditioning
  • Transport
  • Communication
  • Medical social work
  • Nursing services
  • Sterilization and disinfection.
Health Insurance
There is no universal health insurance in India. Health insurance is at present is limited to industrial workers and their families.
  1. 73Employees State Insurance Scheme: It was introduced by an Act of Parliament in 1948. It covers employees drawing wages not exceeding ₹15,000 per month.
    The act provides benefits such as:
    • Medical
    • Sickness
    • Disabled
    • Maternity
    • Dependent
    • Funeral.
  2. Central Government Health Scheme: This scheme was introduced in New Delhi in 1954 to provide comprehensive medical care to central government employees. The schemes based on the principles of cooperative effort by the employee and the mutual advantage of both.
    Facilities under the scheme include:
    • Outpatient care through a network of dispensaries
    • Supply of necessary drugs
    • Laboratory and X-ray investigation
    • Domiciliary visits
    • Hospitalization facilities at government as well as private hospitals recognized for the purpose
    • Special consultation
    • Pediatric services including immunization
    • Antenatal, natal and postnatal services
    • Emergency treatment
    • Supply of optical and dental aids at reasonable rate.
Other Agencies
Defense medical services: Defense services have their own organization for medical care to defense personnel under the banner ‘Armed Forces Medical Services’. The services are provided are integrated and comprehensive.
Health care of railway employees: The railways provide comprehensive healthcare services through the agencies of railway hospitals, health units and clinics. Environmental sanitation is taken care of by Health Inspectors in big stations. Health check-up of employees is provided at the time of recruitment and thereafter at yearly intervals.
Private Agencies
In a mixed economy such as India's private practice of medicine provides a large share of the health services available. There has been a rapid expansion in the number of qualified allopathic physicians to 7.5 lakh in 2005 and doctor population ration is 1:1,428. Most of them they concentrate in urban areas. They provide mainly curative services. Their services are available to those who can pay. The private sector of healthcare services is not organized.
Indigenous Systems of Medicine
The practitioners of indigenous system of medicine provide the bulk of medical care to the rural people. Ayurvedic physicians alone are estimated to be about 4.5 lakh. Nearly 90% of 74ayurvedic physicians serve the rural areas. To promote there indigenous systems, Indian Government established Indian Council for Indian Medicine in 1971. AYUSH is the new approach on this, which encompasses Ayurveda, Yoga, Unani, Siddha, Homeopathy.
  1. Standard safety measures.
Standard precautions previously called universal precautions assumes that blood and body fluid of any patient could be infectious and recommended personal protective equipment (PPE) and other infection control practices to prevent transmission of infections in any healthcare setting.
Universal Precautions
Universal precautions are infection control guidelines designed to protect workers from exposure to diseases spread by blood and certain body fluids.
Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. They are the basic level of infection control precautions, which are to be used in the care of all patients.
Universal Guidelines
  1. Consider sharp items such as needles, scalpel blades, etc. as potentially infective and handle with extraordinary care to prevent accidental injuries.
  2. Place disposable syringes and needles, scalpel blades, and other sharp items in puncture-resistant containers located near the practical area in which they were used. Needles should not be recapped, purposely bent, broken, removed from disposable syringes or otherwise manipulated by hand.
  3. Wear protective barriers to prevent exposure to blood, body fluids containing visible blood and other fluids to which universal precaution apply. The type of protective barriers should be appropriate for the procedure being performed and the type of exposure anticipated.
  4. Immediately and thoroughly wash hands and other skin surfaces that are contaminated with blood, body fluids to which universal precautions apply.
  5. Minimize the need for emergency mouth-to-mouth resuscitation by keeping mouthpieces, resuscitation bags or other ventilation devices easily available for use in areas, where the need is predictable.
  6. Extra care and proper precaution need to be maintained during pregnancy to protect the fetus from increased risk of infection.
  7. In the home setting, flush blood and body fluids down the toilet.
  8. Wrap contaminated items that cannot be flushed down the toilet securely in a plastic bag and place a second bag before discarding in a manner consistent with local regulations for solid waste disposal.
  9. Clean spills of blood and other body fluids with soap and water or a household detergent. Freshly prepared solutions of sodium hypochlorite in concentration of 1:10 dilutions are effective disinfectants. Gloves should be worn while cleaning spills.
Barrier Techniques and Isolation for Infection Prevention and Control
75Isolation is a protective procedure that limits the spread of infectious disease among hospitalized patients, hospital personnel and visitors. The transfer of pathogens from person to person can be decreased by limiting dissemination of pathogens. The most practical way to accomplish this is to control transmitting the pathogens.
The latest Center for Disease Control and Prevention (CDC) guidelines include major features of universal and body substance precautions, which include the importance of body fluids, secretions and excretions in the transmission of nosocomial pathogens. Nurses must understand the various isolation or barrier techniques, if they are to use them correctly and minimize infection risks to patients as well as themselves. There are two tiers of precautions.
Standard Precautions
Standard precautions used in the care of all hospitalized individuals regardless of their diagnosis or possible infection status, e.g. all body fluids, secretions and excretions. The standard precautions provide guidelines on:
  • Hand hygiene
  • Personal protective equipment, e.g. gloves, aprons, masks
  • Safe use and disposal of sharps
  • Safe management of waste and linen
  • Decontamination of patient care equipment (i.e. cleaning, sterilizing, disinfecting).
Transmission-based Precautions
Transmission-based precautions used in addition to standard precautions for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet or contact routes. Summary of CDC recommended practices for precautions.
General Measures
  • Minimize splashing of droplets or aerosols in all procedures, while handling potentially infectious materials
  • Take extra care to avoid accidental wounds from sharps contaminated with potentially infectious materials
  • Avoid contact of open skin lesions with infectious materials
  • Discard all disposable articles contaminated with blood in plastic bags or in container with sodium hypochlorite solutions with caution labels
  • Disinfect all nondisposable and reusable articles before sterilization
  • Discard needles and other sharp instruments in puncture resistant containers.
Do not's
  • Do not eat, drink, smoke or apply cosmetics in workplace
  • Do not do any paper work on potentially contaminated surfaces
  • Refrain from direct patient care with skin lesions
  • Do not keep glutaraldehyde solution beyond the recommended time after atiration.
There are three types of hand hygiene used in clinical settings each of which uses different preparations appropriate in different situations:
  1. Handwashing with plain soap and running water (social handwashing).
  2. Handwashing with antiseptic preparation and running water (aseptic handwashing).
  3. Alcohol-based hand rubs.
  4. Thoroughly wash hands with soap and water:
    • Before wearing gloves
    • After removing gloves
    • After completion of work
    • Before and after eating, preparing food or feeding
    • After using the toilet
    • After blowing nose, coughing or sneezing into the hands
    • Before invasive procedures
    • Before and after contact with wounds
    • After accidental contamination with blood and other body fluids
    • After examination of each patient
    • After handling soiled linen or waste
    • Before providing care to patients whose immune system is deficient
    • Scrub hands and forearms for at least 1-2 minutes for outdoor/minor/ward procedures and for at least 5 minutes for major procedures
    • Take care to clean under the nails with a sterile scrub brush
    • Dry ha nds using a hot blowers or disposable sterile towels
    • Use antiseptic solutions for hands and forearms for major operations.
Steps in Handwashing
Personal protective equipment
  • Wear gloves when there is anticipated contact with blood, body fluids, mucous membranes, non-intact skin, contaminated items or surfaces, and for performing all vascular access procedures
  • Wear gloves in all situations if there is a skin break on the hands
  • Remove after use, before touching non-contaminated items and surfaces, and before going to another patient; perform hand hygiene immediately after removal
  • Discard gloves that are peeling, cracked, discolored or have a visible tears or holes
Do not's
  • Do not wear gloves to examine a patient with intact skin
  • Do not touch eyes, nose, mouth or skin with gloved hands
  • Do not walk around the workplace wearing gloves.
Types of gloves and their uses
Latex gloves: Are used for procedures requiring a high degree of dexterity such as catheterization, surgical procedures, etc.77
zoom view
Figures 2A to J: Steps of handwashing: A. Palm to palm; B. Right palm over left dorsum; C. Left palm over right dorsum; D. Finger's interface palm to palm; E and F. Back of fingers to opposing palms; G. Rotational rubbing of right thumb; H. Rotational rubbing of left thumb; I. Rotational rubbing of left palm; J. Rotational rubbing of right palm.
Vinyl gloves: That are loosely fitting, are appropriate to wear when giving injection or cleaning spillage.
Gowns or aprons
Types of gowns and their uses
Water-repellent gowns: Are used for procedures where there is a risk of extensive splashing of blood, body fluids, secretions or secretions on to the skin or clothing:
  • During surgery
  • All obstetric procedures
  • Lifting a patient with a bleeding wound
  • Emergency care
  • Invasive procedures
  • Postmortem and embalming.
Disposable plastic aprons: Are worn to protect the front of the uniform from soiling, wetting or contamination that may occur during procedures involving close/direct contact with patients/clients such as, bed making, bathing, wound care, dealing with spillages, preparation and serving of food. Remove soiled gown as soon as possible and perform hand hygiene.
78Masks and eye covers
The purpose of mask and eye protection is to protect the wearer where there is a danger of pathogens in blood or other body substances splashing, splattering and spraying on to the mouth, nose and eyes, e.g. dental and operating theater procedures, airway suctioning, obstetrical procedures:
  • Eye protection equipment such as face shield, goggles and spectacles, must be optically clear, antifog and distortion free, close fitting and shielded at the sides
  • Mask are worn when there is a danger of bloodborne pathogens or other body fluids splashing or spraying into practitioner's mouth and nose. Their use is also indicated when caring for susceptible clients, e.g. people with compromised immunity or in situations when microorganisms will be transmitted from patients via the airborne route, e.g. meningococcal meningitis.
Shoe covers
  • Wear shoe covers in all situations where feet/shoes are likely to come in contact with body fluids:
    • During vaginal delivery
    • Urological procedures
    • Emergency care of severe trauma
    • Surgery in the perineal region
    • Prolonged surgical procedures.
  • Use overshoes made of waterproof material or change to a footwear with impervious soles.
Safe Use and Disposal of Sharps
The common guidelines are:
  • Handling sharps:
    • Avoid passing sharp from hand to hand
    • Minimize handling of sharp
    • Do not carry used sharp by hand or pass them to another person.
  • Sharp containers:
    • Used sharps must be discarded into sharps disposal containers
    • Sharp containers should be kept at all places where sharp objects are used
    • Containers are located in a safe position.
  • Disposing sharps:
    • Do not remove syringes by hand or resheath, bend or break them before disposal
    • Do not dismantle needles from syringes or other devices, but discard as a single unit
    • Dispose of needles and syringes immediately after use
    • Place sharp points downwards to sharp containers
    • Ensure containers are securely closed when three quarters are full
    • Ensure containers are disposed of in accordance with local policy
    • Needle safety devices are used when there are clear indications.
Managing Needle Stick Injuries
Following any accidental injury or accidental exposure to blood or body fluids by needle stick, another sharp or a splash of fluid is as follows.
  1. 79First aid:
    • Wash the needle stick or cut with soap and water
    • Flush splashes to the nose, mouth or skin with water
    • Irrigate splashes to the eyes with clean water or saline.
  2. Management:
    • Inform charge nurse immediately
    • Attend the designated treatment facility
    • For the postexposure treatment, dependent factors include
    • Infection status of the person whose body fluid or blood are involved
    • Type of exposure–splash on the skin or deep puncture wound
    • Whether or not the casualty had been vaccinated against hepatitis B
    • Time elapsed since exposure
    • Availability of needed drugs or other therapy.
  3. Documentation: Complete the relevant documentation for reporting accidents.
Safe Management of Waste and Linen
Management of Waste
Management of healthcare waste is a crucial aspect of infection control. Waste generated from healthcare facilities is classified as:
  1. Clinical waste: It is generated from many sources including health care, veterinary and pharmaceutical establishments. Because of its toxic, infectious or dangerous content, it may be hazardous to healthcare personnel, members of the public and environment.
  2. Domestic waste: This waste generated in clinical areas, is not hazardous to those who come into contact with it and can be safely disposed of as household waste.
Safe Handling of Waste
Dealing with clinical waste:
  • All infectious waste must be disposed off into leak resistant clinical waste bags
  • Gloves and aprons should be worn when handling clinical waste bags and containers
  • Clinical waste bags must be suspended in appropriate containers
  • Bags must not be filled not more than three quarters full and loose contents should never be transferred from bag to bag or compacted by hand; this will avoid injuries from concealed sharps that may have inadvertently been discarded with clinical waste
  • All bags must indicate their origin and be labeled with the name of the facility
  • Bags must be sealed at the point of production with a plastic tie closure or heat sealer
  • Waste must not be allowed to accumulate in corridors or other undesignated areas because it could cause harm to others.
Dealing with Spillages
  • Appropriate protective clothing, e.g. gloves and plastic apron can be worn
  • Any spilled fluid may be mopped up with absorbent material
  • Carefully place contaminated material in a new clinical waste bag together with all other spilled clinical waste material
  • 80Seal and label the bag, and dispose of in line with local policy
  • Disinfect the spillage area according to local policy, e.g. hypochlorite
  • Remove protective clothing and wash hands.
Management of Linen
Used linen such as clothings, sheets, pillow covers, towels, etc. should be laundered:
  • Between patient use
  • When visibly soiled
  • At least weekly.
In healthcare facilities, linen that is soiled with blood, excreta or other body fluids, or contaminated with microorganisms from infectious patients, needs to be handled carefully in order to prevent:
  • Contamination of the skin and clothing of the health care personnel
  • Transfer of microorganisms to other patients or clients and environments.
Safe Handling of Linen
To prevent cross infection it is important that linen in healthcare facilities is handled in the same way for all patients. Personal Protective Equipment (PPE) should be worn when handling linen. Safe handling of soiled linen has more importance in infection control.
Linen is handled with minimal agitation and shaking to avoid the dispersal of microorganisms into the air and onto people or objects in the vicinity:
  • Heavily soiled linen is rolled or folded to contain the heaviest soil in the center of the bundle
  • Containment of linen is achieved by placing it immediately into a collection bag at the site of generation. Rinsing or soaking of linen is never carried out due to the risk of splashing of body fluids on to the skin or mucous membranes
  • Ensure that sharps and other objects are not inadvertently discarded into linen bags, which minimizes the risk of injury to pottering and laundry staff.
Decontamination of Patient Care Equipment
Patient care equipment can act as an intermediary in transferring infectious microorganisms from one person to another. It is therefore important that shared or reusable patient care equipment is decontaminated, i.e. made safe by removing, inhibiting or destroying microorganisms, after use. Decontamination includes:
  1. Cleaning: This physical process involves decontaminating an item or surface with a detergent solution followed by thorough drying. Cleaning contributes to infection control because it physically removes organic materials, e.g. blood, other body fluids, soil or dust in which microorganisms can survive. Cleaning is also essential prior to disinfection and sterilization, otherwise microorganisms trapped in organic material may survive further processing.
  2. Sterilization: It is the complete destruction of all living microorganisms including bacterial spores. Sterilization is required for all high-risk procedures and sterilized items need to be stored correctly and checked prior to opening.
  3. Disinfection: It is the destruction or removal of microorganisms to a level that is unlikely to cause infection it does not guarantee complete removal of microorganisms, 81because bacterial spores can still survive, i.e. some form of bacterial life may still be present after disinfection. Disinfection can be achieved by both thermal and chemical methods.
Respiratory Hygiene and Cough Etiquette
Persons with Respiratory Symptoms Should Apply Source Control Measures
Cover their nose and mouth when coughing/sneezing with tissue or mask, dispose of used tissues and masks, and perform hand hygiene after contact with respiratory secretions.
Healthcare Facilities
  1. Place acute febrile respiratory symptomatic patients at least 1 (3 ft) away from others in common waiting areas, if possible.
  2. Postvisual alerts at the entrance to healthcare facilities instructing persons with respiratory symptoms to practice respiratory hygiene/cough etiquette.
  3. Make hand hygiene resources, tissues and masks available in common areas and areas used for the evaluation of patients with respiratory illnesses.
Note: Do not PPE before contact with the patient, generally before entering the room. Use, remove and discard carefully, either at the doorway or immediately outside patient room; remove respirator outside room. Immediately perform hand hygiene.
Transmission-based Precautions
Airborne Precaution
Used for patients who have infections that spread through the air such as tuberculosis, varicella (chicken pox) and rubella (measles).
  1. Place patient in private room that has monitored negative air pressure in relation to surrounding areas 6–12 air changes per hour and appropriate discharge of air outside or monitored filtration if air recirculates.
  2. Keep door closed and patient in the room.
  3. Use respiratory protection when entering room of patient with known or suspected tuberculosis. If patient has known or suspected rubella (measles) or varicella (chicken pox), respiratory protection should be worn unless person entering room is immune to these diseases.
  4. 82Transport patient out of room only when necessary and place a surgical mask on the patient if possible. Consult CDC guidelines for additional prevention strategies for tuberculosis.
Droplet Precautions
Droplet precautions are used for patients with an infection that spread by large particle droplets such as rubella, mumps, diphtheria and the adenovirus infection in infants and young children:
  1. Use a private room, if available. Door may remain open.
  2. Wear a mask when working within 3 ft of patient.
  3. Transport patient out of room only when necessary and place a surgical mask on the patient if possible.
  4. Keep visitors 3 ft from the infected person.
Contact Precautions
Use these for patients who are infected or colonized by a microorganism that spreads through indirect contact:
  1. Place the patient in a private room, if available.
  2. Wear gloves whenever enter the room.
  3. Change gloves after having contact with infective material. Remove gloves before leaving the environment and wash hands with an antimicrobial or waterless antiseptic agent.
  4. Avoid sharing patient care equipment.
  1. Performance appraisal in nursing.
Performance appraisal means the systematic evaluation of the performance of an expert or immediate superior.
Edwin B Flippo, “performance appraisal is a systematic, periodic and so far as humanly possible, an impartial rating of an employee's excellence in matters pertaining to his present job and to his potentialities for a better job.”
The performance of an employee is compared with the job standards. The job standards are already fixed by the management for an effective appraisal.
According to Scott, Clothier and Spriegel, “performance appraisal is a record of progress for apprentices and regular employees, as a guide in making promotions, transfer or demotions, as a guide in making lists for bonus distribution, for seniority consideration and for rates of pay, as an instrument for discovering hidden genius, and as a source of information that makes conferences with employees helpful.”
  1. To determine the effectiveness of employees on their present jobs so as to decide their benefits.
  2. To identify the shortcomings of employees so as to overcome them through systematic guidance and training.
  3. To find out their potential for promotion and advancement.
Purposes and Benefits
Performance appraisal can serve many purposes and has several benefits. Among them are:
  1. To provide backup data for management decisions concerning salary standards, merit increases, selection of qualified individuals for hiring, promotion or transfer and demotion or termination of unsatisfactory employees.
  2. 83To serve as a check on hiring and recruiting practices, and as validation of employment tests.
  3. To motivate employees by providing feedback about their work.
  4. To discover the aspirations of employees and to reconcile them with the goals of the organization.
  5. To provide employees with recognition for accomplishments.
  6. To improve communication between supervisor and employee, and to reach an understanding on the objectives of the job.
  7. To help supervisors observe their subordinates more closely, to do a better coaching job and to give supervisors a stronger part to play in personnel management and employee development.
  8. To establish standards of job performance.
  9. To improve organizational development by identifying training and development needs to employees, and designing objectives for training programs based on those needs.
  10. To earmark candidates for supervisory and management developments.
  11. To help the organization determine if it is meeting its goals.
Principles of Performance Appraisal
  1. Single employee is rated by two raters. Then, the comparison is made to get accurate rating.
  2. Continuous and personal observation of an employee is essential to make effective performance appraisal.
  3. The rating should be done by an immediate superior of any subordinate in an organization.
  4. A separate department may be created for effective performance appraisal.
  5. The rating is conveyed to the concerned employee. It helps in several ways. The employee can understand the position where stands and where should go.
  6. The plus points of an employee should be recognized. At the same time, the minus points should not be highlighted too much, but they may be hinted to employee.
  7. The management should create confidence in the minds of employees.
  8. The standard for each job should be determined by the management.
  9. Separate printed forms should be used for performance appraisal to each job according to the nature of the job.
Kinds of Performance Appraisal
There are many kinds of performance appraisal available. But the management wants to adopt only one of the types of performance appraisal. The appraisal is done adopting any one of the two approaches. These two approaches are traits and results. The traits approach refers to appraising the employee on the basis of attitudes. The result approach refers to appraising the employee on the basis of results of accomplishments of a job.
Ranking Method
Ranking method is very old and simple form of performance appraisal. An employee is ranked one against the other in the working group under this method.
84For example, if there are 10 workers in the working group, the most efficient worker is ranked as number one and the least efficient worker is ranked as number 10.
  1. Each employee or worker can be compared with the other person.
  2. A small organization can get maximum benefits through the ranking method.
  1. A big organization is not able to get sizable benefits from the ranking method.
  2. Ranking method does not evaluate the individuality of an employee.
  3. It lags objectivity in the assessment of employees.
Paired Comparison Method
Paired comparison method is a part of ranking method. Paired comparison method has been developed to be used in a big organization. Each employee is compared with other employees taking only one at a time. The evaluator compares two employees and puts a tick mark against an employee whom he/she considers a better employee. In the same way, an individual is compared with all other existing employees. Finally, an employee who gets maximum ticks for being a better employee is considered as best employee.
  1. This method is suitable for big organizations.
  2. Individual traits are evaluated under this method.
  1. The understanding of this method is difficult one.
  2. It involves considerable time.
Forced Distribution Method
A method, which forces the rater to distribute the ratings of the overall performance of an employee is known as forced distribution method. Groupwise rating is done under this method. This method is suitable to large organizations, but the individual traits could not be appraised under this method.
For example, a group of workers doing the same job would fall into the same group as superior, at and above average, below average and poor. The rater rates 15% of the workers as superior, 35% of the workers as at and above average, 35% of workers as below average and 15% of workers as poor.
Certain categories of abilities or performance of employees are defined well in advance to fall in certain grades under this method. Such grades are very good, good, average, poor and very poor. Here, the individual traits and characteristics are identified.
The appraisal of the ability of an employee through getting answers for a number of questions is called the method of checklist. These questions are related to the behavior of an employee. The evaluation is done by a separate department, but the duty of collection 85of checklist answers is given to a person who is designated as a rater. The rater indicates the answers of an employee against each question by putting a tick mark. There are two columns provided to each question as yes or no.
A model checklist is given below:
  1. Is the employee satisfied with the job?
  1. Does employee finish the job accurately?
  1. Does the staff respect the superiors?
  1. Is ready to accept responsibilities?
  1. Does employee obey the orders?
Forced Choice Method
A series of groups of statements are prepared positively or negatively under this method, both these statements describe the characteristics of an employee, but the rater is forced to tick any one of the statements either out of positive statements or out of negative statements. The degree of description of the characteristics of an employee varies from one statement to another.
The following are the positive statements:
  1. The employee completes the job in time usually.
  2. The employee has the ability to complete the job and complete the job as and when there is a need.
The negative statements are also prepared. The final rating is done on the basis of all such statements. But, the ratter does not know the statements, which are for final rating.
Critical Incident Method
The performance appraisal of an employee is done on the basis of the incidents occurred really to the concerned employee. Some incidents occurred due to the inability of the employee, but the rating is done on all the events occurred in a particular period.
Some of the events or incidents are given below:
  1. Refused to cooperate with other employees.
  2. Unwilling to attend further training.
  3. Got angry over work or with subordinates.
  4. Suggested a change in the method of production.
  5. Suggested a procedure to improve the quality of goods.
  6. Suggestion of a method to avoid or minimize wastage, spoilage and scrap.
  7. Refused to obey orders.
  8. Refused to follow clear cut instructions.
Field Review Method
An employee's performance is appraised through an interview between the rater and the immediate superior or superior of a concerned employee. The rator asks the superiors questions about the performance of an employee, the personnel department prepares a detail report on the basis of this collected information. A copy of this report is placed in the personnel file of the concerned employee after getting approval from the superior.
The success of this type of appraisal method is based on the competence of the interviewer.
Easy Evaluation
With easy evaluation technique the Nurse Manager is required to describe the employee's performance over the entire evaluation period by writing a narrative detailing the strength and weaknesses of the appraise. If done correctly this approach can provide a good deal of valuable data for discussion in the appraisal interview.
Characteristics and Obstacles
The following characteristics are essential elements of effective performance appraisal:
  1. The philosophy, purpose and objectives of the organization are clearly stated, so that performance appraisal tools can be designed to reflect these.
  2. The purposes of performance appraisal are identified, communicated and understood.
  3. Job descriptions are written in such a manner that standards of job performance can be identified for each job.
  4. The appraisal tool used is suited to the purposes for which it will be utilized and is accompanied by clear instructions for its use.
  5. Evaluators are trained in the use of the tool.
  6. The performance appraisal procedure is delineated, communicated and understood.
  7. Plans for policing the appraisal procedure and evaluation appraisal tools are developed and implemented.
  8. Performance appraisal has the full support of top management.
  9. Performance appraisal is considered to be fair and productive by all who participate in it.
Limitations of Performance Appraisal
The following are the limitations of performance appraisal:
  1. The performance appraisal methods are unreliable.
  2. If an employee is wellknown to an employer, the performance appraisal may not be correct.
  3. The inability of supervision to appraise an employee does not bring out the accurate performance appraisal.
  4. Some qualities of an employee cannot be easily appraised through any performance appraisal method.
  5. A supervisor may appraise an employee to be good to avoid incurring displeasure.
  6. Uniform standards are not followed by the supervisors in the performance appraisal.
Potential Appraisal Problems
  1. Leniency error: The tendency of a Manager to over rate staff performance.
  2. Recency error: The tendency of a Manager to rate an employee based on recent events rather than over the entire evaluation period.
  3. Halo error: The failure to differentiate among various performance dimensions when evaluating.
  4. Ambiguous evaluation standards problem: The tendency of evaluators to place differing connotations on rating scale words.
  5. Written comments problem: The tendency of evaluators does not include written comments on appraisal forms.
  1. 87Inventory control
Inventory control mean stocking adequate number and kind of stores, so that the materials are available whenever required. High inventory level leads to high cost of inventories by:
  1. Locking the finance.
  2. Large storage space.
  3. Large handling and administration charges.
  4. Obsolescence.
  5. Spoilage, etc.
ABC analysis
ABC analysis is the analysis of stores items on cost criteria. It has been seen that a large number of items consume only a small percentage of resources and vice versa:
  1. A items: Represents high-cost center.
  2. B items: Intermediate-cost center.
  3. C items: Low-cost center:
    • It helps in economizing ones effort to achieve greater results
    • It helps to segregating those items, which ought to be given priority to maximize results.
ABC analysis tells us that 5-10% of all items (called A category) accounts for 70% of annual consumption costs, another 10–20% of items (B category) account for 20–30% of the costs, while the balance 70% of items (C category) account for about 5–10% of costs:
  • The usefulness of this management tool is that, by focusing on the ‘A’ category items, 70% results can be achieved with just 5% effort
  • Once A category items are identified, it is possible to devote more attention to these items to minimize purchase costs and exercise control over consumption in a more effective manner
  • Other strategies in material management:
    • Purchase planning
    • Forecasting
    • Negotiating prices
    • Minimizing inventory carrying costs
    • Minimizing unofficial inventory
    • Restricting usage
    • Controlling wastage
    • Managing closing stock
    • Audit.
These show greatest results when applied with emphasis on ‘A’ category.
A Items
  • Tight controls
  • Rigid estimates
  • Strict and close watch
  • Safety stocks should be low
  • Management of items should be done at top management level.
B Items
  • Moderate controls
  • Purchase based on rigid requirement
  • Reasonably strict watch and control
  • Safety stocks moderate
  • Management is done at middle level.
C Items
  • Ordinarily control measures
  • Purchased based on usage estimates
  • Controls exercises by storekeeper
  • Safety stocks high
  • Management is done at lower levels.
Rate of Consumption
The items can be classified into:
  • Fast moving
  • Slow moving
  • Nonmoving
  • Obsolete.
VED analysis
The stores when subjected to analysis based on their criticality can be classified into vital, essential and desirable stores. This analysis is termed as VED analysis. V items require a large safety stock, whereas D items can do with little or no reserve.
Inventory Control Methods
Intuitive Method
Intuitive is the ‘want book method’ that is most effective method. The items are recorded in the want book, when the number of units in stock reaches close to zero. The amount ordered then is the best estimate for the storekeeper or worker in the field.
Perpetual Inventory Method
Perpetual inventory method is one of the best accurate and effective methods of inventory are, of course, an ideal situation if the record keeping can be kept up-to-date.
ABC Method
ABC method is based on the fact that some stock items have a much higher annual usage value than others. This after doing a cost analysis, stock items are separated into three classes as listed in Table.
VED Method
In vital, essential and desirable (VED) method each stock item is classified on either vital, essential or desirable based on how critical the item is for providing health services. The vital items are stocked in abundance, essential items are stocked in medium amounts and desirable items we stocked in small amounts. Vital and essential items are always in stock, which means a minimum disruption in the services offered to the people.
Table 5   ABC method
Class number of total items
Rupees value of items
A 10%
B 20%
C 70%
Two-bin Methods
Two-bin methods separate the stock of each item into two bins. One box contains the main stock, the second bin contains enough stock to satisfy demand during the period necessary for replenishment. When the first bin is exhausted, an order for replenishment is immediately placed.
The techniques commonly applied for inventory control are:
  1. ABC analysis.
  2. Setting of various levels.
  3. Use of perceptual inventory, records and continuous stock verification.
  4. Economic order in quantity.
  5. Review of slow moving and non-moving items.
  6. Use of control ratios like:
    • Material consumer/Average inventory
    • Slow moving stores/Total inventory
    • Total inventory/Cost of production
    • Cost of sales/Average finished goods inventory.
Accounting for Inventory
The inventory is being treated as unconsumed expenses and hence is shown in the asset side of the balance sheet under the head of current assets. One must notice that the process of increasing the inventory or stock by entering assets, which were previously omitted must be done either by decreasing other assets like cash in hand or bank balance or by increasing the liabilities of the hospital so as to maintain the ‘double entry principle’.
Perpetual Inventory (Automatic Inventory) System
The control of material, while in storage is effected through what is known as the perpetual inventory. The purpose of perpetual inventory system is:
  1. Recording stores receipts and issues so as to determine at any time the stock in hand, in quantity or value, or both without the need for physical count of stock.
  2. Continuous verification of the physical stock with reference or the balance recorded in the stores records, at any frequency as convenient for the management.
90Perpetual inventory system comprised of:
  • Bin cards (quantitative perceptual inventory)
  • Stores ledger (quantitative cum valued perceptual inventory)
  • Continuous stock taking (physical perceptual inventory).
Bin card
Bin card is a quantitative record of receipts, issues and closing balances of items of stores. Separate bin cards are maintained for each item of medicine or any other material and are placed in shelves or bins, or are suitably hung up as convenient, alongside materials and medicine. If it is not possible all bin cards may be maintained in a single place by using any of the filling techniques.
Stores Ledger
Stores ledger is maintained to record all receipts and issues transaction in respect of materials with the difference that along with the quantities, the values are entered in the receipt, issues and balance columns.
Continuous Physical Stock Verification
The perpetual inventory system is not complete without a systematic procedure for physical verification of stores. The bin cards and stores ledger record the balance, but their correctness can be verified by means of physical verification only.
Three methods of recording the results of stock verification are described below:
  1. Inventory tags: Like a bin card, ‘inventory tag’ is hung along the sides of materials or medicines. Whenever verification is made an entry must be made in the inventory tag with remarks.
  2. Bin cards: Instead of maintaining a separate ‘inventory tag’, entries can be made in ‘bin cards’ itself whenever physical verification is made.
  3. Stock verification sheets: It is necessary to record the result of stock verification in a separate record or sheet. The sheets are maintained data wise, so that when arranged together they give a chronological list of items verified.
zoom view
Figure 3: Stock verification
Periodic stock verification
The entire stock is verified all at a time, at periodical intervals, usually once in a year. It is advantageous to have the verification at the close of the annual accounting period, so as to facilitate valuation of stores for exhibition in the final accounts.
  1. Innovation in nursing.
Refer May 2011 (Part I), Short Essays Question No. 7.
91Nursing Management
Paper 2012 November
  1. Discuss the current trends and issues in nursing administration and nursing education.
  2. Explain the levels of curriculum planning and discuss the role of a principal in the curriculum planning of the institution.
  3. What are the characteristic of an effective leader? Discuss and rationalize the leadership style likely to be adopted by the nursing superintendent of a hospital.
  4. Explain the importance of quality assurance in nursing services.
  1. Use of computers in hospital and community.
  2. Consumer Protection Act.
  3. Disaster management.
  4. Principles and techniques of supervision.
  1. Discuss the current trends and issues in nursing administration and nursing education.
Nursing possesses a rich history characterized by compassion, dedication and service. As society's culture continues to experience change, the profession of nursing is undergoing continuous evolution.
Current Trends and Development in Nursing Administration
Nursing Service in Ancient Times
Introduction to simple nursing can be traced to ancient civilization. In the book of Charaka, it is mentioned that, “The physician, drug, nurse and patient constitute an aggregate of four.” Nurse educators and administrators are now stating a new framework in which the graduate nurse should function.
Influence of Christian Era on Nursing Services
The Parable of Good Samaritan is closely interwoven into nursing service. The Christians applied the parable into their concern for the welfare of the individual. The attitude of taking care of a person as a patient has continued to influence nursing service and hospitals.
The ideal of service has been far reaching in the history of nursing service. Nursing service today realizes that after all, nurses are human too and are entitled to a decent living.
Emergence of Modern Nursing Service
In the 18th century with the emergence of modern medicine and hospital, adequate nursing service became a prime necessity. The expected qualities of nurses included her being fit and able to go through the necessary fatigue of her undertakings, a good watcher, quick in hearing, well-tempered, cheerful, pleasant constantly careful and diligent at night and day, sober, observant to follow physician's order.
Nursing Service Within the Modern Hospital
During 1935–1950, social forces had a tremendous influence upon the development of nursing services. In 1936, the manual essentials of good hospital service was published under the sponsorship of the American Hospital Association and the National League for Nursing Education. This was published to give recognition to the minimum standards of average patient care. The purpose of the manual was to set up principles by which nursing services could function.
Administration was concerned with placing of nursing service as a whole in the hospital. The director of nurses won control over many administrative aspects of the nursing service. Nursing service continued to be responsible for supplies and equipment and for the employment and discharge of nursing service personnel. With the expansion of services to patients, the nursing director was forced to delegate more responsibility and authority to the nurses of the patient's unit. The role of graduate nurse in most hospitals became one of coordinating nursing services and hospital services.
Nursing Service in a Bureaucratic System
The second phase of hospital and nursing service administration is called the bureaucratic system of control. The nursing service groups were brought under one line of authority.
The informal relations unite people together and the vertical lines of communication unite the level of hierarchy. During the system, the decisions were made through the interaction of three groups; the administration, the medical staff and the board of trustees.
Hospital Nursing Service at Midcentury
During the period from 1950s, numerous studies were performed on problems related to patient care. At mid century, the tradition of the hospital as the clinical workshop for the doctor was changed to the patient-centered institution. Specialists began working together to meet the total needs of the patient.
Emergence of Nursing Service Administration
The National Nursing Council published its report ‘Nursing for the Future’, which is known as the Brown's Report. Brown's view point was that nursing service and nursing education should be viewed in terms of what is good for the society. The report indicated that, in nursing service, administrative and supervisory staffs tend to be authoritarian and nurses had little freedom in taking decisions and judgment for the care of patients. Little opportunity was provided for nurse administrators to participate in policy decision making. Brown's report 93pointed out the need for sound legislation regarding, the training and functions of practical nurse and other health workers and also stressed the need for professional and highly technical nursing education and mentioned that, it should be undertaken by universities and colleges.
The study conducted at Teacher's College, Columbia University, resulted in the establishment of courses in nursing service administration. The first definition of nursing administration was formulated “Nursing service administration is a coordinated system of activities, which provide all the facilities necessary for rendering of nursing care to the patient, it includes establishment of goals and policies.”
Emergence of Patient-centered Approach
In 1951, a research and experimental program on the organization of nursing services on a team basis, began at Teacher's College Columbia University and as a result, the concept of team nursing emerged. The newer philosophy in nursing is the patient-centered approach, it stresses a more flexible and creative approach to both supervision and administration in nursing service. The idea of nursing is the holistic approach, that has given dignity and meaning to the concept of nursing service.
In 1962, the progressive patient care plan emerged. It refers to the organization of facilities, services and staff around the medical and nursing needs of patients.
Future of Nursing
Nursing continue to be challenged and rewarded by both new and changing opportunities and constraints. Professional nursing's image continues to be major challenge for all nurses individually and collectively. A number of forces that have affected the development of professional nursing still continue to affect a significant issue, which includes:
  • Societal images and expectation of nurses
  • Degree of the nursing profession's control over the quantity and quality of practitioners
  • Impact of technology and theory on nursing practices roles and setting
  • Professional self-image of nurses
  • Sources of financing for healthcare services.
The changes that seem likely to occur in due course will be changes in the demographics, the deteriorating environment, risky lifestyles and economics of health care and governmental regulation of health care. The changes will be accomplished by changes in both nursing practice and nursing education.
Current Issues of Nursing
There so many issues occurring in the nursing profession, which turned, as these were obstacles to provide proper nursing services to the patients and public at large. These problems can be classified under following heading:
  1. Nursing services.
  2. Nursing education.
  3. Nursing administration.
Nursing Services
Poor working conditions
Nursing personnel constitute a major portion of health manpower. Nursing has permitted into the entire healthcare delivery system to assist the individual in those activities, which contribute to the attainment, sustainment and restoration of health at any point of his or her life cycle within the home, school, workplace, hospital or community at large. But the present working condition of nursing personnel is very poor. This may be due to improper job descriptions, long hours of work and split duty.
Recruitment of trained nurses should be made by selecting candidates, who are settled and trained in their respective states. It is always better to withdraw the selection of nurses by the public service commissioners immediately, as it was badly experienced by the locally trained nurse candidates in recent selection procedure.
Job description
Previously, the job descriptions of nurses were made by the non-nursing persons, so it will not suit the present working pattern of nurses. The clear job description of nurses of all categories needs to be drafted and enforced into practice.
Lengthy hours of duty and split duty
In most of the states and union territories, the duty schedule is ‘on duty’, ‘off duty’ and ‘night duty’. Nurses working hours are more than any of the other government employees. Weekly working hours should be reduced to 40 hours per week; straight shift should be implemented immediately. Extra working to be compensated either by leave or extra emoluments are recommended by the High Power Committee on Nurses and Nursing.
Less salary, allowances and other incentives
Less salary, allowances and other incentives affects private nurses, than government staff nurses.
Less promotional opportunities
Everybody knows that there are less promotional opportunities for nurses. Therefore it should be considered that, each nurse should have at least three promotions during his/her service period as recommended by High Power Committee (1989).
Harassment of nurses by others
There are some instances occurred in various circumstances in different places, harassment of nurses by clerical staff, while taking their salaries and claiming other arrears, leave of their own credit and sometimes by the administrators of the institution.
Nurses working in between doctors on one side and the other side, group ‘D’ officials are facing so many problems. Nowadays, it is very difficult for nurses to control the group ‘D’ officials for so many reasons.
Improper supplies
In most of the hospitals and other health institutions, no standard has been followed in supply of drugs, equipment and linen, etc. For the comfort and other aspects of patients, there is a need to change linen every day. In real sense, sometimes, it is not practicable due to dhobi problem and tearing of linen due to its substandard quality.
Nursing Education
Government institutions
The government schools and colleges face so many problems as mentioned below:
  1. No independent building for schools.
  2. No independent principal for schools.
  3. Inadequate hostel facilities for students.
  4. Acute shortage of qualified teachers in nursing.
  5. Under utilization of clinical facilities.
  6. Inadequate library facilities.
  7. No transport facilities.
  8. No university grants commission (UGC) status for college teachers in nursing.
  9. Less stipend for nursing students.
  10. Variation of salaries from one state to other State or Central Government.
  11. Less supply of audiovisual (AV) aids.
  12. Less promotional opportunities for teachers of both schools and colleges.
  13. No separate budget for schools.
Private institutions
  1. Some private institutions have good facilities, but do not have sufficient and qualified teachers.
  2. Most of the private institutions of nursing are running in hired buildings, hostels, where there are no qualified hands to teach nursing.
  3. Most of the private bodies want students from neighboring states. Most of the institutes have no hospital for their clinical facilities, they depend on government hospitals.
  4. It is always better to stop sanctioning new private nursing schools and colleges. The State Nursing Council and Government should take certain steps to study the facilities according to norms laid by the Indian Nursing Council (INC). Those institutions not meeting the standards should be derecognized and stopped.
Nursing Administration
As far as nursing administration is concerned, it is in pathetic condition. Health Survey and Development Committee (1946), recommended to give gazette ranks for nurse managers and World Health Organization (WHO) guidelines are therefore giving decision-making power to nurses. Both union and State Governments have decided to give some gazette ranks to nurses.
Issues of nursing administration
Issues of nursing administration are as given below:
  1. Noninvolvement of nursing administrators in planning and decision-making in the governmental hospital administration.
  2. No specific power has been assigned to nursing superintendents, but he/she has been made in charge of all inventories and linen of hospital.
  3. Nursing superintendent will have no authorities to sanction leave to their subordinates.
  4. Lack of knowledge in management of hospital among medical/nursing administrators.
  5. Unnecessary interference of non-nursing personnel in nursing administration.
  6. 96No written nursing policies and manuals.
  7. No proper job description for various nursing cadres.
  8. No special incentives like, Republic Day Awards, Teachers Awards, etc.
  9. Inefficiency of nursing councils of state and union to maintain standards in nursing.
  10. No organized staff development program, which includes orientation, in-service education, certified nurse educator (CNE), etc.
  1. Explain the levels of curriculum planning and discuss the role of principal in the curriculum planning of the institution.
  1. Curriculum is the systematic arrangement of the sum total of selected experiences planned by a school for a defined group of students, to attain the aim of particular educational program.
    Florence Nightingale International Foundation; basic nursing education
  2. Curriculum is the composite of the entire range of experiences the learner undergoes under the guidance of the school.
    Lambertson E
  3. All means employed by the school to provide the students with opportunity for desirable experiences.
    Edward and Crug
Principles of Nursing Curriculum
  1. The students should equip with the essential knowledge, skills and attitude.
  2. Expected results of curriculum should be made clear to students.
  3. Teacher considered as facilitator.
  4. Should consider the community needs with emphasis on health needs, lifestyle and cultural background.
  5. Influence of media, modern lifestyles and special measures formed to inculcate right attitude.
  6. Adequate teaching, learning, activities in classroom, clinical and community settings.
  7. Should follow guidelines laid down by statutory bodies.
  8. Nursing curriculum should give importance to high-tech, high-touch approach in nursing care.
  9. Should maintain human component of nursing in the midst of technological advancements in patient care.
  10. Learning environment should closely resemble life situation.
  11. Should involve participatory approach in teaching-learning process.
Phases in Curriculum Administration
There are three phases involved in curriculum administration.
Phase 1: Curriculum Planning
Curriculum planning is a dynamic nature of human life and essential feature of administrative programs of institution and its concomitant effect on the educational scene. Integrated theories of curriculum planning in free India are:
  • 97Faith in each Indian citizen as an end
  • Building new social order in India according to the constitution
  • Democratic way of the life
  • Planned national development
  • Scientific and national free approach to the problems of individual and nation
  • Development of secular outlook and national integration
  • Improvement of economic standards of living
  • International understanding, cooperation and world peace.
Phase 2: Curriculum Organization
Curriculum organization is a prerequisite of any kind of institutional program. In each course of study, subject wise, classwise curriculum organization takes place. The detailed syllabi are prepared as these serve as the bases for writing the textbooks. Highly centralized and decentralized system of curriculum construction, reconstruction and administration are functional aspects to be satisfied for the effective implementation of curricular program.
Educational machinery of state government has to take chief responsibility of curriculum organization as it develops educational policy and its effective implementation for financing adequately the organization of educational programs in schools and colleges. Freedom has to be given to implement curriculum at the school. The effectiveness of curriculum organization depends on:
  1. Quality of syllabi prescribed.
  2. Type of handbooks and textbooks prepared.
  3. Adequacy of guidance provided to teachers.
  4. Institutional aids supplied.
Phase 3: Curriculum Evaluation
Educational administration has to take up the responsibility of curriculum evaluation. It provides needed feedback for further revising and reforming the curriculum implementation from time to time. Curriculum evaluation is carried out by:
  • Supervisory program of classroom instruction
  • Guidance and direction based on educational supervision.
Planning of methods is the means for the improvement of effective implementation of the evaluated program.
Steps of Curriculum Process
The curriculum is based on the philosophy and purposes of the school/college/university and its construction requires an understanding of educational psychology together with knowledge and skill in the principles and practice of nursing education. There are five steps in the development of the curriculum.
  1. Formulating the statement of philosophy of school/college/university.
  2. Establishment of purposes and objective of school/college/university.
  3. Selection of learning experiences to achieve the purposes and objectives.
  4. Effecting organization of the selected learning experience.
  5. Evaluation of the total program.
Formulating the Statement of Philosophy
The philosophy and administration of school or college, institution or educational program originates from the board of trustees and its members constituted by the government or any private trust, who are expected to become acquainted with the interests and problems in the community. For example, community may decide to organize hospital for the care of sick, organization of university or college/school of nursing may follow.
Guidelines for the preparation of a statement of philosophy of a school or college of nursing are as follows:
  1. An educational philosophy states the values, which are believed to be right, true and good by the people responsible for the school or college.
  2. An educational philosophy will be unique to the particular society and individuals whom it serves.
  3. All teaching staff should participate in the formulation of the school philosophy or college philosophy.
  4. School philosophy or college philosophy is used as a screen.
  5. School philosophy or college philosophy should not conflict with the philosophy of the institution of which it is a part.
  6. School philosophy or college philosophy should be re-examined periodically to determine its suitability in the light of changing conditions.
Sample statement of philosophy
“We believe that the basic course in nursing should prepare nurses for first level positions in nursing in both the hospital and the community.”
  1. The curriculum should provide for experience in all the major clinical areas of nursing in the hospital and for experience of public health nursing in the community.
  2. It should develop in the students, the ability to meet the patient's mental and emotional needs and an awareness of the social nature of man, which will enable her to see the patient as a person with a family and as a member of a community.
  3. The curriculum should emphasize the preventive and promotive aspect s of health throughout and the school environment and facilities provided should make it possible to put these principles into practice.
Aims, goals and objectives
One of the major difficulties of the curriculum process is the transition from general aims to the particular objectives of the classroom. A three-step process is necessary here.
Ultimate goals must be stated. Mediate goals derived and finally proximate goals set up, so that the specific objective can be planned at the classroom level:
  1. Ultimate goals are the expected outcomes expressed as patterns or categories of behavior. They will be produced most successfully by an analysis of records of behavior and generalizations about it. Thus, the ultimate goals are the expected end products of an education carried out over time.
  2. Mediate goals are the patterns of expected behavior at given stages over the educational period. Because the patterns of behavior are developed through learning experiences over time, the behavior expected of a 15 year old cannot be expected of a 10 year old. Thus, the mediate goals are statements of intended behaviors in classes of situations at given stages.
  3. 99Proximate goals are the most specific statements of intended behavioral outcomes. Though specific, they are not discrete, but linked in the same way as other kinds of goals.
While determining the purposes and objectives, following factors should be considered:
  1. Statement of philosophy of school/college/university.
  2. Social and health needs of the people.
  3. Kinds of students to be expected in the educational program.
  4. Level of professional competence.
  5. Role of nurse in society.
  6. Statutory minimum requirements.
  7. Teaching, physical and clinical resources availability.
Guidelines for defining and stating objectives for a school/college of nursing:
  1. An objective is the statement of a behavioral change, which the school will seek to bring about in its students (behavior here includes thinking, doing and feeling).
  2. Educational objectives for a school or college of nursing are suggested by information gathered from three major sources:
    1. Investigation of needs of society for nursing services.
    2. Students needs.
    3. Examination of the written or verbal expression of the thinking done by specialists in the various subjects.
Investigation of needs of society
The faculty of a nursing should be knowledgeable about the social conditions in both nation and community.
Economics: The average length of time, which can be spent on formal education, before a person must begin to earn:
  1. The money that can be spent on education, including funds spent for buildings, equipment and qualified teachers.
  2. The capacity of the society to absorb its educated people.
Social and cultural values is as follows:
  1. Attitude of the society toward the different social and occupational groups.
  2. Women's place in the society; the number of jobs open for them.
  3. Distance that the student is able to travel away from the home to be educated.
  4. The image of professional workers of different kinds.
Communication is as follows:
  1. Language, communication among all classes of society.
  2. Use of mass media, such as press, radio, television, etc.
  3. Concern with national, regional and international health problems and programs.
Civics is as follows:
  1. The place of common man in the community.
  2. Opportunities for advancement in social and economic status.
  3. The impact of socioeconomic structure on educational system.
  4. The exercise of responsibilities and rights of citizenship.
Need for nursing service is as follows:
  1. Major health problems of the country should be considered.
  2. The health practices followed within the community; the attitude of the public toward health and disease.
  3. 100Organization of health services, governmental and non-governmental extent and kinds used by the people.
  4. Functions and responsibilities assigned to qualified nurses and auxiliary nursing personnel in the country.
Student's needs
Personal needs these are as follows:
  1. Physical: Health status, hygienic practices, food habits, rest, recreation, health protection, knowledge about health, positive attitude toward one's own health and health of others.
  2. Social: Sense of belonging, affection, feeling of personal worth, achievement, satisfying relationships with others.
  3. Spiritual: Opportunities to continue to practice religion.
Educational needs these are as follows:
  1. General: Study to broaden horizons, to expand knowledge and skills in general education and to improve citizenship.
  2. Specialized: Training in various nursing skills such as:
    1. Ability to plan, organize and give good nursing care.
    2. Flexibility to adapt nursing care to the cultural and personal needs of the patient and to the total situation.
    3. Knowledge of the scope of nursing.
    4. Understanding of the historical background and current trends of nursing.
    5. Appreciation of the value of nursing study and research.
    6. Means for self-development of the student, both as a person and as a nurse.
Examination of the thinking of specialists
Nurse specialists and teachers of subjects other than nursing, will suggest additional objectives based on their specialized knowledge.
  1. Objectives are examined to determine whether they are in accordance with one or more points in the philosophy.
  2. Those, which best support the stated or implied values will be retained and the one with conflict will be discarded.
  3. Objectives must conform to those conditions, which are fundamental to learning.
  4. Objectives should be stated in a clear and meaningful way.
  5. The overall program objectives should cover all aspects of the curriculum.
  6. Objectives should be known, understood and accepted by both teachers and students.
  7. Program objectives are stated in terms of the end product of the curriculum, which are the qualified objectives and through which, the nurse should look to the future of the individual and nursing.
Aims and Objectives of MSc Nursing Program
  1. To prepare nurses for leadership position in nursing and health fields, which can function as specialist nurse practitioner, consultants, educations, administrators and investigators.
  2. To prepare the nursing graduate who are professionally equipped, creative, self-directed and socially motivated to effectively deal with day-to-day problems.
  3. 101Encourage accountability and commitment to lifelong learning, which fosters improvement of quality care.
  1. Increased cognitive, affective and psychomotor competencies and ability to utilize the potentialities for effective nursing performance.
  2. Expertise in the utilization of concepts and theories for the assessment, planning and intervention in meeting self-care needs of an individual for the attainment of his/her fullest potential in the field of specialty.
  3. Ability to practice independently as a nurse specialist.
  4. Ability to function effectively as educators and administrators.
  5. Ability to interpret health-related research and develop initial competencies in conducting research.
  6. Ability to plan and initiate change in the healthcare system, in practice and in the delivery of health care.
  7. Leadership qualities for the advancement of the practice of professional nursing.
  8. Ability to establish collaborative relationship with members of other discipline for maintaining and improving health care.
  9. Interest in lifelong learning for personal and professional advancement.
Selection of Learning Experiences
Learning is the relatively permanent change or modification of behavior that results as a result of practice or experience (Murthy, Gates).
Experience is the lesson one learns as a result of or from his/her interaction with people in various and varied situation and/or with the environment.
Learning experiences
  1. It is the deliberately planned experience in selected situation, where students actively participate, interact and which result in desirable change of behavior in the students.
  2. It refers to the interaction between the learner and the external conditions in the environment to which the learner can react.
  3. Learning experience should be carefully planned to bring specific change in learner's behavior.
Classification/Levels of learning experiences
Direct experience is the first hand experience by having immediate sensory contact with actual object, For example:
  1. Observing samples or specimen, e.g. urine, stool.
  2. Operating machines electrocardiography (ECG), ventilator.
  3. Conducting physical examination on clients.
Vicarious experience: Create the actual situation through rearrangement of the reality.
Symbolic experience: Occur at the conceptual level offered through verbal symbols.
Objectives of learning experiences
  1. Imparting the knowledge: Steps in imparting knowledge include preparation, presentation, comparison of association, generalization and application.
  2. Acquisition of skills: Steps in acquiring skills include preparation, presentation, statement of formulas, practice, correlation and application.
  3. 102Development of aesthetic sense or appreciation: The teacher provides conducive environment for the success of application.
  4. Motivation.
Various learning experiences: To fulfill the educational objectives, learning experiences in terms of theory and practice are to be selected. Selection of learning experiences is done at three levels:
  • Institution
  • Hospital
  • Community.
  • Teaching blocks
  • Partial block system
  • Study day system
  • Daily classes
  • Physical facilities
  • Teaching staff
  • Student selection.
  • Size
  • Type of clinical experience available
  • Distribution of beds
  • Staffing
  • Affiliation.
    Important points in relation to clinical learning:
    1. Nursing services should be well-organized and headed by the registered nurse and midwife.
    2. Physical facilities, equipments and supplies shall be sufficient to practice a high standard of nursing care.
    3. A proper system of records and reports to be followed.
    4. Transport facilities.
    5. Residential accommodation, regular water supply, mess facilities should be available.
    6. There should be complete coordination between the institution and hospital staff.
    7. Accurate record keeping, written procedure manual, standard instructions and policies shall be made available in all clinical areas to facilitate better teaching and learning experience.
Urban facilities:
  1. Should be based on preventive, promotive, curative and rehabilitative aspects of health.
  2. Staff should be registered nurse and midwife.
  3. Adequate physical facilities and sufficient equipments and supplies should be available.
  4. Should have well-organized clinical program and the system of maintaining records and reports.
  5. Well-established reproductive and child health (RCH) program and domiciliary service should be priority.
103Rural facilities:
  1. Activities of primary health centers (PHCs) in rural areas.
  2. Should have good transport facilities.
  3. Should have good accommodation facilities.
  4. Should have good teaching facilities.
  5. Nurses of the center should be registered.
Organization of Learning Experience
Learning experiences are put together to form some kind of coherence. Learning experience selected carefully in relation to desired objectives must be organized so that the learners receive the maximum benefit of a well-planned curriculum.
Approaches to organization of content
Bernstein identified two approaches
  1. Collection-subjects taught as separate entities.
  2. Integrated-focus on common themes or concepts that unite various subjects.
Heidgerken suggest four major approaches
  1. Sociologic: Organized around the content to be used in the society.
  2. Psychologic: Organized around the interests of the learners.
  3. Logic: Arranging in large units and admit greater correlation of the topics.
  4. Problem solving: Organized in terms of everyday life and draw conclusions and generalizations.
A sample of organization of learning experience
  1. Grouping learning experiences under subject headings: More recently, the subject headings have been expanded to include more of the physical, biological and social sciences, maternal and child health and community health nursing and a subsequent reorganization and expansions of the learning experiences have taken place.
    1. Basic
    Physical, biological and social.
    1. Principles and practices of nursing
    Fundamentals of nursing, communication and administration.
    1. Nursing
    Medical, surgical, maternal and child.
    1. Community organization
    Psychiatric, community health.
    1. Professional understanding
    History of nursing, professional adjustments, trends.
  2. Placements: When the broad plan for the organization of learning experiences has been decided upon, the next step is their placement in the total curriculum.
  3. General plan for the curriculum: The actual mechanics of carrying out this organization may be simplified by preparing a general plan, which will show at a glance, the placement of subject matter and clinical experience. To this general plan, may be added, the number of hours to be spent in planned instruction and the clinical experience per week per month. These will be affected by the minimum hours required by the Nursing Council of India.
  4. Correlation chart: From the general plan, the various subjects, with more detailed outlines prepared by the respective teacher/tutors can be set out in a correlation chart, showing what will be taught each week of each year and as far as possible, correlating one subject with another.
  5. 104Teaching system: Three methods are commonly in use:
    1. Teaching block: The teaching block is the part of the total block system of training. It may be scheduling during a block of clinical experience to provide the instruction related to that experience or may be strategically placed at intervals throughout the curriculum, so that the instruction related to the current clinical experience and to new blocks of clinical experience for which students are to be posted.
    2. Study day system: It is literally a day spent by the student each week studying in the school, instead of having one class each day. A different day of the week is assigned to each group of students except for those who are affiliated outside.
    3. Daily classes: These are necessary now and then during the course, even when the other two systems are operating, but will not be so frequently.
Evaluation of the Curriculum
In evaluating a curriculum, the faculty appraises the value of the educational process employed and of the product. Student evaluation is carried out to measure the progress of student throughout the program and upon completion of the program and to determine the extent to which the stated objectives have been met.
Cornerstones of nursing curriculum
The conceptual corners would provide an internally consistent framework that allows for growth, flexibility, adaptability and creativity. These corner stones are:
  1. Nursing knowledge.
  2. Nursing skills.
  3. Nursing values.
  4. Nursing meanings.
  5. Nursing experience.
Knowledge: It Nursing knowledge is discipline specific and includes patterns of knowing, that are unique to the discipline and help to establish boundaries. It is influenced by formal education and ongoing development of nursing skills, values, meaning and experience. Knowledge understandings combined with reasoning that helps nursing students, transition of knowledge into clinical decisions.
Skills: These are deliberate acts or activities in the cognitive and psychomotor domain that operational nursing knowledge, values, meaning and experience. Nursing skills are selected, implemented and evaluated on behalf of those whom we care.
Values: It are enduring beliefs, attributes and ideas that establish moral boundaries of what is right and wrong in thought, judgment, character, attitude and behavior and that forms a decision-making attitude throughout life.
Meanings: It defines the context, purpose and intend of language. Nursing language applies unique meaning to existing words, as well as new phenomena observed within the profession.
Experience: It refer to the unique and active process of defining, refining and changing knowledge, skills, values, meaning used, clinical reasoning as a result of actively engaging in nursing situations. Experience is laden with richness, false starts, challenges, successes and failure and it is how nurse cope up with the responses to these experiences, that is crucial to experimental learning.
  1. 105What are the characteristic of an effective leader? Discuss and rationalize the leadership style likely to be adopted by you as a nursing superintendent of a hospital.
  1. “Leadership is interpersonal influence exercised in a situation and directed through communication process, towards the attainment of a specific goal/goals.”
    LM Prasad, 2006
  2. “Leadership is the process of influencing and supporting others to work enthusiastically towards achieving objectives.”
    Bernard Keys, 1990
  3. “Leadership refers to the relation between an individual and a group around some common interest and behaving in a manner directed or determined by leader.”
    Encyclopedia of social sciences
  4. “Leadership is defined as influence, that is a process of influencing people so that they will strive willingly and enthusiastically toward the achievement of group goals.”
    Heinz Weihrich and Harold K
Leadership is the process of influencing the thoughts and actions of other people (a person /group) to attain the desired objectives.
Qualities of a Leader
  1. Managerial abilities.
  2. Interpersonal relationships.
  3. Temperament (nature of person).
  4. Credibility and forward thinking.
  5. Professionalism.
  6. Advocacy.
Managerial Abilities
  1. Plans, organizes, makes decisions effectively, encourages cooperation and participation.
  2. Assists nurse/subordinates in solving the problems and provide consistent feed-back.
  3. Provides rationale for difficult decisions.
  4. Assess abilities of the workers, guides them to develop new skills.
  5. Knows her/his job and does it well and has confidence in self and others.
  6. Welcomes different opinions and is more interested in giving than receiving.
  7. Provides the workers with adequate facilities.
Interpersonal Relationships
  1. Shows supportive and caring behavior towards subordinates.
  2. Is a good listener and sensitive to other's needs.
  3. 106Guides and motivates to act and work together.
  4. Establishes relationships with all types of workers and able to work with others harmoniously.
Temperament (Nature or Character)
  1. Reliable, open, honest and sincere.
  2. Shows a sense of humor, tactful, friendly and loyal.
  3. Calm and charismatic, modest, neat and patient.
  4. Positive energetic, hard worker, happy and enthusiastic.
  5. Shows a balance between work and home life or personal life.
Credibility and Forward Thinking
  1. Acts as a role model and influences others.
  2. Acts as an activist, challenger, creative thinker, change agent, innovator, risk taker and courageous.
  3. Acts as a facilitator and solution seeker.
  1. Committed to the profession and maintains confidentiality.
  2. Instills hope and pride in the profession.
  3. Stands for rights, while considering others rights (assertive).
  1. Acts as an advocate for others, especially for nursing profession and for nursing staff.
  2. Acts as an advocate with physician and patient advocate.
  3. Acts as an advocate for nursing education and students for the rights and standards.
Implications to Nursing
Regardless of the style selected, the nurse managers should be aware of the effect of the style adopted in the hospital unit or educational institution, staff and on the level of work performance. Effective leadership improves the job performance and quality on the whole.
Leadership Style
  1. Based on behavior:
    • Power orientation
    • Leadership as continuum
    • Likert's management system
    • Managerial grid
    • Tridimensional.
  2. Based on situation approach:
    • Fielder contingency model
    • 107Hersey–Blanchard's situational leadership theory model
    • Path-goal model.
Power orientation
Power orientation approach of leadership style is based on the degree of authority, which a leader uses in influencing the behavior of his subordinates. Based on the degree of use of power, there are three leadership styles:
  1. Autocratic leadership.
  2. Participate leadership.
  3. Free-rein leadership.
Autocratic leadership
Autocratic leader is also known as authorization, directive or monothetic style. In autocratic leadership style, a manager centralize decision-making power to himself. He structures the complete situation for his employee and they do what they are told:
  1. Strict autocrat: The follows autocratic style in a very strict sense. His method of influencing subordinates behaviors is through negative motivation. That is criticizing subordinate imposing penalty, etc.
  2. Benevolent autocrat: It also centralizes decision-making power in him, but his motivation style is positive. He will be getting efficiency in many situations.
  3. Incompetent autocrat: Sometimes, superiors adopt autocratic leadership style just to hide their incompetence.
The main advantage of autocratic style are:
  1. Centralized authority structure and strict discipline.
  2. It provide strong motivation and reward of decision taken person.
  3. Less competent subordinate also scope to working organization.
There are many disadvantage of autocratic style:
  1. People in the organization dislike it, specially when it is strict.
  2. Employee lack of motivation; frustration low morale.
  3. There is more dependence.
Participate leadership
Participate leaders is also called democratic constitution or ideographic. Participation is a mental and emotional values of person in a group situation, which encourages him to contribute to group goals and share responsibility in them. Benefits of participate leadership are:
  1. It is highly motivating technique to employee.
  2. The employee productivity is high, because they are party decision.
  3. They share responsibility with superior and try safeguard.
  4. It provides organizational stability by rising morale and attitude.
Free-rein leadership
Free rein or laissez-faire means giving complete freedom to subordinate; in this style, manager once determine polices, program and limitations for action and the entire process is left to subordinate.
Leadership as a continuum
There are, in fact, a variety of styles of leadership behavior between two extremes of autocratic and free rein.
Likert's management system
Rensis likert, along with his associates of University of Michigan, USA, has studied the patterns and styles of manager for three decades and have developed certain concept and approach, important to understanding leadership behavior.
He has given a continuum of four systems of management. In his management, Likert has taken seven variables of different management. There variables include leadership, motivation, communication, interaction, influencing, decision process, goal setting and control process.
Employee-production orientation
In the studies of the survey research center at the University of Michigan, USA, an attempt was made to study the leadership behavior by locating clusters of characteristic that seemed to be each other and various indicators of effectiveness. The studies identified two concepts, which were called employee orientation and production orientation.
The employee-orientation stress the relationship aspects of employee jobs and emphasizes that every individual is important and takes interest in every one, accepting their individuality and personal needs. This is parallel to democratic concept of leadership behavior. Production-orientation emphasizes production and technical aspects of jobs and employees are taken as tools for accomplishing the jobs. This is parallel to the authoritarian concept of leadership behavior.
Table 1   Ohio State University leadership quadrants
Low structure and high consideration
High structure and high consideration
Low structure and low consideration
High structure and low consideration
Managerial grid
One of the most widely known approaches of leadership styles is the managerial grid, developed by Blake and Mouton. The emphasis, that leadership style consists of factor of both task oriented and related behavior in varying degrees. Their concern for phrase has been used to convey how managers are concerned for people or production, rather than how production getting of group. Thus, it does not represent real production or the extent to which human relationship needs are being satisfied:
  • 1,1 Exertion of minimum efforts is required to get work done and is appropriate sustain organizational morale
  • 1,9 Thoughtful attention to the needs of people, leads to a friendly and comfortable organizational atmosphere and work tempo
  • 9,1 Efficiency results arranging work in such a way that human elements have little effect
  • 5,5 Adequate performance through balance of work requirement and maintaining satisfactory morale
  • 9,9 Work accomplished is from committed people with interdependence through a common stake in organizational purpose and with trust respect.
Tri-dimensional grid
Reddin conceptualized a three-dimensional grid also know as three-dimensional management, borrowing some of the ideas from managerial grid, three-dimensional axes represent task orientation, relationship orientation and effectiveness. By adding an 109effectiveness dimension to task oriented and relationship-oriented behavior dimensions, Reddin has integrated the concept of leadership styles with the situational demand of a specific.
zoom view
Figure 1: Managerial grid
Task orientation is defined as the extent to which a manager directs his subordinate's efforts towards goal attainment. It is characterized by planning, organizing and controlling. Relationship orientation is defined as the extents, which a manager has maintained personal relationship.110
zoom view
Figure 2: Tri-demensional grid
zoom view
Figure 3: Task orientation behavior
Fiedler's contingency theory
The contingency theory of leadership was proposed by the Austrian Psychologist Fred Edward Fiedler in 1964.
The contingency theory emphasizes ‘the importance of both leader's personality and the situation in which that leader operates. They outline two styles of relationship:
  1. Task-motivated.
  2. Relationship-motivated.
Task refers task accomplishment and relationship-motivation refers to interpersonal relationships.
Hersey-Blanchard's situational model
It takes a different perspective of situational variables as compared to fielder's model. Hersey and Blanchard felt that, the leader has to match his leadership style according to the needs of maturity of the subordinates, which moves in stages and has a cycle. Therefore, this theory is also known as life cycle theory of leadership. There are two basic considerations in this model they are leadership style and subordinate maturity.
zoom view
Figure 4: Hersey-Blanchard's situational leadership model
Path-goal model of leadership
Robert House and others have developed a path-goal model of leadership initially presented by Evans. Though the concept of path-goal was presented in 1957, it could not catch much attention. Path-goal model of leadership is basically a combination of situational leadership and Vroom's Expectancy Theory of Motivation.
Application of Leadership in Nursing
Patient care coordination
Even new graduate nurses have leadership responsibilities when they begin their career in nursing. Nursing leadership begins with nursing care of the individual patient. The students are guided to organize nursing care.
  1. Establish good and priorities for each day.
  2. Establish time.
  3. Establish success and failure.
Employee responsibilities
Nurses have specific tasks or duties to perform. These tasks are determined by the plan and objective of the healthcare agency. It is important to read the job description carefully and to continue to evaluate how institutional factors influence one's own practice of nursing. Factors that compromise quality care should be noted and addressed in construction with experienced nurses.
Guidelines for delegating nursing care
New graduate nurses use leadership techniques when they direct the work of non-professional staff and volunteers and consider delegating tasks to non-professional staff.
Mentorship is a relationship in which an experienced individual advise and assist, a less experienced individual. This is an effective way of easing a new nurse into leadership responsibilities.
Preceptor ship
An alternative model is preceptorship. The preceptor is selected to introduce an employee to new responsibilities through teaching and guidance. The relationship is limited by the new employee's needs.
Continuing education
Leadership, managerial and administrative skills are needed.
Rationalize the Leadership Style Likely to be Adopted by the Nursing Superintend of a Hospital
An individua, who is able to perform both roles successfully would be an effective leader. These two roles may require to different sets of behavior from the leader, known as leadership styles.
Leadership behavior may be viewed in two ways, i.e. functional and dysfunctional. Functional behavior influence followers positively and includes such as setting clear goals, motivating, building team spirit, etc. Dysfunctional behavior may be inability to accept employee‘s ideas so it is unfavorable to the followers and denotes ineffective leadership.
Types of Leadership Styles
  • Autocratic style of leadership
  • Democratic style of leadership
  • Laissez-faire style of leadership.
Autocratic leadership is described as:
  • Authoritarian leadership
  • Directive leadership and the leader is referred to as extreme form of Dictator.
A democratic leadership is described as:
  • Participative or consultative style of leadership.
Laissez-faire leadership style is as follows:
  • Permissive
  • Free rein
  • Anarchic
  • Ultra-liberal style of leadership.
Autocratic leadership
The leader assumes complete control over the decisions and activities of the group. The authority for decision-making is not delegated to persons in lower level positions (centralized organization). Personality of the leader (as a Nursing Superintendent):
  1. Firm personality, insistent, self-assured, highly directive, dominating, with or without intention.
  2. Has high concern for work than the people who perform the task.
  3. Uses the efforts of the workers to the best possible, shows no regard to the interests of the employees.
  4. Sets rigid standards and methods of performance and expects the subordinates to obey the rules and follow the same.
  5. Makes all decisions by himself/herself related to the work and pass orders to the workers and expect them to carry out the orders.
  6. There is minimal group participation or none from the workers.
  7. Thinks that what he/she plans and does is the best. May listen to them, but not influenced by their suggestions.
  8. Has no trust or confidence in the subordinates; in turn, they fear and feel they have nothing much in common.
  9. Exercises power, manipulates the subordinates to act according to his/her goals, plans and keeps at the center of attention.
Democratic leadership style
Democratic leadership is also referred to participative, consultative style of leadership.
  1. This style is characterized by a sense of equality among leaders and followers:
    • The leader is people oriented
    • Focuses on the human aspects
    • Builds effective work group
    • Togetherness is emphasized.
  2. Open system of communication prevails:
    • The group participates in work-related decisions (sharing the thoughts in problem solving).
  3. The interaction between the leader and the group is friendly and trusting:
    • 113The leader brings the subject to be discussed to the group
    • Consults
    • Decision of the majority is made and implemented by the entire group
    • Makes final decision after seeking input from the total group
    • Therefore the group feels they have important contribution to make, freedom ideas drawn, develop sense of responsibility for the good of the whole.
  4. Leader works through people not by domination, but by suggestions and persuasions:
    • The leader motivates the workers to set their own goals, makes their own work plans and evaluates their own performance
    • Informs the overall purpose and the progress of the organization.
  5. Performance standards exist to provide guidelines and permit appraisal of workers, thus results in high productivity.
Laissez-faire leadership style
The Laissez-faire leadership is also referred to as free-rein, anarchic, ultra-liberal style of leadership. The leader gives up all power to the group.
Nursing Superintendent: The characteristic of nursing superintend are:
  1. This encourages independent activity by the group members:
    • An outsider would not be able to identify the leader in such a group
    • The leader exerts little or no influence on the group members
    • There is lack of central direction, supervision, coordination and control.
  2. Group members are free to set their own goals, determine their own activities and allowed to do almost what they desire to do. A variety of goals may be set by every individual and it will be difficult to carry out to accomplish the task by the group easily.
  3. This style may be chosen by the leader or it may evolve because:
    • The leader is too weak to exert any influence on the group
    • Attempting to please everyone to feel good
    • Fails to function as an effective leader.
  4. This style is effective in highly motivated professional groups, e.g. research projects, where independent thinking is rewarded or when the leader feels that the problem must be solved by the group alone.
  5. This style is not useful in a highly structured healthcare delivery system or any institution.
  6. The group, where there is no appointed leader, will fall into this category.
  1. Explain the importance of quality assurance in nursing services.
Quality management (QM) and quality improvement (QI) are the basic concepts derived from the philosophy of total quality management (TQM). Now it is preferred to use the term continuous quality improvement (CQI) since TQM can never be achieved and the method of monitoring of health care for CQI is done with quality assurance (QA).
  1. “Quality assurance is a judgment concerning the process of care based on the extent to which that care contributes to valued outcomes.”
    Donabedian, 1982
  2. “Quality assurance is the measurement of provision against expectations with declared intention and ability to correct any demonstrated weakness.”
  3. 114“Quality assurance is a management system designed to give maximum guarantee and ensure confidence that the service provided is up to the given accepted level of quality, the standards prescribed for that service, which is being achieved with a minimum of total expenditure.”
    British Standards Institute
  4. “Continuous quality improvement (CQI) is an ongoing quality improvement measure, using management and scientific methods of quality assurance involving data collection, its analysis and formulating ways to improve performance outcome according to proposed standards.”
    British Standards Institute
  1. Rising expectations of consumer services.
  2. Increasing pressure from national, international, government and other professional bodies to demonstrate that the allocation of funds produces satisfactory results in terms of patient care.
  3. The increasing complexity of healthcare organizations.
  4. Improvement of job satisfaction.
  5. Highly informed consumer.
  6. To prevent rising medical errors.
  7. Rise in health insurance industry.
  8. Accreditation bodies.
  9. Reducing global boundaries.
  1. Quality management (QM) operates most effectively within a flat, democratic and organizational structure.
  2. Managers and workers must be committed to quality improvement.
  3. The goal of QM is to improve systems and processes and not to assign blame.
  4. Customers define quality.
  5. Quality improvement focuses on outcome.
  6. Decisions must be based on data.
According to William Edwards Deming (Deming's 14 Points)
  1. Create consistency of purpose for improvement of product and service.
  2. Adopt the new philosophy.
  3. Cease dependence on inspection to achieve quality.
  4. End the practice of awarding business on the basis of price tag.
  5. Improve constantly and forever the systems of production and service.
  6. Institute training on the job.
  7. Institute leadership.
  8. Drive out fear.
  9. Breakdown barriers between departments.
  10. Eliminate slogans, exhortations and target for the workforce.
  11. Eliminate numerous quotas for the workforce and numerical goals of management.
  12. Remove barriers that rob people of pride and workmanship.
  13. 115Institute a vigorous program of education and self-improvement for everyone.
  14. Put everyone in the company to work to accomplish the transformation.
  1. General approach.
  2. Specific approach.
General Approach
General approach involves large governing or official bodies, evaluating a person or agencies' ability to meet established criteria or standard during a given time.
  1. Credentialing: It is the formal recognition of professional or technical competence and attainment of minimum standards by a person and agency. Credentialing process has four functional components:
    1. To produce a quality product.
    2. To confirm a unique identity.
    3. To protect the provider and public.
    4. To control the profession.
  2. Licensure: It is a contract between the profession and the state in which the profession is granted control over entry into an exit from the profession and over quality of professional practice.
  3. Accreditation: It is a process in which certification of competency, authority or credibility is presented to an organization with necessary standards.
  4. Certification.
  5. Charter: It is a mechanism by which a State Government Agency under state law grants corporate state to institutions with or without right to award degrees.
  6. Recognition: It is defined as a process whereby one agency accepts the credentialing states of and the credential confined by another.
  7. Academic degree.
Specific Approach
Specific approach are methods used to evaluate identified instances of provider and client interactions:
  1. Audit: It is an independent review conducted to compare some aspect of quality performance, with a standard for that performance.
  2. Direct observation: Structured or unstructured based on presence of set criteria.
  3. Appropriateness evaluation: The extent to which the managed care organization provides timely, necessary care at right levels of service.
  4. Peer review: Comparison of individual provider's practice either with practice by the provider's peer or with an acceptable standard of care.
  5. Bench marking: A process used in performance improvement to compare oneself with best practice.
  6. Supervisory evaluation.
  7. Self-evaluation.
  8. Client satisfaction.
  9. Control committees.
  10. 116Services: Evaluates care delivered by an institution rather than by an individual provider.
  11. Trajectory: It begins with the cohort of a person, who shares distinguishing characteristics and then follows the group, going through the healthcare system, noting what outcomes are achieved by the end of a particular period.
  12. Staging: It is the measurement of adverse outcomes and the investigation of its antecedence.
  13. Sentinel: It involves maintaining of factors that may result in disease, disability or complications such as:
    1. Review of accident reports.
    2. Risk management.
    3. Utilization review.
  1. According to Donabedian:
    1. Structure element: The physical, financial and organizational resources provided for health care.
    2. Process element: The activities of a health system or healthcare personnel in the provision of care.
    3. Outcome element: A change in the patient's current or future health, that results from nursing interventions.
  2. According to Manwell, Shaw and Beurre, there are 3A's and 3E's:
    1. Access to health care.
    2. Acceptability.
    3. Appropriateness and relevance to need.
    4. Effectiveness.
    5. Efficiency.
    6. Equity.
Standards are written formal statements, to describe how an organization or professional should deliver health service and are guidelines against which services can be assessed. Kirk and Hoesing (1991) stated that standards are needed to:
  • Provide direction
  • Reach agreement on expectations
  • Monitor and evaluate results
  • Guide organizations, people and patients to obtain optimal results.
Standards are directed at structure, process and outcome issues and guide the review of system's function, staff performance and client care. The organizations providing quality indexes are:
  • Agency for Healthcare Research and Quality (AHRQ)
  • Institute for Healthcare Improvement (IHI)
  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
  • National Association for Healthcare Quality (NAHQ)
  • Institute of Medicine (IOM)
  • National Committee for Quality Assurance (NCQA).
Areas of Quality Assurance
The assurance in various key areas are given below.
Outpatient Department
The points to be remembered are:
  1. Courteous behavior must be extended by all, trained or untrained personnel.
  2. Reduction of waiting time in the outpatient department (OPD) and for laboratory investigations by creating more service outlets.
  3. Provide basic amenities such as toilets, telephone and drinking water, etc.
  4. Provision of polyclinic concept to give all specialty services under one roof.
  5. Providing ambulatory services or running day care centers.
Emergency Medical Services
Services must be provided by well-trained and dedicated staff and they should have access to the most sophisticated life-saving equipment and materials and also have the facility of rendering prehospital emergency medical aid through a quick reaction trauma care team provided with a trauma care emergency van.
Inpatient Services
Provide a pleasant hospital stay to the patient through provision of a safe, homely atmosphere, a listening ear, humane approach and well-behaved, courteous staff.
Specialty Services
A hi-tech hospital with all types of specialty and super-specialty services will increase the image of the hospital.
A continuous training program should be present consisting of ‘on the job training’, skill training workshops, seminars, conferences and case presentations.
Donabedian Model (1985)
Donabedian model is a model proposed for the structure, process and outcome of quality. This linear model has been widely accepted as the fundamental structure to develop many other models in QA.
American Nurses Association Model
American nurses association (ANA) first proposed and accepted model of quality assurance was given by Long and Black in 1975. This helps in the self-determination of patient and family, nursing health orientation, patient's right to quality care and nursing contributions.
Quality Health Outcome Model
The uniqueness of this model proposed by Mitchell and Company is the point that there are dynamic relationships with indicators that not only act upon, but also reciprocally affect the various components.
Plan, Do and Study, Act Cycle
The PDSA is an improvement model advocated by Dr Deming, which is still practiced widely that contains a distinct improvement phase.
Use of Plan do and study, act cycle (PDSA) model assumes that a problem has been identified and analyzed for its most likely causes and that changes have been recommended for eliminating the likely causes. Once the initial problem analysis is completed, a Plan is developed to test one of the improvement changes. During the Do phase, the change is made and data are collected to evaluate the results. Study involves analysis of the data collected in the previous step. Data are evaluated for evidence that an improvement has been made. The Act step involves taking actions that will ‘hardwire’ the change so that the gains made by the improvement are sustained over time.
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Figure 5: Standards of criteria
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Figure 6: Nursing interventions
Six Sigma
Six sigma refers to six standard deviations from the mean and is generally used in quality improvement to define the number of acceptable defects or errors produced by a process. It consists of five steps: Define, measure, analyze, improve and control (DMAIC):
  1. Define: Questions are asked about key customer requirements and key processes to support those requirements.
  2. Measure: Key processes are identified and data are collected.
  3. Analyze: Data are converted to information; causes of process variation are identified.
  4. Improve: This stage generates solutions and make and measures process changes.
  5. Control: Processes that are performing in a predictable way at a desirable level are in control.
Quality tools
Chart Audits
Chart audits is the most common method of collecting quality data using charts as quality assessment tool.
Failure Mode and Effect Analysis: Prospective View
Failure mode and effect analysis is a tool, that takes leaders through evaluation of design weaknesses within their process, enables them to prioritize weaknesses that might be more likely to result in failure (errors) and based on priorities; decide where to focus on process redesign and aim at improving patient safety.
Root Cause Analysis: Retrospective View
Root cause analysis is sometimes called a fishbone diagram, used to retrospectively analyze potential causes of a problem or sources of variation of a process. Possible causes are generally grouped under four categories they are people, materials, policies and procedures, equipment.
Flow Charts
Flow charts are diagrams that represent the steps in a process.
Pareto Diagrams
Pareto diagrams is used to illustrate 80/20 rule, which states that 80% of all process variation is produced by 20% of items.
Histograms uses a graph rather than a table of numbers to illustrate the frequency of different categories of errors.
Run Charts
Run charts are graphical displays of data over time. The vertical axis depicts the key quality characteristic or process variable. The horizontal axis represents time. Run charts should also contain a center line called median.
Control Charts
Control charts are graphical representations of all work as processes, knowing that all work exhibit variation and recognizing, appropriately responding to and taking steps to reduce unnecessary variation.
Indicators of Quality Assurance
  1. Waiting time for different services in the hospital.
  2. Medical errors in judgment, diagnosis, laboratory reporting, medical treatment or surgical procedures, etc.
  3. Hospital infections including hospital- acquired infections, cross infections.
  4. Quality of services in key areas like blood bank, laboratories, X-ray department, central sterilization services, pharmacy and nursing.
Quality Improvement Process
Quality improvement process steps include:
  1. Identify needs, most important to the consumer of healthcare services.
  2. Assemble a multidisciplinary team to review the identified consumer needs and services.
  3. Collect data to measure the current status of these services.
  4. Establish measurable outcomes and quality indicators.
  5. Select and implement a plan to meet the outcomes.
  6. Collect data to evaluate the implementation of the plan and achievement of outcomes.
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Figure 7: Steps of quality improvement process
Quality Assurance Cycle
In practice, QA is a cyclical, iterative process that must be applied flexibly to meet the needs of a specific program. The process may begin with a comprehensive effort to define standards and norms as described in 1–3 steps or it may start with small-scale quality improvement activities in 5–10 steps. Alternatively, the process may begin with monitoring (step 4). The 10 steps in the QA process are discussed.
Planning for Quality Assurance
The first step prepares an organization to carry out QA activities. Planning begins with a review of the organization's scope of care to determine, which services should be addressed.
Setting Standards and Specifications
To provide consistently high-quality services, an organization must translate its programmatic goals and objectives into operational procedures. In its widest sense, a standard is a statement of the quality that is expected. Under the broad rubric of standards, there are practice guidelines or clinical protocols, administrative procedures or standard operating procedures, product specifications and performance standards.
Communicating Guidelines and Standards
Once practice guidelines, standard operating procedures and performance standards have been defined, it is essential that staff members communicate and promote their use. This will ensure that each health worker, supervisor, manager and support person understands what is expected of him or her. This is particularly important, if ongoing training and supervision have been weak or if guidelines and procedures have recently changed. Assessing quality before communicating expectations can lead to erroneously blaming individuals for poor performance, when fault actually lies with systemic deficiencies.
Monitoring Quality
Monitoring is the routine collection and review of data that helps to assess whether program norms are being followed or whether outcomes are improved. By monitoring key indicators, managers and supervisors can determine, whether the services delivered, follow the prescribed practices and achieve the desired results.
Identifying Problems and Selecting Opportunities for Improvement
Program managers can identify quality improvement opportunities by monitoring and evaluating activities. Other means include soliciting suggestions from health workers, performing system process analyses, reviewing patient feedback or complaints and generating ideas through brainstorming or other group techniques. Once a health facility team has identified several problems, it should set quality improvement priorities by choosing one or two problem areas on which to focus. Selection criteria will vary from program to program.
Defining the Problem
Having selected a problem, the team must define it operationally as a gap between actual performance and performance as prescribed by guidelines and standards. The problem statement should identify the problem and how it manifests itself. It should clearly state, where the problem begins and ends and how to recognize, when the problem is solved.
Choosing a Team
Once a health facility staff has employed a participatory approach to selecting and defining a problem, it should assign a small team to address the specific problem. The team will analyze the problem, develop a quality improvement plan and implement and evaluate the quality improvement effort. The team should comprise those, who are involved with, contribute inputs or resources to and/or benefit from the activity or activities in which the problem occurs.122
Analyzing and Studying the Problem to Identify the Root Cause
Achieving a meaningful and sustainable quality improvement effort depends on understanding the problem and its root causes. Given the complexity of health service delivery, clearly identifying root causes requires systematic, in-depth analysis. Analytical tools such as system modeling, flow charting and cause and effect diagrams can be used to analyze a process or problem. Such studies can be based on clinical record reviews, health center's registration data, staff or patient interviews, service delivery observations.
Developing Solutions and Actions for Quality Improvement
The problem-solving team should now be ready to develop and evaluate potential solutions. Unless, the procedure in question is the sole responsibility of an individual, developing solutions should be a team effort. It may be necessary to involve personnel responsible for processes related to the root cause.
Implementing and Evaluating Quality Improvement Efforts
The team must determine the necessary resources and time frame and decide, who will be responsible for implementation. It must also decide, whether implementation should begin with a pilot test in a limited area or should be launched on a larger scale. The team should select indicators to evaluate, whether the solution was implemented correctly and whether it resolved the problem it was designed to address. In-depth monitoring should begin when the quality improvement plan is implemented. It should continue until either the solution is proven effective and sustainable or the solution is proven ineffective and is abandoned or modified. When a solution is effective, the teams should continue limited monitoring.
Joint Commission on Accreditation of Healthcare Organization Quality Assurance Guidelines/steps
Assign responsibility: According to the Joint Commission, “The nurse administrator is ultimately responsible for the implementation of a quality assurance program.” Completing step one of the Joint Commission's ten step process, require writing a statement that described, who is responsible for making certain that QA activities are carried out in the facility. Assigning responsibility should not be confused with assuming responsibility.
Delineate Scope of Care and Services
Scope of care refers to the range of services provided to patients by a unit or department. To delineate the scope of care, for a given department personnel should ask themselves, what is done in the department?
Identify Important Aspects of Care and Services
Important aspects of nursing care can best be described as some of the fundamental contribution made by nurses, while caring for patients. They are the most significant or essential categories of care practiced in a given setting. There is no prescribed list of important aspects of care that every organization must monitor.123
Identify Indicators of Outcome (No Less Than Two; No More Than Four)
A clinical indicator is a quantitative measure that can be used as a guide to monitor and evaluate the quality of important patient care and support service activities. Indicators are currently considered as being of two general types events, i.e. sentinel events and rate based. Indicators also differ according to the type of event they usually measures (structure, process or outcome).
Establish Thresholds for Evaluation
Thresholds are accepted levels of compliance with any indicators being measured. Thresholds for evaluation are the level of or point at which intensive evaluation is triggered. A threshold can be viewed as a stimulus for action.
Collect Data
Once indicators have been identified, a method of collecting data about the indicators must be selected. Among the many methods of data collection is interviewing patient/family, distributing questionnaires, reviewing charts, making direct observation, etc.
Evaluate Data
When data gathering is completed in the process of planning patients care, nurses make assessments based on the findings. In the QA process as a whole, when data collection has been completed and summarized, a group of nurses makes an assessment of the quality of care.
Take Action
Nurses are action-oriented professionals. For many nurses, the greater portion of every day is spent on patient's intervention. These actions and interventions conducted by nurses promote health and wellness for patients. Converting nursing energy into the QA process requires formulating an action plan to address identified problems.
Assess Action Taken
Continuous and sustained improvement in care requires constant surveillance by nurses of the intervention initiated to improve care.
Written and verbal messages about the results of QA activities must be shared with other disciplines throughout the facility.
Nursing Audit
Audit in nursing management is the professional evaluation of the quality of the patient care, by analyzing through all the facilities, services rendered, measures involved in diagnosis, treatment and other conditions and activities that affect the patients.
  1. “Nursing audit refers to the assessment of the quality of clinical nursing.”
  2. “Nursing audit is the means by which nurses themselves can define standards from their point of view and describe the actual practice of nursing.”
    Goster Walfer
  1. It improves the quality of nursing care.
  2. It compares actual practice with agreed standards of practice.
  3. It is formal and systemic.
  4. It involves peer review.
  5. It requires the identification of variations between practice and standards followed by the analysis of causes of such variations.
  6. It provides feedback for those whose records are audited.
  7. It includes follow-up or repeating an audit sometimes later to find out, if the practice is fulfilling the agreed standards.
  • To evaluate the quality of nursing care given
  • To achieve the desired and feasible quality of care
  • To provide a way for better records
  • To focus on care provided and care provider
  • To provide rationalized care thereby maintaining uniform standards worldwide
  • To contribute to research.
Methods of Audit
There are mainly two methods.
Retrospective view: It refers to the detail quality care assessment after the patient has been discharged. The records can be reviewed for completeness of records, diagnosis, treatment, laboratory investigations, consultations, nursing care plan, complications and end results.
Concurrent view: It is achieved by reviewing patient care during the time of hospital stay, by the patient. It includes assessing the patient at the bedside in relation to predetermined criteria like errors, omissions, deficiencies, as well as efficiencies and also excess in the care of patients under them. It involves direct and indirect observation, interviewing the staff responsible for care and reviewing the patients' records and care plan. It can be also done to identify the job satisfaction of staff nurses in accordance with their work performance.
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Figure 8: Audit cycle
Audit Cycle
According to Payne, the steps in audit or utilization review include:
  • Criteria development
  • Selection of cases
  • Work sheet preparation
  • Case evaluation
  • Tabulation of evaluation
  • Presentation of reports.
The basic audit cycle can be depicted as in general, the stages of audit cycle are:
  • Identify the need for change
  • Setting criteria and standards
  • Collecting data on performance
  • Assess criteria against criteria and standards
  • Identify need for change (re-evaluation).
  • Patient is assured of good service
  • Better planning of quality improvement can be done
  • It develops openness to change
  • It provides assurance, by meeting evidence-based practice
  • It increases understanding of client's expectations
  • It minimizes error or harm to patients
  • It reduces complaints or claims.
  • It may be considered as a punishment to professional group
  • Medicolegal importance: They feel that they will be used in court of law as any document can be called for in a court law
  • Many components may make analysis difficult
  • It is time consuming
  • It requires a team of trained auditors.
  1. Use of computers in hospital and community.
Computers are commonly used items in many areas. It is an important thing to people, especially the people who run organizations, industry, etc. Almost anything you know is run or made by computers. Cars and jets were designed on computers, traffic signals are run by computers, most of the medical equipments use computers and space exploration was started with computers. Most of the jobs today require the use of computers. These ‘mechanical brains’ has made a huge impact on our society. It would be hard, if we did not have the computer around.
Most of the nurses will use computers in many aspects of their professional practice. Computers can organize, analyze and store different kinds of data in a rapid, accurate and easily retrievable manner. User-friendly computers are already of great help to the nurse in assessing, diagnosing, planning, implementing and evaluating nursing care. 126The nurse educator and nurse manager have also discovered the usefulness of computers in managing, staffing, budgeting, enhancing instruction, producing grade report, writing papers and improving productivity. In fact, computer skills and knowledge will be soon being expected and perhaps required for a many great positions.
Application of Computers in Hospital
Using computers in health care can improve the quality and effectiveness of care and reduce its cost. However, adoption of computerized clinical information systems in health care lags behind use of computers in most other sectors of the economy.
Improved Quality
  1. Automated hospital information systems can help to improve quality of care because of their far-reaching capabilities. Hospital information systems (HMS) in a hospital, can combine the use of computers for storing and transferring information with using them for giving advice to solve clinical problems.
  2. In addition to alerting physicians of abnormal and changing clinical values, computers can generate reminders for physicians. For complex problems, computer workstations can integrate patient records, research plans and knowledge databases.
  3. Computers and databases can be used to compare expected results with actual results and to help physicians make decisions.
  4. The lives of patients can be improved, if they use computer systems to obtain information, make difficult decisions and contact experts and support groups.
Decreased Costs
When a physician orders a test by computer, it can automatically display information that promotes cost-effective testing and treatment.
Importance of Computers in Hospitals
Importance of computers in medicine is growing and spreading rapidly. The only disadvantage is that a full-fledged installation of all the computerized systems in hospitals is a lengthy and costly process. There are however, some hospital systems, which already work on the basis of computers. Here is an explanation to all such systems, which work on computers.
Uses of Computers in Hospitals
Medical Data
Every day, hospitals and clinics, which are attached to it churn out enormous volumes of data regarding patients, ailments, prescriptions, medications, medical billing details, etc. Such medical records are nowadays recorded into medical billing software. Such mammoth databases are known as electronic medical records (EMR) and electronic health records (EHR). These databases are operated by a set of computers and servers and come in handy during medical alerts and emergencies. The concept of EHR is a bit broader than 127the EMR, as the database is accessible from different clinics and hospitals. Thus, a patient's medical history can be retrieved from any hospital by medical practitioners.
Medical Imaging
‘Tests’ are medical procedures, where specified components of the human body are scanned. A test can be as simple as a regular blood test or it can be a complex computed tomography (CT)/magnetic imaging resonance (MRI). This process is often referred to as a medical imagery. In order to increase the precision of such procedures, computers have been adopted and integrated into the testing equipment. The ultrasound and the MRI are the best examples, where computers have been adopted, in order to make the process faster and precise. Thus, medical tests and tools have become more advanced as a result of the use of computers.
Medical Examination
Many systems are underway for the development of medical monitoring, which will help humans to properly monitor their own health. In many cases, doctors and surgeons also use sophisticated computer-aided equipment to treat their patients. Such systems and procedures include, bone scan procedure, prenatal ultrasound imaging, blood glucose monitors, advanced endoscopy that is used during surgery and blood pressure monitors. Basically, these medical tests and tools provide significant convenience to medical practitioners. One can find that major laboratory equipment and heart rate monitors have already been computerized in many hospitals.
Clinical Practice (Point-of-care Systems)
Computers have a wider application in clinical practice:
  1. Work lists to remind staff of planned nursing interventions.
  2. Computer, generated client documentation.
  3. An EMR and computer-based patient record (CPR).
  4. Monitoring devices that record vital signs and other measurements directly into the client record (electronic medical record).
  5. Computer-generated nursing care plans and critical pathways.
  6. Automatic billing for supplies or procedures with nursing documentation.
  7. Reminders and prompts that appear during documentation to ensure comprehensive charting.
Electronic Patient Records (EPR)
Electronic patient records (EPR) is the venture to put all patients' records online, so that, all hospitals have access to them. This would allow the sharing of information between hospitals, between trusts and health authority. Security of information is also a major concern as well as the updating of all patient records.
It is also possible to book appointments with the doctor over the internet and would be able to look at their own notes also. Patients would also be able to choose where they want for an appointment and to select the practice they attend for a consultation (epidemiological investigation). People's records could be compared to see, what 128treatment worked and what other factors there may have been for some complex illness. Trends could be spotted at their early stage and remedial action taken to stop them quickly. This information would be available no matter, where the hospital was or what the condition of it is.
Benefits of electronic medical record (EMR) health care: Many of these benefits have came about with the development of the (EMR), which is the electronic version of the client data found in the traditional paper record. Electronic medical record (EMR) benefits include:
  1. Improved access to the medical record. The EMR can be accessed from several different locations simultaneously, as well as by different levels of providers.
  2. Decreased redundancy of data entry. For example, allergies and vital signs need only to be entered once.
  3. Decreased time spent in documentation. Automation allows direct entry from monitoring equipment, as well as point-of-care data entry.
  4. Increased time for client care. More time is available for client care, because less time is required for documentation and transcription of physician's orders.
  5. Facilitation of data collection for research. Electronically stored client records provide quick access to clinical data for a large number of clients.
  6. Improved communication and decreased potential for error. Improved legibility of clinician documentation and orders is seen with computerized information systems.
Creation of a lifetime clinical record facilitated by information systems: Other benefits of automation and computerization are related to the use of decision-support software, computer software programs that organize information to aid in decision-making for client care or administrative issues. These include:
  1. Decision-support tools as well as alerts and reminders, notify the clinician of possible concerns or omissions. An example of this is the documentation of patient allergies in the computer system. The healthcare providers would be alerted to any discrepancies in the patient medication orders.
  2. Effective data management and trend finding, include the ability to provide historical or current data reports.
  3. Extensive financial information can be collected and analyzed for trends. An extremely important benefit in this era of managed care and cost cutting.
  4. Data related to treatment such as inpatient length of stay and the lowest level of care provider required can be used to decrease costs.
Computerized Patient Record
The use of CPR has improved the communication among health professionals, increased the speed of communication, decreases the actual amount of time spend on paper work. Many healthcare facilities are working toward Computerized patient record (CPRs) through integrated information systems.
  • Have the patients entire history
  • Can flag drug reaction problems
  • Can eliminate redundancy in record.
Patient data: Computers are useful in a physician's office or in a clinic. In a managed care environment, the information systems make administrative management more efficient. 129The private practitioner, program or facility to manage every aspect of patient care can use one data management system.
Automated Client Care System
Automated client care system allows ‘online’ use of nursing care plans. After analyzing the assessment database and identifying the clients database and nursing diagnosis, nurses are able to create a care plan easily, customize it for each client, type in additions as needed, evaluate and update information at any time and retrieve data appropriate to each specific nursing diagnosis. Specific ways in which an automated client's care plan facilitate. The role of nurse:
  1. Entry of nursing assessments is simplified, e.g. the nurse can touch a computer screen that displays assessment possibilities.
  2. Laboratory data can be ordered by entering a request at a computer workstation.
  3. Laboratory results can be retrieved in a shorter time with less paper work.
  4. The system facilities complete and legible medication orders.
  5. The system promotes consistent physician's orders.
  6. The nursing implications of a physician's order can be sent to nurse. Client preparation needs for a particular test can be listed automatically in the clients nursing care plan.
  7. The use of nursing diagnosis is facilitated; a common format can be used.
  8. Current information can be updated easily. Discontinued medication orders can be detected easily, making all information timely, legible and complete.
Hospital Administration
  1. Computerization of the accounting, payroll and stock system of the hospital.
  2. Keep the record of different medicines, their distribution and use in different wards, etc.
  3. All departments have budgets and these are then managed by the computer system. This is the basis by which health authority pays the salary of each individual.
  4. Tasks such as billing, maintaining financial records and long-term planning are necessary aspects of the business side of hospital. As computers get smaller, less costly, more powerful and easier to use, they will be used increasingly in other areas of healthcare system.
  • Easy to trace the spending of individual areas
  • Cheaper sourcing of materials and items, when buying bulk
  • Budgets are set early, so that they can be adhered to
  • Allows overall monetary control to be decentralized.
  • Expensive patient care has to be balanced with the budgetary controls
  • Epidemics cannot be planned for
  • New procedures tend to be expensive
  • Drug bills are expensive.
Uses of Computers in Community Application
Home Health Care and Telehealth
Telecommunication technology can reduce home healthcare costs and increase frequency and availability of health services. It provides accessibility to support groups, treatment, information and electronic communication with healthcare providers. It helps to access to more to centralized healthcare professionals, who can anticipate and prevent avoidable problems. Also, it helps the clinician to monitor and handle more number of clients. For example, women with high-risk pregnancies, clients with chronic health problems, elderly and postoperative clients. It eliminates the travelling, waiting and discomfort of elderly through televises. It can be used to remember the client to take his medication; so it reduces the risk of complications and number of hospital visits. It also supports the data collection and documentation by using technology.
Web-based solution for care coordination can integrate results from biometric measures and diagnostic tests to automatically alert the clinician about the panic values. Elderly with hearing problems can use the mail order to maintain communication and not use the telephone conversation. In elderly homes, the institution can use monitoring system, which contains sensors to detect falls and alert the nurse to the problem. Also he/she can use informatics in data collection and documentation. Telecommunication and web-based management can be used in elderly homes. Community health nurse should create a strategy that puts them in control of their roles to improve the community health nursing (CHN) in balance with the rapid technology.
Examples of telemedicine
  • Thoracic
  • Addictions
  • Forensic mental health assessments
  • Orthopedic
  • Ophthalmology
  • Pathology
  • Live fetal ultrasound interpretation
  • General health information
  • Live pediatric cardiac echo
  • Crisis Lines
  • Oncology
  • Symptom management
  • Dietary
  • Pre- and post-operative
  • Wound management
  • Home telehealth
  • A 24/7 telenurse lines.
Telenursing refers to the use of telecommunications technology in nursing to enhance patient care.
  1. 131It involves the use of electromagnetic channels (e.g. wire, radio and optical) to transmit voice, data and video communication signals.
  2. It is also defined as distance communication, using electrical or optical transmissions, between humans and/or computers.
  3. Although, telenursing changes the method in which professional nursing services are delivered, it does not fundamentally change the nature of nursing practice.
  4. Telenursing was instituted as an effective mode for providing care to patients, geographically distant from healthcare providers.
  5. Using telecommunications and information technology, nursing care is provided remotely to individuals.
  6. Nurses recognize the value of telecare and telehomecare as essential components of telenursing, that give patients, easy access to high-quality care and eliminate costs and difficulties associated with travel to healthcare facilities.
  7. Telenursing continues to grow as a valuable method for providing nursing care, especially in home health care.
According to the International Telecommunications Union (1999), tele-education is “the use of information and communication technologies to provide distance education.”
Benefits of Computer in Community
  1. The use of standardized language classifications and design support for automated systems that can assist in supporting the integration of other healthcare disciplines that help to coordinate care.
  2. Transfer data into knowledge, such as data about client or caregiver and also organization agency and community resources, also data about domain, specific data such as healthcare providers and outcomes to community health nursing (CHN) interventions.
  3. Information technology is used with the assistance of the computer to manage and process the information.
  4. Informatics provides tools to help, to process, store, retrieve, analyze data and information to improve patient care.
  5. In addition, it can help the nurse in project management, clinical practice and research.
  6. Computerized literature searching is one of the informatics applications in field research.
  7. Informatics also will add to nursing knowledge, improving quality of care and provide high level of competence of patient care.
  8. Internet can provide marketing services such as job posting, advertisements of health services and online risk assessment.
  9. The web-based management provides a way to monitor large number of clients efficiently on daily basis and avoid unnecessary hospital admission.
  10. Surveillance is another aspect of public health that could be dramatically transformed by the application of information technology.
  1. 132Consumer Protection Act.
Consumer Protection Act
Till recently, all cases of disputes regarding negligence on the part of doctors or hospitals were raised in a court of law. It was filed either under the law of torts to claim damages or under the relevant sections (304A, 336, 337 and 338) of the [Indian Penal Code (IPC)], to get the negligent punished. However, after the introduction of the consumer protection act, a drastic change has taken place and litigants are preferring claims through the district, state or national forums. The two main reasons for this are that hardly any costs are involved in this procedure and the case is decided in a short span of 3–4 months.
Consumer Protection Laws are designed to ensure fair competition and the free flow of truthful information in the market place. The laws are designed to prevent businesses that engage in fraud or specified unfair practices from gaining an advantage over competitors and may provide additional protection for the weak and those unable to take care of themselves. Consumer Protection laws are a form of government regulation, which aim to protect the interests of consumers. For example, a government may require businesses to disclose detailed information about products particularly in areas, where safety or public health is an issue, such as food. Consumer protection is linked to the idea of ‘consumer rights’ (that consumers have various rights as consumers) and to the formation of consumer organizations, which help consumers make better choices in the market place.
The Consumer Protection Act of India is also quite specific about what a complaint is, under the law's definitions. First and foremost, the complaint must be made in writing and should concern an unfair action by a business or individual acting in a commercial setting. Defects in goods or unsatisfactory service can be the subject of written complaints, as can excessively high charges for goods or services.
Consumers are not charged a fee for filing such complaints. Decisions may involve complete removal of any defect in a product and replacement of the product. Refunds are specifically provided for in the law.
A Primer on Consumer Protection Act
Consumer Protection Act (CPA) was enacted by Parliament in December, 1986 and came into force on 1st September, 1987. The aim of Act is to provide a simple, speedy and inexpensive redressal for consumer grievances relating to defective goods, deficient services and unfair trade practices.
The CPA defines the obligation of traders and manufacturers as well as of service providers and if the consumer feels that the goods provided or the services given are not to his satisfaction, are defective and below the standards prescribed normally, he is entitled for what he has paid.
Under the CPA, courts have been established at district levels, as the District Consumer Redressal Forum, at the State Level as the State Consumer Redressal Commission and at the National level as the National Consumer Redressal Commission. These have three members including the chairman, who usually is a sitting judge or retired judge of District Court or State High Court or of Supreme Court of India, respectively and other two members one of whom has to be a woman.
133The District Forum can award compensation up to 5 lakh, while the state commission can award compensation up to 20 lakh. The National Commission usually deals with appeals made against the judgments of the state commissions and can award any amount of compensation.
Though the medical profession was initially exempted from the Consumer Protection Act. As stated above, but on 13th November 1995, the Supreme Court of India in its judgment in civil appeal number 688 of 1993, in case of Indian medical association (IMA) vs Shanta VP and others held that medical practitioner can be sued under Consumer Protection Act 1986, for any negligence. The court held that any services rendered by doctors, hospitals are covered in the service as defined under section 2 (1) (0) of the CPA, 1986.
Consumer Protection Councils
They are at two levels namely Central and State Protection Councils.
Central Consumer Protection Council
The objectives of this council shall be to promote and protect the rights of consumer such as:
  1. The right to be protected against the marketing of goods and services, which are hazardous to life and property.
  2. The right to be informed about the quality, quantity, potency, purity, standard and price of goods and services, as the case may be so as to protect the consumer against unfair trade practices.
  3. The right to be assured, wherever possible, access to variety of goods and services at competitive prices.
  4. The right to be heard and to be assured that the consumers interest will receive due consideration at appropriate forums.
  5. The right to seek redressal against unfair trade practices.
State Consumer Protection Councils
The state council shall consists of following members:
  1. The minister in-charge of consumer affairs in the State Government, who shall be its chairman.
  2. Such number of other official or non-official members representing such interest as may be prescribed by State Government.
  3. The State Council shall meet as and when necessary, but not less than two meetings shall be held every year.
The objective of every State Council shall be to promote and protect within the state, the rights of consumers.
Patient's Bill of Rights
The healthcare rights of patients have been the subject of much public debate and legislative action in the latter half of the 20th century. The fundamental right to quality medical care and compensation for medical malpractice, the right to informed consent, and the right to healthcare privacy, are all protected under United States Congressional Law. While these and other laws ensure many rights for medical patients, the changing nature of medical knowledge and care also ensures the continued need to regulate the relationships among 134patients, caregivers, and caregiving institutions. But quite apart from any legal issues, the recognition that patients have rights can transform the doctor-patient relationship from an authoritative and paternalistic one into a true partnership, with the result that the quality of medical care is enhanced.
The government is concerned about the deteriorating services in medical care, both in private nursing homes and public hospitals. Consumer organizations are also pressing for a charter of right of consumers of medical services.
The legislative controls of nursing practice primarily protect the rights of the patients. Until the 1960s patients had few rights; in fact, patients often were denied basic human rights during a time, when they were vulnerable. In 1973, however, the American Hospital Association published its first patient bill of rights.
  1. The patient has the right to considerate and respectful care.
  2. The patient has the right to and is encouraged to obtain from physicians and their direct caregivers relevant, current and understandable information concerning diagnosis, treatment and prognosis.
  3. The patient has the right to make decisions about, the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy and to be informed of the medical consequences of this action. In case of such refusal, the patient is entitled to other appropriate care and notify patients of any policy that might affect patient choice within the institution.
  4. The patient has the right to have an advance directive (such as living will, health care proxy or durable power of attorney for health care) concerning treatment or designating a surrogate decision-maker with the expectation, that the hospital will honor the intent of that directive to the extent permitted by law and hospital policy.
  5. The patient has the right to every consideration of privacy. Case discussion, consultation, examination and treatment should be conducted so as to protect each patient's privacy.
  6. The patient has the right to expect that all communications and records pertaining to his/her care will be treated as confidential by the hospital, except in cases such as suspected abuse and public health hazards, when reporting is permitted or required by law. The patient has the right to expect that the hospital will emphasize the confidentiality of this information, when it releases it to any other parties entitled to review information in these records.
  7. The patient has the right to review the records pertaining to his/her medical care and to have the information explained or interpreted as necessary, except when restricted by law.
  8. The patient has the right to expect that, within its capacity and policies, a hospital will make reasonable response to the request of a patient for appropriate and medically indicated care and services. The hospital must provide evaluation, service and/or referral as indicated by the urgency of the case. When medically appropriate and legally permissible or when a patient has so requested, a patient may be transferred to another facility. The institution to which the patient is to be transferred must first have accepted the patient for transfer. The patient must also have the benefit of complete information and explanation concerning the need for risks, benefits and alternatives of such a transfer.
  9. 135The patient has the right to ask and to be informed of the existence of business relationships among the hospital, educational institutions, other healthcare providers or payers that may influence the patient's treatment and care.
  10. The patient has the right to consent or decline to participate in proposed research studies or human experimentation, affecting care and treatment or requiring direct patient involvement and to have those studies fully explained prior to consent. A patient, who declines to participate in research or human experimentation is entitled to the most effective care, that the hospital can otherwise provide.
  11. The patient has the right to expect reasonable continuity of care when appropriate and to be informed by physicians and other caregivers of available and realistic patient care options, when hospital care is no longer appropriate.
  12. The patient has the right to be informed of hospital policies and practices that relate to patient care, treatment and responsibilities. The patient has the right to be informed of available resources for resolving disputes, grievances and conflicts, such as ethics committees, patient representatives or other mechanisms available in the institution. The patient has the right to be informed of the hospital's charges for services and available payment methods.
A bill of rights that has become law or state regulation has the most legal authority, because it provides the patient with legal recourse. Today, patients are more assertive and involved in their health care. They have more information to review, when looking at treatment options and are demanding to be participants in decision-making about their health care. The patient's right to information and participation in medical care decisions has led to conflicts in the areas of informed consent and access to medical records. Although, the manager has a responsibility to see that all patient rights are met in the unit, the areas that are particularly sensitive, involve the right to privacy and personal liberty, both guaranteed by the constitution.
Patient Responsibilities
In order to receive optimal care, patient and his family are responsible for:
  1. Providing accurate information about present illness and past medical history and wishes for the medical care.
  2. Seeking clarification, when necessary to fully understand health problems and the proposed plan of care.
  3. Following through on agreed plan of care.
  4. Considering and respecting the rights of others.
  5. Being courteous.
  6. Providing accurate information for insurance claims and working with the health system to make payment arrangements when necessary, so that others can benefit from the services provided here.
  7. Following visitation policies of University Hospital.
  1. Disaster management.
Natural disasters are those caused by uncontrollable forces of nature. It is generally impossible to determine, when these disasters can occur. Nature is often mutable especially in certain geographic areas, when the unpredictable acts of nature occur on 136heavily populated areas, widespread damage, great inconvenience and frequently loss of life occurs.
We cannot expect a disaster, but when they happen, they cause huge destruction to man. Disasters may be man-made or natural may be inevitable; but there are methods to prevent or manage the ways people and their communities respond to the calamities or the disasters.
In India, there are ample examples of disasters:
  • In case of Bhopal gas tragedy, it killed 25,000 people and injured 150,000
  • In Gujarat, 2001 earthquake killed 10,000 people and left instant population homeless more than 500,000
  • Tsunami in 2004, killed 100,000 people and many were left homeless.
  1. A disaster can be defined as “any occurrence that causes damage, ecological disruption, loss of human life or deterioration of health services on a scale sufficient to warrant an extraordinary response from outside the affected community or area.”
    Park K
  2. Disaster is an event capable of causing widespread destruction due to the various forces of nature.
    Dr. Sridhar Rao
  3. Disaster can be defined as an ecological disruption exceeding the adjustment capacity of the community.
  4. Disaster is a catastrophe causing injury or illness simultaneously to atleast 30 persons who will require emergency treatment.
    Colin Grant
  5. Emergency management is the continuous process by which all individuals, groups and communities manage hazards in an effort to avoid or ameliorate the impact of disasters resulting from the hazards.
  6. An occurrence, either natural or man-made, that causes human sufferings and creates human needs that victims cannot alleviate without assistance.
    American Red Cross
  7. A major disaster is defined as any Hurricane, tornado, flood, storm, snowstorm, fire, explosion or other catastrophe.
    Disaster Relief Act, 1974
Types of Disasters
Essentially, there are two types of disasters:
  1. Natural disaster.
  2. Man-made disaster.
Natural disaster: It includes Hurricanes, tornado, floods, earthquakes, volcanoes, tsunami and typhoons. Although it is a natural disaster, it can be done to prevent the further destruction or escalation of accidents, death and impact by well-rehearsed disaster plan.
Man-made disaster: It includes war, transport accidents, food or water contaminations and building collapse, fire accidents. Man-made disasters can be prevented.
Impact of Disaster
Effect on human beings: Disaster gives rise to death and injuries of varying severity. Some of the survivors exhibit pain, depression and other psychological reactions. Water-borne diseases (cholera and viral hepatitis A), malaria, plague tend to breakout in the disaster affected area after a few days of catastrophe.
137Some people migrate from the disaster-affected area to safer places. After a disaster the unscrupulous persons resort to looting and stealing. Disaster has profound economic impact. The value of property, livestock and crops, destroyed property and to rehabilitate and resettle the affected population.
Other effects: Cattle, dogs and other animals suffer injuries. Trees and standing crops are either destroyed or damaged. Roads, rails, bridges, buildings and telecommunication installations are damaged. Transportation, power supply, internet and telephone services are disrupted.
Epidemiological Factors
The disaster includes basically four epidemiological factors. They are:
  1. Agent.
  2. Host.
  3. Environment.
  4. Psychological factor.
Agent: This is the physical item that actually causes the injury. It is again of two types
Primary agent: Includes falling buildings, storm, rising water and smoke.
Secondary agent: Includes bacteria and viruses that produce contamination or infection after the primary agent has caused the injury or destruction. In an epidemic, the bacteria or virus causing a disease is the primary agent.
Host: In epidemiological framework as applied to disaster, the host is of humankind. Host factors are those characteristics of human that influence the severity of the disaster's effect. Host factors include age, immunization status, pre-existing health status, degree of morbidity and emotional stability. Individuals most severely affected by disaster are elderly. Who may have trouble leaving the area quickly. Young children, whose immune systems are not fully developed and persons with respiratory or cardiac problems.
Environment: The factors that affect the outcome of a disaster include physical, chemical, biological and social factors.
Physical factors: The time when the disaster occur weather conditions, the availability of food, water and the functioning of utilities such as electricity, and telephone service.
Chemical factors: Leakage of stored chemicals into air, soil, ground water or food supplies.
Biologic factors: Are those that occur or increase as result of contaminated water, improper waste disposal, insects or rodents proliferation.
Social factors: Are those that contribute to the individual, social support system, loss of family member and the questioning of religious beliefs.
Psychologic factors: This are closely related to agent, host and environmental conditions. The nature and severity of the disaster, affect the psychological distress experienced by the victims. According to Demi and Miles, psychological reactions fall into three categories:
  • Mild to severe
  • Normal to pathologic
  • Immediate to delayed.
A few people will be so overwhelmed by the trauma, that they will experience extreme psychological distress immediately, despite others, despite their involvement in the disaster, may appear unaffected psychologically during both the impact and postimpact phases. These people may be using denial and repressions as defenses to handle their 138thoughts and feeling. More common psychological reactions to the disaster include depression, sadness, fear, anger and follow-up with mental healthcare professional, community nurses and others involved in treating clients after disasters should be aware of the possibility of post-traumatic stress disaster syndrome (PSTD).
Phases of a Disaster
There are three phases of disaster. The action of emergency personnel and other health professionals depend on which phase of the disaster is at hand.
Preimpact phase: It is the initial phase of the disaster, prior to the actual warning is given at the sign of the first possible danger to a community, with the aid of weather networks and satellites, many meteorological disasters can be predicted.
The earliest possible warning is crucial in preventing loss of life and minimizing damage. This is the period when the emergency preparedness plan is put into effect; emergency centers are opened by the local civil defense authority. Communication is a very important factor during this phase; disaster personnel will call on amateur radio operators, radio and television stations.
The role of the nurse, during this warning phase is to assist in preparing shelters and emergency aid stations and establishing contacting with other emergency service groups.
Impact phase: It occurs when the disaster actually happens. It is a time of enduring hardship or injury and of trying to survive. This is a time when individuals help neighbors and families at the scene, until outside help arrives. The impact phase may last for several minutes (e.g. after an earthquake, plane crash or explosion) or for days or weeks (e.g. in a flood, famine or epidemic).
The impact continues until the threat of further destruction has passed and emergency operation center is established and put in operation. It serves as the center for communication and other government agencies of healthcare providers to staff shelters. Every shelters has a nurse as a member of disaster action team. The nurse is responsible for psychological support to victims in shelters.
Postimpact phase: Recovery begins during the emergency phase and ends with the return of normal community order and functioning. For person in the impact area, this phase may last for a lifetime (e.g. victims of the atomic bombing of Hiroshima). The victims of a disaster go through four stages of emotional response.
Denial: During this stage, the victims may deny the magnitude of the problem or have not fully registered. The victims may appear usually unconcerned.
Strong emotional response: In the second stage, the person is aware of the problem, but regards it overwhelming and unbearable. Common reactions during this stage are trembling, tightening of muscles, sweating, speaking with difficulty, weeping heightened, sensitivity, restlessness, sadness, anger and passivity. The victim may want to retell or relieve the disaster experience over and over again.
Acceptance: During the third stage, the victim begins to accept the problems caused by the disaster and makes a concentrated effect to solve them. It is important for victims to take specific action to help themselves and their families.
Recovery: The fourth stage represents a recovery from the crisis reaction. Victims feel that they are back to normal. A series of well-being is restored. Victims develop a realistic memory of the experience.
Effects of Disaster on the Community
Not only the individuals are affected physically and emotionally by a disaster but also the entire community is affected. The most important disruptions are the following:
  1. Public service personnel are overworked.
  2. Lifelines are interrupted, include telephone systems, televisions and radio broadcasting, transportation and water and sanitation services.
  3. Rumors run rampant and hard to check.
  4. Public and private buildings may be damaged.
According to American Red Cross, the four phases of community's reaction to a disaster are as follows.
Heroic phase: Strong, direct emotions focusing on helping people to survive and recover.
Honeymoon phase: A drawing together of people who simultaneously experienced the same catastrophic event.
Disillusionment: Feeling of disappointment because of delays or failures, when promises of aid not fulfilled. People seek help to solve their own personal problems, rather than community problems.
Reconstruction phase: A reaffirmation of belief in the community, when new buildings are constructed. However, delays in the process may cause intense emotional responses.
Disaster Management
Responsibilities of agencies and organizations. The key to effective disaster management is predisaster planning and preparation.
Planning for a disaster involves five major areas:
  • The use of technology to forecast events
  • The use of engineering to reduce risks
  • Public education on potential hazards
  • A coordinated emergency response
  • A systematic assessment of effects of a disaster to better prepare for the future.
These disaster planning are shared by local, State and Central government and voluntary agencies.
Government, environmental, technical and economical resources are involved in predisaster preparation. Nurses should play an active role in preparing for disasters by participating in community planning and mock disaster exercises. Nurses can also function as primary teachers in affecting community understanding and the necessity of preparation for disasters.
Established organizations provide many of the community services needed in a disasters. Some of the organizations that are involved in disaster planning and relief are Indian Red Cross, Lions Club, Rotary Club, Home Guards, Local Governments and Community, State Government and Central Government, Indian Army, Department 140of Health and Human Services, Fire Department. Local governments are responsible for the safety and welfare of the citizens. They act to protect the lives and property of the citizens, protect public health, carry out evacuating rescues, local disaster responses organizations should include local area government agencies such as Fire Departments, Police Departments, Emergency or Civil Defense Service and local branch of Red Cross. State Government provide financial support to local governments; helps families either to relocate or repair their homes and provides grants to their families to assist in their recovery.
Community Nurses Responsibility in a Disaster
Disaster nursing can be defined as the adaptation of a professional nursing skills in recognizing and meeting than nursing, physical and emotional needs resulting from a disaster.
Goals for Disaster Nursing
  1. The overall goal of disaster nursing is to achieve the best possible level of health for the people and the community involved in the disaster.
  2. Disaster nursing is multifaceted as the demand of disaster that must be met, much depends up on the location of the nurse at the time the disaster occurs. If the nurse is in the center of disaster area he/she may need to help with evacuation, rescue and first aid until the immediate needs are met.
  3. Hospital nurses will be needed to care for disaster victims, as they are brought in for acute care problems. Most frequently, community health nurses are first called by the health authority to report to shelters, providing care for disaster victims.
  4. The community health nurse brings the principles of both public health and community nursing to bear during the stress of crisis. The nurse must council, teach, assess and be able to delegate to other tasks that the nurse would normally perform.
  5. In the shelters, nurse in-charge evaluates healthcare needs, establishes nursing care priorities and plans for the healthcare supervision.
  6. She need to prepare for isolation of persons with suspected communicable diseases and in general, overseas the health and well-being of all shelter personnel.
There are eight fundamental principles that should be followed by all who have a responsibility for helping the victims of a disaster.
  1. Prevent the occurrence of the disaster whenever possible.
  2. Minimize the number of causalities, if the disaster cannot be prevented.
  3. Prevent further causalities from occurring after the initial impact of the disaster and rescue the victims.
  4. Provide first aid to the injured.
  5. Evacuate the injured to the medical facilities.
  6. Provide definitive medical care.
  7. Promote reconstruction of lives.
Role of Community Health Nurse in Preparedness
The role of community health nurse in preparedness is to facilitate preparation within community and place of employment. The nurse can help to initiate or update plan, provide educational programs material regarding disaster, specific to the area and organize mass causality drills or mock disaster to promote confident development skills, coordinate activities, coordinate participation. It is critical that those persons who will be involved in the actual disaster be involved in the drill.
The community health nurse is also a unique position to provide an updated record of vulnerable population, for example, when calamity strikes disaster.
Most workers now knows, what kinds of population they, attempting to assist are the nurse who leads a preparedness effort can help when response is required.
Personal preparedness: Great stress is placed on the nurse with the client responsibilities, for example a mother whose child needs care will not be able to participate fully. She must be as healthy as possible both mentally and physically, personal preparedness can help ease some of the conflicts that will arise and allows nurses to attend to client's needs determine what types of disaters are most likely to happen (learn about your communities warning signals. Review the disaster plan at the workplace school and other places where the families spend time. Determine how to help elderly or disabled family members and neighbors. Create a disaster plan—discuss the type of disaster that are most likely to happen and review to do in each case. Pick two places to meet including outside the home and outside neighborhood; choose an out of state friend to be your family contact to verify location of each family member).
Role of Community Health Nurse in Impact Phase or Response Phase
The role of the community nurse during disaster, depends greatly on the nurse's past experience, role in the institutions and community's preparedness, specialized training and special interest and flexibility.
The community health nurse is the first to arrive on the scene and must respond accordingly. Once rescue workers begin to arrive at the scene, immediate plans for triage system should begin. Triage is the progress of separating casualties and allocating treatment based on the victims potential for survival. Prioritizing of victim's for treatment can be done in many ways. Some use color coding (American Red Cross), probably the best and most easily understood for category systems is the first priority, second priority, third priority and dying or dead.
  • Red: Most urgent (first priority)
  • Yellow: Urgent (second priority)
  • Green: Third priority
  • Black: dying or dead.
The first priority patients have life-threatening injuries and are experiencing hypoxia. For example; shock, chest pain, internal hemorrhage, head injury, major burns.
The second priority patients have injuries with system affects and complications not yet shock or hypoxia that can wait till 45–60 minutes for treatment.
The third priority casualties have minimal injuries, usually these patients can wait several hours for treatment without danger.
142Dying or dead patients are hopelessly injured. These patients have catastrophic injuries would not survive under best of circumstances. Community health nurse, working as members of assessment team have the responsibility of feedback accurate information to relief managers to facilitate rapid rescue and recovers. Many times nurses are required to make home visits to gather information.
Types of Information Included in Initial Assessment
  1. Geographical extent of disaster's impact.
  2. Population at risk or affected.
  3. Presence of continuing hazards.
  4. Injuries and deaths.
  5. Availability of shelter.
  6. Current level of sanitation.
  7. Status of health involved in ingoing surveillance, use the following methods to gather information:
    • Interview
    • Health and illness
    • Surveys
    • Records: Census, school, vital statistics
    • Observation
    • Physical examination.
Role at Emergency Station
Nurses are involved in providing care at emergency aid stations. The functions of the disaster health service nurse in-charge are as follows:
  1. Arranging with the volunteer medical consultant for initial and daily health checkups based on the health needs of sheltered residents.
  2. Establishing nursing care priorities and planning for healthcare supervision.
  3. Planning for appropriate transfer of patients to community healthcare facilities as necessary.
  4. Evaluating health care needs.
  5. Arranging for secure storage of supplies, equipment, records and medications and periodically checking to see whether material goods must be ordered.
  6. Requesting and assigning volunteer staff to appropriate duties and providing on the job training and supervision.
  7. Consulting with the shelter manager on the health status of patient and workers identifying potential problems and trends.
  8. Consulting with the food supervisor regarding the preparation and distribution of special diets including infant.
  9. Arranging with the mass care supervisor for the purpose and replacement of essential drugs for shelter patients.
Psychological Needs of Victims
Disaster produce physical, social and psychological consequences that are exhibited to various degrees in different persons, families, communities and culture depending on 143their past experiences, coping skills and the scope and nature of the disaster. The following victims of a disaster are more likely to need crisis intervention than others:
  • Those who have lost one or more family members
  • Those who have suffered serious injury
  • Those who have a history of psychological disorder
  • Those who have lost their home or possessions
  • Those who are poor or on a fixed income
  • Elderly individuals
  • Members of minority groups
  • Those without adequate support systems.
Despite of psychological distress, many people can function effectively during the impact phase of disaster, but will later experience emotional distress. Some people will be so overwhelmed by the disaster, that they will experience immediate extreme distress.
At the disaster site or primary triage point, simple support measures can alleviate the psychological trauma experienced by survivors. These measures include the following:
  1. Keeping families together, especially children and parents.
  2. Assigning a companion to frightened or injured victims or placing victims in groups where they can help each other.
  3. Giving survivors, tasks to do, to keep them busy and reduce rumors.
  4. Encouraging individuals to share their feelings and support each other.
  5. Isolating victims, who demonstrate hysterical or panic behavior.
  6. Each disaster victim to be assessed for the level of psychological stress.
  7. Individuals suffering minimal distress usually need family and friends support.
  8. Those who suffer a moderate amount of distress, usually need the help of a support group or short-term counseling.
  9. Persons with severe distress may need extensive therapy and refer those victims that need help to appropriate professional counselors.
Role of the Community Health Nurse in Disaster Recovery
During the recovery phase of a disaster, nurse is involved in efforts to restore the community to normal. Referral of injured victims for rehabilitation and convalescence is important to reduce the chance of long-term disability. Psychosocial needs must be addressed. In addition to identifying those in need of longer-term counseling, nurses must link victims with support agencies to help with food, clothing and shelter needs depending in the extent of damage to the community and the injuries of victims, the recovery phase can be relatively quick or can extend over a long period of time. Community recovery from Gujarat earthquake has still not completely recovered.
Personal Response of Care Providers to Disaster
Disaster workers are after overlooked when those affected by disaster are considered. Many disaster workers report being overwhelmed by the devastation and the extent of personal injuries many work without relief for 24–36 hours. If they are residents of the affected community, they must deal with personal losses in addition to working with the people under their care.
144Healthcare workers are subjected to the same concerns and emotional trauma as other community residents, yet are expected to function in a healthcare capacity. Laube (1985), Churgin (1992) examined the responses of community health nurses, during the Hurricane in 1989.
The nurses experienced conflicts between family and work responsibilities. Many expressed feelings of anger, grief and frustration about their personal losses. Supportive colleagues eased the stress or healthcare workers; the American Red Cross (ARC) encourages disaster workers to go through a debriefing process after their work is complete. This process may consist of one or several sessions and designed to help healthcare workers, recognize and deal with the personal impact of the disaster.
Disaster Preparedness
Disasters can strike quickly and without warning. They can force you to evacuate your neighborhood or confine one to their home. What would one do, if basic services such as water, gas, electricity or telephones, were cut off? Local officials and relief workers will be on the scene after a disaster, but they cannot reach everyone right away. No community is equipped to handle all the demands of a catastrophe. Help the community by preparing oneself. Disaster preparedness begins with every individual.
If one is unprepared for a disaster, it can shatter their life. Knowing what to do when a disaster strikes will help them control the situation better and be in a position to recover more quickly.
People have faced many emergency situations in the past, from floods to ice storms, power outages and water supply problems. Canadians understand the impact of these emergencies and the fear and anxiety they cause. In recent years, disasters have forced more than 4 million Canadians from their homes and caused billions of dollars in damage.
For this reason, the Canadian Red Cross says, “Expect the Unexpected - Plan for it.”
Disasters can happen anywhere and anytime. When disaster strikes, one may not have much time to respond. A highway spill or hazardous material leakage could mean evaction. A winter storm could confine one's family at home. An earthquake, flood, tornado or any other disaster could cut water, electricity and telephones for hours or days. Will the family is prepared to cope with the emergency until help arrives?
Make sure everyone in the family knows what to do before, during and after an emergency. Set up a family meeting to discuss how one can prepare for an emergency. Have an own plan. The family will cope best by preparing for disaster before it strikes. One way to prepare is by buying a disaster preparedness kit. Knowing what to do is the best protection and one's responsibility. Now is the time to prepare.
  1. Principles and techniques of supervision.
Supervision is defined as ‘An art or a process by which designated individual or group of individuals oversee the work of others and establish controls to improve the work as well as the worker’. Supervision is generally termed as an educational process in which a person with better training or more experience, takes the responsibility of training a person with less training or less experience and in this educational process, the leadership of the supervisor and the growth of the supervised, combine to achieve and maintain progressively, the highest level of performance of which the worker is capable.
145Supervision is observation and providing feedback to ensure the quality of the program and to enable the staff to perform to their maximum potential. Traditional approaches to supervision emphasized on ‘inspecting’ facilities and controlling individual performance.
Objectives of Supervision
  1. To help subordinate to do their job skillfully and efficiently.
  2. To develop subordinate's capacity to the fullest extent.
  3. To promote team work.
  4. To promote moral and motivation among workers.
  5. To bridge the gap between personal goal and organizational goal.
Principles of Supervision
  1. Supervision should aim at growth in knowledge and improvement of skill of the person.
  2. Supervision should improve the ability in thinking and adjusting to the new situation.
  3. It should help to formulate objects.
  4. Good supervision stimulates their interest and effect the growth.
  5. No undue pressure for achievement.
  6. Autonomy to the subordinate is preferred.
  7. Supervision should have competence.
  8. Supervision should have received training.
  9. Decision-making is encouraged.
  10. Free communication is required.
  11. No over burdening to be staff.
  12. Good leadership by supervisor.
  13. Suitable climate for work.
  14. Give guidance.
  15. Supervision should encourage innovation allowing free flow of ideas and share positive experiences of personnel.
Common Supervisory Methods
  • Individual conference
  • Group conference
  • Training sessions
  • Review of records
  • Evaluation sessions
  • Direct observation.
Principles Applied to Nursing
  1. Supervision should be focused on the attainment of one goal, the giving of a high quality of nursing care.
  2. Strives to make the ward, a good learning situation.
  3. Supervision is well-planned.
  4. It should foster the ability to think and act herself.
  5. Helps her to attain objectives, stimulates interest and effort.
  6. 146Encourages and challenges her/him to greater endeavor through adequate approval, recommendation and by recognition of work well done.
  7. To make pattern for analysis and to analyze continuously her/his success in reaching the objectives.
  8. Respects the personality of the nurse.
  9. Stimulates the nurses ambition to grow in effective manner.
  1. A supervisor is a person, who is primarily in-charge of a section and is responsible for both quality and quantity of production, for the efficient performance of the equipment and for the employees in his charge and their efficiency, training and morale.
  2. A supervisor drives authority from the departmental head for getting work done from the workers by using the resources of the enterprises.
  3. He issues instructions to the workers, directs their activities and reports to the department head on the performance of his/her section.
Qualities of a Good Supervisor
  • Trained person
  • Understand the training background and ability of the supervised
  • Good knowledge of the local practice
  • Good in health, skills in TG and PR/t have pleasing manner
  • Good listener
  • Supervisor should lead an exemplary life
  • Creative enthusiasm
  • Just impartial human, tolerant and tactful
  • Helpful
  • Good power of judgment.
Supervision consists of:
  • Leadership
  • Communication
  • Motivation
  • Evaluation.
Functions of Supervision
  1. Assignment of the work loads of individual and groups, according to the level of physical and mental competence or preparing the duty roster.
  2. Identify the needs for supplies and equipment and providing materials and supplies to facilitate the staff performance.
  3. Identify the problem and help to solve.
  1. Orientation.
  2. Teaching subordinates.
  3. 147Plan and conduct in service education program.
  4. Ensuring staff developments.
  1. The supervision act as a communicator between the staff and authorities and other health team members.
  2. He/She facilitates communication.
  3. He/She should encourage free communication among persons between worker and community representatives and members of health team.
  1. Supervisor is supposed to carryout performance appraisal of all the staff this include identifying the cause of difficulty.
  2. Providing certificate of eligibility (CE) and guidance.
Other functions
  1. Coordinates there of subordinates and agents and promote team worker.
  2. Promote social contact with in the team to bring staff together and increases group cohesiveness.
  3. Develops mutual confidence.
  4. Raises level of motivation.
  5. Develops good intellectual property right (IPR).
  6. Maintains rules and regulations.
  7. Establish control over the subordinates.
As a manager, supervisor has to perform the following functions:
  • Planning the work
  • Issuing orders
  • Providing guidance and leadership
  • Motivation
  • Preserving records
  • Controlling output and performance of the worker
  • Liaison between management and workers
  • Grievance handling
  • Industrial safety.
Steps in Supervision
When supervision is needed, the spur has to make plan for supervision by using certain steps to follow:
  1. Defining of the job to be done.
  2. Selection and organization of supervisor activities based on available resources.
  3. Anticipation of difficulties.
  4. Establishment of criterion for evaluation determining, what extent the program has met the problem/objectives according to plan.
Types of Supervision
Direct supervision
Face-to-face talk with worker. Points to be considered:
  • 148Do not loose temper
  • Use democratic approach and avoid autographic
  • Give workers, chance to reply
  • Do not talk too much and too fast
  • Be human in behavior
  • Do not give instructions in haphazard way.
Indirect supervision
With the help of record and reports of the worker and through written instructions. This includes:
  • Ensuring and carrying out allotted work
  • Analysis of monthly progress input efforts and achievement
  • Analyzing amount of work allotted
  • Support and guidance.
Methods of Supervision
  1. Technical vs creative supervision.
  2. Cooperative vs authoritarian.
  3. Scientific vs institutive.
  4. Task oriented vs employee oriented.
Technical: These are basic supervisory skills and which need to be trained in group discussion and conference. For example, techniques of service study, record construction, time study, etc.
Creative: It provides maximum adaptation to the situation. For example, instead of orientation period of 2 week, for each new staff member, a variable plan in both contents and time, according to the needs of each individual should be formulated.
Cooperative: Full participation of each member of the group in planning, action and decision.
Authorization: Supervision responsibility centers entirely on the supervisor, with the staff following his/her orders. Both are needed at all situations.
Scientific supervision: Relies on objective study and measurement than personal judgment/opinion.
Intuitive supervision: It needs to maintain IPR.
Task-oriented supervision: It emphasize the task more than performer.
Employee-oriented supervision: Supervisors are more concerned about worker staff, their needs and welfare than assigned tasks.
Tools for Supervision
  • Checklist
  • Rating scales
  • Nurses reports
  • Nursing rounds
  • Job descriptions
  • 149Personnel policies
  • Staff educations
  • Problem solving approach.
Techniques of Supervision
  1. A technique is a way of doing something. Techniques vary with the personality and ability of the individuals, who are being supervised, the activities that are being performed under supervision and the immediate circumstances.
  2. Any technique used for supervision, must be based on sound, democratic, psychological principles, which takes account of the nurse's individuality.
Process of Supervision
Stage 1
Preparation for supervision:
  1. A supervisor should focus on specific issue efficacy of service provided to the relevant problems efficacy in problem utilization and management of limited resources.
  2. Study of document.
  3. Identification of priorities.
  4. Preparation of a supervision schedule.
Stage 2
Tools used for supervision:
  • Job description
  • Task description
  • Weekly time table
  • Checklist/Rating for each work.
As a supervisor the following duties has to be performed:
  1. Establish contact.
  2. Review the objectives, targets and norms.
  3. Review job descriptions.
  4. Note actual/potential conflict.
  5. Observe the actual performance.
  6. Observe the individual nursing staff, carries out his/her tasks.
  7. Identify the gaps and needs for follow-up action based on feedback data attained through the observation.
Stage 3
Follow-up of supervision. Unless actions to follow-up the gaps and needs identified during stage are taken, supervision remains incomplete. Each supervisor must prepare a report on the observations made during supervision. The follow-up action may include:
  1. Organizing in-service training programs/continuing education programs for the nursing personnel.
  2. Reorganization of time table/work plan/duty roaster.
  3. Initiating changes in logistic support or supply system.
  4. Initiating actions for organizing staff welfare activities.
  5. Counseling and guidance regarding career development and professional growth.
Effectiveness of Supervision
The effectiveness of supervision depends on:
  1. Human relations skill.
  2. Technical and managerial knowledge.
  3. Leadership position.
  4. Improved upward relations.
  5. Relief from non-supervisory duties.
  6. General and lose supervision.
Human relations skill: Supervision is mainly concerned with instructing, guiding and inspiring human beings toward greater performance. For purpose of direction, the supervisor has to rely on leadership, counseling, communication and other determinants of human relations.
Technical and managerial knowledge: Guidance implies a complete understanding of all work problems, for which supervisor should have good knowledge about technical aspect of job and also the managerial aspect.
Leadership position: The authority of supervisor must be made commensurate with their duty so as to make the job of supervision a satisfying, rewarding and challenging one.
Improved upward relations: To ensure good quality of supervisors, the supervisors should be regularly allowed to present their views and suggestions to top executive in regard to the personnel and their work performance.
Relief from non-supervisory duties: To make the supervisory duties purposeful, the supervisors are to be relieved of many routine activities, that divert their attention from the real job.
General and Lose Supervision
According to some experience, the general and loose supervision is more productive than close supervision. Here the leader must allow freedom and initiative to his followers for pursuing a common course of action.
Problems of Supervision
Problems of supervision in nursing service
There are no perfect nursing service programs/situations without any problems:
  1. Shortage of nursing personnel.
  2. Individual differences among personnel in interests, capacities and abilities.
  3. Lack of information, insight and understanding of changes and developments in the interest of the continuance and improvement of nursing.
  4. Lack of clearly defined assignments, multiple responsibility and lack of planning on the part of those to whom personnel is responsible.
  5. Outdated policies, procedures and guides to workmanship, which cause them to be disregarded and unused.
  6. Inadequate, unsafe and defective equipment.
  7. Ill-health in the part of personnel.
  8. Undesirable personnel characteristics with special attention to attitudes.
151Nursing Management
Paper 2012 May
    1. Explain the process of recruitment.
    2. Plan an orientation program for a newly recruited staff in ICU.
  1. Discuss in detail healthcare delivery system in India.
  2. Explain the current issues and trends in nursing administration.
    1. Describe the causes of conflict in nursing services.
    2. Discuss the mode of conflict resolution.
  1. Records and reports.
  2. Role of nurse in maintaining occupational health and safety.
  3. Cost analysis.
  4. Discuss the influence of Bhore Committee on national health administration.
    1. Explain the process of recruitment.
    2. Plan an orientation program for a newly recruited staff in ICU.
    1. Explain the process of recruitment.
Recruitment is a process in which the right people for the right post is procured.
It is a source of manpower to meet the requirements of the staffing schedule and to employ effective measures for attracting that manpower in adequate numbers to facilitate effective selection of an efficient student.
It is the process of actively seeking out qualified applicants for existing position in organization in a cost effective manner.
Steps in Recruitment Process
  1. Planning.
  2. Strategy development.
  3. Searching.
  4. Screening.
  5. Evaluation and control:
    • Organizational policies regarding recruitment should prior to the advertisement of a job position
    • 152All possible source of potential applicant must be identified
    • The optimum mode of publicizing seats
    • The recruitment need and qualification required must be used
    • The response to the recruitment effort should be evaluated and adjusted as needed.
Recruitment refers to the process of identifying and attracting job seekers, so as to build a pool of qualified job applicants. The process comprises of five interrelated stages.
zoom view
Figure 1: Steps in recruitment process
General Recruitment for Nursing
The fact that a person decides to apply to a particular course in nursing shows that he/she must have become interested in nursing as a career. At this stage he/she would have been influenced by his/her parents, teachers or friends, by her personal experience of nursing care and by the image of the nurse, which she/he builds up. The way to attract suitable persons to the profession, therefore, is to ensure that a good impression and correct information are being conveyed to the public in general:
  • The public awareness can be done through talks and plays on the radio, by publishing articles in journals, by publication and wide distribution of pamphlets
  • Pamphlets should be attractive and cheap, and written in all the languages of the region
  • Pamphlets should contain information about different types of courses and opportunities for employment and promotion after qualification.
Recruitment for Individual Nursing Institution
After a student chooses nursing as a career, the next decision to be made is where to go for the necessary preparation and this is where individual schools will reap the benefit of having an active recruitment program.
Sources of Recruitment
The sources of recruitment are.
Internal Sources
Internal sources include present employees, employee referrals, former employee and former applicants.
Present employees: Promotion and transfers among the present employees can be a good source of recruitment. Promotions to higher positions have several advantages. They are:
  • It is good in public relations
  • It builds morale
  • 153It encourages competent individuals who are ambitious
  • It improves the probability of a good selection, since information of the candidate is readily available
  • It is less costly
  • Those chosen internally are familiar with the organization.
However, promotions can be dysfunctional to the organization as the advantage of hiring outsiders who may be better qualified and skill is denied. Promotions also result in breeding, which is not good for the organization.
Another way to recruit from among present employees is the transfer without promotion. Transfers are often important in providing employees with a broad-based view of the organization, necessary for the future.
Employee referrals: This is the good source of internal recruitment. Employees can develop good prospects for their families and friends by acquainting the advantages of a job with the company, furnishing cards introduction and even encouraging them to apply. This is very effective because many qualified are reached at very low cost. Most employees known from their own experience about the recruitments for the job what sort of person is looking for? A major concern with the employee recommendation is that referred individuals are likely to be similar type (e.g. race and sex), to those who are already working for the company.
Former employees: Some retired employees may be willing to come back to work on a part-time basis or may recommend someone who would be interested in working for the company. An advantage with these sources is that the performance of these people is already known.
Previous applicants: Although not truly an internal source, those who have previously applied for jobs can be contacted by mail, a quick and inexpensive way to fill an unexpected opening.
Evaluation of internal recruitment
  • It is less costly
  • Organizations typically have a better knowledge of the internal candidates' skills and abilities than the ones acquired through external recruiting.
  • An organizational policy of promoting from within can enhance employees' morale, organizational commitment and job satisfaction.
  • Creative problem solving may be hindered by the lack of new talents
  • Divisions complete for the same people
  • Politics probably has a greater impact on internal recruiting and selection than does external recruiting.
External Sources
Sources external to an organization are professional or trade associations, advertisements, employment exchanges, college/university/institute placement services, walk-ins and writer-ins, consultants, contractors.
Professional or trade associations: Many associations provide placement services for their members. These services may consist of compiling seekers' lists and providing access to members during regional or national conventions.
154Advertisements: These constitute a popular method of seeking recruits as many recruiters; prefer advertisements because of their wide reach. For highly specialized recruits, advertisements may be placed in professional/business journals. Newspaper is the most common medium.
Advertisement must contain the following information:
  • The job content (primary tasks and responsibilities)
  • A realistic description of working conditions, particularly if they are unusual
  • The location of the job
  • The compensation, including the fringe benefits
  • Job specifications
  • Growth prospects
  • To whom one applies.
Employment exchange: These have been set up all over the country in deference to the provisions of the Employment Exchanges Act, 1959. The Act applies to all industrial establishments having 25 workers or more. The Act requires all the industrial establishments to notify the vacancies before they are filled. The major functions of the exchanges are to increase the pool of possible applicants and to do preliminary screening. Thus, employment exchanges act as a link between the employers and the prospective employees.
Campus recruitment: Colleges, universities and institutes are fertile ground for recruitment, particularly the institutes.
Walk-ins, write-ins and talk-ins: Write-ins those who send written enquiry. These job-seekers are asked to complete application forms for further processing.
Talk-in is becoming popular now a days. Job aspirants are required to meet the recruiter (on an appropriated date) for detailed talks. No applications are required to be submitted to the recruiter.
Consultants: ABC consultants, Ferguson Association, Human Resource Consultants, Head Hunters, Batilboi and Consultancy Bureau, AIMS Management Consultants and The Search House are some among the numerous recruiting agents. These and other agencies in the profession are retained by organizations for recruiting and selecting managerial and executive personnel.
Contractors: They are used to recruit casual workers. The names of the workers are not entered in the company records and to this extent, difficulties experienced in maintaining permanent workers are avoided.
Radio, Television
International recruiting: Recruitment in foreign countries present unique challenges to recruiters. In advanced industrial nations more or less similar channels of recruitment are available for recruiters.
Modern Sources of Recruitment
  • Walk-in
  • Consult in
  • Tele recruitment: Organizations advertise the job vacancies through World Wide Web (www).
  1. 155Plan an orientation program for a newly recruited staff in ICU.
Staff Orientation Program
Staff orientation programs may look either formal or informal, may be as short as a day or may continue through out a month, or may or may not include some training, but they should have one thing in common,i.e. planning.
The organization should think beforehand what a staff orientation for that organization should look similar to:
  • What's important for staff to know?
  • Does the organization have unique features that are especially necessary for staff members to understand?
  • What's different about the target population?
  • Who are the important people, within and outside the organization, for this staff person to meet?
  • What impression of the organization do you want new staff members to walk away with?
None of the answers to these questions should be left to chance; they have to be included in the orientation.
The point here is that a staff orientation program is more than simply telling people a few things about the organization. It is a coherent, planned introduction that combines information, experiences and a transmission of the values and culture of the organization (more on this later), all of which are aimed at giving new staff members the foundation they need to do their jobs, and to integrate themselves into the organization and the community as easily as possible.
Why Conduct a Staff Orientation Program?
An orientation for new staff can be a boon to both those staff members and the organization. Some specific advantages to such a program include:
  1. It allows new staff members to hit the ground running. If they have a clear understanding of the organization, their positions and the community, they can jump into their jobs immediately and start to make a difference.
  2. It instills new staff with confidence in both their own ability to be effective, because they know they have the information and contacts they need and the organization, which has had the foresight to provide them with that background and made them feel a part of the operation.
  3. It improves the possibility through facilitating a good start and providing appropriate background, which people will do a good job over the long term and stay longer with the organization.
  4. It makes life easier for others in the organization by eliminating the need for new staff members to ask them constantly for information and advice.
  5. It enfolds the new staff member into an existing social structure, thereby helping him/her to feel comfortable and to bond with others, and at the same time helping to improve the organizational climate (the way the organization ‘feels’ to those who work in and have contact with it).
  6. 156It formally welcomes new staff to the organization and makes them feel that they have support for doing a good job.
  7. By familiarizing new staff members with the organizational culture, it increases the chances that they will fit well into the organization and absorb and become part of that culture.
  8. By making staff knowledgeable and better prepared, it builds the organization's reputation in the community, leading to community support and better services.
A well-conceived and well-run orientation can thus address all the factors such as logistical, professional, social and philosophical that can help a staff member fit into the organization, and do the best job she/he can.
Elements of a Staff Orientation Program
Introduction to the Organization
History: Even if the organization is brand new, it has a history.
Mission: Organization has or should have a mission statement and new staff members should have a copy of it and be given a chance to discuss, it and digest what it means. They should also understand clearly what the real mission of the organization is if it is not stated directly in the mission statement.
Organizational philosophy: Often tied in with its mission, an organization's philosophy guides its structure; the roles of various people within it; the way it treats its employees, volunteers, participants and colleagues; the methods it uses in whatever programs or services it provides and its ethics.
Methods or strategies: While some organizations leave it up to staff members to decide how they will do their jobs, others have set ways of accomplishing their goals.
People: An organization is actually no more than the people who do its work and give it life. Perhaps the most important task of a new staff member is to become familiar with those people and to understand what each of them does. New staff members should meet individually with the following:
  • Administrators:
    • Line staff: An opportunity to find out how veteran staff members do the work of the organization and for the new line staff, to learn with whom they share the most philosophically, and whom they are most comfortable approaching for help and advice
    • Support staff: Receptionists, maintenance people, technology coordinators, etc. often are the glue that holds organizations together.
Organizational structure: This includes several components.
Structure of responsibility: Who reports to whom, who's responsible for what areas of the organization's work and who makes things happen.
Decision-making structure: Who participates in what decisions; when various people can act independently and when they need to check with someone else; who shares in hiring, grievance, conflict resolution and other decisions.
Physical/Geographical structure: Depending upon the size and geography of the organization, anything from where people's desks are located in the (one and only) office to where various sites are located in different towns and what happens at each.
157Logistics and day-to-day routine: This area covers the ‘rules’ of the workplace and the small pieces of knowledge that make it possible for everyone to function in the course of a day (much or most of this information might be conveyed in print that new staff members can read on their own).
Supervision: There are two facets of supervision that new staff members need to know about the basic information about who supervises whom (including whom the new staff member supervises and who supervises her), how often and in what areas of practice; and the more complex issue of the organization's attitude toward supervision.
Policies and procedures: It is important to have a clear set of policies and procedures that explain and govern the various tasks and relationships necessary to keep the organization running.
Thus, new staff orientation should be scheduled and provided systematically to understand their roles and responsibilities.
  1. Discuss in detail healthcare delivery system in India.
Healthcare Delivery System in India
In India, the healthcare system is intended to deliver the healthcare services. It is represented by five major sectors or agencies, which differ from each other by the health technology applied and by the sources of funds for operation. These are as follows.
Public Health Sector
  1. Primary health care: Primary health centers (PHCs).
  2. Hospital/Health centers: Community health centers, rural hospitals, district hospitals/health center, specialist hospitals and teaching hospitals.
  3. Health insurance schemes: Employee's state insurance, central government health scheme and medical insurance.
  4. Other agencies: Defense service and railways.
Private Sector
  1. Private hospitals, polyclinics, nursing home and dispensaries.
  2. General practitioners and clinics.
Indigenous System of Medicine
  • Ayurveda and siddha
  • Unani and tibbi
  • Homeopathy
  • Unregistered practitioners.
Primary Health Care in India
The Government of India is committed to achieving the goal of ‘Health For All’ through ‘primary health care approach’, which seeks to provide universal, comprehensive health care across at a cost, which is affordable. These are described below.158
Village Level
One of the basic tenants of primary health care is universal coverage and equitable distribution of health resources, to implement this policy at the village level; the following schemes are in operation:
  1. Village Health Guide Scheme.
  2. Training of Local Dais Scheme.
  3. Integrated Child Development Service (ICDS) Scheme.
Village Health Guide Scheme
A village health guide is a person with an aptitude for social service and is not a full time government functionary:
  • Health guides now mostly women
  • They serve as link between the community and the governmental infrastructure
  • They provide the first contact between the individual and the health system.
The guidelines for their selection are:
  • They should be a permanent resident of local community
  • They should be able to read and write, having minimum formal education at least up to VIth standard
  • They should be acceptable to all sections of community
  • They should be able to spare at least 2–3 hours every day for community health work.
There are 410 lakh village health guides functioning in the country. The training program is been confirmed during the eight Five-year plan period (1992–1997) to achieve the national target of one health guide for each village or 1,000 rural population.
Training of Local Dais
An extensive program has undertaken the rural health scheme to train all categories of dais in the country to improve their knowledge in the elementary concept of maternal and child health, and sterilization besides obstetric skills:
  • The training is for 30 working days
  • A stipend of 300 is paid each day during the training period
  • Training is given at PHC, subcenter or maternal and child health (MCH) centers for 2 days in a week
  • So that home services are conducted under safe hygienic conditions thereby reducing maternal and infantile mortality.
Anganwadi worker
Angan literally mean ‘courtyard’. Under the ICDS Scheme, there is an anganwadi worker for a population of thousand. There are about 100 such workers in each ICDS. The anganwadi worker is selected from the community, she is accepted to serve. She undergoes training in various aspects of health nutrition and child development for 4 months. The anganwadi worker is a part-time worker and is paid an honorarium of ₹200–250 per month for the services rendered, which include health checkups, immunization, supplementary nutrition, health education, non-formal preschool education and referral services. The beneficiaries are especially nursing mothers, other women 15–45 years and children below the age of 6 years. Along with village health guides, the anganwadi workers are the community's primary link with health services and all other services for young children.159
Subcenter Level
Subcenters were established in the country on 30th June 1996. One subcenter for every 5,000 population in general and for every 3,000 in hilly tribal areas.
Each subcenter is manned by one male and one female multipurpose health workers. At present the functions of a subcenter are limited to mother and child health care, family planning and immunization. It also includes the facilities like International Classification of Diseases (ICD) insertion and simple laboratory investigations such as routine examination of urine for albumin and sugar.
Primary Health Center Level
The concept of PHC level is not new to India. The Bhore Committee in 1946 gave the concept of a PHC as a basic health unit to provide an integrated curative and preventive health care:
  1. The Bhore Committee aimed at having health center to serve a population of 10,000–20,000 with six medicals officers, six public health nurses and other supporting staff.
  2. But in view of limited resources, the Bhore Committee's recommendations could not be fully implemented even after a lapse of 50 years.
Community Health Center
Healthcare delivery in India has been envisaged at three levels namely primary, secondary and tertiary. The secondary level of health care essentially includes community health center (CHCs), constituting the first referral units (FRUs) and the district hospitals. The CHCs were designed to provide referral health care for cases from the primary level and for cases in need of specialist care approaching the center directly. Approximately four PHCs are included under each CHC, thus catering to approximately 80,000 populations in tribal/hilly areas and 1,20,000 populations in plain areas. CHC is a 30-bedded hospital providing specialist care in medicine, obstetrics and gynecology, surgery and pediatric. These center's are however fulfilling the tasks entrusted to them only to a limited extent. The launch of the National Rural Health Mission (NRHM) give us the opportunity to have a fresh look at their functioning.
The NRHM envisages bringing up the CHC services to the level of Indian Public Health Standards (IPHGs). Although, there are already existing standards as prescribed by the Bureau of Indian Standards (BISs) for 30-bedded hospital, these are at present not achievable as they are very resource intensive. Under the NRHM, the Accredited Social Health Activist (ASHA) is being envisaged in each village to promote the health activities. With ASHA in place, there is bound to be a groundswell of demands for health services and the system needs to be geared to face the challenge. Not only does the system require up gradation to handle higher patient load, but emphasis also needs to be given to quality aspects to increase the level of patient satisfaction. In order to ensure quality of services, the Indian Public Health Standards (IPHSs) are being set up for CHCs so as to provide a yardstick to measure the services being provided there.
Objectives of IPHS for CHCs
  • To provide optimal expert care to the community
  • To achieve and maintain an acceptable standard quality of care
  • To make the services more responsive and sensitive to the needs of the community.
Functions of community health centers
Every CHC has to provide the following services, which can be known as the assured services:
  1. Care of routine and emergency cases in surgery:
    • This includes incision and drainage, and surgery for hernia, hydrocele, appendicitis, hemorrhoids, fistula, etc.
    • Handling of emergencies such as intestinal obstruction, hemorrhage, etc.
  2. Care of routine and emergency cases in medicine:
    • Specific mention is being made of handling all emergencies in relation to the National Health Programs (NHP) as per guidelines such as dengue hemorrhagic fever, cerebral malaria, etc. Appropriate guidelines are already available under each program, which should be compiled in a single manual.
  3. 24 hour delivery services including normal and assisted deliveries.
  4. Essential and Emergency Obstetric Care Emergency Medical Dispatch Center (EMDC) including surgical interventions such as cesarean sections and other medical interventions.
  5. Full range of family planning services including laparoscopic services.
  6. Safe abortion services.
  7. Newborn care.
  8. Routine and emergency care of sick children.
  9. Other management including nasal packing, tracheostomy, foreign body removal etc.
  10. All the NHPs should be delivered through the CHCs. Integration with the existing programs such as blindness control, Integrated Disease Surveillance Project (IDSP) is vital to provide comprehensive services.
  11. Others:
    • Blood storage facility
    • Essential laboratory services
    • Referral (transport) facility
    • Manpower.
India's Public Health System has been developed over the years as a three-tier system, namely primary, secondary and tertiary level of health care. District Health System (DHS) is the fundamental basis for implementing various health policies and delivery of health care, management of health services for defined geographic area. District hospital (DH) is an essential component of the district health system and functions as a secondary level of health care, which provides curative, preventive and promotive healthcare services to the people in the district.
Every district is expected to have a link with the public hospital/health centers down below the district such as subdistrict/subdivisional hospitals, CHCs, PHCs and subcenters. As per the information available, 609 districts in the country at present are having about 615 DHs. However, some of the medical college hospitals or a subdivisional hospital is found to serve as a DHs, where a DHs as such (particularly the newly created district) has not been established. Few districts have also more than one DHs.161
Table 1   Staff requirement
Number of staff
General surgeon
1 (proposed)
Public Health Program Manager
1 (proposed)
1 (proposed)
Dresser (certified by Red Cross/ St John's Ambulance)
Laboratory technician
Ophthalmic assistant
1 (optional)
Ward boys
Outpatient department (OPD) attendant
Statistical assistant/Data entry operator
Operation theater (OT) attendant
Registration clerk
Objectives for District Hospitals
The overall objective of IPHS is to provide health care that is quality oriented and sensitive to the needs of the people of the district. The specific objectives of IPHS for DHs are:
  1. To provide comprehensive secondary health care (specialist and referral services) to the community through the DH.
  2. To achieve and maintain an acceptable standard quality of care.
  3. To make the services more responsive and sensitive to the needs of the people of the district and the hospitals/centers from which the cases are referred to the DHs.
The term DH is used here to mean a hospital at the secondary referral level responsible for a district of a defined geographical area containing a defined population.
Grading of District Hospitals
The size of a district hospital is a function of the hospital bed requirement, which in turn is a function of the size of the population it serves. In India the population size of a district 162varies from 35,000 to 3000,000 (Census 2001). Based on the assumptions of the annual rate of admission as 1 per 50 populations and average length of stay in a hospital as 5 days, the number of beds required for a district having a population of 10 lakhs will be around 300 beds. However, as the population of the district varies a lot, it would be prudent to prescribe norms by grading the size of the hospital as per the number of beds:
  • Grade I: District hospitals norms for 500 beds
  • Grade II: District hospitals norms for 300 beds
  • Grade III: District hospitals norms for 200 beds
  • Grade IV: District hospitals norms for 100 beds.
The disease prevalence in a district varies widely in type and complexities. It is not possible to treat all of them at district hospitals. Some may require the intervention of highly specialist services and use of sophisticated expensive medical equipments. Patients with such diseases can be transferred to tertiary and other specialized hospitals. A DH should however be able to serve 85–95% of the medical needs in the districts. It is expected that the hospital bed occupancy rate should be at least 80%.
District hospital has the following functions:
  1. It provides effective, affordable healthcare services (curative including specialist services, preventive and promotive) for a defined population with their full participation, and in cooperation with agencies in the district that have similar concern. It covers both urban population (district headquarter town) and the rural population in the district.
  2. Function as a secondary level referral center for the public health institutions below the district level such as subdivisional hospitals, CHCs, PHCs and subcenters.
  3. To provide wide ranging technical and administrative support, education and training for primary health care.
Essential Services
Services include outpatient department (OPD), indoor and emergency services.
Secondary level healthcare services regarding following specialties will be assured at hospital.
Health insurance
There is no universal health insurance in India. Health insurance at present is limited to industrial workers and their families.
Employees' State Insurance (ESI) Scheme: It was introduced by an act of parliament in 1948. It covers employees drawing wages not exceeding ₹10,000 per month.
The act provides are as follows:
  • Medical benefits
  • Sickness benefits
  • Disabled benefits
  • Maternity benefits
  • Dependent benefits
  • Funeral benefits.
163Central Government Health Scheme: This scheme was introduced in New Delhi in 1954 to provide comprehensive medical care to central government employees. The scheme is based on the principles of cooperative effort by the employee and the mutual advantage of both.
Facilities under the scheme include:
  • Outpatient care through a network of dispensaries
  • Supply of necessary drugs
  • Laboratory and X-ray investigation
  • Domiciliary visits
  • Hospitalization facilities at government as well as private hospitals recognized for the purpose
  • Special consultation
  • Pediatric services including immunization
  • Antenatal, natal and postnatal services
  • Emergency treatment
  • Supply of optical and dental aids at reasonable rate
  • Family welfare services.
Other agencies
Defense medical services: Defense services have their own organization for medical care to defense personnel under the banner ‘Armed Forces Medical Services’. The services are provided are integrated and comprehensive.
Healthcare of railway employees: The railways provide comprehensive healthcare services through the agencies of railway hospitals, health units and clinics. Environmental sanitation is taken care of by health inspectors in big stations. Health checkup of employees is provided at the time of recruitment and thereafter at yearly intervals.
Private agencies
In a mixed economy such as India's, private practice of medicine provides a large share of the health services available. There has been a rapid expansion in the number of qualified allopathic physicians to 7.5 lakh in 2005 and doctor population ratio is 1:1428. Most of them concentrate in urban areas. They provide mainly curative services. Their services are available to those who can pay. The private sector of healthcare services is not organized.
Indigenous systems of medicine
The practitioner's of indigenous system of medicine provide bulk medical care to the rural people. Ayurvedic physicians alone are estimated to be about 4.5 lakhs. Nearly 90% of ayurvedic physicians serve the rural areas. To promote these indigenous systems Indian government established Indian Council for Indian Medicine in 1971. Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) is the new approach on this which encompasses AYUSH.
Objectives of AYUSH:
  • To upgrade the educational standards in the Indian Systems of Medicine and Homoeopathy colleges in the country
  • 164To strengthen existing research institutions and ensure a time-bound research program on identified diseases for which these systems have an effective treatment
  • To draw up schemes for promotion, cultivation and regeneration of medicinal plants used in these systems
  • To evolve Pharmacopoeial standards for Indian Systems of Medicine and Homeopathy drugs.
Voluntary health agencies
A voluntary health agency may be defined as an organization that is administered by an autonomous board, which holds meetings, collects funds for its support, chiefly from private sources and expands money, whether with or without paid workers, in conducting a program directed primarily to furthering the public health by providing health services or health education by advancing research or legislation for health or by a combination of these activities.
Voluntary health agencies in India
  • Indian Red Cross Society
  • Hind Kusht Nivaran Sangh
  • Indian Council for Child Welfare
  • Tuberculosis Association of India
  • Bharat Sevak Samaj
  • Central Social Welfare Board
  • The Kasturba Memorial Fund
  • Family Planning Association of India
  • All India Women's Conference
  • All India Blind Relief Society
  • Professional Bodies such as Trained Nurses' Association of India (TNAI), Indian Medical Association (IMA), Australian Indigenous Doctors' Association (AIDA), etc.
  • International Agencies such as Rockefeller Foundation, Cooperative for Assistance and Relief Everywhere (CARE) and Ford Foundation, etc.
National Health Programs
Since India became free, several measures have been undertaken by National Government to improve the health of the people. Prominent among these measures are the national health programs, which have been launched by the Central Government for control/eradication of the communicable diseases, improvement of environmental sanitation, raising the standard of nutrition, control of population and improving rural health. Various international agencies such as World Health Organization (WHO), United Nations International Children's Emergency Fund (UNICEF), United Nations Population Fund (UNFPA), etc. have been providing technical and material assistance in the implementation of these programs.
National health programs are:
  • National Vector Borne Disease Control Program
  • National Leprosy Eradication Program
  • Revised National Tuberculosis Control Program
  • National AIDS Control Program
  • National Program for Control of Blindness
  • 165Iodine Deficiency Disorders Program
  • Universal Immunization Program
  • National Rural Health Mission
  • Reproductive and Child Health Program
  • Yaws Eradication Program
  • National Cancer Control Program
  • National Guinea Worm Eradication Program
  • National Cancer Control Program
  • National Mental Health Program
  • National Diabetes Control Program
  • National Program for Control and Treatment of Occupational Disease
  • Nutritional Program
  • National Surveillance Program for Communicable Disease
  • Integrated Disease Surveillance Program
  • National Family Welfare Program
  • National Water Supply and Sanitation Program
  • Minimum Needs Program
  • 20 Point Program.
  1. Explain the current issues and trends in nursing administration.
Nursing possesses a rich history characterized by compassion, dedication and service. As society's culture continues to experience change, the profession of nursing is undergoing continuous evolution.
Nursing Service in Ancient Times
Introduction to simple nursing can be traced to ancient civilization. In the book of Charaka it is mentioned that “the physician, drug, nurse and patient constitute an aggregate of four.” Nurse educators and administrators are now stating a new framework in which the graduate nurse should function.
Influence of Christian Era on Nursing Services
The parable of Good Samaritan is closely interwoven into nursing service. The Christians applied the parable into their concern for the welfare of the individual. The attitude of taking care of a person as a patient has continued to influence nursing service and hospitals.
The ideal of service has been far reaching in the history of nursing service. Nursing service today realizes that after all nurses are human too and are entitled to a decent living.
Emergence of Modern Nursing Service
In the 18th century with the emergence of modern medicine and hospital, adequate nursing service became a prime necessity. The expected qualities of nurses included her being fit and able to go through the necessary fatigue of her undertakings, a good watcher, quick in hearing, well tempered, cheerful, pleasant constantly careful and diligent at night and day, sober, observant to follow physician's order.
Nursing Service within the Modern Hospital
During 1935–1950, social forces had a tremendous influence upon the development of nursing services. In 1936, the manual essentials of good hospital service published under the sponsorship of the American Hospital Association (AHA) and the National League for Nursing Education. This was published to give recognition to the minimum standards of average patient care. The purpose of the manual was to set up principles by which nursing services could function.
Administration was concerned with placing of nursing service as a whole in the hospital. The director of nurses own control over many administrative aspects of the nursing service. Nursing service continued to be responsible for supplies and equipment, and for the employment and discharge of nursing service personnel. With the expansion of services to patients, the nursing director was forced to delegate more responsibility and authority to the nurses of the patient's unit. The role of graduate nurse in most hospitals became one of coordinating nursing services and hospital services.
Nursing Service in a Bureaucratic System
The second phase of hospital and nursing service administration is called the bureaucratic system of control. The nursing service groups were brought under one line of authority.
The informal relations unite people together and the vertical lines of communication unite the level of hierarchy. During the system, the decisions were made through the interaction of three groups; administration, medical staff and board of trustees.
Hospital Nursing Service at Midcentury
During the period from 1950, numerous studies were performed on problems relating to patient care. At mid-century the tradition of the hospital as the clinical workshop for the doctor was changed to the patient-centered institution. Specialists began working together to meet the total needs of the patient.
Emergence of Nursing Service Administration
The National Nursing Council (NNC) published its report ‘Nursing for the Future’, which is known as the Brown's Report. Brown's viewpoint was that nursing service and nursing education should be viewed in terms of what is good for the society. The report indicated that in nursing service, administrative and supervisory staffs tend to be authoritarian and nurses had little freedom in taking decisions and judgment for the care of patients. Little opportunity was provided for nurse administrators to participate in policy decision-making. Brown's report pointed out the need for sound legislation regarding the training and functions of practical nurse. Other health workers also stressed the need for professional and highly technical nursing education and mentioned that it should be undertaken by universities and colleges.
The study conducted at Teacher's College, Columbia University resulted in the establishment of courses in nursing service administration. The first definition of nursing administration was formulated—“Nursing service administration is a coordinated system of activities, which provide all the facilities necessary for rendering nursing care to the patient, it includes establishment of goals and policies.”
Emergence of Patient-centered Approach
In 1951, a research and experimental program on the organization of nursing services on a team basis began at Teacher's Columbia University and as a result the concept of team nursing emerged. The newer philosophy in nursing is the patient-centered approach stresses a more flexible and creative approach to both supervision and administration in nursing service. The idea of nursing is the holistic approach that has given dignity and meaning to the concept of nursing service.
In 1962, the progressive patient care plan emerged. It refers to the organization of facilities, services and staff around the medical and nursing needs of patients.
Future of Nursing
Nursing continues to be challenging and rewarding by both new and changing opportunities and constraints. Professional nursing's image continues to be a major challenge for all nurses individually and collectively. A number of forces that have affected the development of professional nursing still continue to affect significant issues, which include:
  • Societal images and expectation of nurses
  • Degree of the nursing professions control over the quantity and quality of practitioners
  • Impact of technology and theory on nursing practices roles and setting
  • Professional self-image of nurses
  • Sources of financing for healthcare services.
The changes that seem likely to occur in due course will be changes in the demographics, the deteriorating environment, risky lifestyles and economics of health care, and governmental regulation of health care. The changes will be accomplished by changes in both nursing practice and nursing education.
Nursing Practice
Demographical Changes
The trends important in future of nursing includes rising number of elderly people, continuing increase in poverty, an increasing cultural diversity in the population and a continued trend urbanization. Each has implication on nursing:
  1. By 2020, more than 20% of the population will be 65 and older, with those over 85 constituting the fastest growing age group. Many older persons are healthy, but the likelihood of illness becomes greater on person's age. It indicates clearly nurse of the future must be prepared to work effectively with rising number of elderly persons.
  2. The number of people living below the poverty line is increasing, particularly among children and elderly. When basic needs for food, clothing and shelter are unmet or uncertain, health care becomes a luxury.
  3. Greater life expectancy of individuals with chronic and acute conditions will challenge the healthcare system's ability to provide efficient and effective continuing care.
  4. Children immunizations, parental care for pregnant woman, nutritious meals and other health maintaining factors are neglected even though some care have been taken on these issues.
  5. 168Preventable conditions are often not prevented due to lack of education, lack of sanitation, crowded living conditions. Improper shelter, homelessness and host of other poverty-related factors.
  6. Nursing as a profession, is committed to provide care to all peoples, regardless of social and economic factors to take challenges to meet these issues:
    1. Cultural diversity refers to the array of people from different racial, religious, social and geographic backgrounds that make up a particular entity, cultural beliefs and practices are quite different. Each group has its own health beliefs, folk remedies and conventional wisdom about health and sickness.
    2. Nurses increasingly need to take these beliefs into consideration when planning and implementing nursing care for individuals of diverse cultural backgrounds.
  7. Urbanization, i.e. people moving from rural farming areas to cities has increased. That trend continues in future. This will create more social problem (homelessness, drugs, mental illness, violence and crime). Nurses of the future will be increasingly confronted with health problems created by these social phenomena.
Environmental Changes
Major environmental tragedies such as nuclear power plant accident, burning oil wells, tsunami, gradual decline in qualities of air, water plant, animal life of the universe leads to many social and health problems. Depletion of the ozone layer, accidental lead and mercury poisoning, pesticide spilling into streams and rivers, and accidental releases of radioactive substances leads to health problems. The related problems of environmental deterioration and overpopulation are healthcare issues that future nurses will undoubtedly have to face.
Changes in Healthy Practices
Obesity is predisposing cause of number of illness due to unhealthy dietary habits, lack of exercise, stress, having contact with multipartner for sex, acquired immune deficiency syndrome (AIDS). Substance abuse is another unhealthy habit, which leads to many problems.
It is clear that nurses will play an increasingly important role in educating people about wellness and self-health care. Nurses will also play an instrumental in educating the public about how to be involved in the development of sound public policies. Nursing through its professional association, will become powerful player in the National Healthcare Politics (NHCP). Nurses will form coalition with customer groups. Individual nurse become politically active as voters, campaign workers, community health activists and political candidate.
As nursing's public profile profits become higher, public scrutiny of the profession will increase. Consumers of nursing services will exercise their political power and pressure to provide quality care.
Healthcare Complexity
The comprehensive healthcare needs of individuals and communities will require a plethora of knowledge and skills provided in an effective and efficient manner (Heller, Oros and Durney-Crowley, 2000). This will require greater degrees of team-based collaboration 169among healthcare professionals. Nursing education programs must therefore incorporate interdisciplinary education and collaborative practice to prepare tomorrow's nurses.
The mounting complexity of patient care and resultant changes in healthcare delivery systems have also afforded nurses a wider range of functionality. Although independence and the entrepreneurial spirit have been cultivated through expanded roles, reimbursement for nursing services shows slow progress. This will continue to force the nursing profession to identify, clarify and communicate its scope of practice.
Shift to Population-based Care and the Increasing Complexity of Patient Care
Rising costs and an aging population have led to new settings and systems of care across the healthcare continuum. Managed care and risk-based contracting mechanisms have forced a shift from episodic care with an acute orientation to care management with a focus on population-based outcomes.
Providing services for defined groups ‘covered’ by managed care will demand skills and knowledge in clinical epidemiology, biostatistics, behavioral science and their application to specific populations. Nurses must demonstrate management skills at both the organizational and patient care levels. These concepts must be incorporated into the nursing curriculum.
Technological Explosion
The rapid growth in information technology has already had a radical impact on healthcare delivery and the education of nurses. Advances in digital technology have increased the applications of telehealth and telemedicine, bringing together patient and provider without physical proximity. Nanotechnology will introduce new forms of clinical diagnosis and treatment by means of inexpensive handheld biosensors capable of detecting a wide range of diseases from miniscule body specimens. Nurses of the 21st century need to be skilled in the use of computer technology.
Emerging Bioethical Issues
Bioethical issues are raised because of new technologies, advancement in medicine and biological sciences.
As new technology emerges, new issues will arise and nurses must be prepared to confront them with both changing technical skills and value system that adapts to the demands of the society. Nurses have already traditionally met these challenges with renewed dedication to provision of quality health care.
Work Environment
Nursing's dissatisfaction with the workplace environment is another issue that must be faced when considering the profession's future. A Georgia Nurses Association survey demonstrated that 82% of the nurses surveyed were dissatisfied with their work (Hatmaker, 2001). This dissatisfaction was multifaceted and included issues such as workplace violence, inability to attend continuing education programs due to heavy workloads, exhaustion and inability to provide safe patient care (Hatmaker, 2001).
170The survey also revealed that 73% would actively discourage their child from choosing nursing as a career. Programs such as Georgia's Commission on Workplace Advocacy are developing to help staff nurses, nurse managers and employers with these challenges (Hatmaker, 2001). Issues such as workplace violence, mandatory overtime, and nurse-patient ratios are being discussed in legislatures across the country. The future of nursing must include resolution of these issues or the sting of the nursing shortage will be more painful.
Issues of Nursing Administration
As far as nursing administration is concerned; it is in pathetic condition. Health Survey and Development Committee (1946) recommended giving gazette ranks for Nurse Managers and WHO guidelines are therefore, giving decision-making power to nurses. Both union and state governments have decided to give some gazette ranks to nurses.
Issues of nursing administration are as given below:
  1. Non-involvement of nursing administrators in planning and decision-making in the governmental hospital administration.
  2. No specific power has been assigned to nursing superintendents, but he/she has been made in-charge of all inventories and linen of hospital.
  3. Nursing superintendent will have no authority to sanction leave to their subordinates.
  4. Lack of knowledge in management of hospital among medical/nursing administrators.
  5. Unnecessary interference of non-nursing personnel in nursing administration.
  6. No written nursing policies and manuals.
  7. No proper job description for various nursing cadres.
  8. No special incentives like, Republic day awards, teacher's awards, etc.
  9. Inefficiency of nursing councils of state and union to maintain standards in nursing.
  10. No organized staff development program, which includes orientation, in-service education, CNE, etc.
Problems, Prevailing in the Nursing Administration
Issues related to noninvolvement: Non-involvement of nursing administrators in planning and decision-making in the government hospital administration.
Assignment of non-specific power: Non-specific power has been assigned to the nursing superintendent, but he/she has been made in-charge of all inventories and linen of hospital.
Issues related to sanctioning leave: Nursing superintendent will have no authorities to sanction leave to their subordinate.
Lack of technical expertise: Administrators always depend on the advice of clerical staff in all matters including technical aspects.
Lack of knowledge: Nurses do not have enough knowledge in management of hospital and how to manage the staffs and other subordinates.
No written policies: Nurses do not have proper written policies and manuals and there is no proper job description for various cadres.
Lack of staff development program: In many hospital and institutions they do not organize staff development program, which includes in-service education, continuing nursing education, etc.
171No special incentives: No special incentives such as Rajyotsava Award, Republic Day Award as government itself honor these awards to other government employees such as teachers, police persons.
Ambiguity: Prevalence of role ambiguity, among administration administrators.
Non-nursing personnel: Unnecessary interference of non-nursing personnel in nursing administration.
Improper Job description: No proper job description for various nursing cadres.
Inefficient nursing council: Inefficiency of nursing council of state and union to maintain standards in nursing.
Problems and Challenges Faced By the Nursing Administrator
  • Lack of adequate training
  • Problem of personnel management
  • Inadequate number of nursing staff
  • Shortage of trained manpower
  • Lack of motivation
  • No involvement in planning
  • No career mobility
  • Poor role model
  • Non-nursing activities
  • No research scope
  • No proper authority
  • Professional risk/hazards
  • No autonomy in nursing activities.
Constrains and Barriers in Nursing Services Administration
  • Planning of nursing manpower
  • Management and development
  • Staff development
  • Development/Awards
  • Nursing legislation
  • Trained nurse managers
  • Diversification in nursing profession
  • Leadership inadequacy
  • Lack of strength, weakness, opportunity and threat
  • Lack of awareness to meet social, economic and technical changes in the society and consumer protection act
  • Lack of communication
  • Nursing care audit.
Administration is an enabling process for achieving the laid down objectives of an organization through formulated plans and policies, whereas management is the process of putting administration into practice or effect. In other words administrators are responsible for formulating policies, plans and procedure to achieve expected goals.
    1. 172Describe the causes of conflict in nursing services.
    2. Discuss the mode of conflict resolution.
    1. Describe the causes of conflict in nursing services.
An expressed struggle between at least two interdependent parties, who perceive incompatible goals, scarce reward and interference from the other party in achieving their goals. They are in a position of opposition in conjunction with cooperation.
Characteristics of Conflict
The characteristics of a conflict situation are:
  1. At least two parties (individuals or groups) are involved in some kind of interaction.
  2. Mutually exclusive goals and mutually exclusive values exist, either in fact or as perceived by the patients involved.
  3. Interaction is characterized by behavior destined to defeat, reduce or suppress the opponent or to gain a mutually designated victory.
  4. The parties face each other with mutually opposing actions and counteractions.
  5. Each party attempts to create an imbalance or relatively favored position of power vis-a-vis the other.
Types of Conflicts
Conflict has been described and studied from the standpoint of its context, or where it occurs. Three types of conflicts are intrapersonal conflict, interpersonal conflict and organizational conflicts.
Intrapersonal Conflict
Intrapersonal conflict occurs within an individual in situations in which he/she must choose between two alternatives. Choosing one alternative means that he/she cannot have the other; they are mutually exclusive, For example, we might internally debate whether to complete an assignment, i.e. due for the next day or watch a favorite television program.
Interpersonal Conflict
Interpersonal conflict is conflict between two or more individuals. It occurs because of differing values, goals, action or perceptions. For example, when you want to go to a science fiction movie, but partner may prefer to attend an opera. Interpersonal conflict becomes more difficult when we are involved in issues relating to racial, ethnic and lifestyle values and norms.
Organizational Conflicts
Conflict also occurs in organization because of differing perceptions or goals. Organizational conflicts may be intrapersonal or interpersonal, but they originate in the structure and 173function of the organization. Typically, aspects of the organizations style of management, rules, policies and procedures give rise to conflict. When a conflict occurs within an organization, it is important that the conflict be resolved in a constructive way in order to maintain the team's motivation. The leader's role takes on special significance.
Two areas responsible for conflict in organizations are role ambiguity and role conflict:
  1. Role ambiguity occurs when employees do not know what to do, how to do it or what the outcomes must be. This frequently occurs when policies and rules are ambiguous and unclear.
  2. Role conflict occurs when two or more individuals in different positions within the organization believe that certain actions or responsibilities belong exclusively to them. The conflict could relate to competition. For example, in some hospitals, conflict have existed between the nurse and the social workers about the responsibility for providing discharge planning. Both groups see discharge planning as an important aspect of their own care of the patients.
  3. Organizational structure: May be another source of conflict. Often this is seen as a conflict over territory. Everyone tries to protect his/her current territory or area of responsibility and perhaps expand it. This type of conflict increases as organization grows. To minimize it organizations use job descriptions, organizational charts and other such mechanism.
  4. Scarcity of resources: Resources are not only monetary. Resources may also refer to employees, space or other elements critical to the operation of any unit within an institution.
Conflict Process
Before managers can or should attempt to intervene in conflict, they must be able to assess its six stages accurately:
  1. Latent conflict (also called antecedent conditions).
  2. Perceived conflict.
  3. Felt conflict.
  4. Manifest conflict.
  5. Conflict resolution.
  6. Conflict aftermath.
Latent Conflict
The first stage in the conflict process, latent conflict, implies the existence of antecedent conditions such as short staffing and rapid change. In this stage, conditions are ripe for conflict, although no conflict has actually occurred and none may ever occur. Much unnecessary conflicts could be prevented or reduced if managers examined the organization more closely for antecedent conditions.
Perceived Conflict
If the conflict progresses, it may develop into the second stage, i.e. perceived conflict. Perceived or substantive conflict is intellectualized and often involves issues and roles. The person recognizes it logically and impersonally as occurring. Sometimes, conflict can be resolved at this stage before it is internalized or felt.
Felt Conflict
The third stage, felt conflict, occurs when the conflict is emotionalized. Felt emotions include hostility, fear, mistrust and anger. It is also referred to as affective conflict. It is possible to perceive conflict and not feel it. A person also can feel the conflict, but not perceive the problem.
Manifest Conflict
Manifest conflict is also called overt conflict, action is taken. The action may be to withdraw, compete, debate or seek conflict resolution. People often learn pattern of dealing with manifest conflict early in their lives and family background and experiences directly how affect conflict is dealt with in adulthood.
Gender also may play a role in how we respond to conflict. Men are socialized to respond more aggressively to conflict, while women are more apt and try to avoid conflicts or to pacify them. Power also plays a role in conflict resolution. Therefore, the action an individual takes to resolve conflict is often influenced by culture, gender, age, power position and upbringing.
Conflict Aftermath
The final stage in the conflict process is conflict aftermath. There is always conflict aftermath-positive or negative. If the conflict is managed well, people involved in the conflict will believe that their position was given a fair hearing. If the conflict is managed poorly the conflict issues frequently remain and may return later to cause more conflict.
Conflict Resolution
When conflict is resolved in some form, it is called conflict resolution. It can be defined as the methods and processes, concerned in facilitating the peaceful ending of conflict, some of these methods are mediation, negotiation, diplomacy as well as creative peace building.
Outcomes of Conflict
We often hear people about conflict situation resulting in win-win, win-lose and lose-lose. Filley (1975) identified these three different positions or outcomes of conflict.
Win-lose outcome: Occurs when one person obtains his/her desired ends in the situation and the other individual fails to obtain what is desired. Often winning occurs because of power and authority within the organization or situation.
Lose-lose outcome: In lose-lose situation, there is no winner. The resolution of the conflict is unsatisfactory to both parties.
Win-win outcome: These are of course the most desirable. In these situations, both parties walk away from the conflict having achieved all or most of their goals or desires.
  1. Discuss the mode of conflict resolution.
Conflict Management
The optimal goal in resolving conflict is creating a win-win solution for all involved. This outcome is not possible in every situation and often the manager's goal is to manage the 175conflict in a way that lessens the perceptual differences that exist between the involved parties. A leader recognizes, which conflict management strategy is most appropriate for each situation. The choice of most appropriate strategy depends on many variables such as the situation itself, urgency of the decision, power and status of the players, importance of the issue, and maturity of the people involved in the conflict.
Common Conflict Resolution Strategies
In compromising, each party gives up something it wants for compromising not to result in a lose-lose situation, both parties must be willing to give up something of equal value. It is important that parties in conflict do not adopt compromise prematurely, if collaboration is both possible and feasible.
zoom view
Figure 2: Conflict process
The competing approach is used when one party pursues what it wants at the expense of others. Because only one party wins, the competing party seeks to win regardless of the cost to others. Win-lose conflict resolution strategies leave the loser angry, frustrated and wanting to get even in the future.
Managers may use competing when a quick or unpopular decision needs to be made. It is also appropriately used when one party has more information or knowledge about a situation than the other. Competing in the form of resistance is also appropriate when an individual needs to resist unsafe patient care policies or procedures, unfair treatment, abuse of power or ethical concerns.
Cooperating is the opposite of competing. In the cooperating approach, one party sacrifices his/her beliefs and allows the other party to win. The actual problem is usually not solved in this win-lose situation. Accommodating is another term that may be used for this strategy. 176The person cooperating or accommodating often collects IOUs from the other party that can be used at a later date. Cooperating and accommodating are appropriate political strategies if the item in conflict is not of high value to the person doing the accommodating.
Smoothing is used to manage a conflict situation. One person ‘smoothes’ others involved in the conflict in an effort to reduce the emotional component of the conflict. Managers often use smoothing to get someone to get accommodate or cooperate with another party. Smoothing occurs when one party in a conflict attempts to compliment the other party or to focus on agreements rather than differences. Although it may be appropriate for minor disagreements, smoothing rarely results in resolution of actual conflict.
In the avoiding approach, the parties involved are aware of a conflict, but choose not to acknowledge it or attempt to resolve it. Avoidance may be indicated in trivial disagreements, when the cost of dealing with the conflict exceeds the benefits of solving it, when the problem should be solved by people other than you, when one party is more powerful than the other or when the problem will solve itself. The great problem in using avoidance is that the conflict remains, often only to re-emerge at a later time in an even more exaggerated fashion.
Collaborating is an assertive and cooperative means of conflict resolution that results in a win-win solution. In collaboration, all parties set aside their original goals and work together to establish a superordinate or priority common goal. In doing so, all parties accept mutual responsibility for reaching the superordinate goal. Although, it is very difficult for people truly to set aside original goals, collaborating cannot occur if this does not happen. For example, a nurse who is unhappy that she/he did not receive requested days off might meet with his/her superior and jointly establish the superordinate goal that staffing will be adequate to meet the patient safety criteria. If the new goal is truly a jointly set goal, each party will perceive that an important goal has been achieved and that the superordinate goal is most important. In doing so, the focus remains on problem solving and not on defeating the other party.
Collaboration is rare when there is a wide difference in power between the groups or individuals involved. In collaboration, problem solving is a joint effort with no superior-subordinate, order-giving, order-taking relationship. True collaboration requires mutual respect; open and honest communication; equitable, shared decision-making powers.
For a leader to gain competence in facilitating collaboration, the following ten lessons must be learned:
  1. Know the self: As individuals come to the process of collaboration, they must be conscious of their own goals and values so that they may be more reflective.
  2. Learn to value and manage diversity: Diverse perspective assists with synthesis and improve quality of the collaboration process. Diversity includes both gender and cultural differences.
  3. Develop constructive conflict resolution skills: Conflict resolution skills are essential for successful collaboration. These skills include an understanding of the conflict process, the nature of emotional versus task conflict and effective conflict management.
  4. 177Use power to create win-win situations: While dominant power has no place in the collaboration process, the leader can use power to mediate, draw out others, show respect for members, demonstrate good will share information and use the power of position to facilitate the collaborative process.
  5. Master interpersonal and process skills: Interpersonal skills such as flexibility and cooperation are important as well as the organizational skills of systems thinking, especially understanding organizational connections.
  6. Recognize that collaboration is a journey: Establish rapport, clarifying expectations and requesting feedback takes time and lack of time often limits opportunities for effective collaboration. But each collaborative effort is a step in the journey to establish a climate of collaboration for future conflict.
  7. Leverage multidisciplinary forums to increase collaboration: Shared decision-making is a hallmark of the collaborative process. Use forums to both listen to others and to put forth your own position.
  8. Appreciate that collaboration can occult spontaneously: Sometimes, the best collaboration may begin in a hallway conversation that result in people beginning to work together and share ideas to solve a conflict. Such exchanges can be exciting when a shared commitment for action is agreed upon.
  9. Balance autonomy and unity in collaborative relationships: The leader must balance cooperation with the need to meet one's own needs to find integrative solutions.
  10. Remember that collaboration is not required for all decisions: Autonomous decision-making is still vital and taking the time for the collaborative process is often not cost-effective for many conflict issues.
Negotiation is probably the most rapidly growing technique for handling conflicts. According to Hampton, Summer and Webber, negotiation includes bargaining power, distributive bargaining, integrative bargaining and mediation. They are defined as follows:
  1. Bargaining power: Refers to another person's inducement to agree to the terms.
  2. Distributive bargaining: What either side gains is at the expense of the other. Most labor-management bargaining falls into this category.
  3. Integrative bargaining: Negotiators reach a solution that enhances both parties and produces high joint benefits. Each party looks out for its own interest, with the focus shifting to problem solving from reducing demands to expanding the pool of resources.
  4. Mediation: Mediators attempt to eliminate surrender as a demand. They encourage each party to acknowledge that they have injured the other, but are also dependent on each other.
Specific Skills in Managing Conflict
  1. Establish clear rules or guidelines and make them known to all.
  2. Create a supportive climate with a variety of options. This makes people feel comfortable about making suggestions. It energizes them, promoting creative thinking and leading to better solutions. It strengthens relationship.
  3. Tell people they are appreciated. Praise and confirmation of worth are important to everyone for job satisfaction.
  4. Stress peaceful resolution rather than confrontation. Build a bridge of understanding.
  5. 178Confront when necessary to preserve peace. Do so by educating people about their behavior. Tell them the behavior they perceive, what is wrong with it and how it needs to be corrected.
  6. Play a role that does not create stress or conflict. Do not play an ambiguous and fluctuating role that creates confusion among employees.
  7. Judge timing that is best for all. Do not postpone indefinitely.
  8. Keep the focus on issues and off personalities.
  9. Keep communication two-way.
  10. Emphasize shared interests.
  11. Examine all solutions and accept the one most acceptable to both parties.
  12. If conflict is evident at decision-making or implementation stage, work to reach an agreement. Commit to a course of action serving some interests of all parties. Seek agreement rather than power.
  13. Understand barriers to cooperation or resolution and focus on the dynamics of conflict to resolve it.
  14. Determine needs that are being ignored or frustrated and require recognition and nurturing.
  15. Build trust by listening, clarifying and allowing the challenges to unwind completely. Give feedback to make sure you understand. Let people know you care and that you trust them.
  16. Renegotiate problem solving procedures to forestall further anger, distrust and defensiveness.
Managing Unit Conflict
Managing unit conflict effectively requires an understanding of its origin. Some common causes of organizational conflicts are:
  1. Poor communication.
  2. Inadequately defined organizational structure.
  3. Individual behavior (incompatibilities or disagreements based on differences of temperament or attitudes).
  4. Unclear expectations.
  5. Individual or group conflicts of interest.
  6. Operational or staffing changes.
  7. Diversity in gender, culture or age.
All these types of unit conflicts can disrupt working relationship and result in lower productivity. It is imperative that the manager can identify the origin of unit conflicts and intervene as necessary to promote cooperative, if not collaborative conflict resolution.
The following is the list of strategies that a manager may use to deal effectively with interpersonal, organizational or unit conflict.
Confrontation: Many times the subordinates inappropriately expect the manager to solve their interpersonal conflicts. Managers instead can urge subordinates to attempt and handle their own problems by using face-to-face communication to resolve conflicts, as e-mails, answering message machines and notes are too impersonal for the delicate nature of negative words.
Third party consultation: Sometimes, managers can be used as neutral party to help others resolve conflicts constructively. This should be done only if all parties are motivated to solve the problem and if no differences exist in the status or power of the parties involved. 179If the conflict involves multiple parties and highly charged emotions, the manager may find outside experts helpful for facilitating communication and bringing issues to the forefront.
Behavior change: This is reserved for serious cases of dysfunctional conflict. Educational modes, training development or sensitivity training can be used to solve conflict by developing self-awareness and behavior change in the involved parties.
Responsibility charting: When ambiguity results from unclear or new roles, it is often necessary to have the parties come together to delineate the function and responsibility of roles. If areas of joint responsibility exist, the manager must clearly define such areas as ultimate responsibility, approval mechanisms, support services and responsibility for informing. This is useful technique for elementary jurisdictional conflict.
Structure change: Sometimes, managers need to intervene in unit conflict by transferring or discharging people. Other structure changes may be moving a department under another manager, adding an ombudsman or putting a grievance procedure in place. Often increasing the boundaries of authority for one member of the conflict will act as effective structure change to resolve unit conflict. Changing titles and creating policies also are effective techniques.
Soothing one party: This is a temporary solution that should be used in a crisis when there is not time to handle the conflict effectively or when the parties are so enraged that immediate conflict resolution is unlikely regardless of how the parties are soothed, the manager must address the underlying problem later or this technique will become ineffective.
  1. Records and reports.
Record is the collection of materials that serves as the legal record of the client's healthcare experience.
Records are formal legal, administrative tools that permanently document information relevant to direct and indirect patient care.
Purpose of Recording
The most common type of written communication in health care is the client record:
  1. Communication.
  2. Education.
  3. Legal documentation.
  4. Quality assurance.
  5. Reimbursement.
  6. Financial billing.
  7. Research education.
  8. Program planning and evaluation.
  9. Indicates plan for future.
  10. Improving nursing care.
Value of Records
  1. It provides an accurate and detailed account of treatments and care given to the patient.
  2. It is of great value in the diagnosis, treatments and nursing care.
  3. It saves duplication of work in the future care.
  4. The written record has the legal value.
  5. It is a tool for communication.
  6. It serves as a reference material for research work.
  7. It provides a baseline for local, state, national and international health services.
Types of Documentation System
The two main documentation systems are:
  1. Source-oriented records.
  2. Problem-oriented records.
Source-oriented Records
Because patients in hospitals and long-term care facilities receive care from a variety of disciplines, these institutions commonly use source-oriented records. In this documentation system, members of each discipline record their findings in a separately labeled section of the chart. Nurses chart in the nurses notes section as well as in the graphic data section. A typical source-oriented records includes the following sections:
  • Admission data
  • Advance directive
  • History and physical
  • Physician's order
  • Progress notes
  • Diagnostic studies
  • Laboratory data
  • Nurses notes
  • Graphic data
  • Rehabilitation and therapy notes
  • Discharge planning.
Problem-oriented record
Problem-oriented records are organized around the patient's problems. It consists of four components:
  1. Database: It consists of many parts such as demographic data, history, physical and nursing assessment data, and pertinent family and social history.
  2. The problem list: It is the concise listing of problems that have been identified from the data base.
  3. The plan of care: It includes the physician's orders and the nursing care plan for addressing the identified problems.
  4. Progress notes: It is organized according to the problem list.
Types of Charting or Formats of Recording
The goal of all the charting is a clear, concise representation of all the healthcare experience. The most common types are:
  1. 181Narrative charting.
  2. Subjective, objective, assessment and plan (SOAP) charting.
  3. Problem, intervention, evaluation (PIE) charting.
  4. Focus charting.
  5. Charting by expectation.
Narrative charting
Narrative charting is used with both source-oriented and problem-oriented charts. The narrative chart entry tells the story of the patient's experience in a chronological format. The goal is to track the client's changing health status and progress toward goals. It is especially useful when attempting to construct a timeline of events, such as cardiac arrest or other emergency situations.
It requires to spend bit of time writing out all the details of the patient's care in sequence. Patient's status, activities, nursing intervention and response to treatment may all need to be included. The advantage is that it can allow ramble on without organizing the data.
SOAP charting
The SOAP charting is used in source-oriented and problem-oriented records. SOAP is an acronym for subjective data, objective data, assessment and plan. This format may be used to address single problems or to write the summative patient notes. Variation in this format includes SOAPIE and SOAPIER. This stands for intervention, evaluation and revision.
PIE charting
The PIE charting is used for problem, intervention and evaluation. Problems are identified at the time of admission assessment.
Focus charting
Focus charting highlights on the client's concerns, problem or strengths. The charting is done in three columns. The first column contains the time and date. The second column identifies the focus or problem addressed in the note. The third column charting is in a data-action-response (DAR) format. DAR is an acronym for data, action and response.
Records in Nursing Education
Records play an important part in nursing education program. Apart from being necessary for the day-to-day administration of the school of nursing, they provide continuity from the time the school is established, thus facilitating evaluation of the program.
The type of records usually kept in school office may be divided into three categories:
  1. Records concerning students.
  2. Records concerning staffs.
  3. General school records.
Records concerning students
  1. Application forms and other reports called at the time of recruitment, selection and appointment, such as references, medical reports, school records and results of any tests carried out at the time of selection.
  2. A record of each student's clinical experience.
  3. A progress report showing grades and other pertinent information.
  4. A final record/permanent record giving a summary of instruction, clinical experience grades and other relevant material.
  5. A health record.
Record concerning school staff
In the personnel file of each staff member there should be following:
  1. Application form.
  2. Copy of letter of appointment (or posting order) and any subsequent letter showing change in status.
  3. Job description.
  4. Records of staff members educational qualification, previous experience, any short term educational courses attended, membership in professional societies and professional activities such as the contribution of the articles in journals, holding office in associations or organizations, participation in seminars, conferences, etc.
  5. Periodic evaluation and progress report.
  6. Leave record.
  7. Health record.
General school records
General school records should consist of:
  1. The philosophy, objectives and curriculum of the school.
  2. Written policies of school.
  3. Statements of budget proposals and allotments.
  4. Letters of agreement with affiliating agencies.
  5. Minutes of staff meetings.
  6. Copy of school brochure (or prospectus).
  7. Inventories of stock.
Records in Community Setting
Every organization uses some kind of records. In community setting the healthcare agency maintains certain records under following headings:
  1. Forms, case cards and registers:
    1. Family and village record.
    2. Eligible couple and child register.
    3. Sterilization and intrauterine device (IUD) registers.
    4. MCH card/register.
    5. Child card/register.
    6. Birth and death register.
    7. Subcenters/PHC/Clinical registers.
    8. Stock and issue register.
    9. Reports of blood stain on malaria and filarial.
    10. Malaria parasites positive case register and others.
  2. Diaries:
    1. Diary of health worker (male and female).
    2. Diary of health assistant (male and female).
  3. Reports:
    1. Monthly reports of health worker.
    2. Compilation report of health worker.
PHC monthly report
In addition to this, each organization should maintain:
  1. Cumulative records.
  2. Family records.
Importance of Records in Hospital or Health Centers
A medical record should furnish all healthcare providers with concise, accurate, written pictures of patient's medical and nursing care planned and given, and the patient's response to treatment. Records have following advantage to the individual and family, nurse, doctor, authorities and also contribute to education and research health planning.
For the individual and the family
The records help the individual and the family to become aware of and to recognize their health needs under following headings:
  1. Serves to document the history of patient.
  2. Assist in continuity of care.
  3. Serves as evidence to support or to refuse the legal questions that arise.
  4. Serves to recognize the health needs and can be used as a research and teaching tool.
For the doctor
  1. Serves as a guide for diagnosis, treatment, follow-up and evaluation for service.
  2. Indicates progress and continuity of care.
  3. Helps in self-evaluation of the medical practice.
  4. Protect the doctor in case of legal issues.
  5. Used for teaching and research.
For the nurse
  1. Provides with documentation of service rendered, i.e. shows health condition of the client.
  2. Provides data essential for planning and evaluation of service for further improvement.
  3. Serves as a guide for professional growth.
  4. Enable to judge the quality and quantity of work done.
  5. Serves as a communication tool between staff and other members involved in care.
  6. Indicate plan for future.
For the authorities
  1. Provides management with statistical information necessary for decision in regard to utilization of the resources, planning for administrative control and future reference.
  2. Furnish documentary evidence for proposal of evaluation of care in terms of quality, quantity and adequacy.
  3. Helps the supervisory evaluate the services rendered, teaching done and person's actions and reactions.
  4. Helps in guidance of staffs and students when planned, records are utilized as an evaluation tool during conferences.
  5. Helps the administrator assess the health assets and needs of the community.
  6. Helps in making studies for research, for legislative action and for planning budget.
  7. 184Serves as a legal evidence of the service rendered by each employee or worker. It protects the organization in event of legal questions.
  8. Provides justification for expenditure of funds.
Documentation in Home Health Care
Healthcare Financing Administration (HCFA) guidelines govern home healthcare documentation. Among the requirements for the care are:
  1. Certification of homebound status.
  2. A plan of care.
  3. Ongoing assessment of need for skilled care.
The most commonly used home health documentation form is known as Outcome and Assessment Information Set (OASIS). It writes a progress note on patient's each visit. It includes the following:
  • Assessment highlighting changes in the client's condition
  • Interventions performed
  • The client's response to interventions
  • Any interaction or teaching that is conducted with the caregivers
  • Any interaction with the patient's physician.
Computerized Documentation
The technology that exists is virtually unlimited and the future holds incredible potential for computerization in healthcare delivery system. There are many benefits to computerized documentation. Documentation systems that are now available minimize repetitive clerical and monitoring tasks, and increase time available for direct client care.
Uses of computerized documentation
  1. Software programs allow access to specific assessment data quickly and the information can be quickly transferred to different reports.
  2. Computers also help to reduce errors (e.g. better legibility than hand written notations).
  3. It helps in preparing standardized nursing care plans.
  4. It increases job satisfaction and productivity.
  5. It documents all facets of clients care.
  6. It helps in enhancement of quality improvement activities.
Computerized documentation will potentially change drastically with the increased use of technology. Therefore in future, nursing will potentially use either pen based or voice recognition computers in documentation. A notebook sized computer with handwriting recognition capacities would allow documentation with ease and flexibility which is not possible in current systems.
Another form of computerized documentation is a complete computer-based client record (CCR). The CCR is a comprehensive system that utilizes many components of data collection and has a much broader scope than current charting system.
Guidelines for safe computer charting
  1. The password that is used to enter and sign off computer files should not be shared with another caregiver. A good system requires frequent change in personal passwords to prevent an unauthorized person from assessing and tampering with records.
  2. 185Avoid leaving the computer terminal unattended after being logged on.
  3. Follow the correct protocol for correcting errors according to agency policy.
  4. Software systems have a system for backup files. If inadvertently a permanent record has been deleted, follow the agency policy. It may be necessary to type an explanation into the computer file with date, time and initials, and submit an explanation in writing to the manager.
  5. Avoid leaving information about client displayed on a monitor where others may see it. Keep a log that accounts for every copy of a computerized file that is generated from the system.
  6. Follow the agency's confidentiality procedure for documenting sensitive material, such as a diagnosis of human immunodeficiency virus (HIV) infection.
  7. Printouts of computerized records should be protected. Shredding of printouts and logging of the number of copies generated by each caregiver are ways to minimize duplicate records and protect the confidentiality of the client information.
Long-term Care Documentation
Increasing numbers of older adults and disabled people require long-term healthcare facilities. Nursing personnel's often face challenges much different from those in acute care setting. Long-term facilities usually provide two types of facilities, i.e. skilled or intermediate. Clients needing skilled are requiring more extensive nursing care and specialized nursing skills.
Requirements for documentation in long-term care settings are based on professional standards, federal and state regulations and the policies of healthcare agency. Usually the nurse completes a nursing care summary at least once a week for clients requiring skilled care and every 2 weeks for those requiring intermediate care. Summarizes should address the following:
  1. Specific problems noted in the care plan.
  2. Mental status.
  3. Activities of daily living.
  4. Hydration and nutrition status.
  5. Safety measures needed.
  6. Medication.
Principle of Record Writing
  1. Written clearly, accurately, appropriately and legibly.
  2. All entries should be signed by them who writes it.
  3. Care should be taken not to make errors on the records.
  4. All records should be written with black ink or typed for better legibility.
  5. It should be written in chronological order as to date and time.
  6. It should be written continuously with no blank spaces. If any space is leftover, it should be crossed out, dated and signed.
  7. Lengthy corrections of records are written as amendments.
  8. Each page of record should be properly identified with name, age, IP No, date, etc.
  9. Use only standard abbreviations.
  10. It should be truthful, brief and complete.
A full report is given in the morning before distribution of assignment and another time at the end of the shift of duty to the oncoming staff. It includes information about each patient's condition including problems and suggested methods of assisting him/her as well as his/her treatment and day-to-day progress. Most reports are done orally between the staff and certain reports need to be written.
Oral communication about a patient's status is called reporting.
A report is a system of communication aimed at transferring essential information necessary for safe and holistic patient care.
Types of Reports
  1. Oral report.
  2. Written report.
Oral report
Oral reports are given when information is required for immediate use. An oral report is made by nurse to another nurse who is supposed to relieve her. Staff nurses and students present oral reports to in-charge nurse who in turn gives new orders, makes changes in assignments and conveys any other information needed by them to carry out their work. A definitive time and place to be arranged, so that the reports can be given without interruption:
  1. Reports between head nurse and his/her assistant: The assistant head nurse is to takeover the management of the ward in the absence of the head nurse. It is advisable for the head nurse and his/her assistants to record memoranda of information on a notebook or on the notepad, which they plan to report.
  2. Reports between nurses who are assigned to bedside care on change of shift: Contents include change of condition of patients assigned to the nurses, treatments and medications, adaptations in method required by each patient, information about the patient as a person and his/her diagnosis. The reports may be given to relieving staff by going through care plan, so that questions are asked and answered immediately.
  3. Reports of staff members to the in-charge nurse: When the nurse is ready to go off duty the head nurse receives a concise report on each patient and also on incomplete assignments. They have to give report regarding changes in condition and results of treatment.
  4. Nurse in-charge report to the bedside nurse: The information to be given to bedside nurses mainly includes the changes in the condition of the patient. She/He should also communicate the information, which she receives from her superior administrators.
  5. Reports of the head nurse to the administrative supervisor: The administrative supervisor needs to receive from the head nurse, overview of the ward in detail, to understand its problems and needs. She/He is told about the complaints of patients, visitors, doctors or members of the nursing staff as well as accidents and errors.
  6. Reports to the clinical instructor: As she/he is responsible for teaching the students, she/he needs information concerning new drugs being used. Staffing and equipment 187problems as they effect the student's assignments and the quality of patient care are also of concern to her/him.
  7. Reports of the head nurse to the director of nursing or her/his assistant: In small hospitals one of these individual may assume direct responsibility for supervision of the wards. But in large hospitals it is not possible. They should receive information regarding general picture of the wards, difficulties in giving treatment, nursing care problems like staffing. She/He is informed of accidents, mistakes or complaints and any other problem of administrative nature, which involves patients, visitors or personnel.
  8. Reports of nurse in charge to the physician: This report includes information about the patient's condition, results of treatment, inability to carry out his/her orders or difficulties in doing so.
  9. Reports on policy changes: The doctor is informed of changes in administrative routine, which affects the patient's care.
Written report
Reports are written when the information is to be used by several people or is more or less permanent value. A written report should show an awareness of thinking and time. It should concentrate on the past, present and future state of patient or the event. Different types of reports are:
  1. Day, evening and night reports: It is to provide means of transferring important information about the patients to the head nurse, the ward nurses, night nurses, nursing officer, and the day and night supervisors.
  2. Census report: The daily census or the number of patients in the hospital at the midnight furnishes important source material for hospital statistics. It should be well understood by all that the census figures must be correct. All forms are collected by night supervisor. The report shows total number of admission, discharges, transfers, births and deaths.
  3. Interdepartmental reports: Reports of the patients to be discharged are sent to the admitting office, business office and information desk. Special charges for drug, dressings or other equipment's used by patients are reported to the business office. Reports on the condition of danger list patients and others, who are acutely ill, may be sent to the director of the hospital, the director of the nursing and to the telephone switch board.
  4. Interagency reports: Interagency report is essential when patient is discharged. In some hospitals, this can be done through telephone, but written report is more satisfactory. The interagency report should contain information about the treatment, which the patient has undergone in hospital and which is to be carried on at home or by some other agency.
  5. 24-hour report: Supervisory and nursing administration personnel need to be kept informed of what is happening in and around all the patient care areas. It should give a good general picture of the ward. Information should include the total number of patients, the name, diagnosis and condition of all seriously ill patients, and all new admissions.
  6. Accident report: Many different kinds of accidents can occur in a hospital, e.g. minor injury such as from hot water bottle. Most of them are minor in nature. However, a report needs to be made of each accident. It needs to complete, clear and accurate, so as to be legal value.
  7. 188Department reports: A variety of reports produced periodically in every faculty can give the manager valuable departmental information. The information from reports enables a manager to evaluate performance of the unit and determine expenses compared to the budget. While each faculty may vary in the type and number of reports generated for use by the nursing managers, every nursing manager ought to be familiar with, the three financial reports on regular basis. In most cases, these three monthly reports provide the manager with needed valuable information.
    These three reports are labor hour report, operating statement and expense report:
  • Labor hour reports:
    • Each hospital department has some mechanism for determining and recording total work hours
    • Each faculty should have a mechanism for differentiating productive and non-productive hours spent in place of work in addition to a specific job department.
Reports Used in Hospital Setting
  1. Change of shift reports.
  2. Transfer reports.
  3. Incident reports.
  4. Day, evening and night reports.
  5. Legal reports.
  6. Telephone report.
  7. Telephone order.
Change of shift reports
A change of shift is a report given to all nurses on the next shift. Its purpose is to provide continuity of care to clients by providing the new care givers a quick summary of client needs and details of care to be given.
Key element of a change to shift:
  1. Follow a particular order (e.g. follow room number in a hospital).
  2. Provide basic identifying information for each client (e.g. name, room number and bed designation).
  3. For new clients, provide the reason for admission or medical diagnosis (or diagnosis), surgery (date), diagnostic tests and therapies in past 24 hours.
  4. Includes significant change in client's condition and present information in order.
  5. Provide exact information.
  6. Report clients need for special emotional support.
  7. A physician prescribed order, which includes with the current nurse.
  8. Provide a summary of newly admitted clients, including diagnosis, age, general condition, plan of therapy and significant information about the clients support people.
  9. Report on client who has been transferred or discharge from the client.
  10. A clearly state priority of care and care that is due after the shifts begins.
  11. Be concise.
Transfer reports
Patient will be frequently transferred from one unit to another to receive different levels of care. A transfer report involves communication of information about clients from the 189nurse on sending unit to the nurse on the receiving unit. When giving transfer request; nurse should include the following information:
  1. Client's name, age, primary doctor and medical diagnosis.
  2. Summary of medical progress up to the time of transfer.
  3. Current health status—physical and psychological.
  4. Current nursing diagnosis or problems and care plan.
  5. Any critical assessment or interventions to be completed shortly.
  6. Needs for any special equipment, etc.
Incident reports
Nurses usually become involved in client-related incidents at some point in their careers. They must understand the purpose of incident reports and the correct way to report information. While incident reporting, the following points need to be kept in mind:
  1. The nurses who witness the incident or who found the client at the time of incident should file the report.
  2. The nurse describes in concise what happened specifically objective terms, etc.
  3. The nurse does not interpret or attempt to explain the cause of the incident.
  4. The nurse describes objectively the clients, conditions when the incident was discovered.
  5. Any measures taken by the nurse, other nurses or doctors at the time of incident are reported.
  6. No nurse is blamed in an incident report.
  7. The report is submitted as soon as possible to the appropriate authority.
  8. The nurse should never make photocopy of the incident report.
Legal reports
Incident reports and reports on client's accidents, mistakes and complaints, are legal in nature. These are times when a hospital is criticized for what is claimed to be negligence or poor care because of a condition that resulted in discomfort and perhaps serious harm to the patient or client. In such reports, the content is stated briefly and objectively giving all pertinent information. Accuracy, timeliness, completeness and relevancy to the problems are maintained promptly, while making such reports.
Telephone reports
Health professionals frequently report about a client by telephone. Nurses inform physician about a change in a client's condition; a radiologist reports the result of an X-ray study; a nurse may report to a nurse on another unit about a transferred client.
The nurse receiving a telephone report should document the date and time, the name of the person giving the information and the subject of the information received and designs the notation.
Telephone orders
Physicians often order a therapy (e.g. medication) for a client by telephone. Most agencies have specific policies about telephone orders. Many agencies allow only registered nurse to take telephone orders.
While the physician gives the order, write it down and repeat it back to the physician to ensure accuracy. Question the physician about any order, i.e. ambiguous, unusual (e.g. an abnormally high dosage of medication) or contraindicated by the clients condition. Then transcribe the order onto the physician's order sheet, indicating it as verbal order (VO) or telephone order (TO).190
Role of Administrator in Recording and Reporting
The nurse administrator should see that everybody is following common guidelines for recording information:
  1. Information recorded is true and complete.
  2. Entries should be legible and written in ink.
  3. Only facts should be recorded.
  4. Entries should be brief, accurate, legible and correctly spelt.
  5. If item error is made, while writing, the nurse should not erase or overwrite, instead draw a single line over it and sign it. Then note it down correctly.
  6. Do not leave blank space in note.
  7. Always make chart for self and never for someone else. A nurse is accountable for information into the chart.
  8. Should be written in chronological order of date and time.
  9. Each page of record should be properly identified with identification data.
Principles of Data Entry and Management or Guidelines for Quality Documentation and Reporting
It is easier to accept and adopt if nurse keep in mind the purpose of the record:
  1. Accuracy.
  2. Completeness.
  3. Correctness.
  4. Confidentiality.
  5. Fact.
  6. Conciseness.
  7. Objectivity.
  8. Organization.
  9. Timeliness.
  10. Legibility.
Keeping Records and Reports
It is an important responsibility of nurse administrator. The main points include:
  1. The reports and records should be kept under safe custody.
  2. No individual sheet is separated from the complete record.
  3. Records should be kept in place, inaccessible to patients and visitors.
  4. No stranger is permitted to read the records.
  5. Records are not handed over to the legally and ethically obligated to keep in confidence all the informations provided in the records.
  6. All records to be handled carefully. Careless handling can destroy the records.
  7. Protection from loss.
  8. Filing should be done according to hospital system such as alphabetically, numerically with index cards and geographically.
  9. Assess periodically to determine the use of the record and re-examine for means of simplification.
  10. All records are identified with the biodata of the patients such as name, age, ward, bed number, outpatient (OP) number, inpatient (IP) number, diagnosis, etc.
  11. 191Records are never sent out of the hospital without the doctor's permission. Reference is made by writing separate sheets and sending to the agency that requires them, e.g. reference letter, discharge summaries.
  1. Role of nurse in maintaining occupational health and safety.
All occupational fields have their own hazards. There are varieties of hazards to which workers may be exposed and which may cause various diseases. By following the proper guidelines and precautions, all occupational hazards can be minimized.
Occupational Environment
‘Occupational environment’ is meant by the sum of external conditions and influences, which prevail at the place of the work and have a bearing on the health of the working population. Basically there are three types of interaction in the working environment:
  1. Man and physical, chemical and biological agents.
  2. Man and machine.
  3. Man and man.
Man and Physical, Chemical and Biological Agents
Physical agent: The physical factors in the working environment, which may be adverse to health are: heat, cold, humidity, air movement, heat radiation, light, noise, vibrations and ionizing radiation. The factors act in different ways on the health and efficiency of the workers, singly or in different combinations. The amount of work and the breathing place, toilet, washing and bathing facilities are also important factor in occupational environment.
Chemical agents: These comprise a large number of chemicals, toxic dust and gases, which are the potentially hazardous to the health of the workers. Some chemical agents cause disabling respiratory illnesses, some causes injury to health and deleterious effect on the blood and other organs of the body.
Biological agents: The workers may be exposed to viral, rickettsial, bacterial and parasitic agents, which may result from close contact with animals or their products, contaminated water, soil or food.
Man and Machine
An industry or factory implies the use of machines driven by power with emphasis on mass production. The unguarded machines, protruding and moving parts, poor installation of the plant and lack of safety measures are the cause of accidents, which is the major problem in industries. Working in long hours in unphysiological postures is the cause of fatigue, backache disease of joints and muscles and impairment of the workers health and efficiency.
Man and Man
There are numerous psychological factors that operate in the place of work. These are human relationships amongst workers themselves on the one hand and those in authority 192over them on the other hand. Examples of psychosocial factors include the type and rhythm of work, work stability, service conditions, job satisfaction, leadership style, security, workers participation, communication, system of payment, welfare conditions, degree of responsibility, trade union activities, incentives and a host of similar other factors; all entering the field of human relationships. In modern occupational health, the emphasis is upon the people, the conditions in which they live and work, their hopes and fears and their attitudes toward their job, their fellow workers and employers. According to the ecological approach, occupational health represents a dynamic equilibrium or adjustment between the industrial worker and his/her occupational environment.
Importance of Occupational Health in Hospitals
Hospitals are large, organizationally complex, system driven institutions employing large numbers of workers from different professional streams. They are also potentially hazardous workplaces and expose their workers to a wide range of physical, chemical, biological, ergonomical and psychological hazards. Thus, occupational health and safety issue relating to the personal safety and protection of its workers is a very important environmental health concern for hospitals. Hospitals also play an integral role in community protection through wider public health issues including injury and illness prevention, health surveillance, disease notification and disaster management. Additionally, over and above their core business of acute healthcare for inpatients, hospitals are also concerned for the safety and protection of those inpatients with respect to nosocomial infection control, evacuation plans for internal emergencies, and food preparation and handling by the hospital kitchen. Finally, hospitals are also concerned with environment protection through their waste management strategy and in particular, the collection and disposal of contaminated waste.
Hence, discussion of environmental health issues relating to hospitals can be conveniently divided into four parts such as personal (staff) protection, patient protection, population (community) protection and environment protection.
Personal (staff) Protection
Physical hazards
Radiation exposure
There is a wide range of radiation hazards related to medical imaging (X-rays, nuclear scans utilizing radioactive isotopes) and radiation oncology, which utilizes ionizing radiation from a variety of sources to treat a range of malignant tumors. These sources include:
  1. Sealed sources containing radioactive material such as isotopes of radium, cobalt and strontium.
  2. Linear accelerators emitting short wave length gamma waves. Licensing users of this technology is strictly controlled
  3. Appropriate training, certification and credentialing of users.
  4. Demonstrated implementation of safety precautions related to storage, use and shielding of non-target personnel.
  5. Regular inspection, maintenance and certification of equipment by the Department of Physics within Queensland Health.
  6. Ongoing monitoring of radiation exposure of staff using the equipment.
193Back injury
Hospital staff and particularly nurses are prone to back injury from the need to lift and roll immobilized or disabled patients for toilet, washing, dressing and pressure care. Hospitals are now required to give training on back care to all new staff. This training, combined with the use of ward persons to assist nurses and the use of hydraulic lifting devices, has decreased the risk of back injury considerably.
Burns due to steam sterilizing
Larger hospitals now have Central Sterilizing Departments utilizing appropriately trained, dedicated staff that are familiar with and follow set policy and procedure. This type of specialized set up minimizes risk of physical injury from hot equipment. However, smaller peripheral steam sterilizers are still required in some departments such as the operating theaters. Wherever possible many smaller satellite hospitals now use the Central Sterilizing Department of their larger referral base hospital for their sterilization needs.
Laser burns
Lasers are now frequently used in operating theaters and appropriate protective equipment must be used, especially eye protection to prevent retinal burns. The use of this equipment is covered by set protocols.
Electrical defibrillators
Use of this equipment is restricted to those staff who have undergone competency-based training and certification.
Personal violence
Risk of injury from personal violence is an important hazard in emergency departments who at times deal with mad, bad or intoxicated patients. Similarly, psychiatric units who have to look after the psychotically disturbed are also at risk. Again, staff education and set policy and procedure needs to be in place for dealing with aggressive patients. Personal security alarms, a system for rapidly mobilizing ancillary staff, and a set approach to safely restraining, immobilizing and sedating violent patients are all important components.
Chemical hazards
Toxic chemicals in use in hospitals include:
  1. Industrial cleaners used by contracted cleaning staff.
  2. Chemical sterilizers, in particular glutaraldehyde used for the sterilization of endoscopes and other equipment that cannot be steam sterilized.
  3. Tissue preservatives such as formaldehyde used to store and preserve body tissue prior to histopathology.
  4. Chemical reagents used in the hospital pathology laboratory.
  5. Cytotoxic drugs requiring preparation prior to parenteral administration to cancer patients.
  6. Processing chemicals for X-ray film development.
  7. Anesthetic gases in the operating theater.
The hierarchy of principles for controlling chemical hazards is well-documented and utilized within hospitals:
  1. Elimination (use an alternative process or strategy, e.g. disposables).
  2. Substitution (use the least toxic chemical that will do the job).
  3. Isolation (keep the relevant chemical in one isolated area if possible).
  4. Enclosure (e.g. glutaraldehyde fume cupboard, preparation enclosure for cytotoxic, closed circuit anesthetic machines with scavenging of exhaust gases).
  5. 194Ventilation (X-ray processors).
  6. Personal protection (gloves, goggles, plastic gowns, etc. where appropriate).
  7. Personal hygiene (hand washing after use).
  8. General cleanliness (clean up spills, appropriate storage, etc.).
Again, relevant staff must have appropriate training and education in the use of any of these chemicals and must be informed of any dangers including those of low risk.
Biological hazards
Management of biological hazards should be comprehensively covered in the hospital's infection control manual with the policies and procedures developed, and monitored by an Infection Control Committee chaired by an infection control nurse. There are three important modes of disease transmission from patients to staff.
Airborne and droplet aerosol exposure: This includes viral upper respiratory tract infections, measles and tuberculosis (TB). Preventative measures include:
  1. Keeping distance (> 1 m) from frontal coughing as much as possible.
  2. Wash hands after every patient contact and especially avoid rubbing eyes before washing.
  3. High filtration face masks (where applicable generally not practical in the OP setting).
  4. Isolate inpatients in a negative air pressure room.
Skin contact exposure: This includes Staphylococcus aureus and varicella. Prevention requires protective gown and gloves.
Exposure to infectious fluids via broken skin, eyes, mucous membranes and parenteral exposure: This includes hepatitis B, hepatitis C, and HIV from all body fluids except sweat, as well as gastroenteritis and hepatitis A from fecal fluid. Preventative measures include universal precautions (gloves, gown, goggles and mask) and appropriate management of sharps, spills and contaminated waste.
If acute exposure to a biological hazard does occur, staff members need to be aware of relevant policies and procedures for appropriate management of the exposure. This will include:
  1. Appropriate washing for mouth, eyes or skin exposure.
  2. First aid for penetrating sharps injury.
  3. Prophylaxis for high-risk exposure.
  4. Testing of the source if possible.
  5. Testing and follow-up of exposed staff.
  6. Incident reporting.
Psychological hazards
Hospitals are stressful places for sick and injured patients and their families. However, they can also be stressful for staff due to such factors as:
  1. Shift work, on call duty, fatigue and ‘burn out’.
  2. High workload and demand.
  3. High or unrealistic patient expectations.
  4. Verbal abuse or threats from disgruntled or intoxicated patients.
  5. High or unrealistic expectations from supervisors and management.
  6. Problematic interpersonal work relationships.
  7. Frustrations due to limited resources, especially staffing levels.
  8. Poor organizational climate with low staff morale.
195Hospitals are part of a high demand, high expectation service industry and are heavily reliant on staff for the friendly, safe, effective and efficient delivery of services. To optimize productivity and attitude of staff, senior management must be committed to ensure a conducive organizational climate with high staff morale. Clear priorities and direction, realistic performance goals and workloads, commitment to continuing education and quality assurance, reception to staff feedback and support with counseling services for stressed staff are all important components.
Patient Protection
Nosocomial infection control
Minimizing adverse outcomes of health care for IP is of prime importance to hospitals and a major focus of quality assurance activities. A very significant indicator of quality care is the nosocomial infection rate.
The hospital's infection control nurse and infection control committee are concerned with the prevention, surveillance and control of nosocomial infections. The infection control program should be documented in the hospital's infection control manual, which outlines the principles, strategies, policy and procedures for infection control in the hospital. All staff needs to be familiar with its contents. Regular feedback on surveillance of nosocomial infection rates will help motivate staff to remain vigilant.
Patient safety
Injury prevention for patients may require some of the following interventions when appropriate:
  • Diligence in keeping bed rails up particularly for those patients with an altered conscious state from medication or illness
  • Bathroom/Toilet aids particularly for the elderly or disabled
  • Nurse and physiotherapy assisted mobilization during recovery
  • Walking aids for the disabled and during recovery
  • Occupational therapy home assessment for home aids
  • Community nurse visits for bathing, etc. following discharge.
Evacuation plans for internal emergencies
Various internal emergencies including fire, explosion and bomb threat may require evacuation of all or parts of the hospital. Well-documented and rehearsed evacuation plans are required to ensure the safe evacuation of disabled, immobilized or otherwise helpless patients. In critical care areas this will include manual back up for life support systems.
Food safety
Hospital kitchens prepare meals for inpatients and in many cases prepare meals for the staff canteen. It is obviously imperative that food storage, handling and preparation is done to the highest standards and poses no risk to already sick or compromised patients.
Role of Occupation Health Nurse
Occupational health nurses (OHNs), as the largest single group of healthcare professionals involved in delivering health care at the workplace, have responded to these new challenges. 196They have raised the standards of their professional education and training, modernized and expanded their role at the workplace, and in many situations has emerged as the central key figure involved in delivering high quality occupational health services to the working populations. OHNs, working independently or as part of a larger multiprofessional team, are at the frontline in helping to protect and promote the health of working populations.
Occupational health nurses are registered nurses who independently observe and assess the worker's health status and to respect them from job tasks and hazards. Using their specialized experience and education, these registered nurses recognize and prevent health effects from hazards exposure.
Educationally prepared to recognize adverse health effects of occupational exposure and address methods for hazard abatement and control, OHNs bring their nursing expertise to all industries such as meat packing, manufacturing, construction as well as the healthcare industry. The OHNs:
  1. Have special knowledge of workplace hazards and the relationship to the employee health status.
  2. Understand industrial hygiene principles of engineering controls, administrative controls and personal protective equipment.
  3. Have knowledge of toxicology and epidemiology as related to the employee and the work site.
Typical OHN Activities
  1. Observation and assessment of both the worker and the work environment.
  2. Interpretation and evaluation of the worker's medical and occupational history, subjective complaints and physical examination, along with any laboratory values or other diagnostic screening tests, industrial hygiene and personal exposure monitoring values.
  3. Interpretation of medical diagnosis to workers and their employers.
  4. Appraisal of the work environment for potential exposures.
  5. Identification of abnormalities.
  6. Description of the worker's response to the exposures.
  7. Management of occupational and non-occupational illness and injury.
  8. Documentation of the injury or illness.
Role of the Occupational Health Nurse in Workplace Health Management
The occupational health nurse may fulfill several, often interrelated and complimentary roles in workplace health management, including:
  • Clinician
  • Specialist
  • Manager
  • Co-ordinator
  • 197Adviser
  • Health educator
  • Counselor
  • Researcher.
Primary prevention: The occupational health nurse is skilled in primary prevention of injury or disease. The nurse may identify the need to assess and plan interventions. For example, modify working environments, systems of work or change working practices in order to reduce the risk of hazardous exposure.
Emergency care: The occupational health nurse is a registered nurse with a great deal of clinical experience and expertise in dealing with sick or injured people. The nurse should provide initial emergency care of workers injured at work, transfer of the injured worker to hospital and emergency services. OHNs employed in mines, on oil rigs in the desert regions are more responsible for this work.
Treatment services: In some countries occupational health services provide curative and treatment services to the working population, in other countries such activities are restricted.
Nursing diagnosis: Occupational health nurses are skilled in assessing client's healthcare needs, establish a nursing diagnosis and formulating appropriate nursing care plans in conjunction with the patient or client groups, to meet those needs. Nurses can then implement and evaluate nursing interventions designed to achieve the care objectives. The nurse has a prominent role in assessing the needs of individuals and groups and has the ability to analyze, interpret, plan and implement strategies to achieve specific goals.
Individual and group care plan: The nurse can act on the individual, group, enterprise or community level.
General health advice and health assessment: The OHN will be able to give advice on a wide range of health issues and particularly on their relationship to working ability, health and safety at work or where modifications to the job or working environment can be made to take account of the changing health status of employees.
Occupational health policy and practice development, implementation and evaluation: The specialist occupational health nurse may be involved with senior management in the enterprise, in developing the workplace health policy and strategy including aspects of occupational health, workplace health promotion and environmental health management.
Occupational health assessment: Occupational health nurses can play an essential role in health assessment for fitness to work, pre-employment or pre-placement examinations, periodic health examinations and individual health assessments for lifestyle risk factors.
Health surveillance: Where workers are exposed to a degree of residual risk of exposure and health surveillance is required by law. The OHN will be involved in undertaking routine health surveillance procedures, periodic health assessment and in evaluating the results from such screening processes. The nurse will need a high degree of clinical skill when undertaking health surveillance and maintain a high degree of alertness to any abnormal findings.
198Sickness absence management: Occupational health nurses can contribute by helping managers to manage sickness absence more effectively. The nurse may be involved in helping to train line managers and supervisors on how to best use the occupational health services.
Rehabilitation: Planned rehabilitation strategies, can help to ensure safe return to work for employees who have been absent from work due to ill health or injury. The OHN is often the key person in the rehabilitation program who will devise the rehabilitation program, monitor progress and communicate with the individual, the occupational health physician and the line manager.
Maintenance of work ability: The OHN may develop proactive strategies to help the workforce maintain or restore their work ability in health and safety
Hazard identification: The OHN often has close contact with the workers and is aware of changes to the working environment. Because of the nurses expertise in health and in the effects of work on health they are in a good position to be involved in hazard identification.
Risk assessment: Legislation is increasingly being driven by a risk management approach. OHNs are trained in risk assessment and risk management strategies depending upon their level of expertise.
Management: In some cases the OHN may act as the manager of the multidisciplinary occupational health team, directing and coordinating the work of other occupational health professionals. The OHN manager may have management responsibility for the whole of the occupational health team or the nursing staff or management responsibility for specific programs.
Administration: The OHN can have a role in administration. Maintaining medical and nursing records, monitoring expenditure, staffing levels and skill mix within the department and may have responsibility for managing staff involved in administration.
Budget planning: Where the senior OHN is the budget holder for the occupational health department, they will be involved in securing resources and managing the financial assets of the department. The budget holder will also be responsible for monitoring and reporting within the organization on the use of resourses:
  • Marketing
  • Quality assurance
  • Professional audit
  • Continuing professional development.
Occupational health team: The OHN acting as a coordinator, can draw together all of the professionals involved in the occupational health team. In many instances the nurse will be the only member of the team who is permanently employed by the institution.
Worker education and training: The OHN has a role in worker education. This may be within existing training programs or those programs that are developed specifically by OHNs. For example, inform, educate and train workers on how to protect themselves from occupational hazards, workplace preventable diseases or to raise awareness of importance of healthy practices.
199Environmental health management: The OHN can advise the enterprise on simple measures to reduce the use of natural resources, minimize the production of waste, promote recycling and ensure environmental health.
To manage and staff on issues related to workplace health management: Occupational health nurses act as advisors to the management and staff on the development of workplace health policies and practices, and can fulfill an advisory role by participating in. For example, health and safety committee meetings, health promotion meetings, and may be called upon to provide independent advice to managers or workers who have specific concerns over health-related risks.
As a conduit to other external health or social agencies: Occupational health nurses act in an advisory role when seeing individuals who may have problems that whilst not directly related to work may affect future work attendance or performance.
Health Educator
Workplace Health promotion: Health education as one of the key prerequisites of workplace health promotion is integral aspect of the OHNs role. In some countries the nurse is required to support activities aimed at adoption of healthy lifestyles within ongoing health promotion process, as well as participate in health and safety activities. OHNs can carry out a needs assessment for health promotion.
Counseling and reflective listening skills: Where the nurse has been trained in using counseling or reflective listening skills they may utilize these skills in delivering care to individuals or groups.
Problem-solving skills: Due to the close working relationship, which OHNs have with the working population and because of the nurses' position of trust, OHNs are often approached for advice on personal problems.
Research skills: Nurses are becoming increasingly familiar with both quantitative and qualitative research methodologies, and can apply these in occupational health nursing practice. In the main, OHNs working at the enterprise level are more likely to use simple survey techniques or semistructured interviews and to use descriptive statistical techniques in their presentation of the data.
Evidence-based practice: Occupational health nurses are skilled in searching the literature, reviewing the evidence available, which may be in the form of practice guidelines or protocols and applying these guidance documents in a practical situation. OHNs should be well skilled in presenting the evidence, identifying gaps in current knowledge.
Epidemiology: The most widely used and accepted form of investigation into occupational-related ill health and disease is based on large-scale epidemiological studies.200
Ethics in Occupational Nursing
The International Commission on Occupational Health (ICOH) has published useful guidance on ethics for occupational health professionals. This guidance is summarized in the following three paragraphs:
  1. Occupational health practice must be performed according to the highest professional standards and ethical principles. Occupational health professionals must serve the health and social well-being of the workers, individually and collectively. They also contribute to environmental and community health.
  2. The obligations of occupational health professionals include protecting the life and the health of the worker, respecting human dignity, and promoting the highest ethical principles in occupational health policies and programs. Integrity in professional conduct, impartiality and the protection of confidentiality of health data, and the privacy of workers are part of these obligations.
  3. Occupational health professionals are experts who must enjoy full professional independence in the execution of their functions. They must acquire and maintain the competence necessary for their duties, and require conditions, which allow them to carry out their tasks according to good practice and professional ethics.
  1. Cost analysis.
The total amount of money that needed to be spent by an organization or a person, or government.
Factors Affecting Cost
The volume of service provided is the greatest factor affecting costs. Other factors include length of patient stays, salaries, price of the material, case mix, seasonal factors and efficiencies (such as simplification of procedures and quality management to prevent errors that increase patient complications and increase costs). Still other factors that have an impact on cost are regulation and competition for market share; third party payers; the age and size of the agency; type and amount of services provided; the agency's mission; and relationships among nurses, physician and other personnel.
Cost Containment
The goal of the cost containment is to keep cost within acceptable limits for volume inflation and other acceptable personnel's. It involves the following:
  1. Cost awareness.
  2. Cost monitoring.
  3. Cost management.
  4. Cost avoidance.
  5. Cost reduction.
  6. Cost control.
Cost Awareness
Cost awareness focuses the employee's attention on costs. It increases organizational awareness of what costs are the process available for containing them, how they can be managed and by whom.
Cost Monitoring
Cost monitoring focuses on how much will be spent where, when and why. It identifies reports and monitors costs. Staffing costs should be identified. Recruitment, turnover, absenteeism and sick time are analyzed, and inventories are controlled.
Cost Management
Cost management focuses on what can be done by whom to contain costs. Programs, plans, objectives and strategies are important. Responsibility and accountability for the control should be established. A committee can identify long- and short-range plans, and strategies.
Cost Avoidance
Cost avoidance means not buying supplies, technology or services. Supply and equipment cost should be carefully analyzed. Costs and effectiveness of disposable versus reusable items are compared. The receipts, storage and delivery of disposables, and labor and processing cost of reusable items are part of the analysis. The least expensive and most effective supplies, equipment and services should be identified, and expensive and less effective items avoided.
Cost Reduction
Cost reduction means spending less for goods and services. The amount of reduction depends on the size of the agency, previous efficiency, skills of managers and cooperation of employees.
Cost Control
Cost control is effective use of available resources through careful forecasting, planning, budget preparation, reporting and monitoring.
Cost Analysis
Cost analysis is the system of analyzing the relationship between the fixed and the variable cost.
Types of Cost Analysis
  • Cost-benefit analysis (CBA)
  • Cost-benefit ratio (CBR)
  • Cost-effectiveness analysis (CEA)
  • 202Cost-of-illness (COI) analysis
  • Cost-minimization analysis (CMA)
  • Cost-utilization analysis (CUA)
  • Cost-consequences analysis (CCA).
Cost-benefit Analysis
Cost-benefit analysis is measurement of the relative costs and benefits associated with a particular project or task.
The cost-benefit analysis is a tool, which is useful in setting priorities for various sources of action to meet objectives and provide an estimate of the net financial value associated with each course of action (e.g. manpower and labor, material and equipment facilities). All the inputs and outputs have to be converted into momentary terms because all inputs (i.e. costs) and all the outcomes (i.e. benefits) are valued in money terms.
Cost-benefit analysis is a procedure by which all the costs resulting from installing and operating a system are determined and converted to a money amount, and the ratio is calculated to reflect the relationship of costs and benefits.
Cost-benefit analysis is a tool with great potential for the decision makers as long as he/she recognizes the difficulty in determining the true costs and benefits of various alternatives. This tool can be especially useful when trying to decide between alternative expenditure of money.
Basic approaches of cost-benefit analysis
Two basic approaches for CBA are:
  1. Ratio approach.
  2. Net-benefit approach.
Ratio approach: This approach indicates the amount of benefits (or outcomes) that can be realized per unit expenditure on a technology versus a comparator. In the ratio approach, a technology is cost beneficial versus a comparator if the ratio of the change in costs to the change in benefits is less than one.
Net-benefit approach: This approach indicates the absolute amount of money saved or lost due to a use of a technology versus a comparator. In the net benefits formulation, a technology is cost beneficial versus a comparator if the net change in benefits exceeds the net change in costs.
Cost-benefit Ratio
“Cost-benefit ratio (Z) is the numerical relationship between the value of the financial cost of a program and the value of benefits.”
“It is defined as the ratio of the value of benefits of an alternative to the value of alternative cost.”
Z= Present value of economic/benefits present value of economic cost.
Cost-benefit analysis is often used in the public sector where there is no net income to serve as a guideline.
203In order to determine the ratio, it is necessary to assign value to both the cost and the benefits in monetary terms. In practice, it is difficult to assign monetary values to healthcare outcomes. It is difficult to measure the value of life and even more difficult in measuring the difference in health outcomes that do not involve life or death.
Cost-benefit analysis is designed to consider the social cost and benefits attributable to the project. The benefits are expressed in monetary terms to determine whether a given program is economically sound and to select the best out of several programs.
Cost-of-illness Analysis
Cost-of-illness analysis determination of the economic impact of an illness or condition (typically on a given population, region or country), e.g. of smoking, arthritis or bedsores, including associated treatment costs.
Cost-effectiveness Analysis
“A technique that measures the cost of alternatives that generate the same outcome.” The CEA is the technique for choosing, from alternative courses of action, a preferred choice when objectives are not clear in such areas as sales, costs or profits:
  • It is a desired effect of careful planning
  • It means getting the most for your money
  • The product is worth the price.
Cost effective methods are those search a less for costly way of achieving a defined result. CEA are easier to make as it is clear. It helps the administrator in managing his/her health resources. The problem is to find the way of achieving the objective at lower cost.
A more CEA-oriented approach would consider different approaches to save a life and find out, which one cost least that would be the cost-effective and generates similar outcomes.
For example, suppose a hospital has been treating a certain type of patient using a particular approach is cost-effective, we must first establish that the clinical money than the old approach. If a new approach generates the exact outcome for less money, then it is cost-effective. Steps in CEA include:
  1. Identify the program goal or client outcome to be achieved.
  2. Identify at least two alternative means of achieving the desired outcomes.
  3. Collect baseline data on clients.
  4. Determine the cost associated with each program activity.
  5. Determine the activities of each group of clients will receive.
  6. Determine the client changes after the activities are completed. Combine the cost, amount of activity and outcome information to express costs relative to outcome of program goals.
  7. Compare cost outcome information for each goal to present CEA.
Cost-effectiveness analysis basics
A general misconception is that CEA is merely a means of finding the least expensive alternative or getting the ‘most bang for the buck’. In reality, CEA is a comparison tool; 204it will not always indicate a clear choice, but it will evaluate options quantitatively and objectively based on a defined model. CEA was designed to evaluate healthcare interventions, but the methodology can be used for non-health economic applications as well. It can compare any resource allocation with measurable outcomes to any other resource allocation with measurable outcomes.
Conducting, evaluating and using analyses
Increasing numbers of analyses are conducted in academia or research organizations and published in peer-reviewed journals. Government organizations use analyses to help shape public policy. Health insurers use CEAs to determine, which kinds of health interventions to cover.
Cost-effectiveness ratio
The CER is simply the sum of all benefits divided by the sum of all costs. This is comparable to a return on investment calculation; however, the benefits are not measured in terms of just dollars, but in a ratio that incorporates both health outcomes and dollars.
Cost-effectiveness ratio
New metric used in CEA the DALY
The disability-adjusted life year (DALY) was introduced by the WHO and the World Bank in 1993 and has been used since, with some variations, for two related purposes:
  1. To measure the ‘burden of disease,’ the extent to which premature deaths and disabilities cause a loss of health status compared to everyone's living to old age in good health. The other purpose is
    In CEA, the DALY represents the number of years of disability-free life that would be gained from a particular health intervention yielding a cost per DALY, where cost data are available or can be inferred. Gaining a DALY through a health intervention reduces the burden of disease; it is the same as averting the loss of a DALY. The calculation includes assumptions about severity (if the health condition is not fatal), the age at which an illness or intervention occurs the duration of ill health with and without the intervention and the remaining life expectancy at the age when the gain occurs.
  2. To compare the value of health interventions that have multiple or different health outcomes occurring at different ages. In particular, it allows for measuring and comparing health outcomes other than saving lives.
    The DALYs allow analysts to compare the cost-effectiveness of different interventions and different health outcomes by expressing diverse health outcomes in a common unit. As a result, it can help guide where best to invest scarce health resources. For example, a coronary artery bypass costs on average across world regions, US $37,000 per DALY gained, far beyond the per capita income of most countries, compared with an average of only US $409 for the poly pill (several medications for preventing heart disease in a single pill). The latter is a ‘best buy’ for developing countries. However, both interventions are much less cost-effective than saving life years of a middle-aged person by treating active tuberculosis (and thereby preventing transmission) at a cost as low as US $15 per DALY and illustrates the relative costs of these and other health interventions.
Cost-effectiveness in improving health care
Cost-effective care is that judged to provide good health value for expenditure. Health value refers to the benefits of a particular medical intervention, which might include longer life, better quality of life or both. Expenditures should include not only the costs of a test or treatment itself, but the subsequent costs it might cause, including additional medical interventions, work disability, costs of long-term care and so forth.
Cost-effectiveness analysis is a method for assessing the gains in health relative to the costs of different health interventions. It is not the only criterion for deciding how to allocate resources, but it is an important one, because it directly relates the financial and scientific implications of different interventions. The basic calculation involves dividing the cost of an intervention in monetary units by the expected health gain measured in natural units such as number of lives saved.
Principles, which are basic to cost-effectiveness in health care are:
  1. Government healthcare programs should be screened for cost-effectiveness.
  2. Health education and physical fitness should be primary curricular items in our entire educational system from elementary through secondary schools. Healthy lifestyles for adults should include continued health education, disease prevention and physical exercise.
  3. Health promotion and disease prevention must receive primary emphasis on all healthcare plans with payment for such medical care being equal to or greater than that provided for acute medical care.
  4. Major efforts must be made throughout the profession to promote and emphasize quality ambulatory care provided by those best trained to provide such care—the family physician.
  5. There should be incentives provided to both physicians and patients to maximize value in health care, i.e. highest quality at lowest costs.
  6. Medical education should emphasize cost-awareness and cost-effectiveness at all levels of education such as undergraduate, graduate and continuing medical education programs.
  7. Patients must be educated regarding the necessity of their involvement in cost-effective medical care and in cost containment. This can be achieved through informational programs emphasizing personal responsibility for healthy lifestyles and cost-effective medical care. The use of health insurance deductibles and copayments are also useful tools in emphasizing cost containment, but these should not be prohibitive in achieving access to quality health care.
Cost-minimization Analysis
Cost-minimization analysis is determination of the least costly among alternative interventions that are assumed to produce equivalent outcomes.
Cost-utility Analysis
Cost-utility analysis is form of CEA that compares costs in monetary units with outcomes in terms of their utility, usually to the patient, measured, e.g. in quality-adjusted life-years (QALYs).
Cost-consequence Analysis
Cost-consequence analysis is form of CEA that presents costs and outcomes in discrete categories without aggregating or weighting them.
Purpose of Cost Analysis
  1. The administrator utilizes data provided by a cost study to interpret the needs of the nursing units and to gain financial support for the unit.
  2. It can be used to show the portion of the requested funds being used for research programs.
  3. It will show the relationship of the faculty salaries to the cost per student.
  4. It assists the administrator in measuring change and provides the necessary data, which can serve as a guide in modifying the program.
  5. It gives the supporting data when the board of trustees, central administrators, legislators, foundations and other groups question the high cost of nursing education.
  6. It provides valuable information for institutions questions of higher learning that wish to establish a new baccalaureate program.
Steps of Cost Analysis
  1. A clear statement of objectives.
  2. Identifying all alternative actions that can achieve the objectives.
  3. Identifying all the costs and all benefits with each alternative.
  4. Converting all costs and all benefits for each alternative to momentary value, and quantitative evaluation of costs and benefits of each.
  5. Selection of the best cost-effective approach.
Role of the Administrator in Cost Analysis
  1. Understanding methods of cost analysis and participating with cost study of nursing units and for the college. The administrator needs to know the cost of operating the nursing education unit in order to make wise education decisions. A school of nursing should operate economically and efficiently.
  2. The administrator interprets the cost analysis to the faculty and others, and gains support for the study. They interpret findings to the personnel at the college and at the health service agencies.
  3. The administrator participates in the cost analysis committees. The cost analysis committee is composed of the finance officer, dean of the college, a nurse faculty member, the administrator of the school of nursing, representatives from the central administrator of the health service agencies and directors of nursing service for the various agencies involved.
  4. The administrator encourages and leads to members of the overall study staff.
Cost-Effectiveness in health and medicine is the product of over 2 years of comprehensive research and deliberation by a multidisciplinary panel of economists, ethicists, psychometricians and clinicians.
This study published in the Journal of the American Medical Association shows that nicotine patch therapy in conjunction with physician counseling is a cost-effective 207approach to smoking cessation. This is an example of information in published CEAs that can support coverage decisions and justify health improvement programs.
  1. Discuss the influence of Bhore Committee on national health administration.
National Health Committees
Various committees of experts have been appointed by the government from time-to-time to render advice about different health problems. The reports of these committees have formed an important basis of health planning in India. The goal of National Health Planning in India is to attain health for all by the year 2000.
Bhore Committee, 1946
Bhore Committee, known as the Health Survey and Development Committee, was appointed in 1943 with Sir Joseph Bhore as its Chairman. It laid emphasis on integration of curative and preventive medicine at all levels. It made comprehensive recommendations for remodelling of health services in India. The report, submitted in 1946, had some important recommendations such as:
  1. Integration of preventive and curative services of all administrative levels.
  2. Development of PHCs in two stages:
    1. Short-term measure: One PHC as suggested for a population of 40,000. Each PHC was to be manned by two doctors, one nurse, and four public health nurses, four midwives, four trained dais, two sanitary inspectors, two health assistants, one pharmacist and 15 other class IV employees. Secondary health center was also envisaged to provide support to PHC and to coordinate and supervise their functioning.
    2. A long-term program (also called the 3 million plan) of setting up primary health units with 75-bedded hospitals for each 10,000 to 20,000 population and secondary units with 650–bedded hospital, again regionalized around district hospitals with 2,500 beds.
  1. Major changes in medical education, which includes 3 month training in preventive and social medicine to prepare ‘social physicians’.
The details of the short-term and long-term program as follows.
Short-term Program
Personal and impersonal health services should be provided. A province wide organization for the combined preventive and curative health work will be provided by the establishment of a number of primary, secondary and district health units and special health services for mothers and children, school children and industrial workers, which will deal also with the more important disease prevalent such as malaria, tuberculosis, venereal diseases, leprosy and mental diseases.
The bed population ratio should be raised from 0.24 per 1,000 to 1.03 at the end of 10 years. Provision of housing accommodation for health staff is essential in the interests or efficiency.
Village communications should be developed in order to enable health organization to provide efficient service.208
Long-term Program
The smallest administrative unit should be the primary unit serving an area with a population of about 10,000–20,000. About 15–25 primary units will together constitute a secondary unit. At the primary, secondary and district health units will be a health center as the focal point for radiating different types of health activity.
The objectives to be kept in view after the first 10 years should be as follows:
  1. Raising of hospital accommodation to two beds per 1,000 of population.
  2. Creation of 18 new medical colleges in addition to the 43 to be established during the first 10 years.
  3. Establishment of 100 training centers for nurses.
  4. Nursing training of 500 hospital social workers.
209Nursing Management
Paper 2010 May
  1. Discuss the factors to be kept in mind, planning for an in-service program for staff nurses. Prepare a plan for new recruits to an ICCU.
  2. What is quality assurance (QA)? How does a nursing professional ensure quality and competency in patient care setting?
  3. Explain the term ‘public relation’. How would you as a public health nurse establish and maintain public relation in the community?
  4. Explain the term management by objective. Discuss how this will be applicable in nursing service and its benefits in current times.
  1. Physical facilities in a college of nursing with UG and PG programs.
  2. Disciplinary actions in nursing.
  1. Discuss the factors to be kept in mind planning for an in-service program for staff nurses. Prepare a plan for new recruits to an ICCU.
  1. “Continuing nursing education of the health workers includes the experiences after initial training, which helps health care personnel to maintain and improve existing and acquire new competence relevant to the performance of their responsibilities. Appropriate continuing education should reflect community needs in the health and lead to planned improvements in the health of the community.”
  2. ‘’Continuing education is all the learning activities that occurs after an individual has completed basic education.” “That education, which builds on previous education.”
  • Unified approach
  • Relationship with other systems
  • Comprehensiveness
  • Accessibility for women health workers
  • Integration with the management process
  • Internally coordinated
  • Analysis of needs as a basis for learning
  • Credibility and economic.
  1. To ensure safe and effective nursing care, nurses need to keep abreast with interest, knowledge and technical advances.
  2. To meet the needs of population and should cater to the needs of service.
  3. Development of nurses will occur by updating their knowledge and prepare them for specialization.
  4. For career improvement.
  5. Professional roles are changed as society altered and a new knowledge and technologies emerge.
  6. Nursing functions require a high degree of skill, knowledge, competence and educational preparation.
  7. The demand after specialized nursing services is increasing more rapidly.
  8. Planned programs are needed to increase their competence as practitioners.
  9. Nurses with research aptitudes and preparation are needed.
  10. To provide and prepare faculty, who seeing continuing nursing education as a personal responsibility as well as professional and university responsibility.
  11. To provide a variety of continuing nursing education opportunities of high quality to nurses in both education and service changes.
Faculty Administrator
  1. Teaching is a part of his/her responsibility.
  2. He should possess a high degree of administrative skill.
  3. He must assess and uses the various abilities of different faculty members.
  4. Search for faculty with wide varied knowledge.
  5. Help the faculty member to strengthen their teaching skills.
  6. Provide conductive environment for faculty members and learner to promote personal and professional development.
  7. Encourages supplementary education and creativity.
  8. Fosters the expansion of learner's talent.
  9. The effective administration is prepared to meet unexpected.
  10. Supports his faculty and accepts responsibility, encourages team spirit, working with other members.
  11. Recognizes the person's contribution.
Interprofessional Continuing Education
It is imperative for the future; educational programs now include course content open to all these in various health fields. Nurses have to accept and participate in disciplinary in-service education. It requires input from all professional groups for whom it is intended.
Planning for In-Service Education
Planning is the keystone for the administrative process. Without adequate planning, continuing education offerings are fragmented, haphazardly constructed and often unrelated. A successful continuing education program is the result of careful and detailed planning.
211Effective planning is required at all levels, local, state, regional, national and eventually international—to avoid duplication and fragmentation of efforts and to help keep at minimum gap in meeting the continuing education needs of nurses.
Planning Formula
  1. What is to be done?
    Get a clear understanding of what your unit is expected to do in relation to the work assigned to it. Break the unit's work into separate jobs in terms of the economical use of the men, equipment, space, materials and money that you have at your disposal.
  2. Why is it necessary?
    When breaking the units into separate jobs, think the objectives of each job. The best way to improve any job is to eliminate unnecessary motion, materials, etc.
  3. How is it to be done?
    In relation to each job, look for better ways of doing it in terms of the utilization of materials, equipment and money.
  4. Where is it to be done?
    Study the flow of work and the availability of the materials, and equipments best suited men for doing the job.
  5. When is it to be done?
    Fit the job into a time schedule that will permit the maximum utilization of men, materials, equipment and money, and the completion of the job at the wanted time. Provisions must be made for possible delays and emergencies.
  6. Who should do the job?
    Determine what skills are needed to do the job successfully, select or train the man best fitted for the job.
Steps in the Planning Process
  1. Establishing goals with the purpose or mission of the organization:
    • Purpose gives direction in planning. It identifies the reason for existence. Purpose are based on the learning needs and social needs; so it has to be reviewed from time and restated as appropriate.
  2. Establishing goals and objective:
    • Planning moves towards goals, which are significant and realistic, which can be attained; goals serve to stimulate and should be reachable
    • An objective is specific, it is a desired end or accomplishment to be sought.
      Objective: As follows:
    • To assist the nurse in identifying and meeting current learning needs generated by changing professional practice
    • To encourage the nurse to identify and influence social changes, which have implication for nursing and to modify practice accordingly
    • To promote the development of leadership potential of nurse
    • To identify nursing problem and in seeking solution to them
    • To disseminate new information from varied channel
    • To facilitate a return to practice
    • 212To assess the health needs of nurses, hospital and community to plan, implement and evaluate educational programs in hospital and health facilities.
  3. Determining needs and priorities: Assessment of needs will be done by survey, through mailed questionnaires, interview formal and informal discussions with participants and checklist. After assessing the needs prioritization of needs has to be done.
  4. Assessing the available resources for establishing the program: Careful assessment of ways and means to meet the established program goal. Faculty finances and facilities may be seen as the major resources required for a continuing nursing education program. A broad survey of the major resources are necessary to the total continuing nursing education program and a more detailed assessment for any specific course or activity. Upon the resources planning includes deciding necessary to the activity and then determining the availability.
  5. Plan the budget, appropriate for the program: Separate budget is required for each specific activity and each individual offering is expected to be self-supporting. Sometimes budget for in-service training or continuing education program will be sanction by government, university grants or fee collected from participants. The coordinators have to write the proposal after the problem has been identified and substantiating data collected, guideline studied, guidelines has to be followed in writing the proposal.
Reassessing the Goals
  1. Applies adult learning principles, when helping employees to learn new skills or information.
  2. Uses teaching techniques that empower staff.
  3. Sensitive to the learning deficits of the staff and creatively minimize these difficulties.
  4. Prepare employees readily regarding knowledge and skill deficits.
  5. Actively seeks out teaching opportunities.
  6. Frequently assess learning needs of the unit.
Programming of professional courses in nursing is a joint responsibility of a director of continuing nursing education and a dean of school of nursing. The formal channels of communication make possible the optional use of the nursing faculty to explore the needs of continuing nursing education to set priorities, to plan courses and to teach them.
Evaluate the Results at Stated Intervals
Evaluation is needed to assess the effectiveness of the program or the progress in order to find out what extent pre-set goals have been achieved evaluations should be done at different stages of program.
Purpose of Evaluation
  1. To identify the area, which require greater attention.
  2. To identify bottlenecks in various activities carried out during the operation of the program.
  3. 213To assess the applicability of training in the field and actual situation.
  4. Qualitative improvement in instruction, promote better training, determines future changes and needs.
  5. For quality control or qualitative improvement.
What to Evaluate
  1. Evaluation should cover:
    • Growth and satisfaction of participants
    • The outcome course and the whole program or activity
    • Effectiveness of faculty members
    • Transfer of knowledge
    • Effect on the system.
  2. Procedure for evaluation:
    • Pretest and post-test
    • Attitude test
    • Observation of skill
    • Questionnaires
    • Audio or video tapes.
  3. Evaluation design:
    • Focus of evaluation—what do you want to find out
    • Devise the instrument—collection of information
    • Organize the information—coding, organizing, storing and retrieving
    • Analyze the information
    • Report the finding
    • Re—assessing the goal
    • Updating, modify the plan periodically based on needs
    • Evaluate the design for validity, reliability, credibility, timeliness and pervasiveness.
  1. What is QA? How does a nursing professional ensure quality and competency in patient care setting?
Quality assurance is a management process that provides a sound basis for decision making and problem solving. Management of care by competent clinical nurses and nurse managers ensures the quality of that care. The key element of quality assurance is continuous improvement.
  1. Quality assurance is defined as all the arrangements and activities that are meant to safeguard, maintain and promote the quality of care.
  2. Quality assurance is defined as a systematic process for closing the gap between actual performance and the desirable outcomes.
    Ruelas and Frenk
  3. Nursing quality assurance is the systematic testing or evaluation of nursing practice.
    Smeltzer, Hinshaw, Feltman (1987)
Concept of Quality Assurance
Quality assurance in health care is often taken to be an innovation of the late 20th century, but its gestation has a much longer history. In 19th century the concept of quality in nursing was first introduced by Florence Nightingale. She prepare the cycle of standards setting observation, review and improvement. The improvements in the hospital at Scutari were only possible because her observations allowed her to demonstrate that hospitalization of the wounded soldiers led to an increase rather than a decrease in mortality.
According to Ellis and Whittington (1993) Nightingale ‘Notes on Nursing’ were in fact standards of the nursing care and remained benchmarks for high, but achievable quality for many years. The same author described in brief the development of the process of quality assurance programs in nursing. As early as in 1965, the Royal College of Nursing in UK set up a ‘Standards of Care’ project. This has now developed into a major program of research development and education.
Quality assurance whether in health or education had two main objectives:
  1. To provide technical assistance in designing and implementing effective strategies for monitoring quality and correcting systemic deficiencies.
  2. To refine existing methods for ensuring optimal quality health care through an applied research program.
    Decker (1985) and Schroeder (1984)