Beruflich Dokumente
Kultur Dokumente
A Text book on
NUrSing
Management
(According to Indian Nursing Council Syllabus)
AUTHORS :
Mr. Anoop.N
Mr. Chetan Kumar.M.R
Mr. Deepak.K
Mr. Lingaraju.C.M
Mr. Mithun Kumar.B.P
Mr. Sarath Chandran.C
Dedicated to all
M.Sc. NURSing
STUDEnts
From:
M.Sc. (Nursing) II year
Batch: 2009-2011
PADMASHREE INSTITUTE
OF NURSING
This book is designed according to INC syllabus of M.Sc. Nursing. Each unit is described in
detailed according to the updated with recent and advanced information on nursing
management and administration. All the authors struggled a lot tirelessly round the clock
for the birth of this successful text book.
I am sure that this book will be widely used and will make a worthy contribution to the
nursing profession. I wish all the best for the authors for such a contribution in the field of
nursing management.
Thandhe, Tayee, Guru, Devaru. We are very much indebted to our lovable parents for
their continuous guidance, support and encouragement for accomplishment of our dream,
the release of this text book.
Guide us when we are in need, we extremely thankful to Asso. Prof. Ellakuvana Bhaskara
Raj.D, for his encouragement, timely guidance, constant advice and support for successful
completion of this book.
We also thank all PG faculties of Padmashree Institute of Nursing who guided, supported
in all our endeavors.
―Administer‖ derived from the Latin word ―ad + ministraire‖, - to care for or to look after
people to manage affairs. Administration is the activities of groups co-operating to accomplish
common goals. -Herbert A Simon
Administration may be defined as the management of affairs with the use of well thought out
principles and practices and rationalized techniques to achieve certain objectives. - Goel
DEFINITION:
ADMINISTRATION:
Administration has to do with getting things done; with the accomplishment of defined
objectives. - Luther Gullick
MANAGEMENT:
• Management may be defined as the art of securing maximum results with a minimum of
effort so as to secure maximum prosperity and happiness for both employer and
employee and give the public the best possible service. - John Mee
These two words are slightly similar and can employ interchangeable.
Nature of work It is concerned about the It puts into action the policies
determination of objectives and plans laid down by the
and major policies of an administration.
organization
Efficiency - ―Doing things right‖ Getting the most output for the least inputs
Managerial levels
Someone who coordinates and overseas the work of other people so that organizational goals are
accomplished.
First-line Managers
Middle Managers
Top Managers
Individuals who are responsible for making organization-wide decisions and establishing plans
and goals that affect the entire organization.
Functions:
Skills:
• Conceptual skills - The ability to think and conceptualize about abstract and complex
situations concerning the organization
Importance of management:
• Cost effectiveness
• Delegation of responsibility
• Effective communication
PRINCIPLES OF ADMINISTRATION
Management principles are derived and developed in the following two steps.
Henri Fayol (1841 - 1925): Graduated from the National School of Mines in Saint Etrenne in
1860
4. Principle of unity of command: Employee should receive orders from one boss only.
5. Unity of direction: All the efforts of the members and employees of the organization must be
directed to one direction that is the achievement of common goal.
9. Principle of scalar chain: Means line of authority or chain of superiors from highest to
lowest rank
10. Principle of Order: Principle of Order It refers to orderly arrangement of men and material
a fixed place for everything and everyone in the organization
11. Principle of Equity: Principle of Equity Fair and just treatment to employees.
14. Principle of Esprit De Corps: Principle of Esprit De Corps Means union is strength.
PRINCIPLES OF ADMINISTRATION
Fayol's definition of management roles and actions distinguishes between Five Elements:
• Prevoyance. (Forecast & Plan)- Examining the future and drawing up a plan of
action. The elements of strategy.
• To organize - Build up the structure, both material and human, of the undertaking.
• To coordinate - Binding together, unifying and harmonizing all activity and effort.
ELEMENTS OF ADMINISTRATION:
POSDCORB”
• Planning
• Organizing
• Staffing
• Directing
• Co-ordinating
• Reporting
• Budgeting
SCOPE OF ADMINISTRATION
Legislative: It includes most not mealy delegated legislation, but the preparatory work
done by the administrative officials.
Social: It includes the activities of the department s concerned with food, social factors.
INDIAN CONSTITUTION
Introduction
The majority of the Indian subcontinent was under British colonial rule from 1858 to
1947. This period saw the gradual rise of the Indian nationalist movement to gain independence
from the foreign rule. The movement culminated in the formation of the on 15 August 1947,
along with the Dominion of Pakistan. The constitution of India was adopted on 26 January 1950,
which proclaimed India to be a sovereign democratic republic.
After the Indian Rebellion of 1857, the British Parliament took over the reign of India
from the British East India Company, and British India came under the direct rule of the Crown.
The British Parliament passed the Government of India Act of 1858 to this effect, which set up
the structure of British government in India.
The provisions of the Government of India Act of 1935, though never implemented fully,
had a great impact on the constitution of India. The federal structure of government, provincial
autonomy, bicameral legislature consisting of a federal assembly and a Council of States,
separation of legislative powers between center and provinces are some of the provisions of the
Act which are present in the Indian constitution.
In 1946, at the initiative of British Prime Minister Clement Attlee, a cabinet mission to
India was formulated to discuss and finalize plans for the transfer of power from the British Raj
to Indian leadership and providing India with independence under Dominion status in the
Commonwealth of Nations. The Mission discussed the framework of the constitution and laid
down in some detail the procedure to be followed by the constitution drafting body. Elections for
the 296 seats assigned to the British Indian provinces were completed by August 1946. The
Constituent Assembly first met and began work on 9 December 1946.
The Indian Independence Act, which came into force on 18 July 1947, divided the British
Indian territory into two new states of India and Pakistan, which were to be dominions under the
Commonwealth of Nations until their constitutions were in effect.
Constituent Assembly
The Constitution was drafted by the Constituent Assembly, which was elected by the
elected members of the provincial assemblies. Jawaharlal Nehru, C. Rajagopalachari, Rajendra
Prasad, SardarVallabhbhai Patel, MaulanaAbulKalam Azad, Shyama Prasad Mukherjee and
NaliniRanjanGhosh were some important figures in the Assembly.
In the 14 August 1947 meeting of the Assembly, a proposal for forming various
committees was presented. Such committees included a Committee on Fundamental Rights, the
Union Powers Committee and Union Constitution Committee. On 29 August 1947, the Drafting
Committee was appointed, with DrAmbedkar as the Chairman along with six other members. A
Draft Constitution was prepared by the committee and submitted to the Assembly on 4
November 1947.
Parts
Parts are the individual chapters in the Constitution, focused in single broad field of laws,
containing articles that address the issues in question.
Part X - The scheduled and Tribal Part XXI - Temporary, Transitional and
Areas Special Provisions
Federal Structure
The constitution provides for distribution of powers between the Union and the States.
It enumerates the powers of the Parliament and State Legislatures in three lists, namely Union
list, State list and Concurrent list. Subjects like national defense, foreign policy, issuance of
currency are reserved to the Union list. Public order, local governments, certain taxes are
examples of subjects of the State List, on which the Parliament has no power to enact laws in
those regards, barring exceptional conditions. Education, transportation, criminal laws are a few
subjects of the Concurrent list, where both the State Legislature as well as the Parliament has
powers to enact laws.
In 2000 the National Commission to Review the Working of the Constitution (NCRWC) was
setup to look into updating the constitution of India.
Judicial review is actually adopted in the Indian constitution from the constitution of the United
States of America. In the Indian constitution, Judicial Review is dealt under Article 13. Judicial
Review actually refers that the Constitution is the supreme power of the nation and all laws are
under its supremacy. Article 13 deals that
1. All pre-constitutional laws, after the coming into force of constitution, if in conflict with it in
all or some of its provisions then the provisions of constitution will prevail. If it is compatible
with the constitution as amended. This is called the Theory of Eclipse.
2. In a similar manner, laws made after adoption of the Constitution by the Constituent Assembly
must be compatible with the constitution, otherwise the laws and amendments will be deemed to
be void-ab-initio.
In such situations, the Supreme Court or High Court interprets the laws as if they are in
conformity with the constitution.
1. Health care delivery system refers to the totality of resources that a population or
society distributes in the organization and delivery of health population services. It
also includes all personal and public services performed by individuals or institutions
for the purpose of maintaining or restoring health. -Stanhope(2001)
Everyone from birth to death is part of the market potential for health care services.
The consumer of health care services is a client and not customer.
Consumers are less informed about health services than anything else they purchase.
Health care system is unique because it is not a competitive market.
Restricted entry in to the health care system.
Goals/Objectives of Health Care Delivery System:
1) To improve the health status of population and the clinical outcomes of care.
2) To improve the experience of care of patients families and communities.
3) To reduce the total economic burden of care and illness.
4) To improve social justice equity in the health status of the population.
Principles of Health Care Delivery System:
India is a union of 28 states and 7 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 health care delivery, independent of the Central
Government.
Health system in India has 3 links
National Level
PHC 1/30,000
People in the
population
Health administration at the central level
The official organs of the health system at the national level consist of 3 units:
1. Union Ministry of Health and Family Welfare.
2. The Directorate General of Health Services.
3. The Central Council of Health and Family Welfare.
Cabinet Minister
Minister of State
Deputy Ministers
Dept. of Health Dept. of Family WelfareDept. of Indian System of Medicine and Homoeopathy
Secretary
Secretary health
Secretary
Chief Director Joint Secretary
Additional Secretary (1) (3)
Director JS
Director General of
Health Services
Director
Director FW Services Director Director
Health Services
Medical education ISM and
dditional/deputy joint directors of health services dealing with one or more programmes
Principal/Deans of medical colleges
Taluk Health
organisation
T.B.A.
Covers T.B.A. VHG VHG T.B.A. VHG
1,000
population
PHC
Covers 1,00,000 population
Community Health Centre
PHC PHC
Healthcare systems
The healthcare system is intended to deliver the healthcare services. It constitutes the
management sector and involves the organisational matters. It operates in the context of the
socioeconomic and political framework of the country. In India, it is represented by five major
sectors and agencies which differ from each other by the health technology applied and by the
source of funds for the operation.
i. Public health sector
ii. Private sectors
iii. Indigenous system of medicine
iv. Voluntary health agencies
v. National health programmes
Primary healthcare in India
It is a three-tier system of healthcare delivery in rural areas based on the
recommendations of the Shrivastav Committee in 1975.
1. Village level: The following schemes are operational at the village level:
a. Village health guides scheme
b. Training of local dais
c. ICDS scheme
2. Sub-centre level: This is the peripheral outpost of the existing health delivery system in
rural areas. They are being established on the basis of one sub-centre for every 5000
population in general and one for every 3000 population in hilly tribal and backward
areas. Each sub-centre is manned by one male and one female multipurpose health
worker.
Functions
a. Mother and child healthcare
b. Family planning
c. Immunization
d. IUD insertion
e. Simple laboratory investigations
3. Primary health centre level: The Bhore committee in 1946 gave the concept of a
primary health centre as a basic health unit to provide as close to the people as possible.
The Bhore committee aimed at having a health centre to serve a population of 10,000 to
20,000. The national health plan, 1983 proposed reorganization of primary health centres
on the basis of one PHC for every 30,000 rural population in the plains, and one PHC for
every 20,000 population in hilly, tribal and backward areas for more effective coverage.
Functions of the PHC
a. Medical care.
b. MCH including family planning.
c. Safe water supply and basic sanitation.
d. Prevention and control of locally endemic diseases.
e. Collection and reporting of vital statistics.
f. Education about health.
g. National health programmes as relevant.
h. Referral services.
i. Training of health guides, health workers, local dais, and health assistants.
j. Basic laboratory services.
Community health centres
As on 31st March 2003, 3076 community health centres were established by upgrading
the primary health centres, each CHC covering a population of 80,000 to 1.20 lakh with 30 beds
and specialist in surgery, medicine, obstetrics and gynecology, and pediatrics‘ with x-ray and
laboratory facilities.
Functions
1. Care of routine and emergency cases in surgery.
2. Care of routine and emergency cases in medicine.
3. 24-hour delivery services including normal and assisted deliveries.
4. Essential and emergency obstetric cases including surgical 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 national health programmes should be delivered.
11. Blood shortage facility.
12. Essential laboratory services.
13. Referral services.
Organisational Structure of Panchayat Raj Institutions
Asst. District Health and Family Welfare Officer (Sub- division level/Dy.
Dy. CMO/ District Malaria
Senior
Officer
Medical Superin
District
tendent
Health Education Officer/ Dmeio
CMOs)
Medical Officer (FW & MCH)
District Nursing
cal Officers of Primary Health centres (Coordinators Supervisor
at PHC
Assistant
level) Statistical Officer
Planning and organizing nursing service at various levels – local, regional, national, and
international
Placement of nurses in the healthcare organization
A high power committee on nursing and nursing profession was set up by the
Government of India in July 1987 under the chairmanship of Smt. Sarojini Vasadapan, an
eminent social worker and former chairperson of Central Social Welfare Board with Smt.
Rajkumari Sood, Nursing Advisor to Government of India, as the member secretary. The terms
of reference of the committee were as follows:
a. Looking into the existing working conditions of nurses with particular reference to the
status of the nursing care services both in rural and urban areas.
b. To study and recommend the staffing norms necessary for providing adequate nursing
personnel to give the best possible care, both in the hospitals and community.
c. To look into the training of all categories and levels of nursing, midwifery personnel to
meet the nursing manpower needs at all levels of health service and education.
d. To study and clarify the role of nursing personnel in the healthcare delivery system
including their interaction with other members of the health team at every level of health
services management.
e. To examine the need for organisation of the nursing services at the national, state,
district, and lower levels with particular reference to the need for planning and
implementing the comprehensive nursing care services with the overall healthcare system
of the country at their respective levels.
f. To look into all other aspects which the committee may consider relevant with reference
to their terms of reference.
g. While considering the various issues under the above norms of reference, the committee
will hold consultations with the state governments.
The findings of this committee give a grim picture of the existing working condition of
nurses, staffing norms for providing adequate nursing personnel, education of nursing personnel
to meet the nursing manpower needs at all levels and the role of nursing personnel in the
healthcare delivery system.
Their recommendations on the organisation of nursing services at central, state and
district levels, and the norms of nursing service and education are given below.
Placement of nurses at the central level
At the central level there is a post of nursing advisor in the medical division of
Directorate General of Health Services. The nursing advisor is directly responsible to the Deputy
Director General (Medical). The nursing advisor is assisted by nursing officer and support staff
for all his/her work. She/he advises the DGHS, Ministry of Health and Family Welfare as well as
other ministries and departments, for example, railways, labour, Delhi Administration, etc. on all
matters of nursing services, nursing education, and research. The nursing advisor also takes care
of administration aspects of Raj Kumari Amrit Kaur College of Nursing and Lady Hardinge
Health School, Delhi.
There is a post of deputy nursing advisor at the rank of Assistant Director General (ADG-
Nsg) in the training division of Department of F. W. Presently the deputy nursing advisor deals
with training of ANMs, dais, health supervisor, etc. There is no direct linkage between the
nursing advisor and deputy nursing advisor as there are independent posts.
Nursing organisational set up at the central level
DGHS
DDG (N)
Deputy Nursing
PHN Supervisor Senior tutor superintendent
Secretary (Health)
ANM
Note
The Principal, College of Nursing will be equal to the rank of ADNS and will be eligible
for promotion to the post of DDNS/DNS. The salary scales and structure of the staff of colleges
of nursing will be as per norms of the Indian Nursing Council and the UGC.
Placement of nurses at district level
Nurses, public health nurses, lady health visitors, auxiliary nurse midwives, etc. have
played vital role in providing healthcare services at various levels in both urban and rural areas
of the district. They have been the mainstream in providing primary healthcare services in the
rural and urban areas from the very beginning.
Director nursing
DMO DHO
officer
LHV
ANM
The above recommended organisational set up will need full administrative and financial
support of the government. It will look after the overall nursing components, development of
nursing standards, norms, policies, ethics, recruitment, selection and placement roles for both
hospitals and community health nursing, development in speciality nursing, higher education in
nursing, and research. These will promote professional autonomy and accountability.
The National Rural Health Mission (NRHM) has been launched with a view to bringing
about dramatic improvement in the health system and the health status of the people, especially
those who live in the rural areas of the country..
Public sector
Public agencies are financed with tax monies, thus these are accountable to the public. The
public sector includes official (governmental) agencies and voluntary agencies.
Federal Government has the responsibility for the following aspects of health care.
At the federal level, the primary agencies are concerned with health are organized under the
Department of Health and Human Services (DHHS).
Providing direct care for certain groups such as Native Americans, military
personnel, and veterans.
Safeguarding the public health by regulating quarantines and immigration laws and
the marketing food, drugs and products used in medical care.
Prevents environmental hazards, gives grantsin aids to states, local areas and individuals
and supports research.
Administration of social security, social welfare and related programmes
Organization and Functions of Nursing Services and Education at National, State,
District, and Institutions: Hospital and Community
Organization and functions of nursing services and education At centre/ national level
Organization of health care at centre level is done by three structures these are
Functions:
The functions which are performed by the department of health and through DGHS are given in
the union list and concurrent list and these are as under:
1. Conducting health and morbidity surveys, planning and organizing health programmes
with active participate of state governments, co-ordination of health care activities
through central health council, consultative committee of parliament, statutory bodies
etc.; appraisal of health schemes and feed back in order to maintain uniformity, norms
etc.
2. Maintenance of international health relations, administration of port health and
quarantine laws..
3. Administration of central health institutions, training colleges, laboratories and hospitals,
4. Promotion and maintenance of appropriate standards of education in medical, nursing,
dental, pharmaceutical and ancillary health personnel through statutory bodies.
5. Promotion of medical and public health research.
6. Establishing and maintenance of drug standards,
7. Health intelligence.
8. Central bureau of health intelligence was set up in 1961 for collection, complication,
analysis and evaluation of information.
9. Maintenance of a central medical library.
Central family welfare council
This department mainly deals with FW matters. Secretary with support of team members, plan
co-ordinates, evaluates and supervises the implementations of FW programme in the state and
co-ordinates the activities and the functions of the technical divisions of the FW department like
Health is a state subject. The union government has mainly an advisory, guiding and
coordinating function. The main functions of the council are as under:
To consider and recommend broad lines of policy on all matters of health like, primary
health care, medical care, nutrition, environmental health, health education etc.
To make proposal for legislation in the field of medical and public health matters
To lay down the pattern of development in the country as a whole
To make recommendations regarding distribution of available grants-in-aid
Apart from Governmental actions, Nursing education and services are organized by Indian
nursing council and other statutory bodies in national level.
AT STATE LEVEL
Health secretariat
It is the official organ of the ministry. Major function of the secretariat include helping
minister in
Apart from governmental actions it will be organized by state nursing councils and universities
AT DISTRICT LEVEL
At district level health organisation is maintained by taluks or block, their main function
is, to plan and implement community development programmes.
Panchayati raj system is a local self governing system in rural area which work parallel
to official structure of administration. It consists of three –tier structure of rural local self
government.
Gram sabha- it is comprised of all the adult men and women of the village. This body
meets at least twice in a year and discusses important issues and considers proposals pertaining
to various developmental aspects including health matters
Gram Panchayat- it is the executive organ of the gram sabha. Its main function is
overall planning and development of the villages. The Panchayat secretary has been given
powers to function for wide areas such as maintenance of sanitation and public health, socio
economic development of villages.
Panchayat samiti- it is responsible for the block development programme. The funds for
the development activities are processed through Panchayat samiti. The block development
officer and his/her technical staff extend assistance and guidance to gram Panchayats in carrying
out developmental activities in their villages.
INSTITUTIONAL LEVEL –
AT HOSPITAL
Organization of nursing services and education
Director of nursing
Nursing services must function under a senior competent nursing administrator –
variously called as director of nursing, nursing superintendent, principal matron, or matron-in-
chief. She is responsible to the hospital administrator for overall programme and activities of
nursing care of all patients in the hospital. Nursing programme is administered by her through
appropriate planning of services, determining nursing policies in collaboration with hospital
management and nursing procedures in collaboration with nursing staff, giving general
supervision, delegation of responsibility, coordination of interdepartmental nursing activities‘,
and counseling the hospital administration on nursing problems.
She has a dual role: the first one is the administrative responsibility towards hospital
administration, and the second one is the coordinating of all professional activities of nursing
staff with those of medical staff.
The role of the nursing superintendent starts in a new hospital from helping to establish
the overall goals, policies and organization, and facilities to accomplish these goals in the most
effective and efficient manner. The functional elements of the role of nursing superintendent
includes the following
Formation of the aims, objectives and policies of nursing services as an integral part of
hospital service
Staffing based on nursing requirements in relation to accepted standard of medical care
Planning and directing nursing services
Maintaining supplies and equipments
Budgeting
Records and reports
Nursing supervisor
Each department or clinical division, e.g. Medical, surgical, obstetrical, operation
theatres, outpatient department, nurseries, etc. should have a supervisor. As they may be more
than one nursing unit in each division or department, supervisors have a general administrative
and coordinating function within their respective division. However, supervisors will also have
limited clinical functions
Student nurse
Students nurse cannot be employed on nursing duties except under supervision of fully
qualified staff nurses.
Organization
Status and relationship
Responsibilities
Staffing pattern, shift pattern
Departmental functions
Requisitioning of supplies
Utilization, care and maintenance of equipment
Nursing procedures, coordination with domestic services
Handling of the patients clothing and valuables
Isolation technique
Functions
Of hospital in nursing services and education
Man power
Instrument
Equipments
Drugs
Other facilities
The standards prescribed are , a PHC covering 20000-30000 population with six beds on well the
block level PHC are ultimately going to be upgraded as CHC with 30 beds of providing
specialized services.
The objectives of IPHS for PHCs are:-
To provide comprehensive primary health care to the community through the PHC
To make the services more responsible and sensitive to the needs of the community
Minimum requirements are:-
The assured services cover all the essentials of preventive, promotive, curative and rehabilitative
primary health care. This implies a wider range of services that includes
Medical care
Maternal and child health care
Full rage family planning services including counseling and appropriate referral for
couples having infertility
MTP services
Health education for prevention and management of malnutrition, anemia and vitamin A
deficiency and co-ordinates with ICDS
School health services
Adolescent health care
Disease surveillance and control of epidemics
Collection and reporting of vital events
Promotion of sanitation
Testing water quality
Nutritional health programme
Training health workers
Training of ASHA
Staffing pattern
The man power that should be available in the PHC is as follows
AYUSH practitioner - 1
Accountant manager - 1
Pharmacist 1 2
Health worker 1 1
Health educator 1 1
Clerks 2 2
Laboratory technician 1 2
Class IV 4
Facilitative role
Developmental role
Clinical role
Supportive role
Functions of PHC
Medical care
Immunization services
Principles
Excellence
Innovations
Accountability
Collaboration
Accessibility
Integrity
Environment
Elements
Primary care
Illness prevention
Health promotion
Community capacity building
Service integration
Standards of CHC
In order to provide quality care in CHCs IPHS are being prescribed to provide optimal expert
care to the community and achieve and maintain an acceptable standards of quality of care.
These standards would help to monitor and improve the functioning of CHCs.
CHCs has to provide the following services like
Care of routine and emergency cases in surgery
Care of routine and emergency cases in medicine
24 hour delivery services
Essentials of emergency obstetric care.
Full range of family planning services including laparoscopic services
Safe abortion services
New born care
Routine and emergency care of sick children
Other management of medical and accidental conditions
All the national health programmes should be delivered through CHCs
PLANNING PROCESS
HEALTH IN FIVE YEARS PLANS
INTRODUCTION
Five years plan is mechanism to bring about uniformity in policy formulation in programmes of
national importance
The specific objectives of the health programme, during Five years plan, are as follows:
1. Control & eradication of major communicable diseases.
2. Strengthening of basic health services through the establishment of the PHC & sub
enters.
3. Population control.
4. Development of health manpower resources.
For the purpose of planning the health sectors has been divided in two following sub sectors.
1. Water supply & sanitation.
2. Control of communicable diseases.
3. Medical education, training & research.
4. Medical care including hospitals, dispensaries & PHCs.
5. Public health services.
6. Family planning.
7. Indigenous system of medicine.
FIRST FIVE YEAR PLAN (1951 – 1956)
The first Indian Prime Minister, Jawaharlal Nehru presented the first five-year plan to the
Parliament of India on 8 December 1951. The first plan sought to get the country's economy out
of the cycle of poverty. The plan addressed, mainly, the agrarian sector, including investments in
dams and irrigation. The agricultural sector was hit hardest by the partition of India and needed
urgent attention.[2] The total planned budget of 206.8 billion was allocated to seven broad areas:
1) Irrigation and energy
2) Agriculture and community development
3) Transport and communications
4) Industry
5) Social services
6) Land rehabilitation
7) Other sectors and services
The specific objectives were;
1. Provision of water supply & sanitation.
2. Control of malaria.
3. Preventive health care of the rural population.
4. Health services for mother & children.
5. Education & training in health.
6. Self sufficiency in drug & equipments.
7. Family planning & population control.
During this plan period the public sector outlay was Rs. 2356 crore of which Rs. 140 crore were
allotted for health programs.
During this plan period the public sector outlay was Rs. 37,250 crore of which Rs. 3,277 crores
were allotted for health programs.
The sixth plan also marked the beginning of economic liberalization. Price controls were
eliminated and ration shops were closed. This led to an increase in food prices and an increase in
the cost of living.
Family planning was also expanded in order to prevent overpopulation. In contrast to China's
strict and binding one-child policy, Indian policy did not rely on the threat of force. More
prosperous areas of India adopted family planning more rapidly than less prosperous areas,
which continued to have a high birth rate.
3. Health
o Reduce infant mortality rate to 28 and maternal mortality ratio to 1 per 1000 live
births
o Reduce Total Fertility Rate to 2.1
o Provide clean drinking water for all by 2009 and ensure that there are no slip-
backs
o Reduce malnutrition among children of age group 0-3 to half its present level
4. Women and Children
o Raise the sex ratio for age group 0-6 to 935 by 2011-12 and to 950 by 2016-17
o Ensure that at least 33 percent of the direct and indirect beneficiaries of all
government schemes are women and girl children
o Ensure that all children enjoy a safe childhood, without any compulsion to work
5. Infrastructure
o Ensure electricity connection to all villages and BPL households by 2009 and
round-the-clock power.
o Ensure all-weather road connection to all habitation with population 1000 and
above (500 in hilly and tribal areas) by 2009, and ensure coverage of all
significant habitation by 2015
o Connect every village by telephone by November 2007 and provide broadband
connectivity to all villages by 2012
o Provide homestead sites to all by 2012 and step up the pace of house construction
for rural poor to cover all the poor by 2016-17
6. Environment
o Increase forest and tree
o Attain WHO standards of air quality in all major cities by 2011-12.
o Treat all urban waste water by 2011-12 to clean river waters.
o Increase energy efficiency by 20 percentage points by 2016-17.
I. Various health and family welfare committees
1. Bhore committee
In 1946, the recommendations and guidance provided by the Bhore Committee formed
the basis for organization of basic health services in India. The report was submitted to
the government.-side was the focal point of these recommendation
The Bhore Committee made two types of recommendations;
a) A Comprehensive blue print for the distant future (20 to 40 years from then) and the
smallest service unit was to be Primary Health Unit, serving a population of 10,000 to
20,000
b) A short-term scheme covering 2 to 5 years period from then with emphasis on setting up
30 bedded hospitals, one for every two Primary Health Care
The country – side was the focal point of these recommendations. Other
recommendations were:
Formation of village health committee to secure active cooperation and support in the
development of health program.
Provision of Doctors of future who should be ―Social Doctor‖, combines both
curative and preventive of the public.
Formation of District Health Board for each district with district health officials and
representatives of the public.
To ensure suitable housing, sanitary surroundings, safe drinking water supply
elimination of unemployment and lay special emphasis on preventive work.
2. Mudaliar committee 1962
In 1959, the Government of India appointed another committee known as ―Health Survey
and Planning Committee popularly known as Mudaliar Committee under the
Chairmanship of Dr. A.L mudaliar.
Recommendations:
a) Consolidation of advances made in the first two-year plans
b) Strengthening of the district hospital with specialist services
c) Regional organizations in each state
d) Each primary health centre not to serve more than 40,000 populations.
e) To improve the quality of health care provided by primary health centres
f) Integration of medical and health services on the pattern of Indian Administrative
service.
3. Chadah Committee, 1963
Under the chairmanship of Dr. M.S. Chadah, Government of India appointed a committee
to study the arrangement necessary for the maintenance phase of the National Malaria
Eradication Programe.
Recommendations
1. Vigilance operations in respect of the NMEP should be the responsibility of the
general health services (e.g.) PHC.
2. The vigilance operations should be should be done through monthly home visits by
basic workers (Junior Health Assistant male)
3. Now each Junior Health Assistant Male to cover 3 – 5000 population
4. Mukherjee Committee, 1965
Under the chairmanship of Shri Mukerji, the then secretary of health to the Government
of India was appointed to review the strategy for the family planning program.
Recommendations
To have separate staff for the family planning program.
The family planning assistants were to undertake family planning duties only
The basic health workers were to be utilized for purposes other than family planning.
To delink the malaria activities from family planning of it‘s that the later would receive
undivided attention of its staff.
Mukherjee Committee, 1966
Multiple activities of the mass programmes like family planning, small pox, leprosy,
trachoma, etc. were making it difficult for the states to undertake these effectively because of
shortage of funds. A committee of state health secretaries, headed by the Union Health
Secretary, Shri Mukherjee, was set up to look into this problem.
5. Jungalwalla Committee, 1967
Under the Chaimanship of Dr. Jungalwalla Director, National Institute of Health
Administration and Education, New Delhi was appointed to examine the various
problems of service conditions of doctors. This committee is known as the committee on
integration of Health Services.
Recommendation
1. The main steps recommended towards integration were
a) Unified cadre
b) Common Seniority
c) Recognition of extra qualifications
d) Equal pay for equal work
e) No private practice and good service conditions
6. Kartar Singh committee, 1973
The Government of India constituted a committee in 1922, known as the committee on
multipurpose workers under Health and Family Planning, under the Chairmanship of
kartar Singh, Additional Secretary, Ministry of Health and Family Planning, Government
of India.
Recommendations
The Present Auxiliary Nurse Midwives to be replaced by the newly designated ―Female
Health Workers‖ and the present day Basic Health Workers, malaria surveillance workers,
vaccinators, health education assistants (Trachoma)and the family planning health
assistants to redesignated by ―Male Health Workers‖.
The program has to be introduced in areas where malaria is in maintenance phase and
smallpox has been controlled and later to other areas.
One primary health centre for 50,000 populations.
Each PHC should be divided into 16 sub centers and each covers 3,000 to 35, 00
population.
Each sub centre to be staffed by a male and female health worker.
One male health supervisor to supervise 3 to 4 male health workers and one female health
supervisor to supervise the work of 4 female health workers.
The lady health visitors to be designated as female health supervisors.
The doctor in charge of a primary health centre should have the overall in charge of all
the supervisors and health workers in the area.
7. Shrivastav Committee, 1975
The Government of India in the Ministry of Health and Family Planning had in
November 1974 set up a ‗Group on Medical Education and Support Manpower‘
popularly known as Shrivastav Committee.
Recommendations
Creation of bands of paraprofessional and semiprofessional health workers from within
the community itself (e.g. school teachers, postmasters, gram sevaks) to provide simple
promotive, preventive and curative health services needed by the community.
Establishment of 2 cadres of health workers, namely multipurpose health workers and
health assistants between the community level workers and doctors at PHC.
Development of a ‗Referral Services Complex‘ by establishing proper linkages between
PHC and higher level referral services.
Establishment of a Medical and Health Education Commission for planning and
implementing the referrals needed in health and medical education on the lines of the
University Grants Commission.
8. Balaji Committee 1986-19877
The Ministry of Health and Family welfare, Government of India, following the adoption
of the National Policy on education, 1986, set-up a committee on Health Manpower,
Planning, Production and Management in 1986 under the chairmanship of Prof. JS Balaji,
Professor of Medicine, AIIMS, and New Delhi
Recommendations
To formulate a National Policy on education in Health Services
To prepare curriculum for schoolteachers this should constitute a holistic approach
including social, moral, health and physical education.
Health service statistics needs to be improved in quality
To utilize the services of Indian system of medicine viz. Homeopathy, in the area of
National Health Program.
Health related components to be included in IX, X Grades
Continuing education program for the health personnel.
Health manpower requirements for nursing personnel.
Introduction
National Health Policy was last formulated in 1983, and since then there have
been marked changes in the determinant factors relating to the health sector. Some of the
policy initiatives outlined in the NHP-1983 have yielded results, while, in several other
areas, the outcome has not been as expected.
Current scenario
Financial resources: The public health investment in the country over the years has been
comparatively low, and as a percentage of GDP has declined from 1.3 percent in 1990 to 0.9
percent in 1999. The aggregate expenditure in the Health sector is 5.2 percent of the GDP. Out of
this, about 17 percent of the aggregate expenditure is public health spending, the balance being
out-of-pocket expenditure.
Equity: In the period when centralized planning was accepted as a key instrument of
development in the country, the attainment of an equitable regional distribution was considered
one of its major objectives.
Objectives
Financial resources
Equity
Delivery of national public health programmes
The state of public health infrastructure
Extending public health services
Role of local self-government institutions
Population stabilization
Medical and Health Education
Providing primary health care with special emphasis on the preventive, promotive and
rehabilitative aspects
Re-orientation of the existing health personnel
Practitioners of indigenous and other systems of medicine and their role in health care
AYUSH
The Indian Systems of Medicine and Homoeopathy (External website that opens in a new
window) (ISM&H) were given an independent identity in the Ministry of Health and Family
Welfare in 1995 by creating a separate Department of Ayurveda, Yoga and Naturopathy, Unani,
Siddha and Homoeopathy (External website that opens in a new window) (AYUSH) in
November 2003.
The infrastructure under AYUSH sector consists of 1355 hospitals with 53296 bed capacity,
22635 dispensaries, 450 Undergraduate colleges, 99 colleges having Post Graduate Departments,
9,493 licensed manufacturing units and 7.18 lakh registered practitioners of Indian Systems of
Medicine and Homoeopathy in the country.
Budget: An outlay of Rs.775 crore has been allocated for the Department during the Tenth Five-
year Plan. The Plan allocation for 2006-07 is Rs. 381.60 crore.
Subordinate Offices
Address the unmet needs for basic reproductive and child health services, supplies and
infrastructure.
Make school education up to age 14 free and compulsory, and reduce dropouts at primary and
secondary school levels to below 20 percent for both boys and girls.
Reduce infant mortality rate to below 30 per 1000 live births.
Reduce maternal mortality ratio to below 100 per 100,000 live births.
Achieve universal immunization of children against all vaccine preventable diseases.
Promote delayed marriage for girls, not earlier than age 18 and preferably after 20 years of
age.
Achieve 80 percent institutional deliveries and 100 percent deliveries by trained persons.
Achieve universal access to information/counseling, and services for fertility regulation and
contraception with a wide basket of choices.
Achieve 100 per cent registration of births, deaths, marriage and pregnancy.
UNIT II
Management FUNCTions of administration
Planning and control
Co-ordination and delegation
Decision making – decentralization
basic goals of decentralization.
Concept of management
Planning
Planning means to decide in advance what is to be done. It charts a course of actions for
the future. It is an intellectual process and it aims to achieve a coordinated and consistent
set of operations aimed at desired objectives.
Facilitates co-ordination.
Controlling
Steps of control:
o The control function, whether it is applied to cash, medical care, employee morale
or anything else, involves four steps.
1. Establishments of standards.
2. Measuring performance
CO-ORDINATION
Definitions
Co-ordination is the orderly arrangement of group efforts to provide unity of an action in pursuit
of common purpose.
Co-ordination is the orderly synchronization of efforts to provide the proper amount, timing and
directing of execution resulting in harmonious and unified actions to a stated objective. (NEW
MAN,1953)
Characteristics
Group effort: The financial, human and technical resources are properly organized and
co-ordinate.co-ordination transcends and permeates all managerial functions.
Unity of action: Co-ordination applies to the group effort, not individual effort, co-
ordination stress the unity of effort and unity of action.
Common purpose
Principles of co-ordination
2. Principle of early stages: co-ordination should start from the very beginning of planning
process. At the time of policy formulation and objective setting.
3. Reciprocal relationships: As the third principle: all factors in a situation are reciprocally
related, in other words all the parts influence and are influenced by other parts. For
example when A works with B and he is turn works with C and D, each of the four finds
himself influenced by others influenced by the people in the total situation.
Importance of co-ordination
In the work that need to be accomplished is highly predictable and hence can be planned in
advance, a manager can specify a head of time what actions his subordinating the routine
rescuing activities, rules and procedures are helpful which specify in detail a head of time, what
courses of action the subordinates should take if some situation should arise.
Most of the managers assign specific goals/ targets to their subordinates facilitate co-ordination.
Rules, regulations and procedures as well as the goals apart, managers also use the chain of
command to achieve co-ordination. When situations arise the specified rules or targets do not
cover that, subordinates are trained to bring the problem to their concerned manager. Co-
ordination through the hierarchy works well as long as the number of problems that must be
brought to the boss is not great.
To make his job of coordinating easier, a manager may hire an assistant. When subordinate
brings a problem to him, the assistant can comic the information on the problem, research the
problem, provide alternative solutions available. This increases, undoubtedly, the manager‘s
ability to handle the problems and coordinate the work of his subordinates.
In some big organizations where the volume of contacts between two departments grows, many
managers appoint a special liaison person to facilitate coordination.
9. Conferences
Conferences at regular intervals also ensure better coordination. Conferences provide adequate
platform for discussion of various problems being encountered by different departments.
11. Miscellaneous
Types of co-ordination
Coordination can be classified into two broad categories, one on the basis of its shape in the
organization and other on the basis of its scope and coverage. On the former basis, it can be
classified into vertical and horizontal coordination and on, the latter basis, into internal and
external coordination.
The term vertical coordination is used when coordination is to be achieved between various links
or different levels of the organization vertical coordination is needed to ensure that all the levels
in the organization act in harmony and in accordance with organizational policies and
programmers. It is the function of the top executives to bring about this co-ordination. Vertical
coordination is secured through delegation of authority and with the help of directing and
controlling.
The term ―horizontal coordination‖ is used when coordination has to be achieved between
departments on the same level in the management hierarchy. Thus, when coordination is brought
between production department, sales department, personnel department etc it is said to be
horizontal coordination.
2. Internal and external coordination
The various factors with whom it has interaction include government, customs, supplies and
competitors. An enterprise has to keep proper coordination with these. Such type of coordination
is known as external co-ordination and it is essential for the survival of the enterprise. External
coordination also involves interaction with other business, economic and research institutions to
have the benefits of latest information and technological advances.
DIFFICULTIES OF CO-ORDINATION
Lack of coordination and understanding between and among individuals, groups, and
departments.
lack of good interpersonal relations
failure in accomplishing objectives according to time and work schedule
Lack of direction and consequently aimless individual efforts.
Functioning of departments in the organization as watertight compartments.
Lack of initiative and loyalty towards the organization.
DELEGATION
Delegation is defined as transferring of responsibility to subordinates on behalf of the manager.
It is an act through which a manager gives authority to others to attain certain assignments.
Salient Features:
1. Not to delegate total authority
2. Not to delegate authority which he himself does not possess
3. Should be only for organisational purpose and not personal purpose
4. It does not imply reduction in power
Characteristics:
1. Delegation of authority can be exercised only by higher authority
2. Delegation can be of any kind
3. Delegation does not mean transfer of final authority
4. Does not involve surrender of power
Kinds of delegation:
1. Full delegation
2. Partial delegation
3. Conditional delegation
4. Formal delegation
5. Informal delegation
Principles of delegation:
1. Should be written and specific
2. Authority and responsibility should be equal
3. Should be properly planned and exercised
4. Right person should be chosen
5. Good reporting system should be established
6. Should have certain objectives to get certain results
7. Superiors should be ready to give support and guidance
8. Overall responsibility lies with the superior
Symptoms of poor delegation
1. Dissatisfied subordinates
2. Disorganized effort
3. Long queue in front of boss office
4. Boss always busy
5. Boss carrying big suitcase
6. Work never completed in time
7. Constant time pressure
8. Hold up of activities due to pending orders from boss
Definition
Decision making is a systematic process of choosing among alternatives and putting the
choice in to action. -Lancaster and Lancaster
Mechanistic decision
It usually occurs in a situation involving a limited number of decision variables where the
outcome of each alternative is known.
Tools used for these kinds of decisions are charts, list, decision tree etc.
Analytical decision
It involves a problem with a large number of decision variables where the outcome of
each decision alternatives can be computed.
Judgmental decision
Decision involves a problem with a limited number of decision variables but the out of
the decision alternatives are unknown.
These types of decision are useful in marketing investment and to solve the personal
problems.
Adaptive decision
Decisions involving a problem with a large number of decision variables where outcomes
are not predictable.
Such ill structured problems require contribution of many people with diverse technical
background. Eg. Research finding.
a. Non routine decision: made by directors of nursing. The out of the problem will be
unpredictable. Eg. Changing ways of organizing for the delivery of nursing care.
b. Routine decision: Routine decision: made by mid level and low level managers, the
outcome will be predictable. Eg. Assigning the duty roster, assign the security laws.
Routine decisions: Involve no extraordinary judgment, analysis and authority, since they are
dealing with less important problems. Routine decisions demand power to select the shortest
path, within the given means and ends.
Strategic decisions: Aim at determining or changing the means and ends of the enterprise. They
require a thorough study, analysis and reflective thinking on the part of administrators. Strategic
decisions are usually taken by top managers, while routine decisions are made mostly by lower
level managers.
DECISION STRATEGIES
A strategy is an artful or cleaver plan for applying technique in pursuit of a goal. Before
selecting any method of decision manager should adopt a decision strategy. Some strategy suited
for some type of problems than others, they are;
3. Mixed scanning: making a decision that satisfies to remove least promising solutions, and
then select best of remaining options.
6. Eliminate critical limiting factor: making a decision by removing most powerful obstacle
to success.
7. Maxima: an optimistic approach in which, while assuming the highest possible p ay off
from use of any action the individual chooses that action alternative that will yield the
largest pay off.
8. Mini-regret: an approach designed to minimize the surprise resulting from any action
decision by selecting the action alternative that will yield a result midway between the most
desired and the least desired out comes.
9. Precautionary: making a decision by choosing the action that will maximize gain of
minimize loss regardless of opponents actions. It is useful when the manager engaged in a
zero sum conflict with another.
10. Evolutionary: while taking a decision individual has to make series of small changes
leading towards goal. It is based on the assumption that subordinates can better adjust to
series of small changes than a quantum leap.
11. Chameleon: taking a decision by making vague plan, adjusted to changing circumstances.
It consists of farming management decision in general terms, so that they can be interpreted,
differently at different times.
There are six important bases for decision making which are referred to as aids to
decision making and they include experience, authority, facts, intuition, research, analysis and
experimentation.
1. Experience: Experience is the most important and valued basis for making decisions.
Experience gives the administrator the requisite vision, that trains him to apply his
knowledge to the best of its use and that helps him to recognize the crucial factors from
unnecessary details.
2. Authority: Provides an important basis for enabling managers to take quick and sound
decisions.
3. Facts: Provide the solid basis for decision making. Decisions become wrong only when
adequate facts are not available on the problem. The computer technology has been
introduced for supplying greater facts to operating managers.
4. Intuition: It is the residuary basis for covering up deficiencies in other three bases of
decision making. It includes guess work, and common sense views.
5. Research and analysis: These are the most effective basis for choosing among alternatives.
It helps in finding out relationships among the other important variables.
Internal factors
Cultural environment
Philosophical environment
Social back ground
Time
Poor communication
Cooperation
Coordination
The first step is to determine what the real problem is?. If the problem is not ascertained
correctly at the beginning, money and effort spent on the decision making will be a waste. The
original situation will not come under control. But new problems will start from this incorrect
appraisal of the situation.
The problem should be thoroughly analysed to find out adequate background information
and data relating to the situation. This analysis may provide the manager with some revealing
circumstances that will help him to gain an insight into the problem. The whole approach should
be based around the important factors. Only pertinent and closely connected factors are selected,
as dictated by the principle of the limiting or strategic factor.
After anodizing the problem attempts are made to find alternative solutions to the
problem. In the absence of alternatives decision making process will become.
Instead of picking the best solution managers have to really on a course of action that is
satisfactory enough under the existing circumstances and limitations.
The decisions can be made effective through the action of other people. In order to
overcome the opposing on the part of employee‘s managers can make three important
preparations.
a. Communication of decisions
As a safe guard against the incorrect decisions managers are required to a system of
follow up care of the decisions so as to modify them at the earliest.
1. Individual
2. Group
3. Committees
Individuals as decision makers
The autocratic manager‘s fears that decisions made by others may be more costly, less
effective and represents a threat to his/ her position. There are mainly 3 behavioural
characteristics that influence the decision making.
Perception of the problem: it is affected by ones previous experience and value system.
Personal value system: basic convictions about what is right, good or desirable.
The role theory: it predicts how actions will be performed in certain roles and how it will
be affected certain circumstances. Specific behaviour associated with position constitutes
roles.
Group comprises two or more people who share common interest and come together to
accomplish an activity through face to face interaction. Commitment to the decision and to the
implementation is important and may be increased by participation in the decision making
process.
Members may become more interested in arguments and winning than finding a solution.
A committee a group of people chosen to deal with a particular topic or problem. It can
be formal or informal committee. A committee appointed to collect data analyze finding make
recommendations is an ‗ad hoc committee‘.
Advantages of decision making by committee
Time consuming
Expensive
5. Optimizing Model
6. Satisfying Model
This model is at least 200 years old. It is assumed to maximize satisfaction and fulfils the
―perfect knowledge assumption‖ that‖ in any given situation calling for a decision, all possible
choices and the consequences and potential outcome of each are known.‖ Seven steps are
identified in this analytically precise model:
f. Implement.
g. Follow up.
The normative model for decision making is unrealistic because of its assumption that there are
clear-cut choices between identified alternatives.
They define decision making as a social process and emphasis how mangers work rather
than should behave in their normative way. It is used when information is rather than should
behave in their normative way. It is used when information is objective, the problem is structured
or routine, and options are known and predictable. They identified 5 alternative decision making
process:
A- Autocratic
C – Consultative
G – Group
I – First variant
II – Second variant
The unstructured problem rule: If the quality of decision is important and the leader
doesn‘t poses adequate information to solve the problem and if the problem is
unstructured then eliminate AI, AII, and CI.
The acceptance rule: If the acceptance of the decision by the subordinates is critical for
the effective implementation, if it is uncertain that an autocratic decision made by the
leader would receives the acceptance then AI, AII are eliminated from the feasible set.
The conflict rule: if the acceptance of the decision is critical and if it is uncertain that an
autocratic decision made by the leader would receives the acceptance and subordinates
are likely to be in conflict over the appropriate solution then AI, AII, CI is eliminated
from the feasible set.
The fairness rule: if the quality of the decision is unimportant, acceptance is critical, and
an uncertain to result from an autocratic decision. AI, AII, CI and CII are eliminated.
Various adaptations of decision tree analysis are found in the literature; the essential
elements described in the 1960s are standard. All factors considered important to a decision can
be represented on a decision tree. Vroom arranged answers to seven diagnostic questions in the
form of a decision tree to identify types of leadership style used in management decision making
models. The questions focus on protecting the quality and acceptance of the decision and deal
with adequacy of information, goal congruence, structure of the problem, acceptance by
subordinates, conflict, fairness, and priority for implementation.
Magee and Brown depict decision trees as starting with a basic problem and use branches
to represent ―event forks‖ and ―action forks.‖ The number of branches at each fork corresponds to
the number of identified alternatives. Every path through the tree corresponds to a possible
sequence of actions events, each with its own distinct consequences. Probabilities of both
positive and negative consequences of each action and event are estimated and recorded on the
appropriate branch.
A1
A2
Decision point 1
A3
Alternatives A4
Simon developed the descriptive model based on the assumption that the decision maker
is a rational person looking for acceptable solutions based on known information. This model
allows for the fact that many decisions are made with incomplete information because of time,
money, or people limitations, and the cause of time, money, or people limitations, and the fact
that people do not always make the best choices. Simon wrote that few decisions would ever be
made if we always sought optimal solutions. Instead, he contended, we identify acceptable
alternatives. Steps in the descriptive model are as follows:
Nagelkerk and Henry used a model designed by Mintzberg, Raisinghani, and Teoret (the
MRT model) to design and test the nature of strategic decision making that entailed substantial
risk. They worked with chief nurse executives employed in six acute care hospitals with 400 or
more beds each.
Supporting Activities
Selecting the Single Best Choice Developing Potential Solutions
In decision making
In applying this model, participants used mixed scanning of general and specific
information from subordinates to identify complex problems. To develop potential solutions they
gathered facts from hospital documents. They made their selection of the single best solution by
It was concluded that top managers make these final choices using intuition, formal
analysis, and knowledge of organizational politics. In making good choices, top managers do
extensive planning, communicating, and politicking.
5. Optimizing Model
Decision maker select the solution that maximally meet the objective for a decision.
Usually this process involves assessing the pros and cons of each known outcomes as well as
listing benefits and costs associated with each option. The goal is to select the most ideal
solution. This process is most expedient and may be the most appropriate when time is an issue.
6. Satisfying Model
Decision maker selects the solution that minimally meets the objective for a decision. It is
more conservative method compared to an optimizing approach. This process is most expedient
and may be the most appropriate when time is an issue.
1. Judgemental technique
3. Delphi technique
4. Decision tree
1. Judgmental technique
It can be defined as the analysis of decision problem using scientific method to provide
manager the needed quantitative information in making decision.
a) Operational research makes the decision analytic, objective and quantitative based.
b) Steps of OR technique
Carrying out through the mathematical process of finding and series of action
which will give optimal solution.
1. Linear programming: Uses linear mathematical equations to determine the best way to use
limited resources to achieve maximum results. This technique is based on the assumption
that a linear relationship exists between the variables and the limits of variation can be
calculated. Linear programming is a sophisticated short cut technique in which computers
can be used. Three conditions must be existing before linear programming must be utilized.
a. Either a maximal or a minimal value is sought to optimize the objective. The value may be
expressed in terms of cost or quantity.
b. The variables affecting the goal must have a linear relationship. The ratio of change in one
variable to the changes in the other variable must be constant.
c. Constraints to the relationship of the variable exist.
It can be used to determine a minimal cost nutrition diet or determine a class size, class
hours, and instructors in school of nursing.
2. Queuing theory: It deals with waiting lines or intermittent servicing problems. It balances
the cost of waiting versus the prevention of waiting by increasing the services. A group of
items waiting to receive service is known as a ‗queue‘. By decreasing or eliminating the
waiting line to reduce waiting line cost, there is an increase in cost of labor and physical
facilities.
3. Games theory: In normal games, each player or group of player tries to choose a course of
action which will frustrate opponent‘s action and help in winning the game. The same will
apply in the context of business by maximize his loss.
4. Programme evaluation and review technique (PERT): PERT is a network system model
for planning and control under certain conditions. It involves identifying the key activates in
a project, sequencing the activities in a flow diagram, and assessing the duration for each
phase of work.
a. It is appropriate for project work that involves extensive research and development.
g. Can manipulate the time required to move from one event to another.
Closely related to PERT. Critical path method calculates a single time estimate for each
activity, the longest possible time. CPM is useful where the cost is a significant factor.
6. Computers in decision making:
In management information system computers can be used for various activities like
patient classification system, supplies and material management system, staff scheduling,
policy and procedure changes and announcements, patient charges, budget information and
management, personal records, statistical reports, administrative reports and memos etc.
3. Delphi technique
It allows members who are dispersed over a geographic area to participate in decision
making without meeting face to face. This is possible through the use of questionnaire. The
members will return the questionnaires anonymously; the results of the first questionnaire are
centrally compiled and sent to each member. Again the members are asked for suggestions.
This process continues until the consensus is reached. Little changes usually occur after the
second round.
4. Decision trees
A decision tree is a graphic method that can help the supervisor in visualizing the
alternatives available, outcomes, risk and information needs for a specific problem over a
period of time. It helps to see the possible directions that actions may take from each decision
point and to evaluate the consequences of a series of decisions. The process begins with a
primary decision having at least two alternatives. Then the predicted outcome of each
decision considered and the need for further decision is contemplated.
1. It is characterized by order and direction that enables managers to determine where they
are.
DECENTRALIZATION
Introduction
The nursing service administrator should explicitly define the standards, policies, and
scope of decision to be undertaken by top administration and those to be handled by departments
and their subunits.
The term centralized and decentralized refer to the degree to which an organization has
spread its lines of authority, power, and communication.
The centralization tends to concentrate decision making at the top level of the
organization, whereas decentralization disperses decision making and authority throughout
decision making and authority throughout and further down the organizational hierarchy. The
centralization and decentralization can be thought of as two theoretical extremes of one
continuum. In other words the decentralization is the extent of authority is passed down to lower
levels in the organization. The centralization is the extent to which authority is retained at the top
of the organization.
Authority decentralization
Decentralized structure
The decentralized structure is flat in nature and organizational power is spread out
throughout the structure. These are few layers in the reporting structure, and managers have a
broad span of control. Communication patterns are simplified and problems tend to be addressed
with ease and efficiency at the level at which they occur. Employees have autonomy and
increased job satisfaction within this type of structure.
Nursing Administrator
Appropriate resources
Advantages
Limitations
Concepts of management
The concept of management is not fixed. It has changing according to time and circumstances.
The concept of management has been used in integration and authority etc.
The concept of management is not fixed. It has changing according to time and circumstances.
The concept of management has been used in integration and authority etc. Different authors on
management have given different concepts of management. The main concepts of management
are as follows:
Functional Concept:
According to this concept 'management is what a manager does'. The man followers of this
concept are Louis Allen, George R. Terry, Henry Fayol, E.F.L. Brech, James L. Lundy, Koontz
and O. Donnel, G.E Milward, mcfarland etc. The functional concept as given by some of the
authors is given below:
II. James L. Lundy, " Management is principally the task of planning, coordinating, motivating
and controlling the effort of others towards a specific objective. Management is what
management does. It is the task of planning, executing and controlling."
IV. Howard M. Carlisle, "Management is defined as the process by which the elements of a
group are integrated, coordinated and/or utilized so as to effectively and efficiently achieve
organizational objectives."
V. Henry Fayol, "To manage is to forecast, and plan, to organize, to command, to coordinate
and to control."
'Getting Things Done Through Others' Concept:
According to this concept, 'Management is the art of getting things done through others'.
It is very narrow and traditional concept of management. The followers of this concept are
Koontz and O Donnell, Mooney and Railey, Lawrence A. Appley, S. George, Mary Parker Follet
etc. Under this concept, the workers are treated as a factor of production only and the work of the
manager is confined to taking work from the workers. He need not do any work himself. Modern
management experts do not agree with this concept of management. Some of these authors have
explained this concept in the following words:
I. Mary Parker Follet, "Management is the art of getting things done through others."
II. Harold Koontz, "Management is the art of getting things done through and wit people in
formally organized groups. It is the art of creating and environment in which people can perform
as individuals and yet cooperate towards attaining of group goals.
III. J.D. Mooney and A.C. Railey, "Management is the art of directing and inspiring people."
I. Donald J. Clough, "Management is the art and science of decision-making and leadership".
III. Association of Mechanical Engineers, U.S.A., "Management is the art and science of
preparing, organizing and directing human efforts applied to control the forces and utilize
the materials of nature for the benefit to man."
IV. F.W. Taylor, "Management implies substitution of exact scientific investigation and
knowledge for the old individual judgment or opinion, in all matters in the establishment."
Productivity Concept:
II. F. W. Taylor, "Management is the art of knowing what you want to do in the best
and cheapest way."
III. Marry Cushing Niles, "Good management achieves a social objectives with the best use of
human and material energy and time and with satisfaction of the participants and the public.
Universality Concept:
According to this concept, "Management is universal". Management is universal in the sense that
it is applicable anywhere whether social, religious or business and industrial. The followers of
this concept are Henry Fayol, Lawrence A. Appley, F.W. Taylor, Theo Haimann etc. According
to-
I. Henry Fayol, "Management is an universal activity which is equally applicable in all types
of organization whether social, religious or business and industrial".
III. Theo Haimann, "Management principles are universal. It may be applied to any
kind of enterprises, where the human efforts are coordinated."
Management is principally the task of planning, coordinating, motivating, and controlling the
efforts of others towards a specific objective. -James lundy 1963
The mission statement of an; organization describes the purpose for which that organization
exists.
Mission statements provide information and inspiration that clearly and explicitly outline
the way ahead for the organization. They provide vision.
Individuals want productive and meaningful lives .therefore, the purpose of the
organization and of each of its units should be defined a teamwork approach should be
properly trained: and all individuals within the organization should be treated with
respect.
Organizational purpose moves and guides the organization toward a perceived goal.
Many writers indicate that the purpose or mission statement should be created from mission
statement should be properly trained and all individual s within the organization should
be treated with respect.
Organizational purpose moves and guides the organization toward a perceived goal.
The mission or purpose statement incorporates the culture of the organization, including
strong leadership, rules and regulations, achievement of goals, and the notion that people
are more important than work.
Employees who participate in developing the vision statement believe in their own
abilities and are more committed to the organization.
The vision statement is shared companywide so that employees live the vision.
The mental exercise of creating one is more meaningful than the contents of the statement
itself. Vision, values, mission or purpose statements are meaningful only to the creators.
VISION
Employees who participate in developing the vision statement believe in their own
abilities and are more committed to the organization than employees who do not
participate.
The vision statement is shared companywide so that employees may live the vision. It is
updated to keep pae with technology and trends. A vision statement is sometimes.
The mental exercise of creating one is more meaningful than are the contents of the
statement itself.
Vision values, mission, or purpose statements are meaningful only to the creators.
Translated for the community, these statements place value on the way nurses care for
people.
It follows that ethnic populations are considered in developing vision and values
statements for nursing entities. Nursing education teaches the meaning of values such as
tolerance and compromise.
Examples of values are informality, creativity, honesty, quality, courtesy, and caring.
Philosophy
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.
Effective communication are essential for all aspect of effective administration .staff
must be adequately and correctly informed about plan, methods ,schedules, problems
events and progress.
Flexibility:
I. Historical and
I. HISTORICAL
LATE NINETEENTH CENTUR. The states of nursing that today had its beginning in
madras around the 17‘s in the 19TH century. This started with training for women for
improving nursing in military hospitals.
BEGINNING OF TWENTIETH CENTURY: The trend set in the late 19th century
found its effect in the period .by the start of this century we find establishment of nursing
training by the start of this century we find establishment of nursing training centers.
The missionary nurses were meeting has members of the medical missionary
association of India set up by the missionary doctors in 1905.
1908: The association of nursing of superintends broadened its scope and the trained
nurses‘ and association of India (TNAI) was found this year.
1909-1912: SAW The publication of nursing journals of India this provided a forum for
sharing of ideas and experience.
Filling the need for systematic preparation of nurses for better patients care services from
1909 the north India board was set up by the missionary nurses and are the medical
association of India in 1911.
1934: The Bengal nurses act was enacted for the nurses midwives and health visitors of
undivided Bengal.
1936: The mid-India board of education was formed in 1934 and was affiliated to
Christian nurses league in 1936.
1939: By this time we need all the provinces in India except Assam had nursing councils
1920-1940: It will be interest for you to know that during 1920 to 1940 nursing was
lapping forward in the Weston countries nurses in India to did not want to lag behind.
1940-1946: The Second World War ravaged the world during this period. For obvious
regions expansions‘ of military and civil hospitals took place during the war years.
1943: Commissioned rank was given to the Indian military nursing systems.
1941 -46: During the period the state nursing services with standardized pay scales and
terms of services were established in madras in UP (1944)
1946: The university nursing programmed leading to bachelors degrees in nursing were
lunched at the college of nursing ,Delhi and Christian medical college Vellore under delhi
and madras university respectively.
1947: We earned our independence on august 15th in 1947. Two nations were also burned
in this date, this brought on foreseen change in its wake, which has responsible for
bringing many human in to the field of nursing.
1950: This also replaced the various junior grade courses in nursing and midwifery in the
standardized courses shorter and simpler than the sinuous nursing and senior midwifery
courses
1953: The registering nurses trained in countries were no reciprocal registration existed,
and maintained Indian nurses register.
1963: A WHO assisted technical project was undertaken at the INC revise general
nursing midwifery.
1965: A WHO publication on guide for schools of nursing in India came out this year.
This period also saw the formation of many commissions and commits to recommended
nurses for improving the health care delivery systems
Educational trends
FMHW Programme :
GNM programme
M Phil
PhD programmes
1. University of Delhi.
2. Jawaharlal Nehru University.
3. Calcutta university
4. MGR university of health science, madras
5. Madras university
6. IGNOU
7. RGUHS
8. MANGALORE UNIVERSITY
9. SNDT university
10. Punjab university, Chandigarh
11. MAHE- maniple
Central institutions.
A. Profession of NSG :
The issue related to nursing are.
Status of nursing in society in the health care delivery system.
Values reflected in our nursing performances.
Attitude, human approach.
Quality in nursing vis-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.
B. Nursing education :
C. Nursing practice :
D. Nurse themselves:
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.
Doctor halfdal mehalar former director general of the world health organization
Luther Gulick:
He was influenced by Taylor and Fayol. He used Fayal‘s five elements of
administration viz.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:
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.
Organising (O): establishment of the formal structure of authority through which
work subdivisions are arranged, designed and coordinated for the defined
objective.
Staffing (S): the whole personnel function of bringing in and training the staff, and
maintaining favourable conditions of work.
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.
Coordinating (CO): all important duties of interrelating the various parts of the
work.
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.
Budgeting (B): all that goes with budgeting in the form of fiscal planning,
accounting and control.
Luther Gulick was very much influenced by Fayal‘s 14 basic elements of administration
in expressing his principles of administration as follows:
1. Davison of work or specialization
2. Bases of departmental organization
3. Coordination though hierarchy
4. Deliberate coordination
5. Decentralization
6. Unity of command
7. Staff and line
8. Delegation
9. Span of control
Lyndal urwick:
Lyndal urwick also one of the among 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 co-
equal.
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 prescribed of every duty.
4. 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.
Phenomenological 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.
Aims:
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 sciencetific
producers.
‗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: 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: critical thinking is reflecting on a situation, a plan an event under the rule of
standards and antecedent to making a decision.
(Mackenzie)
Critical thinking is both a philosophical orientation toward thinking and a cognitive
process characterized by reasoned judgment and reflective thinking.
(Jones and brown)
INTRODUCTION
Planning is a deliberative, systematic phase of the nursing process that involves decision
making and problem solving. In planning the nurse refers to the client‘s assessment data and
diagnostic statements for direction and formulating client goals and designing the nursing
strategies required to prevent, reduce or eliminate the client‘s health problems.
Meaning
The program evaluation & review technique (PERT) was developed by the Special Projects
Office of the U.S. Navy and applied to the planning &control of the Polaris Weapon system in
1958. It worked then, it still works; and it has been widely applied as a controlling process in
business & industry.
2. The total time & budget needed to complete the project or program.
4. The sequence of steps or activities that will be required to accomplish the project or program.
a. The optimistic time: This occasionally happens when everything goes right.
b. The most likely time : It represents the most accurate forecast based on normal developments.
USES
Why should nurse managers use the PERT system for controlling?
3. It establishes a system for periodic evaluation & control at critical points in the program.
6. Many records are used to control expenses and otherwise conserve the budget.
These include personnel staffing reports, overtime reports, monthly financial reports and
others. All these reports should be available to nurse managers to help them monitor, evaluate,
and adjust the use of people and money as a part of the controlling process.
4. It identifies the most critical elements in the plan, thus focusing management attention .i.e.
most constraining on the schedule.
GANTT CHARTS
Early in this century Henry L. Gantt developed the Gantt Chart as a means of
controlling production. It depicted a series of events essential to the completion of a project or
program . It is usually used for production activities.
Figure shows a modified Gantt chart that could be applied to a manager nursing administration
program or project. The 5 major activities that the nurse administrator has identified are
segments of a total program or project.
It could be applied to a project such as implementing a modality of primary nursing or
implementing case management.
1. Gather data
2. Analyze data
3. Develop a plan
4. Implement the plan.
5. Evaluation, feedback, and modification
Definition
―MBO is a comprehensive managerial system that integrates many key
managerial activities in a systematic manner, consciously directed toward the effective &
efficient achievement of organizational objectives.‖
Objectives of MBO:
1. To measure and judge performance
2. To relate individual performance to organizational goals
3. To clarify both the job to be done and the expectations of accomplishment
4. To foster the increasing competence & growth of these subordinates
5. To enhance communication between superior and subordinates
6. To serve as a basis for judgments about salary and promotion
7. To stimulate the subordinates motivation and
8. To serve as a device for organizational control and integration.
Characteristics of MBO
2. On the other hand, MBO is likely to affect every management technique. MBO
employs several technique but it is not merely the sum total of these techniques. It is a
way of thinking about management.
3. MBO is bound to have some relationship with every management technique. Certain
degree of overlapping is there. In fact often MBO provides the stimulus for the
introduction of new techniques of management & enhances the relevance & utility of
the existing ones.
2. Planning
During action planning, managers decide in the who, what, whom, and how‖ detail
needed to achieve each objective.
Implementing plans
1. To control their performance managers must be allowed to implement plans in their own
way.
2. Element of self control
Reviewing performance
i. Clarity of objectives
ii. Role clarity
iii. Periodic feedback of performance.
iv. Participation by managers in the management process
v. Realization that there is always scope for improvement of performance in every
situation.
2. Clarity in organizational action
3. Personnel satisfaction
4. Basis for organizational change.
Limitations of MBO
5. Inflexibility
6. Frustration
1. Purpose of MBO
4. Participation
6. Other factors:-
i. Implementing MBO at lower levels
ii.MBO & Salary Decision
iii. Conflicting objectives.
VENTURE PLANNING
Venture Planning
It is not about writing a Business Plan. Sometimes a business plan is not needed. Venture
Planning does not require detailed funding, source analysis, professional opinions, entity
formation or detailed market analysis. Venture Planning is development of a means of comparing
various business models, usually through financial modeling to answer the following questions:
Which venture concept produces the most sales, the best margins, the highest net profit
and the lowest breakeven?
Which model requires the least investment by entrepreneurs and others?
Which concept requires equity as opposed to debt financing?
Which produces the highest "Return on Investment" and the best liquidity?
Which model requires the entrepreneur to give up the least
equity? Identify and quantify the risks involved with execution of each
There often occurs a crisis situation in the healthcare set- up when nurses try to defend existing
models of practice instead of embracing change. In order to gain successful planning of good
ventures, we should examine the existing realities (traditional), and analyze and adapt to the
changing context of nursing practice. Some of the traditional realities are;
According to Porter-O‘ Grady (2003), the emerging realities for nursing practice for this century
will be;
The nurse administrator needs to know the plans and programs of the health facility
administrator and of other departments in which personnel contribute to the joint effort of
providing health care services.
Should be a participatory , voting member of all committees of the institution including
those dealing with budgeting, planning, credentialing, auditing, utilization, infection
control, patient care improvement, library or any other committees concerned with
nursing services, nursing activities and nursing personnel.
Should develop a marketing operational plan based on the overall view of the agency
problems and activities.
Marketing plan should include gathering and analysis of data related to product or service
Operational plan consist of pinpointing possible strengths, weaknesses, problems and
opportunities.
Before launching a venture, a control plan is made to measure performance of
implementation of venture within a time frame.
Selected and trained personnel will be assigned to compare expected results with actual
results for making corrections in all elements of plan and its implementation in future.
Change occurs over time, often fluctuating between intervals of change then a time of
settling and stability. Change management entails thoughtful planning and sensitive
implementation, and above all, consultation with, and involvement of, the people affected by the
changes. If you force change on people normally problems arise. Change must be realistic,
achievable and measurable. These aspects are especially relevant to managing personal change.
Definition
A change agent is someone who deliberately tries to bring about a change or innovation,
often associated with facilitating change in an organization or institution. To some degree,
change always involves the exercise of power, politics, and interpersonal influence. It is critical
to understand the existing power structure when change is being contemplated.
A change agent must understand the social, organizational, and political identities and
interests of those involved; must focus on what really matters; assess the agenda of all involved
parties; and plan for action. The change agent should have the following qualities;
Change represents loss. Even if the change is positive, there is a loss of stability. The
leader of change must be sensitive to the loss experienced by others.
The more consistent the change goal is with the individual‘s personal values and beliefs,
the more likely the change is to be accepted. Likewise the more difficult the goal is from
the individual‘s personal values; the more likely it is to be rejected.
Those who actively participate in change process feel accountable for the outcome.
Timing is important in change. With each successive change in a series of changes,
individual‘s psychological adjustment to the change occurs more slowly. And for this
reason the leader of change must avoid initiating too many changes at once.
The key principles driving the elements of the Change Management are:
2. Executive Ownership
Rationale- empirical:
This strategy emphasizes reason and knowledge. People are considered rational beings
and will adopta change if it is justified and in their self- interest. Here the change agent‘s role is
communicating the merit of the change to the group. If the change is understood by the group to
be justified and in the best interest of the organization, it is likely to be accepted. This strategy is
useful when little resistance to change is expected. It is assumed that once if the knowledge and
rationales are given, people will internalize the need for change and value the result.
Normative- re-educative:
This is based on the assumption that group norms are used to socialize individuals. The
success of this approach often requires a change in attitude, values, and/ or relationships. This
strategy is most used when the change is based on culture and relationships within the
organization. The power of the change agent, both positional and informal, becomes integral to
the change process.
Power- coercive:
This approach is based on power, authority, and control. Desired change is brought about
by political or economic power. It requires that the change agent have the positional power to
mandate the change. The outcome of change is often based either on follower‘s desire to please
the leader or fear of the consequences for not complying with the change. This strategy is
effective for legislated changes, but other changes using this strategy are often short- lived.
Change requires movement, which as physics indicates, is a kinetic activity that that
requires energy to overcome resistance.
Barrier Discussion Strategy
Lack of shared vision Lack of widespread involvement, input, and Normative- re-
ownership of change will cripple a change educative strategy
effort.
Lack of trust Trust in the change agent and ability of self to Rational- empirical
bring about change is necessary. and normative- re-
educative strategies
Poor timing or Poor timing and lack of planning can fail to Introducing change
inadequate time bring desired change. at a time when
planned people are ready to
change guarantees
success
Fear that power, Every change represents potential for loss to Normative- re-
relationships, or someone. educative strategy
control will be lost
Amount of personal Sometimes change is desired, but people are not Slow the change
energy needed for willing to do what is necessary to effect the process and give
change may be great change. time to catch- up and
energize
Types of changes
Hohn (1998) identified four different types of change: Change by exception, Incremental
Change, Pendulum Change and Paradigm Change.
Change theories are used in nursing to bring about planned change. Planned change
involves, recognizing a problem and creating a plan to address it. There are various change
theories that can be applied to change projects in nursing. Choosing the right change theory is
important as all change theories do not fit every change project. Some change theories used in
nursing are Lewin‘s, Lippitt‘s, and Havelock‘s theories of change. The characteristics of change
theories are;
Problem identification
Plan for innovation
Strategies to reduce innovation
Evaluation plan
The theoretical foundations of change theory are robust: several theories now exist, many
coming from the disciplines of sociology, psychology, education, and organizational
management. Kurt Lewin (1890 – 1947) has been acknowledged as the ―father of social change
theories‖ and presents a simple yet powerful model to begin the study of change theory and
processes. He is also lauded as the originator of social psychology, action research, as well as
organizational development.
"Unfreezing" involves finding a method of making it possible for people to let go of an old
pattern that was counterproductive in some way. In this stage, the need for change is recognized,
the process of creating awareness for change is begun and acceptance of the proposed change is
developed
"Moving to a new level" involves a process of change--in thoughts, feelings, behavior, or all
three, that is in some way more liberating or more productive. The need for change is accepted
and implemented in this stage.
"Refreezing" is establishing the change as a new habit, so that it now becomes the "standard
operating procedure." Without some process of refreezing, it is easy to backslide into the old
ways.The new change is made permanent here.
Lewin also created a model called ―force field analysis‖ which offers direction for
diagnosing situations and managing change within organizations and communities.
According to Lewin‘s theories, human behavior is caused by forces – beliefs, expectations,
cultural norms, and the like – within the "life space" of an individual or society.
These forces can be positive, urging us toward a behavior, or negative, propelling us away from
a behavior.
―Driving Forces‖- Driving forces are those forces affecting a situation that are pushing in
a particular direction; they tend to initiate a change and keep it going. In terms of improving
productivity in a work group, pressure from a supervisor, incentive earnings, and competition
may be examples of driving forces.
―Restraining Forces‖- Restraining forces are forces acting to restrain or decrease the
driving forces. Apathy, hostility, and poor maintenance of equipment may be examples of
restraining forces against increased production.
Lippitt‟s theory is based on bringing in an external change agent to put a plan in place
to effect change. There are seven stages in this theory. The first three stages correspond to
Lewin's unfreezing stage, the next two to his moving stage and the final two to his freezing
change. In this theory, there is a lot of focus on the change agent. The third stage assesses the
change agent‘s stamina, commitment to change and power to make change happen. The fifth
stage describes what the change agent‘s role will be so that it is understood by all the parties
involved and everyone will know what to expect from him. At the last stage, the change agent
separates himself from the change project. By this time, the change has become permanent.
The seven phases shift the change process to include the role of a change agent through the
evolution of the change.
• Phase 3:Assess the resources and motivation of the change agent(commitment the
change, power, and stamina)
• Phase 5: Ensure the role and responsibility of the change agent is clear and understood
(communicator, facilitator, and subject matter expert.
• Phase 6:Maintain the change through communication, feedback, and group coordination
• Phase 7:Gradually remove the change agent from the relationship, as the change becomes
part of an organizational culture.
Havelock's change theory has six stages and is a modification of the Lewin's theory of
change. The six stages are building a relationship, diagnosing the problem, gathering resources,
choosing the solution, gaining acceptance and self renewal. In this theory, there is a lot of
information gathering in the initial stages of change during which staff nurses may realize the
need for change and be willing to accept any changes that are implemented. The first three stages
are described by Lewin's unfreezing stage the next two by his moving stage and the last by the
freezing stage.
John Kotter's highly regarded books 'Leading Change' (1995) and the follow-up 'The
Heart Of Change' (2002) describes a helpful model for understanding and managing change.
Each stage acknowledges a key principle identified by Kotter relating to people's response and
approach to change, in which people see, feel and then change: Kotter's eight step change model
can be summarized as:
Increase urgency - inspire people to move, make objectives real and relevant.
Build the guiding team - get the right people in place with the right emotional
commitment, and the right mix of skills and levels.
Get the vision right - get the team to establish a simple vision and strategy focus on
emotional and creative aspects necessary to drive service and efficiency.
Communicate for buy-in - Involve as many people as possible, communicate the
essentials, simply, and to appeal and respond to people's needs. De-clutter
communications - make technology work for you rather than against.
Empower action - Remove obstacles, enable constructive feedback and lots of support
from leaders - reward and recognize progress and achievements.
Create short-term wins - Set aims that are easy to achieve - in bite-size chunks.
Manageable numbers of initiatives. Finish current stages before starting new ones.
Don't let up - Foster and encourage determination and persistence - ongoing change -
encourage ongoing progress reporting - highlight achieved and future milestones.
Make change stick - Reinforce the value of successful change via recruitment,
promotion, and new change leaders. Weave change into culture.
Identify ―change agents‖ and engage people at all levels in the organization.
Ensure the message comes from the top, and executives and line managers are
―walking the talk.‖
Help management avoid attempts to short circuit the change management process.
Foster change in people‘s attitudes first, then focus on change in processes, then
change in the formal structure.
Manage both supporters and champions, as well opponents and possible detractors.
Accept that all people go through the same steps – some faster, some slower – and it
is not possible to skip steps.
Build a safe environment that enables people to express feelings, acknowledge fears,
and use support systems.
Fail to provide visible support and reinforce the change with other managers.
Do not take the time to understand how current business processes would be affected by
change.
Delayed decision-making, which leads to low morale and slow project progress.
Are not directly or actively involved with change project.
Fail to anticipate the impact on employees.
Underestimate the time and resources needed
Abdicate ownership of the project to another manager.
Fail to communicate both the business reasons for the change and the expected
outcome to employees and other managers
Change the project direction mid-stream
Do not set clear boundaries and objectives for the project
Organizational ageing
The organization has to undergo progress through certain developmental stages within the
organizational structure termed organizational ageing. The young organization is characterized
by high energy, movement and constant change and adaptation; while the aged organizations will
have established ‗turf boundaries functioning in an orderly and predictable fashion, and are
focused on rules and regulations. In any type of ageing, organizations must find a balance
between chaos and stagnation. Some areas that undergo restructuring during an organizational
ageing are;
• leadership changes
• organizational restructuring
• outsourcing and offshoring
• new technologies and tools
• new competitors and markets
INNOVATIONS IN NURSING
Introduction
Change is a natural social process of individuals, groups, organizations and society. The
source of change originates inside and outside health care organizations. Change today is
constant, inevitable, pervasive and unpredictable, and varies in rate and intensity, which
unavoidably influences individuals, technology and systems at all levels of the organization.
A constant flow of new ideas is needed to procure new products, services, processes,
procedures and strategies for dealing with the change occurring in every sphere of endeavour:
technology social system, government and everyday living. Innovation is the key to survival and
growth of health care and nursing.
Change, innovation and creativity are comparison terms but can also be differentiated.
Changes occur when the system is disrupts; innovation uses changes to create new and different
approaches to resolve an issue and develop new products or procedures. (Huber 1996).
Process of Innovation
The process of the innovation may include several steps. They are:
Assessment
It is the first step of process and it requires a look at both the strength and
problems. An administrator must focus on what is specific content requirement the
expected outcome. Specific content requirement changes often in the health care, as new
technologies and research bring new knowledge needs.
Defining objectives
It is the second step. The administrator should search for research or technique
that could address the identical needs. Asking the peers for the suggestion is also helpful.
This is the place where the creativity begins. It is important to look at many different
ways to address the learning objectives before selecting one.
Planning
Once a strategy has been selected the third step, planning is important.
Understand who the stakeholders are and what their investment is in the status quo or in
change can be helpful in planning the strategies to bring them on board. Many stake
holders do not like the changes and will resist the new approaches. Using the change
theory it can assist in demonstrating the needs and provide information that can make
resistors more amenable to change. It‘s important to take time to develop a support for
the strategy. In more complex strategies it may be important to bring other
administrators.
Theories
Planned change using linear approaches
Theories for planned change
Key idea: Change can be planned, implemented and evaluated in six sequential stages. The
model is advocated for development of effective change agents and use as a rational problem
solving process. The six stages are:-
1. Building a relationship
2. Diagnosing the problem
3. Acquiring relevant resources
4. Choosing the solution
5. Gaining acceptance
6. Stabilizing the innovation and generating self renewal
Lippitt, Watson and westly (1958) are credited with this planned change model
Key idea: change can be planned, implemented and evaluated in seven sequential phases.
Ongoing sensitivity to forces in the change process is essential. The seven phases are:
1. The client system become aware of the need for the change
2. The relationship is developed between the client system and change
3. The change problem is defined
4. The change goal are set and options for achievements are explored
5. The plan for the change is implemented
6. The change is accepted and stabilized
7. The change entities redefine their relationship
Key idea: Change for an individual occurs over five phases when choosing to accept or reject an
innovation/idea. Decision is to not accept the new idea may occur at any five stages. The change
agent can promote acceptance by giving information about benefits and disadvantages and
encouragement. The five stages are:
1. Knowledge
2. Persuasion
3. Decision
4. Implementation and
5. Confirmation
Application to practice: Useful for individual change.
Nonlinear change
Chaos theory
Organization can no longer rely on rules, policies, and hierarchies to get work
accomplished in flexible ways. According to the chaos theory perspectives because of rapidly
changing nature of human and world factors health organizations cannot control long term
outcomes. The assertion of chaos theory are that ‗organization are potentially chaotic‘(thietat
and Forgues, 1995). In other words, ‗order emerges through fluctuations and chaos‘.
Organization will experience periods of stability interrupted with periods of intense
transformation.
The human side of the managing change refers to staff responses to change that either
facilitate or interfere with change process. Responses to all or part of the change process by
individuals and group may vary from full acceptance and willing participation to open rejection.
Responses may be categorized behaviourally or emotionally. Some nurses may manifest their
dissatisfaction visibly; others may quietly accommodate the change. Some individuals
consistently reject any new thinking or way of doing things. The initial response to change may
be, but not always, reluctance and resistance. Resistance and reluctance are common when the
change threaten the personal security. Eg: -Changes in the structure of an agency can result in
changes of position for personnel.
The change agent‘s recognition of the ideal and common patterns of the individuals
behaviour responses to change can facilitate an effective change process (Rogers 1983).
*****
Unit IV
ORGANISATION Concept , principles, objectives, Types and theories,
MinimUM reqUIrements for organisation,
Developing an organizational StrUCtURe, levels,
organizational Effectiveness and organizational
Climate,
Organizing NURsing services and patient care:
Methods of patient
assignment- Advantages and disadvantages,
primary NURsing care,
Planning and Organizing: hospital, UNIT and
ancillary services(specifically central sterile sUPPLY
department, LAUndry, kitchen, laboratory services,
emergency etc)
Disaster management: plan, resoURces, drill, etc
Application to NURsing service and eDUCation
ORGANIZATION
Definition
• An organization may be defined as a formally constituted group of people who
have identified tasks and who work together to achieve a specific purpose defined
by the organization.
-J D Mooney
- Pfiffiner.
- Luther Gullick
-Chester I Bernard.
Nature of organization
• P- Purposes
• P- Process
• P- Place setting
Importance of organization
It ensures an optimum use of human efforts through specialization and also make use
of all resources , determines needs for innovative and new technologies in terms of cost
effectiveness and accomplish objectives.
Principles of organization
According to Ms. T.K.Adranvala
• Division of labor
• Hierarchy of authority
• System for co-ordination and control
• Span of control – it depends on ,
-Unity of objectives
-Division of work &specialization
-Job description
-Unity of command
-Principle of adequate authority
-Span of supervision
According to BT Basavanthappa
There are six principles of organization as follows:
1. Hierarchy
2. Span of control
3. Integration vs. disintegration
4. Centralization vs. decentralization
5. Unity of command
6. Delegation
According to Russell C. Swansburg & Richard J. Swansburg
Principle of
specialization Theories of
organization Definition :
Organizational theory (OT) is the study of organizations for the benefit of
identifying common themes for the purpose of solving problems, maximizing
efficiency and productivity, and meeting he needs of stakeholders
c) Administrative theory
2) Neoclassical theory
3) Modern theories
b) Socio-technical approach
4) Individual processes:
a) Motivational theory
b) Role theory
c) Personality theory
Weber (1947) based the concept of the formal organization on the following principles:
C) Administrative theory
The elements of administrative theory (Henri Fayol, 1949) relate to accomplishment of tasks,
and include
Principles of management,
The concept of line and staff,
Committees and
Functions of management.
i) Principles of management
• Division of work
• Authority and responsibility
• Discipline
• Unity of command
• Unity of direction:
• Subordination of individual interest to general interest
• Remuneration of personnel
• Centralization
• Scalar chain
• Order
• Equity
• Stability of tenure of personnel
• Initiative
• Esprit de corps
c) Committees :
• Committees are part of the organization.
• Members from the same or different hierarchical levels from different departments can
form committees around a common goal.
• They can be given different functions, such as managerial, decision
making, recommending or policy formulation.
• Committees can take diverse forms, such as boards, commissions, task groups or ad hoc
committees.
• Committees can be further divided according to their functions.
• For e.g. In agricultural research organizations, committees are formed for research,
staff evaluation or even allocation of land for experiments
d) Functions of management
• Fayol (1949) considered management as a set of ,
• Productivity increases as a result of high morale, which was influenced by the amount
of individual, personal and intimate attention workers received.
• The individual :An individual is not a mechanical tool but a distinct social being, with
aspirations beyond mere fulfillment of a few economic and security works. Individuals
differ from each other in pursuing these desires. Thus, an individual should be
recognized as interacting with social and economic factors.
• The work group: The neoclassical approach highlighted the social facets of work
groups or informal organizations that operate within a formal organization. The
concept of 'group' and its synergistic benefits were considered important.
3) Modern theories
• It is based on the concept that the organization is a system which has to adapt to changes
in its environment.
1. A systems viewpoint
2. A dynamic process of interaction
3. Multileveled and Multidimensional
4. Multi motivated
5. Probabilistic
6. Multidisciplinary
7. Descriptive
8. Multivariable
9. Adaptive
a) The Systems Approach:
The organization consists of the following three basic elements (Bakke, 1959):
(i) Components :
· the individual,
· the formal and informal organization,
· patterns of behavior emerging from role demands of the organization,
· role comprehension of the individual, and
· the physical environment in which individuals work.
• Communication:
Is a means for eliciting action, exerting control and effecting coordination to link decision
centers in the system in a composite form.
• Balance :
Is the equilibrium between different parts of the system so that they keep a harmoniously
structured relationship with one another.
• Decision analysis:
Decision to produce depends upon the attitude of the individual and the demands of the
organization.
b) Socio-technical approach
• People (the social system) use tools, techniques and knowledge (the technical system) to
produce goods or services valued by consumers or users (who are part of the
organization's external environment).
• Therefore, an equilibrium among the social system, the technical system and
the environment is necessary to make the organization more effective.
• The situational approach is based on the belief that there cannot be universal guidelines
which are suitable for all situations.
4) Individual Processes
a) Motivational Theory
• When a person enters into a contract with an organization some calculation will be
made in regards to the individual‘s ―E‖ put forth.
• Organizations also put forth an ―E‖, either by resources alone (salary), or by other items
such as prestige and stature. This exchange sets the limits of a physical and
―psychological contract‖ between the organization and the person
• Management must carefully consider how to maintain or adjust the psychological
contract in order to keep the person a productive member of the team.
c) Role Theory
Organizations need to acknowledge that its employees manage many roles and that
problems or conflicts can arise and create tensions that can change the ability of the
individual to reach their goals.
Organizations should be sure to support their team members in meeting new roles by
giving time for transition, or offering training and support.
When role conflict arises the organization can nurture employee‘s ability to relieve
tension by allowing time to devote to caring for roles outside the office.
d) Personality Theory
• Personality is the unique and enduring traits, behaviors and emotional characteristics in
an individual.
• Type A personalities are competitive, impatient, seekers of efficiency and always seem to
be in a hurry.
• Type B personalities are laid back and possess more patience and emotional stability,
but tend to be less competitive.
• In a work environment Type A‘s tend to be more productive in the short term and pursue
more challenging work. However, they also have a greater tendency towards health risks
and are less likely than Type B‘s to be in top executive positions.
• Organizations can play a role in developing their staff for success. Workshops, seminars,
even book clubs that focus on developing EQ an strengthen organizational success.
• Allowing for a diverse set of experiences, with appropriate support can maximize and
expand the capabilities of each employee.
Minimum requirements for organization
Clarity:
-Where they stand in relation to the quality and quantity of their performances
Economy:
• Nurses need as much self-control of their work as they can possibly be given.
Direction of vision-
• Nurse managers must direct their vision and that of their employees
-toward performance,
- toward strength.
Decision making-
• Nurses should be organized to make decisions on the right issues and at the right levels.
• They should be organized to convert their decisions into work and accomplishments.
• They can adapt to show objectives requiring changes in their functions and productivity.
• The organizational structure should produce continuous learning for the job each
nurse holds and for promotion.
TYPES OF ORGANIZATIONAL STRUCTURE
1) Tall or Centralized Structure.
3) Matrix Structure.
4) Adhocracy Structure.
5) Shared Governance.
• A Tall organization is named so because a chart of its relationship appears tall and
narrow.
• It is also called Centralized, because most of the decision making authority and power
is held by few persons in central positions.
e.g. In an acute care hospital, the nursing position would be that of the chief nursing
officer, with 2 or 3 assistants.
ADVANTAGES DISADVANTAGES
Implementation of
decisions may
excessively delay.
• The chart of relationships shows few levels and a broad span of control.
• Decision making is commonly spread out among many people and those closest to the
situation are given wide latitude in determining appropriate actions.
ADVANTAGES DISADVANTAGES
Matrix Structure
• These structures are most often found in very large, multifaceted organizations.
ADVANTAGES DISADVANTAGES
Adhocracy Structure
This type of structure uses teams of specialists who are organized to complete
a particular project or task.
Shared Governance
• It represents a professional practice model in which the nursing staff and nursing
management are both involved in making decisions as opposed to having the decisions
made at an administrative level only.
• Disadvantages:
ORGANIZATIONAL EFFECTIVENESS
• Nurse Managers define the goals and provide the resources for both the organizational
effectiveness and organizational performance.
For e.g-
• Community relationships.
• Organizational
• The organization is effective or productive when the people are performing care
that meets client‘s needs and for which employees have a sense of accomplishment.
An organization can be shaped through:
Making the structure more manageable. Increasing clinical nurses autonomy reduces
the organization's size.
Decentralization.
ORGANIZATIONAL CLIMATE
• It is the emotional state and the perceptions and feelings shared by members of the
system.
Organizational climate, defined differently by many researchers and scholars, generally refers to
the degree to which an organization focuses on and emphasizes:
• Innovation
• Flexibility
• Leadership
• It includes
-Room attractiveness
-Illumine
-Job satisfaction
-High salaries
-Career development experiences that will help them to determine and direct their
professional futures.
Hellriegel and Slocum (2006) explain that organizations can take steps to build a more positive
and employee-centered climate through:
• Communication – How often and the types of means by which information is
communicated in the organization
• Values – The guiding principles of the organization and whether or not they are
modeled by all employees, including leaders
• Norms – The normal, routine ways of behaving and treating one another in the
organization
• Policies and rules - These convey the degree of flexibility and restriction in
the organization
• Nurse Managers should establish a management strategy to support new nurses and
involve them in decision making.
• Nurse Managers should establish a climate in which discipline is applied fairly and
uniformly.
• Establishing trust and openness through communication that includes prompt and
frequent feedback and stimulates motivation.
• Providing opportunities for growth and development, including career development and
continuing education programs.
• Marketing the nursing organization to the practicing nurses, other employees and
the public.
• Analyzing the compensation system for the entire organization and structuring it
to reward competence, productivity and longevity.
• Promoting self esteem, autonomy, and self fulfillment for practicing nurses including
feelings that their work experiences are of high quality.
• Providing job security with an environment that enables free expression of ideas and
exchange of opinions.
• Helping practicing nurses to overcome their short comings and to develop their strengths.
INTRODUCTION
―A hospital may be soundly organized, beautifully situated and well equipped, but if the
nursing care is not of high quality the hospital will fail in its responsibility.‖
ORGANIZING NURSING SERVICES
Meaning of nursing service and nursing service administration
Nursing Service
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.
Nursing service administration
Nursing service administration is a complex of elements in interaction and is organized to
achieve the excellence in nursing care services. It results in output of clients whose health is
unavoidably deteriorating, maintained or improved through input of personnel and material
resources used in a process of nursing services.
Plan of organization:
Every hospital has the basic system of coordination of vast number of activities
i.e. the Director of Nursing service, she is responsible for maintaining standards for
patient care in terms of quality nursing service must be familiar with the formal
organizational structure of the hospital and its relationship in various department and
their functions. The plan of organization should indicate inter as well as intra-department
relationship. The plan also should indicate area of responsibility and to whom and for
whom each person is accountable and the channels of communication.
Policy and administrative manuals:
The policy and procedure manual are required for the operation of the hospital.
Policies are established within the department to guide the nursing staff, which includes
duty hrs, rules and regulations etc. These are periodically revised and reviewed at regular
intervals.
Personnel records:
Personnel records include the information relating to the individual such as
recruitment and selection, medical records, training and development, transfer records,
promotion, disciplinary action records, performance records, absenteeism data, leave
record and salary records, etc.
Personnel policies:
It reflects an analysis of the total job of nursing in accordance with the types of
functions to be performed. It also indicates the qualitative and quantity of service to be
maintained and the purpose for which the hospital exist.
Health services:
Supervision of health of each employee by means of pre-employment physical
examination, periodic examination, immunization and provision of diagnostic, preventive
and therapeutic measures. The education of employee in the principle of health and
hygiene so that they may develop healthy habit of living and working.
In-service education:
It is the essential components of staff development programme, which aims at
augmenting, reinforcing nurse‘s knowledge, skill and attitude. It includes orientation
programme, skill training, leadership and management training, on the job training, staff
development.
Co-ordination:
Regular consultation and discussion between the heads of departments and with
members of the medical staff could be an integral part of the administration.
Advisory committee:
Each committee has a clear statement and its membership is appropriate to the
purpose. After carefully weighing the advice of the committee, she makes the final
decision about the matter within her area of responsibility and becomes accountable for
implementation.
Eating Feeds self Needs some help in Cannot feed self but is Cannot feed self
preparing able to chew and any may have
swallowing difficulty
swallowing
Comfort Self Needs some help with Cannot turn without Completely
sufficient adjusting position/ bed.. help, get drink, adjust dependent
position of extremities
…
Treatment Simple – Any Treatment more Any treatment more Any elaborate/
supervised, than once per shift, than twice /shift… delicate procedure
simple foley catheter care, requiring two
dressing… I&O…. nurses, vital signs
more often than
every two hours..
CASE METHOD
Features:
It was the first type of nursing care delivery system. In this method, nurses assume total
responsibility for meeting all the needs of assigned patients during their time on duty. It involves
assignment of one or more clients to a nurse for a specific period of time such as shift. The
patient has a different nurse each shift and no guarantee of having the same nurses the next day.
Nurse‘s responsibility includes complete care including treatments, medication and
administration and planning of nursing care. This is the way most nursing students were taught –
take one patient and care for all of their needs. This model is used in critical care areas, labor and
delivery, or any area where one nurse cares for one patient‘s total needs. Here nurses were self-
employed when the case method came into being, because they were primarily practicing in
homes. It lost much of that autonomy when healthcare became institutionalized in hospitals and
clinics and now called as private duty nursing.
Merits:
♣ The nurse can attend to the total needs of clients due to the adequate time and proximity
of the interactions.
♣ Good client nurse interaction and rapport can be developed.
♣ Client may feel more secure.
♣ RNs were self-employed.
♣ Work load can be equally divided by the staff.
♣ Nurse‘s accountability for their function is built-it.
♣ It is used in critical care settings where one nurse provides total care to a small group of
critically ill patients.
Demerits:
♠ Cost-effectiveness.
♠ The greater disadvantage to case nursing occurs, when the nurse is inadequately trained
or prepared to provide total care to the patient.
♠ Nurse may feel overworked if most of her assigned patients are sick.
♠ She/he may tend to ‗neglect‘ the needs of patient when the other patients ‗problem‘ or
‗need‘ demands more time.
FUNCTIONAL NURSING
Features:
This system emerged in 1930s in U.S.A during WWII when there was a severe shortage
of nurses in US. A number of Licensed Practice Nurses (LPNs) and nurse aides were employed
to compensate for less number of registered nurses (RNs) who demanded increased salaries. It is
task focused, not patient-focused. In this model, the tasks are divided with one nurse assuming
responsibility for specific tasks. For example, one nurse does the hygiene and dressing changes,
whereas another nurse assumes responsibility for medication administration. Typically a lead
nurse responsible for a specific shift assigns available nursing staff members according to their
qualifications, their particular abilities, and tasks to be completed.
Charge Nurse
RN UAP
Medication Nurse RN LPN Hygiene Nurse
Treatment Nurse Vital signs Nurse
Demerits:
♠Client care may become impersonal, compartmentalized and fragmented.
♠Continuity of care may not be possible.
♠Staff may become bored and have little motivation to develop self and others.
♠The staff members are accountable for the task.
♠Client may feel insecure.
♠Only parts of the nursing care plan are known to personnel.
♠Patients get confused as so many nurses attend to them, e.g. head nurse, medicine nurse,
dressing nurse, temperature nurse, etc.
TEAM NURSING
Features:
Developed in 1950s because the functional method received criticism, a new system of
nursing was devised to improve patient satisfaction. Care through others became the hallmark of
team nursing. Team nursing is based on philosophy in which groups of professional and non-
professional personnel work together to identify, plan, implement and evaluate comprehensive
client-centered care. In team nursing an RN leads a team composed of other RNs, LPNs or LVNs
and nurse assistants or technicians. The team members provide direct patient care to group of
patients, under the direction of the RN team leader in coordinated effort. The charge nurse
delegates authority to a team leader who must be a professional nurse. This nurse leads the team
usually of 4 to 6 members in the care of between 15 and 25 patients. The team leader assigns
tasks, schedules care, and instructs team members in details of care. A conference is held at the
beginning and end of each shift to allow team members to exchange information and the team
leader to make changes in the nursing care plan for any patient. The team leader also provides
care requiring complex nursing skills and assists the team in evaluating the effectiveness of their
care.
Charge Nurse RN
RN LPN NA RN LPN NA
Advantages:
♣ High quality comprehensive care can be provided to the patient
♣ Each member of the team is able to participate in decision making and problem solving.
♣ Each team member is able to contribute his or her own special expertise or skills in caring
for the patient.
♣ Improved patient satisfaction.
♣ Feeling of participation and belonging are facilitated with team members.
♣ Work load can be balanced and shared.
♣ Division of labour allows members the opportunity to develop leadership skills.
♣ There is a variety in the daily assignment.
♣ Nursing care hours are usually cost effective.
♣ The client is able to identify personnel who are responsible for his care.
♣ Barriers between professional and non-professional workers can be minimized, the group
efforts prevail.
Disadvantages:
♠ Establishing a team concept takes time, effort and constancy of personnel. Merely
assigning people to a group does not make them a ‗group‘ or ‗team‘.
♠ Unstable staffing pattern make team nursing difficult.
♠ All personnel must be client centered.
♠ There is less individual responsibility and independence regarding nursing functions.
♠ The team leader may not have the leadership skills required to effectively direct the team
and create a ―team spirit‖.
♠ It is expensive because of the increased number of personnel needed.
♠ Nurses are not always assigned to the same patients each day, which causes lack of
continuity of care.
♠ Task orientation of the model leads to fragmentation of patient care and the lack of time
the team leader spends with patients.
MODULAR NURSING
Features:
Modular nursing is a modification of team nursing and focuses on the patient‘s
geographic location for staff assignments. The concept of modular nursing calls for a smaller
group of staff providing care for a smaller group of patients. The goal is to increase the
involvement of the RN in planning and coordinating care. The patient unit is divided into
modules or districts, and the same team of caregivers is assigned consistently to the same
geographic location. Each location, or module, has an RN assigned as the team leader, and the
other team members may include LVN/LPN or UAP. The team leader is accountable for all
patient care and is responsible for providing leadership for team members and creating a
cooperative work environment. The success of the modular nursing depends greatly on the
leadership abilities of the team leader.
Merits:
♣ Nursing care hours are usually cost-effective.
♣ The client is able to identify personnel who are responsible for his care.
♣ All care is directed by a registered nurse.
♣ Continuity of care is improved when staff members are consistently assigned to the same
module
♣ The RN as team leader is able to be more involved in planning & coordinating care.
♣ Geographic closeness and more efficient communication save staff time.
♣ Feelings of participation and belonging are facilitated with team members.
♣ Work load can be balanced and shared.
♣ Division of labor allows members the opportunity to develop leadership skills
♣ Continuity care is facilitated especially if teams are constant.
♣ Everyone has the opportunity to contribute to the care plan.
Demerits:
♠ Costs may be increased to stock each module with the necessary patient care supplies
(medication cart, linens and dressings).
♠ Establishing the team concepts takes time, effort, and constancy of personnel.
♠ Unstable staffing pattern make team difficult.
♠ There is less individual responsibility and autonomy regarding nursing function.
♠ All personnel must be client centered.
♠ The team leader must have complex skills and knowledge.
PROGRESSIVE PATIENT CARE:
Features:
It is a method in which client care areas provide various levels of care. The central theme
is better utilization of facilities, services and personnel for the better patient care. Here the clients
are evaluated with respect to all level (intensity) of care needed. As they progress towards
increased self care (as they become less ethically ill or in need of intensive care or monitoring)
they are marred to units/ wards staffed to best provide the type of care needed.
Principal elements of PPC are:
i) Intensive care or critical care: Patients who require close monitoring and intensive care
round the clock, e.g. patients with acute MI, fatal dysarythmias, those who need artificial
ventilation, major burns, premature neonates, immediate post or cardiothoracic, renal transplant,
neurosurgery patients. These units have 9-15 numbers of beds, life-saving equipment and skilled
personnel for assessment, revival, restoration and maintenance of vital functions of acutely ill
patients. Nursing approach in these units is patient-centered.
ii) Intermediate care: Critically ill patients are shifted to intermediate care units when their vital
signs and general condition stabilizes, e.g. cardiac care ward, chest ward, renal ward.
iii) Convalescent and Self Care: Although rehabilitation programme begins from acute care
setting, yet patients in these areas participate actively to achieve complete or partial self-care
status. Patients are taught administration of drugs, life style modification, exercises, ambulation,
self-administration of insulin, checking pulse, blood glucose and dietary management.
iv) Long-term care: Chronically ill, disabled and helpless patients are cared for in these units.
Nurses and other therapists help the patients and family members in coping, ambulation, physical
therapy, occupational therapy along with activities of daily living. Patients and family who need
long-term care are, cancer patients, paralyzed and patients with ostomies.
v) Home care: Some hospital/centers have home care services. A hospital based home care
package provides staff, equipment and supplies for care of patient at home, e.g. paralyzed
patients, post-operative, mentally retarded/spastic patient and patient on long chemotherapy.
vi) Ambulatory care: Ambulatory patients visit hospital for follow up, diagnostic, curative
rehabilitative and preventive services. These areas are outpatient departments, clinics, diagnostic
centers, day care centers etc.
Merits:
♣ Efficient use is made of personnel and equipment.
♣ Clients are in the best place to receive the care they require.
♣ Use of nursing skills and expertise are maximized.
♣ Clients are moved towards self care, independence is fostered where indicated.
♣ Efficient use and placement of equipment is possible.
♣ Personnel have greater probability to function towards their fullest capacity.
Demerits:
♣ There may be discomfort to clients who are moved often.
♣ Continuity care is difficult.
♣ Long term nurse/client relationships are difficult to arrange.
♣ Great emphasis is placed on comprehensive, written care plan.
♣ There is often times difficulty in meeting administrative need of the organization, staffing
evaluation and accreditation.
Advantages:
♣ Primary Nursing Care System is good for long-term care, rehabilitation units, nursing
clinics, geriatric, psychiatric, burn care settings where patients and family members can
establish good rapport with the primary nurse.
♣ Primary nurses are in a position to care for the entire person-physically, emotionally,
socially and spiritually.
♣ High patient and family satisfaction
♣ Promotes RN responsibility, authority, autonomy, accountability and courage.
♣ Patient-centered care that is comprehensive, individualized, and coordinated; and the
professional satisfaction of the nurse.
♣ Increases coordination and continuity of care.
Disadvantages:
♠ More nurses are required for this method of care delivery and it is more expensive than
other methods.
♠ Level of expertise and commitment may vary from nurse to nurse which may affect
quality of patient care.
♠ Associate nurse may find it difficult to follow the plans made by another if there is
disagreement or when patient‘s condition changes.
♠ It may be cost-effective especially in specialized units such as the ICU.
♠ May create conflict between primary and associate nurses.
♠ Stress of round the clock responsibility.
♠ Difficult hiring all RN staff
♠ Confines nurse‘s talent to his/her own patients.
CASE MANAGEMENT
Features:
The case manager (RN or social worker with managerial qualification) is assigned
responsibility of following a patient‘s care and progress from the diagnostic phase through
hospitalization, rehabilitation and back to home care. For eg; case manager for cardiac surgery
patients assists them go through diagnostic procedures, pre-operative preparations, surgical
interventions, family counseling, post-operative care and rehabilitation.
Case management involves critical paths, variation analysis; inter shift reports, case
consultation, health care team meetings, and quality assurance. Critical paths visualize outcomes
within a time frame. Variation analysis notes positive or negative changes from the critical paths,
the cause, and the corrective action taken. Case consultation may be indicated when the client‘s
condition differs from the critical path as noted in the inter shift report. Case consultation is
conducted about once a week for a few minutes immediately after inter shift report to deal with
variations.
Health care team meetings provide an interdisciplinary approach to problem solving. The
case manager needs to identify no more than three priority goals and decide what team members
should be present after considering the patient, family physician, social service, various
therapists, and others involved. The case manager should set the time and place for the meeting,
make the arrangements, and post the date, time, place, and people to attend. The case manager
calls the meeting to order, states the goals, initiates discussion, documents the plans, and sets
time limits for follow through. The variance between what is expected and what happened is
assessed for quality assurance.
Responsibilities of case managers:
♥ Assessing clients and their homes and communities.
♥ Coordinating and planning client care.
♥ Collaborating with other health professionals in the provision of care.
♥ Monitoring client progress and client outcomes.
♥ Advocating for clients moving through the services needed.
♥ Serving as a liaison with third party payers in planning the client‘s care.
Merits:
♣ Case management provides a well coordinated care experience that can improve the care
outcome, decrease the length of stay, and use multiple disciplines and services efficiently.
♣ Provides comprehensive care for those with complex health problems.
♣ It seeks the active involvement of the patient, family and diverse health care professionals
Demerits:
♠ Nurses identify major obstacles in the implementation of this service, financial barriers
and lack of administrative support.
♠ Expensive
♠ Nurse is client focused and outcome oriented
♠ Facilitates and promotes co-ordination of cost effective care
♠ Nursing case management is a professionally autonomous role that requires expert
clinical knowledge and decision making skills.
ii. Support groups: once the idea is developed, the entrepreneur, discuss project, and then
finds support groups to join hands and complete the project.
iii. Temporary organization and securing funds: a group should be formalized called as a
hospital trust, which must be registered under the society‘s act or companies act. The
originator is the chairman and others are members who are assigned different tasks.
A detailed work out as to how much capital will be required for establishing the hospital.
v. Hospital design:
Bed planning: it should be realized that the hospitals are not only utilized by the
population in the vicinity but also will constitute the indirect population in the larger
catchment area. About 85% bed occupancy is considered optimum.
Hospital size: as a very large hospital of 1000 beds or more becomes extremely unwidely
to operate, and a small hospital of 50 or less are not profitable. From functional efficiency
point of view, it is advisable to plan two separate hospitals of 400 beds, each with a scope
of future expansion, rather than a single one of 800 beds.
Land requirements: in rural and semi-urban areas, plentiful land may be available
permitting the hospital to grow horizontally, whereas in urban areas there will always be
great premium on land and only avenue will be a vertical growth.
Public utilities: the national building code of ISI suggests 455 liters of water per
consumer per day (LPCD) for hospitals up to 100 beds and 340 LPCD for hospitals of
100 beds and over.
Additional availability of water in case, staff quarters and nurse‘s hostel are a part of
hospital campus. The hospital sewage disposal is connected to the public sewage disposal
system, otherwise it needs to build and operate its own sewage disposal plant.
It is preferable that power supply should be available on a multi-grid instead of uni-grid
system in general use, to ensure a continuous supply of electricity to hospital at all times.
Electricity requirement is 1 KW per bed per day2.
Approval of plan by the local authorities: once the detailed plan has been formulated,
the local bodies are consulted and persuaded for approval of plans.
vi. Circulation routes: the utility and success of hospital plans depend on the circulation
routes on hospital site and within building. there are two types of circulation in the
hospital :-
Internal circulation: the circulation space involves corridors, stairways and lifts.
Corridors with less than 8 ft. Width are not desirable in hospitals and protective corner
beading is a necessity in hospital corridors.
External circulation: only one entrance to the hospital for vehicular traffic from the main
road is desirable. the entrance and exit points should be wide enough to take two lanes of
traffic, one entry for clarity of all visiting traffic and one exit for security from
administrative viewpoint.
vii. Distances, compactness, parking and landscaping: distances must be minimized for all
movements of patients, medical, nursing and other staff, for supplies aiming at minimum
of time and motion.
Functional efficiency depends on the compactness of the hospital which is achieved by
constructing multistoried as they are convenient due to compactness as compared to
horizontal development of hospital which demands more land involving extra costs and
installation of services, roads, water supply, sewage etc.
One car parking space per 2 beds is desirable in metropolitan towns, lesser in smaller
urban areas while much less in semi-urban and rural areas. Separate parking for 3-
wheelers and scooters, employees and staff parking areas separate from public parking
should be considered.
viii. Zonal distribution and inter-relationship of departments: the departments which come in
close contact with the public (e.g. outpatient department, emergency and casualty) should
be isolated from the main in patient areas and allotted areas closer to the main entrance.
The supportive services like X-ray and laboratory services need to be located near the
OPD‘s. From the main entrance should be main inpatient zone consisting of ICU, wards,
OT and delivery suit. The other supportive and clinico-administrative department in the
hospital consists of hospital stores, kitchen and dietary department, pharmacy etc. these
departments should be preferably grouped around a service core area.
ix. Gross space requirements: gross total area (building gross)-780-1005 sq ft, add walls,
partitions: 95-125 sq ft. a building gross square footage figure includes everything a
building‘s perimeter viz. stairs, corridors, wall thickness and mechanical areas.
On average, space will be required for a reception and enquiry counter in the main
waiting area near the OPD entrance. The bed distribution is calculated as:
Bed:population= A x S x 100
365 x PO
Where, A= number of in-patient admissions per thousand population per year
S= average length of stay (ALS)
PO= percentage occupancy
Bed distribution among various specialties will vary from hospital to hospital and
conforms to following range:
Medical: 30-40%
Surgical: 25-30%
Obstetrical: 15-18%
Pediatric: 10-12%
Miscellaneous: 10-15% (including eye and ENT)
x. Climatic consideration in design: in very hot climate buildings need to be cooled in
summer by artificial means. Some natural cooling can be achieved by building
orientation and design. The building should be open, and oriented in such a way that even
a slight breeze can pass through the building to cool its insides. Another way is to keep
thick walls and small windows where the thick walls absorb the heat during day and
dissipates during night, and small windows minimize the amount of radiated heat
entering the building.
xi. Equipping a hospital: hospital equipment covers a broad range of items necessary for
functioning of all services. the universal application of equipment in the hospital can be
classified as:
Physical plant: it includes lifts, refrigeration and air-conditioning, incinerators, boilers,
kitchen equipments, mechanical laundry, central oxygen etc.
Hospital furniture and appliances: beds, stretchers, trolleys, bedside lockers, movable
screens, operation tables, instrument trolleys etc.
General purpose furniture and appliances: it includes office machines (typewriters,
calculators, filing system, and computers), office furniture, crockery and cutlery.
Therapeutic and diagnostic equipments: it includes equipments for general use (BP
instruments, suction machines, glassware washers etc.) and equipment interacting with
patients during diagnostic and therapeutic procedures ( defibrillators, X-ray machines
etc.)
xii. Cost evaluation of construction of hospital: the most common method of estimating the
cost is on the basis of per bed cost. It will also vary in type of facilities the hospital
provides, like teaching, training and research facilities.
Outpatient department:
Outpatient department is the one where all patients except those who require emergency
treatment, come for service in the hospital.
Planning and organization of the OPD:
Location: it should be easily accessible to those who come for outside, and should be a separate
wing for OPD attached to the hospital accessible from the main entrance to the hospital with
direct approach from the main road.
Space: the space requirement will depend upon the land available and location of the hospital.
Generally 0.66-1 sq ft area per annual outpatient attendance should be provided for OPD. If there
are 3 lakhs visit in a year, the total space requirement for OPD will be 2-3 lakh sq ft or 4.5-6.8
acres.
Size: the size of OPD depends upon the volume of attendance, clinics provided and extent of
facilities like blood bank, emergency department.
Zones of OPD:
FUNCTIONAL ZONE: this zone is mainly used by the patients attending the OPD,
attendants and relatives. This area includes parking area, entrance hall, waiting space,
enquiry and registration, and medical social services.
ADMINISTRATIVE ZONE: this zone is required in a large hospital to plan, organize,
supervise, evaluate and co-ordinate the facilities being provided. the various functional
units of this zone are
Office of the OPD in-charge
Administrative control nurses station
Cash counters
Medical record room
DIAGNOSTIC AND SUPPORTIVE ZONE: the various functional units in this area are:
Clinical laboratory
Imaging section
AMBULATORY ZONE: This is a zone where the patients come in direct contact with
the doctors and paramedical staff for consultancies, advice and treatment. it includes units
like:
Clinics for various medical disciplines
Pharmacy
Treatment room
Minor OT
STAFF ZONE: this zone is used exclusively by the staff members only. It includes duty
rooms, stores, housekeeping and conference room.
Functional management:
OPD timings: it is recommended that OPD shall work 6 days in a week with facilities of
morning and evening clinics. The morning timings is usually from 8am-12 pm, whereas
the evening hours shall be from 3pm to 5 pm, and specialty clinics from 2 pm to 4pm.
overcrowding and waiting time of the patients and relatives must be minimized.
Records: a unit record system combining both in-patients record and continuous out
patient record is recommended.
Public relations: public complaints can be minimized and defused through public
relations, the entire staff of OPD including public relations persons should act as agents.
Facilities in OPD:
The waiting lines should have enough furniture so that patients don‘t have to
stand in queues but can sit comfortably.
The general procedure and rules should be painted on boards or walls for the
public.
The registration area should be easily recognized and reachable.
Health education messages can be promoted through TV-VCR system, closed
circuit TV and also to reduce the boredom of the waiting patients and their
relatives in OPD.
Staffing of OPD: It includes the medical staff (consultant, professor, senior lecturers,
medical officers, residents, junior and senior should be available), nursing staff (usually
one nurse/OPD/clinic), paramedical staff (for injection room, dressing room, registration
and MRD), receptionists and medico social worker.
Planning and organization of Wards:
A ward is the most important part of hospital where the sick persons are kept for supervised
treatment. It is also a nodal point for research in medicine and nursing field, training and
teaching of medical, nursing and paramedical personnel.
Types of wards:
a. General wards: in these wards, patients with non-specific ailments, requiring no life
saving care are admitted. The nurse patient ratio of 1:5 in big wards, and catering to the
patient‘s routine investigation, treatment and care needs.
b. Specific wards: these include patients admitted for specific care due ti illness or social
reasons. It includes:
Emergency ward
Intensive care unit
Intensive coronary care unit
Nursery
Special septic nursery
Burns ward
Post operative ward
Post natal ward
c. Units with specialist nursing, treatment and equipment: wards like burn ward, transplant
ward functions at national or regional centers where particular service skills are
concentrated.
Ward planning:
Physical facilities: it includes:
Size of ward: size of the ward depends on- types of patient (an area of 100-120 sq
ft/bed is required and smaller rooms of 2-4 beds are preferable), requirement of
ward staff (a small ward will have same requirement throughout the day, helped
by a head nurse and a clerk for administrative and clerical responsibilities)
Patient housing area: this is an area where patients are kept for treatment.
The area per bed within the ward is 80 sq ft/bed but in acute ward it is 100
sq ft/bed
Space left between two rows of bed is 5 ft.distance between two beds is
31/2 to 4 ft.
Clearance between wall and side of bed is 2ft.
Length of bed is 6‘6‖, width of the bed is 3‘.
Size of rooms:
Single bed room should have a size of 125 sq ft/bed
2 bed room 160 sq ft/bed
4 bed room 320 sq ft/bed
6 bed room 400 sq ft/bed
ICU 120-150 sq ft/bed
Obstetrics and orthopedics 120 sq ft/bed
Open ward
Open ward
Rigg,s ward
Rigg‘s unilateral ward
Ward management: it is the optimal utilization of the ward resources to produce maximum
output, namely care and comfort of patients. It includes:
Strategic management: responsibility of giving a strategic direction to a ward lies
within the nursing unit set up in each ward. Strategy formulation for ward has to
be done in the context and parameters defined by the strategy, direction, resources
and constraints of hospital.
Operational management: whereas strategic management gives an anchor and
direction, operational management works towards the strategy. The responsibility
of operational management of a ward rests with the ward head nurse/ nursing unit
with the help of other ward personnel like ward clerk. It includes objectives of
providing comfort and good care to the patients and long term objective of
improvement and establishment of systems in functioning of the ward.
Central Sterile Supply Department (CSSD):
Definition of CSSD: A CSSD is a department that furnishes all supplies required for the nursing
units and departments of a hospital- theatres, wards, out-patient and casualty departments with
complete, sterile equipment ready and available for immediate treatment of patients.
These supplies include sterile linens, sterile kits, operating room packs, needles, syringes and
other medical surgical supplies. In addition, the personnel in this department clean, inspect,
repair, assemble, wrap and sterilize special treatment trays for various nursing units.
Planning and organizational consideration of CSSD:
Planning of CSSD: the CSSD should be planned in all hospitals above 100 beds. Theatre sterile
supply unit (TSSU) is to meet emergent and large requirement of OT and is established inside
OT complex. In large hospitals like 500 beds and above, TSSU is established in addition to the
CSSD in service area.
Above 500 beds CSSD in service area and a separate unit for
OT to be called theatre sterile supply unit (
TSSU).
Processing
Separation of sterilized items by a partition or corridor
Packing of items
Area requirements:
It is recommended that the area of 1.64 sq.m/bed for a CSSD would be appropriate up to 400
bedded hospitals, and for more than 400 beds an area of 1 sq.m/bed would be sufficient.
The manual of IGNOU has recommended following functional area for a 100 bedded hospitals:
Facilities In sq.meter
10.50
entrance
7.00
lockers
7.00
Staff change room
7.00
Dirty receipt and disassembly
17.50
Washing, disinfection and decontamination
10.50
assembly
10.50
Linen processing
14.00
sterilization
21.00
Sterile storage
distribution 10.50
7.00
Trolley wash
10.50
Trolley bay
17.50
Bulk store
3.50
Duty room
3.50
toilet
Total per 100 bed hospital 164.50
Staffing pattern:
One CSSD worker per 30 beds plus one supervisor is recommended. In 200-300 beds hospital,
you need 10-15 persons. Staff for 1000 bedded hospitals is:
Supervisor – 1(senior most and trained technician)
Asst. Supervisor- one of the senior technician
Technicians – 6 (promoted attendants)
Sweepers- 15
Clerk- 1
Equipments and materials required:
Hot and cold running water
Cleaning brushes and jet water gadgets
Ultrasonic washers
Hot air oven for drying instruments and sterilization
Globe processing unit
Instrument sharpener like needle sharpening machines
Stem sterilizers and boiler for steam
Autoclaves of various sizes including gas autoclave
Testing equipment
Chemicals to clean materials
Wall fixtures like sinks, taps
Trolleys for supply of sterilized items and separate trolleys for collection of used items
are needed
Methods of sterilization:
Sterilization is a process of freeing an article from all living organisms including bacteria,
fungus, using dry or wet heat, chemicals or irradiation.
a. Steam sterilization: autoclaving is the commonest method
b. Hot air sterilization: Vaseline and oils cannot be sterilized with steam. these items are
exposed to hot air to 160-1800c for 40 minutes.
c. Gas sterilization with ethylene oxide
d. Sub atmospheric pressure sterilization with formalin: it is meant to disinfect instruments
like endoscopes. the temperature required is 900c for 10-30 minutes.
e. Chemical sterilization with activated glutaraldehyde
f. Gamma irradiation sterilization: it is used for disposable goods but is a costly method.
g. Formaldehyde steam sterilization
Inventory management:
i. Stock: to ensure the availability of sterilized items to the hospital units, five times the
average daily requirements. The replacement and procurement of condemned items
should be laid out so that situation of ‗stock out‘ can be avoided.
ii. Issue of materials: the principle of ‗first in- first out‘ ensures proper rotation of supplies
in CSSD and prevents any item from being kept for longer time so that its sterilization
date expires.
iii. Distribution of sterile items: the method that can be used for distribution of sterile items
are:
Grocery system: in case CSSD is open 24 hrs, wards and departments can send
requisition to CSSD and stock is supplied accordingly.
CSSD is open for limited hours:
Clean for dirty exchange system: one clean item is provided for each item
in the ward used.
Milk round system: it includes daily topping up of each ward/ department
stock level to a pre determined level decided by users.
Basket system: a basket with daily requirement of ward is changed
everyday irrespective sterile items used or not, and the items of the whole
basket is sterilized every day.
In case the items are to be stocked in wards, the date of sterilization is written on
each item so that the unused items are returned to CSSD for re-sterilization after
72 hrs.
Washer
Toilet
Laundry management:
The management of laundry contributes to morale of the staff and patients with fresh laundered
linen:
a. Sequence of operation:
Collection of laundry by laundry staffs in trolley with clean and dirty linen
separately and is sorted out as soiled, infected and foul linen to avoid nosocomial
infection.
Disinfection is done using disinfectants for infected linens.
Sluicing and washing: sluicing is done for foul linen in sluice machine and then the
linen along with those that are disinfected are put in washer for cleaning.
Hydro-extractor: it is then put in extractor for removing extra water.
Drier tumbler: the linens are put for drying.
Pressing: the linens are pressed
Mending: the torn linen is sent for repair or condemnation and replacement.
Repaired linen is again washed in washer and washing cycle after that is to be
completed.
Distribution to ward is done by laundry staff after it is ready for use.
b. Linen distribution system:
Topping up: in this, the ward is given certain number of stock of linen based on
24 hours requirement and shortfall of linen due to use is topped up by the laundry
staff everyday and used ones are collected.
‗Clean for dirty‘ exchange: the issue of clean linen to exchange number of pieces
of dirty linen.
Exchange trolley system: this is expensive and not used in India. In this, total
trolley is supplied which has 24 hours requirement and next day fresh trolley is
supplied with same number of pieces and old trolley is taken back to laundry
irrespective as how many pieces have been used and linen is brought and washed.
c. Quality control of laundry services: the quality assurance of laundry should be developed
since laundry is important from where infection can be transmitted to other patients,
which should be seen by the hospital infection control committee.
d. Policies and procedures:
Collection and distribution system of linens with periodicity to each ward and
department.
Detailed instruction about handling infected and foul linen.
Charter of duty of each person handling laundry and training schedule of staffs.
Sluicing and disinfection procedures.
Operation of laundry machines.
Maintenance and service contracts of machines.
Provision of detergents
Procedure for condemnation of linen and procurement of new linen
Fire safety drills and fire extinguishing measures
Record of distribution, collection, inventory of detergents and linen
procured/condemned.
Security arrangements for laundry.
Regular physical verification of linen and fixing responsibility of any type of loss.
Kitchen services:
A hospital dietary service includes most importantly a production unit that converts raw material
into palatable food. The preparation and distribution of food from store to spoon has many
challenges for the administration such as proper preparation, cost accounting, pilferage and
wastage.
Functions of dietary services:
The dietary services cater for the
following: therapeutic diet
in-patient catering
diet counseling
education and training
Staff requirements:
Chief dietician - - - - 1
Senior Dietician - - - - 1
Dietician - - - 1 1
Asst. dietician 1 2 3 5 7
Steward - - 1 1 1
Storekeeper(ration) - - - 1 1
Storekeeper(general) - - - 1 1
Clerk/typist - - - 1 1
Head cook 1 1 1 2 2
Therapeutic cooks - - 2 2 3
Cooks 4 6 8 10 16
Asst. cook 6 14 20 28 32
Cleaners, waiters 4 4 6 8 10
Store attendants - 1 1 2 2
Sweepers 1 1 2 2 3
Space requirement:
Hospital kitchen is divided into number of divisions which have a particular activity. The broad
areas are supplies receiving area, storage area, cooking area, pots and pan wash, garbage
disposal, LPG stove and refrigeration facilities, housekeeping, dietician, steward offices and
circulation area.
Following space requirements are recommended for different size of hospitals:
200 beds or less: 20 sq ft per bed
200-400 beds: 16 sq ft per bed or 18 sq ft per bed
500 beds and above: 15 sq ft per bed
Functional areas in department:
a. Recipient area: this is the place where all provisions are off loaded. these are checked for
right quality and quantity, hence area should have unloading points, ramps, trolleys and
weighing scales.
b. Storage area: this area where the provisions are categorized and stored in separate areas.
the areas should have enough shelves and bins:
Dry provisions like flour, dal, sugar, oil etc.
Fresh provisions like vegetables, milk, butter, meat etc.
They are further divided based on temperature requirements:
items to be stored at room temperature like onion, potato etc
Items require cool temperature (8-100c is maintained) for which walk-in cooler
can be provided to store milk, eggs, butter etc.
Deep fridge where temperature is below 00c fish and meat should be stored.
c. Day store: it is an area where provisions for one days cooking issued to the cooks are
stored.
d. Preparation area: it is an area where provisions are cleaned, washed, soaked; meat is
chopped, cut and sliced etc. the items like kneader, weighing scale, slicer etc has to be
provided.
e. Cooking area: it should have pressure cooker, cooking range oven etc.
f. Service area: the food is put in service pots in trolleys and if it is a centralized distribution
system, it is put in service trays, with specifying the name of patients.
g. Washing area: this is meant for washing cooking and service pots, hence should have
liberal hot and cold water.
h. Disposal area: the area where all garbage and left over food is collected for disposal.
Staff room
Distribution area and service
Staff toilet
Wards
Distribution of diet:
a. Centralized service: the food is set in individual tray centrally at dietary department
including therapeutic diet of patients and are transferred to wards in trolleys and served to
the patients.
b. Decentralized service: the food is sent to wards and served as per the need of the patient.
Dietary store management:
Storage of food items: for dry storage, the temperature should be 70 0c, with adequate
ventilation has to be insured. The storing shelves, bins should be placed 10‖ above the
floor.
Purchase of food products: the items can be purchased from open market or through
calling tenders. The items to be purchased should have AG MARK OR IDI. For this, an
internal purchase committee may be constituted by the hospital administration.
Equipment planning: equipment purchase depends on the objectives and basic functions
of the department, workload and availability of the personnel, and quality standards.
Modern gadgets like mixer grinders, pressure cookers, dish washers etc. Should be a part
of hospital kitchen.
Financial control:
The first thing to be done for an effective financial control is to control the labor
costs.
Menu planning should be done in such a way that it reduces the inventory,
selection of items common to many areas of patient care, reduced handling,
wastage, use of automation or more equipment requiring less operational staff are
some measures that can be put to practice for an effective financial control.
Laboratory services:
The basic function of laboratory services is:
To assist doctors in arriving at or confirm a diagnosis and to assist in the treatment and
follow-up of patients.
The laboratory not only generates prompt and reliable reports, and also functions as store
house of reports for future references.
It also assists in teaching programmes for doctors, nurses and laboratory technologists.
It carries out urgent tests at any part of day or night.
Functional divisions:
The hospital laboratory work generally falls under the following five divisions:
a. Hematology
b. Microbiology
c. Clinical chemistry/ biochemistry
d. Histopathology
e. Urine and stool analysis
Functional planning:
It covers the following activities:
Determining approximate section wise workload.
Determining the services to be provided.
Determining the area and space requirement to accommodate equipment, furniture and
personnel in technical, administrative and auxiliary functions.
Dividing the areas into functional units i.e. Hematology, biochemistry, microbiology etc.
Determining the number of work stations in each functional units.
Determining the major equipments and appliances in each unit.
Determining the functional location of each section in relation to one another, from the
point of view of flow of work and technical work considerations.
Identifying the electrical and plumbing requirements for each area/ work station.
Considering utilities i.e. lighting, ventilation, isolation of equipments or work stations.
Working out the most suitable laboratory space unit, which is a standard module for work
areas.
Organization:
Location: it is preferable to have hospital laboratory planned on the ground floor and so
located that it is accessible to the wards. In large hospitals, the entry of outpatients to the
laboratory can be obviated by opening a sample collection counter in the outpatient
service area itself.
Outpatient sample collection: it should be located in the outpatient department itself. The
design of this area should include waiting room for patients, venepuncture area and
specimen toilets separately for male and female patients, along with provision of
containers with appropriate preservatives and keeping record of each patient.
Area/space: in a small hospital, the laboratory facility consists of a room in which all the
routine urinalysis, hematology and clinical chemistry investigations are carried out. As
the hospital size increases, the requirement of technical and administrative services also
increases with the necessity for departmentalization of the laboratory. The requirement of
space for the laboratory consists of :-
Primary space: this space is utilized by technical staff for the primary task of
carrying professional work.
Secondary space: it is utilized for all supportive activities.
Administrative space, i.e. Offers for the pathologists and others, staff toilets etc.
Circulation space: it is the space required for uncluttered movement of personnel
and materials within the department between various technical work stations,
rooms, stores and other auxiliary and administrative areas.
Laboratory space unit (LSU): it is a module of space and all calculations for
technical work areas and some auxiliary area are based on LSU. For allocation of
primary space, one of the most suitable sizes of a LSU is one measuring 10‘ x 20‘
giving a LSU module of 200 sq. ft. a rectangular module is functionally more
efficient because in the same overall space, it can accommodate longer runs of
benching due to its longer perimeter.
Layout: structural flexibility should be achieved by use of movable or adjustable
benching systems in association with an installation of service mains that has been
designed to permit the repositioning of outlets.
Administrative and auxiliary areas: the administrative area (the area is the central
collection point for receiving specimens and is the reception and interaction area for
patients and hospital staffs) is separated from the technical work area so that the non-
laboratory personnel need not enter the technical areas.
Reception and sample collection: this is the area should be well ventilated and lighted,
should have a chair where the patient can sit in comfort and where his arm can be
stretched for the phlebotomy, a bed where the patient can lie down for pediatric
collection or aspiration cytology.
Bar-coding system for samples: this system is used to trace the samples. The sample is
received and then bar coded, and then sent to processing area. This protects patient
identity.
Specimen toilet: it is provided for the collection of urine and stool specimens.
Pathologist office: it is so placed that the pathologist can have an easy access to the
technical areas particularly histopathology unit.
Glass washing and sterilizing unit: small labs collect blood in bottles that are washed and
reused. This is partitioned into washing and sterilizing area, containing sterilizer, pipette
washer and sinks.
Report issue: the reports should be issued in printed format. The hospital lab software can
be made as per the requirement of the hospitals.
Utility services: it includes water, gas and compressed air systems. Piping systems should
be easily accessible for maintenance and repairs with minimum disruption of work. For
safety purpose and to facilitate repairs, each individual piping system should be identified
by color, coding or labeling.
Internal design and fitments:
a. Work benches: the height of the work bench on which the technicians sit while
working (revolving stools) vary from 75-90 cm depending upon the height of the
workers.
b. Lighting: natural light should be used to the fullest. Each work bench should be
provided with adequate electric points especially fluorescent fixtures that give
uniform illumination and minimize heat.
c. Storage: each laboratory bench length should have storage space for reagents,
chemicals, glass wares and other items, provided in the form of under bench
drawers, cupboards etc.
d. Partitions: it may be required between some laboratory spaces.
e. Air conditioning: whole or at least histopathology section of the laboratory
should be air conditioned due to accumulation of formalin vapors or else a
powerful exhaust system should be installed.
f. Working surface/ flooring: the surface of work benches should be resistant to
heat, chemicals, stain proof and easy to clean. Floor should be easy to clean, and
not slippery. Flexible vinyl flooring is preferred for laboratory floor coverings.
Staffing: the hospital laboratory services should be under the control and direction of
a doctor with qualifications in pathology or a PG degree in the new discipline of
―laboratory medicine‖.
Number of personnel: staff requirement of laboratory technicians can be worked out
empirically on the basis of generally accepted norm which is about 30 tests per day
per technician.
Equipment:
Some of the core instruments that are needed are:
Colorimeters/ spectrophotometers: they were used in old days, are now
replaced by new auto-analyzers these days.
Auto analyzers: it is used maximum in biochemistry works.
Cell counter: it gives a more complete blood picture. The principle of the
instrument is to pass the cells through a thin capillary.
Centrifuge
Refrigerators
Pressure sterilizers
Pipette washers
Analytical balance
Semi auto analyzer
ELISA reader
Blood gas analyzer
PCR instrument
Flow cytometer
Emergency services:
An emergency department must be developed as a mini hospital within a hospital i.e.
Independent and self sufficient in day to day working.
DISASTER MANAGEMENT
DEFINITION
Disaster is ―any occurrence that causes damage, economic disruption, loss of human life
and deterioration of health and health service on a scale sufficient to warrant an extraordinary
response from outside the affected community or area‖. (WHO)
―Disaster can be defined as an overwhelming ecological disruption, which exceeds the capacity
of a community to adjust and consequently requires assistance from outside. -Pan American
Health Organisation(PAHO)
Disaster is an event, natural or manmade, sudden or progressive, which impacts with such
severity that the affected community has to respond by taking exceptional measures. -W. Nick
Carter
CLASSIFICATION OF DISASTERS
Disasters are commonly classified according to their causes into two distinct categories:
Natural disaster
Man-made disaster
Natural disasters
Metrological disaster: Storms (Cyclones, typhoons, hurricanes, tornados, hailstorms,
snowstorms), cold spells, heat waves and droughts.
Typological Disaster: landslides, avalanches, mudflows and floods.
Telluric and Teutonic (Disaster originate underground): Earthquake, volcanic
eruptions and tsunamis (seismic sea waves).
Biological Disaster: communicable disease, epidemics and insect swarms (locusts).
Man Made Disasters
Warfare: conventional warfare (bombardment, blockade and siege) and non-conventional
warfare (nuclear, chemical and biological).
Civil disasters: riots and demonstration.
Accidents: transportation (planes, trucks, automobiles, trains and ships); structural
collapse (building, dams, bridges, mines and other structures); explosions and fires.
Technological failures: A mishap at a nuclear power station, leak at a chemical plant
causing pollution of atmosphere or the breakdown of a public sanitation.
PRINCIPLES OF DISASTER MANAGEMENT
Prevent the disaster
Minimize the casualties
Prevent further casualties
Rescue the victims
First aid
Evacuate
Medical care
Reconstruction
READINESS FOR DISASTER
Readiness for disaster involves two aspects:
1. Resource for readiness.
2. Disaster pre planning.
1. Resources for readiness:
RED CROSS: Its primary concern in a disaster situation is to provide relief for human
suffering in the form of food, shelter, clothing, medical care, and occupational rehabilitation
of victims.
COMMUNITY AND LOCAL GOVERNMENT: It shares the responsibility in clearing rubble,
maintaining law and order, determining the safety of a structure of habitation, repairing
bridges, resuming transportation, maintaining sanitation, providing safe food and drinking
water, etc.
CIVIL DEFENCE SERVICES: The civil defense and its medical facility programmers provide
for shelters, establishing communication linkage, post disaster services, assistance to affected
community in the area of health, sanitation, maintaining law and order, fire fighting, clearing
debris, prevention and control of epidemic of various diseases etc.
2. Disaster pre-planning: It is important to make the best possible use of the resources.
Some of the pre-planning aspects for disaster related to medical care as follows:
HOSPITAL DISASTER PLANING: Depending upon the hospital‘s location and size, it
mobilizes its resources to manage any disaster. It should provide for immediate action in the
event of:
i. An internal disaster in hospital itself eg. fire, explosion, etc.
ii. Some minor external disaster.
iii. Major external disaster.
iv. Threat of disaster.
v. Disaster in neighboring communities/country.
EVACUATION: There is usually a system which on order of the medical superintendent, is
activated : eg.
i. Percentage of evacuation (discharge) of the patient from the hospital.
ii. Addition of extra beds.
iii. Preparation of emergency ward.
iv. Such facilities should be near to X-ray, operation theatre, central supply, medical store,
etc.
DISASTER
IMPACT
PREPAREDNESS RESPONSE
MITIGATION RECOVERY
PREVENTION DEVELOPMENT
TRIAGE
The word triage is derived from French word ―trier‖ which means sorting or choosing.
Objectives of triage
An effective triage system should be able to achieve the following:
Ensure immediate medical intervention in life threatening situations.
Expedite the care of patents through a systematic initial assessment.
Ensure that patients are prioritised for treatment in accordance with the severity of their
medical condition.
Reduce morbidity through early medical intervention.
Improve public relations by communicating appropriate information to friends
and relatives who accompany patients.
Improve patients flow within emergency departments and/or disaster
management situation.
Provide supervised learning for appropriate personnel.
Principles of triage
The main principles of triage are as follows:
Every patient should be received and triaged by appropriate skilled health-care professionals.
Triage is a clinic-managerial decision and must involve collaborative planning.
The triage process should not cause a delay in the delivery of effective clinical care.
Triage system
Triage consists of rapidly classifying the injured on the bases of severity of their injuries and the
likelihood of their survival with prompt medical intervention
1. GOLDEN HOUR
A seriously injured patient has one hour in which they need to receive Advanced Trauma Life
Support. This is referred to as the golden hour
2. IMMEDIATE OR HIGH PRIORITY
Higher priority is granted to victims who‘s immediate or long term prognosis can be dramatically
affected by simple intensive care.
Immediate patients are at risk for early death
They usually fall into one of two categories. They are in shock from severe blood loss or
they have severe head injury
These patients should be transported as soon as possible
Color code
Red indicate high priority treatment or transfer
Yellow signals medium priority
Green indicate ambulatory patients
Black indicates dead or moribund patients
2. Functions of the disaster management committee- The functions of the committee are:
a. To prepare a hospital disaster plan for the hospital
b. To prepare departmental plan in support of the hospital plan
c. Assign duties to the staff
d. Establishment of criteria for emergency care
e. To conduct, supervise and evaluate the training programmes
f. To supervise the mock drills
g. Updating of plans as need arises
h. Organise community awareness programmes, through mass media
i. Assist in information, education, communication (IEC) programmes in respect of
the disaster preparedness, prevention and management.
3. Role and functions: The effective implementation of the program will depend upon clarity
of the plan, role and functions of the different members and the staff. They are:
a. Disaster co-ordinator: The co-ordinators role will be:
o Organising
o Communicating
o Assigning duties
o Deployment of staff
o Taking key decisions
b. Administrator: The responsibilities of the administrator is to execute the authority
through the departmental heads
c. Departmental heads: Development of departmental plans
d. Nursing superintendent : deployment of nursing staff
e. Medical staff: specific role of rendering medical care both pre-hospital and hospital care
f. Nursing staff: nursing care and support critical care
4. Important departments
The important department of the hospital have to play a key role in the disaster management.
a. Accident and emergency department
b. Operating department
c. Critical care units
d. Radiology departments
e. Laboratory
f. Bloodbank
5. Support areas
Prompt supply of drugs, linen and surgical items, fluids are required in the hospital and due
care has to be taken to incorporate the role and function of following units.
a. Laundry
b. CSSD
c. Dietary department
d. Housekeeping services
e. Medical records
f. Public relations
g. Communications
h. Transportation
i. Mortuary
j. Medic-social worker
k. Engineering department
l. Security and safety services
m. Media relations
DISASTER DRILL
Definition
A disaster drill is an exercise in which people simulate the circumstances of a disaster so that
they have an opportunity to practice their responses.
Features
On a basic level, drills can include responses by individuals to protect themselves, such as
learning how to shelter in place, understanding what to do in an evacuation, and organizing
meet up points so that people can find each other after a disaster.
Disaster drills handle topics like what to do when communications are cut off, how to
deal with lack of access to equipment, tools, and even basic services like water and
power, and how to handle evacuations.
It also provides a chance to practice for events such as mass casualties which can occur during
a disaster.
Regular disaster drills are often required for public buildings like government offices and
schools where people are expected to practice things like evacuating the building and assisting
each other so that they will know what to do when a real alarm sounds.
Community-based disaster drills such as whole-city drills provide a chance to practice the full
spectrum of disaster response. These drills can include actors and civilian volunteers who play
roles of victims, looters, and other people who may be encountered during a disaster, and
extensive planning may go into such drills. A disaster drill on this scale may be done once a
year or once every few years.
Benefits
Used to identify weak points in a disaster response plan
To get people familiar with the steps they need to take so that their response in a disaster
will be automatic.
ROLE OF NURSES IN DISASTER MANAGEMENT
I. In disaster preparedness
1) To facilitate preparation with community
For facilitating preparation within the community, the nurse can help initiate updating disaster
plan, provide educational programmes & material regarding disasters specific to areas.
2) To provide updated record of vulnerable populations within community
The nurse should be involved in educating these populations about what impact the disaster can
have on them.
3) Nurse leads a preparedness effort
Nurse can help recruit others within the organization that will help when a response is required.
It is wise to involve person in these efforts who demonstrate flexibility, decisiveness, stamina,
endurance and emotional stability.
4) Nurse play multi roles in community
Nurse might be involved in many roles. As a community advocate, the nurse should always seek
to keep a safe environment. She must assess and report environmental hazards.
5) Nurse should have understanding of community resources
Nurse should have an understanding of what community resources will be available after a
disaster strikes and how community will work together. A community wide disaster plan will
guide the nurse in understanding what should occur before, during and after the response and his
or her role in the plan.
6) Disaster Nurse must be involved in community organization
Nurse who sects greater involvement or a more in-depth understanding of disaster management
can be involved in any number of community organizations such as the American Red Cross,
Ambulance Corps etc.
II. In disaster response
1) Nurse must involve in community assessment, case finding and referring, prevention, health
education and surveillance
2) Once rescue workers begin to arrive at the scene, immediate plans for triage should begin.
Triage is the process of separating causalities and allocating treatment based on the victim‘s
potential for survival.
o Higher priority is always given to victim‘s potential who have life threatening injuries but
who have a high probability of survival once stabilized.
o Second Priority is given to victims who have injuries with systemic complications that are
not yet life threatening but who can wait up to 45-60 minutes of treatment.
o Last priority in given to those victims who have local injuries without immediate
complications and who can wait several hours for medical attention
3) Nurse work as a member of assessment team
Nurse working as members of an assessment team have the responsibility of give accurate feed
back to relief managers to facilitate rapid rescue and recovery.
4) To be involved in ongoing surveillance
Nurse involved in ongoing surveillance uses the following methods to gather information –
interview, observation, physical examination, health and illness screening surveys, records etc.
III. In disaster recovery
1) Successful Recovery Preparation
Flexibility is an important component of successful recovery preparation.
Community clean up efforts can incure a host of physical and psychological problems. Eg.
Physical stress of moving heavy objects can cause back injury, severe fatigue and even death
from heart attacks.
2) Health teaching
The continuing threat of communicable disease will continue as long as the water supply remains
threat and the relieving conditions remain crowded. Nurses must remain vigilant in teaching
proper hygiene and making sure immunization records are up to date.
3) Psychological support
Acute and chronic illness can be exacerbated by prolonged effects of disaster. The psychological
stress of cleanup and moving can bring about feelings of severe hopelessness, depression and
grip.
4) Referrals to hospital as needed
Stress can lead to suicide and domestic abuse. Although most people recover from disasters,
mental distress may persist in vulnerable populations. Referrals to mental health professionals
should continue as long as the need exists.
5) Remain alert for environmental health
Nurse must also remain alert for environment health hazards during recovery phase of a disaster.
Home visit may lead the nurse to uncover situations such as lack of water supply or lack of
electricity.
PARAMETERS FOR NURSING PRACTICE
All nurses providing health care at mass gatherings must be competent in the basic principles of
first aid including CPR and use of automated external defibrillator. In addition nurses should
possess the following minimum care competencies.
Nursing assessment
Perform respiratory airway assessment
Perform a cardiovascular assessment including vital signs, monitoring for signs of shade.
Perform an integumentary assessment, including burn assessment
Perform a pain assessment.
Perform a trauma assessment from head to toe
Perform a mental status including Glasgow coma scale
Know the indications of intubation
Unit V
Human Resource Staffing
for health Philosophy
Norms: Staff inspection UNIt(SIU), Bajaj
Committee, High power committee, Indian
NURsing cOUncil (INC)
Estimation of NURsing staff
reqUIrement- activity analysis
VarioUS research stUDIes
RecrUItment: credentialing, selection, placement,
promotion
Retention
Personnel policies
Termination
Staff development programme
DUties and responsibilities of varioUs category of
NURsing personnel
Applications to NURsing service and eDUCation
HUMAN RESOURCES FOR HEALTH
Introduction
STAFFING
Definition
Staffing is the systematic approach to the problem of selecting, training, motivating and
retaining professional and non professional personnel in any organization.
It involves manpower planning to have the right person in the right place and avoid ―Square
peg in round hole‖.
Philosophy
Components of the staffing process as a control system include a staffing study, a master
staffing plan, a scheduling plan, and a nursing management information system (NMIS).
Nurse administrators of a hospital nursing department might adopt the following philosophy.
1. Provide an all professional nurse staff in critical care units, operating rooms,
labor, delivery unit, emergency room.
2. Provide sufficient staff to permit a 1:1 nurse-patient ratio for each shift in every critical
care unit.
3. Staff the general medical, surgical, Obsteritic and gynecology, pediatric and psychiatric
units to achieve a 2:1 professional –practical nurse ratio.
4. Provide sufficient nursing staff in general medical, surgical, Obsteritic, pediatric and
psychiatric units to permit a 1: 5 nurse-patient ratio on a day and after noon shifts an
d1:10 nurse –patient ratio on the night shift.
6.Vocationalisation of education at 10+2 levels as regards health related fields with appropriate
incentives, so that good quality paramedical personnel may be available in adequate numbers.
In relation to nursing, the Bajaj Committee recommended staffing norms for nursing manpower
requirements for hospital nursing services and requirements for community health centres and
primary health centres on the basis of calculations as follow:
Hospital Nursing Services-
1. Nursing superintendents. 1:200 beds
2. Deputy nursing superintendents 1:300 beds
3. Departmental nursing 7:1000 + 1 Addl:1000 beds
(991 x 7 + 991)
4. Ward nursing 8:200 + 30% leave reserve
supervisors/sisters
5. Staff nurse for wards 1:3 (or 1:9 for each shift)
+30 leave reserve
6. For OPD, Blood Bank, X-ray,
Diabetic clinics, CSR, etc 1:100 (1:5 OPD)
+30% leave reserve
It also requires nursing manpower to cater to the needs of the rural community as follows:
Manpower requirements by 2000 AD:
Sub-centre ANM/FHW 323882
Health supervisors /LHV 107960
Primary Health Centres PHN 26439
Community health centre Nurse-midwives 26439
Public health nursing supervisor 7436
Nurse-midwives 52,052
District public health nursing officer 900
In additional to the above, 74361 Traditional Birth Attendants will be required.
To establish and monitor a uniform standard of nursing education for nurses midwife,
Auxiliary Nurse-Midwives and health visitors by doing inspection of the institutions.
To recognize the qualifications under section 10(2)(4) of the Indian Nursing Council
Act, 1947 for the purpose of registration and employment in India and abroad.
To give approval for registration of Indian and Foreign Nurses possessing foreign
qualification under section 11(2) (a) of the Indian Nursing Council Act, 1947.
To prescribe the syllabus & regulations for nursing programs.
Power to withdraw the recognition of qualification under section 14 of the Act in case
the institution fails to maintain its standards under Section 14 (1)(b) that an institution
recognized by a State Council for the training of nurses, midwives, auxiliary nurse
midwives or health visitors does not satisfy the requirements of the Council.
To advise the State Nursing Councils, Examining Boards, State Governments and
Central Government in various important items regarding Nursing Education in the
Country.
THE EXISTING NORM BY INC WITH REGARD TO NURSING STAFF FOR WARDS
AND SPECIAL UNITS:
Staffing pattern according to the Indian Nursing Council (relaxed till 2012)
Collegiate programme-A
Qualifications and experience of teachers of college of nursing-
1. Professor-cum-Principal
Masters Degree in Nursing
Total 10 years of experience with minimum of 5 years of teaching experience
2. Professor-cum- Vice Principal
Masters Degree in Nursing
Total 10 years of experience with minimum of 5 years in teaching
3. Reader/Associate Professor
-Masters Degree in Nursing
Total 7 years of experience with minimum of 3 years in teaching
4. Lecturer
Masters Degree in Nursing with 3 years of experience.
5. Tutor/Clinical Instructor
M.Sc.(N) or B.Sc. (N) with 1 year experience or Basic B.Sc. (N) with post basic
diploma in clinical specialty
Teacher student ratio= 1:10 (All nursing faculty including Principal and Vice principal)
Two M.Sc (N) qualified teaching faculty to start college of nursing for proposed less than or
equal to 60 students and 4 M.Sc (N) qualified teaching faculty for proposed 61 to 100 students
and by fourth year they should have 5 and 7 M.Sc (N) qualified teaching faculty respectively,
preferably with one in each specialty.
Part time teachers and external teachers:
Microbiology
1.
Bio-chemistry
2.
Sociology.
3.
Bio-physic
4.
Psychology
5.
Nutrition
6.
English
7.
Computer
8.
Hindi/Any other language
9.
Any other- clinical discipliners
10.
Physical education
11.
The above teachers should have post graduate qualification with teaching experience in
respective area
School of nursing-B
Qualification of teaching staff-
M.Sc. (N) with 3 years of teaching experience or B.Sc.(N)
1. Professor cum principal basic or post basic with 5 years of teaching experience.
Professor cum vice M.Sc. (N) or B.Sc. (N) (Basic)/Post basic with 3 years of
2. principal teaching experience.
M.Sc. (N) or B.Sc. (N) (Basic) / Post basic or diploma in
3. Tutor/clinical instructor nursing education and Administration with two years of
professional experience.
INTRODUCTION
Staffing is certainly one of the major problems of any nursing organization, whether it be
a hospital, nursing home, health care agency, or in educational organization. Estimation of staff
requirements is important for rendering good and quality nursing care
Patient Classification Systems
Patient classification system (PCS), which quantifies the quality of the nursing care, is
essential to staffing nursing units of hospitals and nursing homes. In selecting or implementing a
PCS, a representative committee of nurse manager can include a representative of hospital
administration, which would decrease skepticism about the PCS.
The primary aim of PCS is to be able to respond to constant variation in the care needs of
patients.
Characteristics
Differentiate intensity of care among definite classes
Measure and quantify care to develop a management engineering standard.
Match nursing resources to patient care requirement .
Relate to time and effort spent on the associated activity.
Be economical and convenient to repot and use
Be mutually exclusive , continuing new item under more than one unit.
Be open to audit.
Be understood by those who plan , schedule and control the work.
Be individually standardized as to the procedure needed for accomplishment.
Separate requirement for registered nurse from those of other staff.
Purposes
The system will establish a unit of measure for nursing, that is , time , which will be used
to determine numbers and kinds of staff needed.
Program costing and formulation of the nursing budget.
Tracking changes in patients care needs. It helps the nurse managers the ability to
moderate and control delivery of nursing service
Determining the values of the productivity equations
Determine the quality: once a standards time element has been established, staffing is
adjusted to meet the aggregate times. A nurse manager can elect to staff below the
standard time to reduce costs.
Components:
The first component of a PCS is a method for grouping patient’s categories: Johnson
indicates two methods of categorizing patients. Using categorizing method each patient is
rated on independent elements of care, each element is scored, scores are summarized
and the patient is placed in a category based on the total numerical value obtained.
The second component of a PCS is a set of guidelines describing the way in which
patients will be classified, the frequency of the classification, and the method of reporting
data..
The third component of a PCS is the average amount of the time required for care of a
patient in each category. A method for calculating required nursing care hours is the
fourth and final component of a PCS.
Patient Care Classification
Patient Care classification using four levels of nursing care intensity
Eating Feeds self Needs some help in Cannot feed self Cannot feed self
preparing but is able to any may have
chew and difficulty
swallowing swallowing
Patient Census
As a result, patient classification systems (PCS), also known as workload management or patient
acuity tools, were developed in the 1960s.
Important Factors of staffing
There are 3 factors: quality, quantity, and utilization of personnel.
Quality and Quantity:
This factor depends on the appropriate education or training provided to the nursing personnel
for the kind of service they are being prepared for i.e., professional, skilled, routine or ancillary.
Utilization of personnel: Nursing personnel must be assigned work in such a way that her/his
knowledge and skills learnt are based used for the purpose she was educated or trained.
Other factors affecting staffing
1. Acutely Ill : Where the life saving is the priority or bed ridden condition which might
require 8-10 hours / patient /day ie., direct nursing care in 24 hours or nurse patient ratio
may have to be 1:1, 2:1,3:1…
2. Moderately Ill: here 3.5 HPD are required in 24 hours or nurse patient ration of 1:3 in
teaching hospitals and 1:5 non-teaching hospitals.
3. Mildly Ill: this required 1-2 HPD and for such patients 1:6 or 1:10.
4. Fluctuation of workload: workload is not constant.
5. Number of medical staff: In PHC , 30,000 to 50,000 population getting care from 3 to 4
medical staff but only 1 PHN gives care for all… like in hospital the ratio is vary from
medical and nursing staff.
Modified approaches to nurse staffing and scheduling
Many different approaches to nurse staffing and scheduling are being tried in an effort to
satisfy needs of the employees and meet workload demands for patient care. These include
game theory, modified workweeks (10 or 12hours shifts), team rotation, premium day, weekend
nurse staffing .Such approaches should support the underlying purpose, mission, philosophy and
objectives of the organization and the division of nursing and should be well defined in a staffing
philosophy, statement and policies.
Modified work week: This using 10 and 12 hour shifts and other methods are common place.
A nurse administrator should be sure work schedules are fulfilling the staffing philosophy and
policies, particularly with regard to efficiency. Also, such schedules should not be imposed on
the nursing staff but should show a mutual benefits to employer, employees and the client served.
One modification of the worksheet is four 10 hour shifts per week in organized time
increments. One problem with this model is time overlaps of 6 hours per 24 –hour day.
The overlap can be used for patient –centered conference, nursing care assessment and
planning and staff development. It can be done by hour or by a block of 3-4 hours.
Starting and ending time for the 10 hours shifts can be modified to provide minimal
overlaps, the 4- hour gap being staffed by part-time or temporary workers
A second scheduling modification is the 12 hour shift, on which nurses work even shifts ,
on which nurses work seven shift in 2 weeks: three on , four off: four on, three off . They
work a total 84 hours and are paid of overtime. Twelve hour shifts and flexible staffing
have been reported to have improved care and saved money because nurses can better
manage their home and personal lives.
The weekend alternatives: another variation of flexible scheduling is the weekend
alternative. Nurses work two 12 hour shifts and are paid for 40 hours plus benefits. They
can use the weekdays for continued education or other personal needs. The weekend
scheduled has several variations. Nurses working Monday through Friday have all
weekends off.
Other modified approaches: team rotation is a method of cyclic staffing in which a
nursing team is scheduled as a unit. It would be used if the team nursing modality were a
team practice.
Premium day weekend: nursing staffing is a scheduling pattern that gives the nurse an
extra day off duty, called a premium day, when he/she volunteers to work one additional
weekend worked beyond those required by nurse staffing policy. This technique does not
add directly to hospital costs.
Premium vacation night: staffing follows the same principle as does premium day
weekend staffing. An example would be the policy of giving extra 5 working days of
vacation to every nurse who works a permanent night shifts for a specific period of time ,
say 3, 4, or 6 months.
A flexible role: this programme has enabled the hospitals to better meet the staffing
needs of units whenever workload increases. Since establishment of the resources acuity
nurse position, nurses position, nurse‘s morale has improved because they know short-
term helps is more readily available and will be more equitably distributed among units.
Cross training: It can improve flexible scheduling. Nurses can be prepared through
cross-training to function effectively in more than one area of expertise. To prevent errors
and incidence job satisfaction during cross training nurses assigned to units and in pools
require complete orientation and ongoing staff development.
Scheduling with Nursing Management Information Systems
Planning the duty schedule does not always match personnel with preferences. This is
one major dissatisfaction among clinical nurses. Posting the number of nurses needed by time
slot and allowing nurses to put colored pins in slots to select their own times can improve
satisfaction with the schedule.
Hanson defines a management information system as ―an array components designed to
transform a collective set of data into knowledge that is directly useful and applicable in the
process of directing and controlling resources and their application to the achievement of specific
objectives‖.
The following process for establishing any MIS:
1. State the management objective clearly.
2. Identify the actions required to meet the objective.
3. Identify the responsible position in the organization.
4. Identify the information required to meet the objective.
5. Determine the data required to produce the needed information.
6. Determine the system‘s requirement for processing the data.
7. Develop a flowchart.
Productivity
Productivity is commonly defined as output divided by input. Hanson translates this definition
into following:
Required staff hours
×100
Provided staff hours
Example
380 hours
X 100 = 95% productivity
400 hours
Productivity can be increased by decreasing the provided staff hours holding the required staff
hours constant or increasing them.
Measurement
In developing a model for an MIS, Hanson indicates several formulas for translating data
into information. He indicates that in addition to the productivity formula, hours per patient day
(HPPD) are a data element that can provide meaningful information when provided for an
extended period of time.
HPPD is determined by the formula
Staff hours
Patient days
For example,
52000
2883
Answer = 18 HPPD
Another useful formula
1. Budget utilization
Provided HPPD
X 100 = budget utilization
Budgeted HPPD
Example
18.03 % so, answer is 112.7% Budget utilization.
16
2. Budget adequacy
Budgeted HPPD X100, this is known as Budget adequacy
Required HPPD
Nurse to patient ratio Number of patients cared for by one nurse typically specified by job
category (RN, Licensed Vocational or Practical Nurse-LVN or LPN);
this varies by shift and nursing unit; some researchers use this term to
mean nurse hours per inpatient day
Total nursing staff or All staff or all hours of care including RN, LVN, aides counted per
hours per patient day patient day (a patient day is the number of days any one patient stays in
the hospital, i.e., one patient staying 10 days would be 10 patient days)
RN or LVN FTEs per RN or LVN full time equivalents per patient day (an FTE is 2080 hours
patient day per year and can be composed of multiple part-time or one full-time
individual)
Nursing skill (or The proportion or percentage of hours of care provided by one category
staff) mix of caregiver divided by the total hours of care (A 60% RN skill mix
indicates that RNs provide 60% of the total hours of care)
Patient Focused Care A model popularized in the 1990s that used RNs as care managers and
unlicensed assistive personnel (UAP) in expanded roles such as
drawing blood, performing EKGs, and performing certain assessment
activities
Primary or Total A model that generally uses an all-RN staff to provide all direct care
Nursing Care and allows the RN to care for the same patient throughout the patient's
stay; UAPs are not used and unlicensed staff do not provide patient care
Team or Functional A model using the RN as a team leader and LVNs/UAPs to perform
Nursing Care activities such as bathing, feeding, and other duties common to nurse
aides and orderlies; it can also divide the work by function such as
"medication nurse" or "treatment nurse"
Magnet Hospital Characterized as "good places for nurses to work" and includes a high
Environment/Shared degree of RN autonomy, MD-RN collaboration, and RN control of
governance practice; allows for shared decisionmaking by RNs and managers Jean
Ann Seago, Ph.D.,RN
VARIOUS RESEARCH STUDIES
1. ESTIMATION OF DIRECT COST AND RESOURCE ALLOCATION IN INTENSIVE
CARE: CORRELATION WITH OMEGA SYSTEM.
Department of Public Health & Medical Information, Hôpital Ambroise Parè, Boulogne, France.
Comment in: Intensive Care Med. 1999 Feb;25(2):245-6.
Abstract
OBJECTIVE: An instrument able to estimate the direct costs of stays in Intensive Care Units
(ICUs) simply would be very useful for resource allocation inside a hospital, through a global
budget system. The aim of this study was to propose such a tool.
DESIGN: Since 1991, a region-wide common data base has collected standard data of intensive
care such as the Omega Score, Simplified Acute Physiologic Score, length of stay, length of
ventilation, main diagnosis and procedures. The Omega Score, developed in France in 1986 and
proved to be related to the workload, was recorded on each patient of the study.
SETTING: Eighteen ICUs of Assistance Publique-Hôpitaux de Paris (AP-HP) and suburbs.
PATIENTS: 1) Hundred twenty-one randomly selected ICU patients; 2) 12,000 consecutive
ICU stays collected in the common data base in 1993.
MEASUREMENTS: 1) On the sample of 121 patients, medical expenditure and nursing time
associated with interventions were measured through a prospective study. The correlation
between Omega points and direct costs was calculated, and regression equations were applied to
the 12,000 stays of the data base, leading to estimated costs. 2) From the analytic accounting of
AP-HP, the mean direct cost per stay and per unit was calculated, and compared with the mean
associated Omega score from the data base. In both methods a comparison of actual and
estimated costs was made.
RESULTS: The Omega Score is strongly correlated to total direct costs, medical direct costs
and nursing requirements. This correlation is observed both in the random sample of 121 stays
and on the data base' stays. The discrepancy of estimated costs through Omega Score and actual
costs may result from drugs, blood product underestimation and therapeutic procedures not
involved in the Omega Score.
CONCLUSIONS: The Omega system appears to be a simple and relevant indicator with which
to estimate the direct costs of each stay, and then to organise nursing requirements and resource
allocation.
Manpower
planning
Job analysis
OBJECTIVES OF RECRUITMENT:
To attract people with multi-dimensional skills and experiences that suit the present and
future organizational strategies
To induct outsiders with new perspective to lead the company
To infuse fresh blood at all levels of organization
To develop an organizational culture that attracts competent people to the company
To search or heat hunt/ head pouch people whose skills fit the company‘s values
To devise methodologies for assessing psychological traits
To seek out non-conventional development grounds of
talent
To search for talent globally and not just within the company
To design entry pay that competes on quality but not on quantum
To anticipate and find people for positions that does not exist yet.
PRINCIPLES OF RECRUITMENT:
Recruitment should be done from a central place. Eg: Administrative officer/Nursing Service
Administration.
1) Termination and creation of any post should be done by responsible officers, eg:
regarding nursing staff the Nursing superintendent along with her officers has to take the
decision and not the medical Superintendent.
2) Only the vacant positions should be filled and neither less nor more should be employed.
3) Job description/ work analysis should be made before recruitment.
4) Procedure for recruitment should be developed by an experienced person
5) Recruitment of workers should be done from internal and external sources
6) Recruitment should be done on the basis of definite qualifications and set standards.
7) A recruitment policy should be followed
8) Chances of promotion should be clearly stated
9) Policy should be clear and changeable according to the need.
SOURCES OF RECRUITMENT:
The sources of recruitment are:
DIRECT
SOURCES OF
RECRUITMENT
INDIRECT
I) Internal sources:
Internal sources 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:
o It is good public relations
o It builds morale
o It encourages competent individuals who are ambitious
o It improves the probability of a good selection, since information of the
candidate is readily available
o It is less costly
o 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.
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.
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:
Advantages:
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.
Disadvantages:
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.
II) 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.
Advertisements: 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 and
To whom one applies.
Employment exchange: Employment exchanges have been set up all over the country in
deference to the provisions of the Employment exchanges (Compulsory Notification of
Vaccination) 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 enquire. These job-seekers
are asked to complete applications forms for further processing.
Talk-in is becoming popular now-in 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 Resources Consultants Head
Hunters, Bathiboi and Co, Consultancy Bureau, Aims Management Consultants and The Search
House are some among the numerous recruiting agents.
Contractors: Contractors 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 presents unique challenges
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
RECRUITMENT PROCESS / STEPS:
As was stated earlier, recruitment refers to the process of identifying and attracting job
seekers so as to build a pool of qualified job applicants. The process comprises five inter-related
stages, via:
Planning
Strategy
development
Searching
STEPS
Screening
Evaluation &
Control
DEFINITION
1) Credentialing is the process by which selected professionals are granted privileges to practice
within an organization. In health care organizations this process has been largely confined to
physicians. Limited privileges have been granted to psychologists, social workers and selected
categories of nurses, such as nurse anesthetists, surgical nurses, and midwifes.
Russell C Swan‘s burg
2) Credentialing is the process of establishing the qualifications of licensed professionals,
organizational members or organizations, and assessing their background and legitimacy.
3) A credential is an attestation of qualification, competence, or authority issued to an individual
by a third party with a relevant de jure or de facto authority or assumed competence to do so.
PURPOSE OF CREDENTIALING
The purpose of credentialing is:
1) To prevent a problem before it happens.
2) To research the qualifications and backgrounds of individuals and companies. Credentialing
is also the process of reviewing and verifying information.
SIGNIFIANCE
Credentialing is very significant because it shows that an individual or company
performing a service is qualified to do so. For example: your doctor must have certain credentials
to prescribe medicine to you.
LEGAL PROTECTION
It is a good idea to have credentialing process to protect you and your business from a
lawsuit or other legal problems. For instance, let‘s say you hire a teacher to work in your day
care center, and this person is a sex offender. The credentialing process could have prevented
this through a background check.
PROFESSION
Almost all professions require, to a certain degree, some sort of credentials. Police
departments, Firefighters, lawyers, accountants and nurses all need credentials. You need
credentials to drive a car or semi-truck. All states require citizens to take a driving test.
WHO IS CREDENTIALED?
1) Practitioners: Medical Doctors (MD), Doctor of osteopathy (DO), Doctor of Podiatric
Medicine (DPM), Doctor of Chiropractic (DC), Doctor of dental Medicine (DMD), Doctor of
Dental Surgery (DDS), Doctor of Optometry (OD), Doctor of Psychology (PhD) and Doctor of
Philosophy (PhD).
2) Extenders: Physician of assistant (PA), Certified Nurse Practitioner (CRNP), Certified Nurse
Midwife (CNM).
Facility and Ancillary service Providers: Hospitals , Nursing Homes, Skilled Nursing
Facilities, Home Health, Home Infusion Therapy, Hospice, Rehabilitation Facilities,
Freestanding Surgery Centers, Freestanding Radiology Centers, Portable X-ray Suppliers, End
Stage Renal Disease Facilities, Clinical Laboratories, Outpatient Physical therapy and Speech
Therapy providers, Rural Health Clinics, Federally Qualified Health Centers Orthotic and
Prosthetic providers and Durable Medical Equipment (DME) providers.
COMPOTENTS OF CREDENTIALING
As with physicians, the components of a credentialing system for nurses would be:
1) Appointment: Evaluation and selection for nursing staff membership.
2) Clinical privileges: Delineation of the specific nursing specialties that may be managed
types of illnesses or patients that may be managed within the institution for each member of
the nursing staff.
3) Periodic reappraisal: Continuing review and evaluation of each member of the nursing staff
to assure that competence is maintained and consistent with privileges.
CRETERIA FOR APPOINTMENT:
Criteria for appointments would include proof of licensure, education and training, specialty
board certification, previous experience, and recommendations.
Clinical privileges criteria would include the proof of specialty training and of performance of
nursing procedures or specialty care during training and previous appointments.
PRINCIPLES OF CREDENTIALING ACCORDING TO (ANA)
A report of the Committee for the study of Credentialing in Nursing was made in 1979. It
included fourteen principles of credentialing related to:
1) Those credentialed.
2) Legitimate interests of involved occupation, institution, and general public.
3) Accountability
4) A system of checks and balances
5) Periodic assessments
6) Objective standards and criteria and persons competent in their use
7) Representation of the community of the interests
8) Professional identity and responsibility
9) An effective system of role delineation
10) An effective system of program identification
11) Coordination of credentialing mechanisms
12) Geographic mobility
13) Definitions and terminology
14) Communications and understanding.
SELECTION
INTRODUCTION
“The selection process starts when applications are screened in the personnel department.
Selecting includes interviewing, the employer‘s offer, acceptance by the applicant, and signing
of a contract or written offer‖.
Those applicants who seem to meet the job requirements are sent blank job-application forms
and are directed to fill them up and return the same for further action. The job application form is
one of most important tools in the selection process.
DEFINITION
―It is the process of choosing from among applicants the best qualified individuals,
Selecting includes interviewing, the employer‘s offer, acceptance by the applicant, and signing
of a contract or written offer‖. Selection may be carried out centrally or locally, but in either case
certain policies or methods are adopted.
SELECTION POLICIES
1. 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, analyzing entrance standards, assessing academic
achievement with subsequent performance, and knowing from which parts of the state or country
the students 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
It may also ask the student to write short easy on her interests and her reasons for
choosing nursing as a career. It should give details of any material she should submit such as a
medical certificate, evidence of date of birth etc. and should give the exact address to which it
should be sent. The names of the persons given as references should be asked to furnish
information regarding the candidate‘s character and personality, and the information to be given
by the head teacher should include candidate‘s attendance at school, studies completed, grades,
rank in class and his or her own evaluation of the candidate‘s suitability of nursing.
A job application form serves three main purpose:
1) It enables the hospital authorities to weed out unsuitable candidates.
2) It acts as a frame of reference for the interview.
3) It forms the basis for the personal record file of the successful candidates
2. 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 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 programme it offers.
The members of the selection committee should include
a) The head of the college of nursing
b) Professor
c) Representative of the local controlling authority
d) Representative of the nursing division of the state
e) An educational psychologist
The procedure for selection should consist of a personal interview of the candidate and
possibly a separate interview with her parents. It may also include tests of previous
achievements, both written and oral, to assess her knowledge of various subjects such as
Arithmetic, English, the regional language and general science and her ability to express herself
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. The college
should make every effort to start the course on the appointed day with the full quota of students.
Only in exceptional circumstances should students be admitted later and in their cases, special
arrangement should be made for them to cope up with the other students.
3. Orientation programme:
After admission an orientation programme 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 programme may take three to five days.
4. Development of master plan:
When a particular batch is admitted the class teacher may draw a master plan according
to which the whole programme is planned. Date of examinations and periodic evaluation
measures etc are formulated.
5. Parent teachers association:
All parents are enrolled in the parent teachers association and this will help to have a
contact between the family members and teachers. This will help to improve the administration.
Meetings of PTA are held frequently and the parents are kept informed of the students progress.
Before taking any disciplinary actions PTA members are called when students unrest
occurs due to certain problems. Thus parents are also involved in the administration of students.
STEPS IN SELECTION: The steps which constitute the employee selection process are the
following:
I. Interview by personnel department
II. Pre-employment tests-written/oral/practical
III. Interview by department head
IV. Decision of administrator to accept or reject
V. Medical examination
VI. Check of references
VII. Issue of appointment letter.
I. Interviewing:
Interviewing is the main method of appraising an applicant‘s suitability for a post. This is
the most intricate and difficult part of the selection process. The employment interview can
be divided into four parts:
The warm-up stage
The drawing-out stage
The information stage
The forming an-opinion stage
Main objectives of an interview:
1) For the employer to obtain all the information about the candidate to decide about his
suitability for the post.
2) To give the candidate a complete picture of the job as well as of the Organization.
3) To demonstrate fairness to all candidates.
THE INTERVIEW LETTER:
INTERVIEW LETTER
Date
Address
Dear
With reference to your application dead ……………… for the post of………………………………………. .
I am pleased to call you for an interview at …………….. on.................................in the personnel department.
You are required t fill up the enclosed job-application form and bring it with you at the time of the interview.
Please bring your original certificates and certificates and testimonials with you. We look forward to seeing you.
Your sincerely,
( Personnel Manager )
1) Tests of general ability: These tests can give a useful indication of candidate‘s mental
caliber. It has been observed that for various professions, there is an optimum level of
I.Q.while selecting individuals who have I.Q.s within the required optimum range-not higher
or lower.
2) Tests of aptitude: aptitude tests measure whether an individual has the capacity or latent
ability to learn a new job, if given adequate training .These tests measure skills & abilities
that have the potential for later development in the person tested.
3) Tests of achievement: Tests of achievement measure the present level of proficiency that a
person has achieved. In hospitals, these tests can be used for typists, stenographers,
laboratory technicians, radiographers, etc. These tests can also be used at the end of training
programmers to assess the level of proficiency achieved.
4) Personality tests: Personality tests are used to assess certain personality characteristics.
These tests are used in selecting candidates for sales jobs, supervisory job, management
trances, etc., because certain personality characteristics are essential to succeed in such jobs.
III. Final approval by the head of the hospital:
In some hospitals, the selection committee consists of one person from the personnel
department, the department head/supervisor of the concerned department and one representative
of the head of the hospital. After the interviewing all the candidates, the selection committee
submits its recommendations for approval to the head of the hospital, who is generally the hiring
authority.
In other hospitals, the head of the hospital may prefer to interview all the candidates
himself for the key jobs and leave it to the selection committee for the less vital jobs. In case of
appointment of a department head, one expert is also usually included in the selection committee.
Different hospitals adopt different policies according to their own convenience for the selection
of their employees. Generally this authority lies with the Medical superintendent or
Administrator or Business Manager or Chief Executive who is legally termed the ‗Occupier‘.
IV. References:
The references provided by the applicant should be cross-checked to ascertain his past
performance and to obtain relevant information from his past employer and others who have
knowledge of his professional competence.
The references letters should be brief and should require as little writing as possible by
the person to whom it is sent. If it is directed to a former employer, it should ask for the
following data:
Date of joining
Date of leaving
Job title
Last salary drawn
Promotion/demotion, if any
Unauthorized absentee record
Reason for termination/ leaving
Ability to work with others
Dependability
Emotional stability
Health conditions
Does the employee habitually borrow money?
Would you re-employ?
Any other information
V. Medical examination:
The medical examination of a prospective employee is an aid both to the employee and to
the management. The selection of the right type of employee who can give his best and be happy
requires a thorough knowledge of his physical capacities and handicaps. The purpose of the
medical examination is threefold:
a) It is for the protection of the applicant himself to know whether that job will suit him or not
from the medical point of view.
b) It is for the protection of the other employees so that they are not at risk of any communicable
or other disease which the prospective employee may have.
c) It is for the protection of the employer as well, so that he may avoid selecting a wrong person.
The medical examination will eliminate an applicant whose health is below the standard or one
who is medically unfit.
VI. Joining report by the employee:
When new employees reports for joining, he should be given an appointment letter, his
job description and handbook of the hospital. He should be asked to submit his joining report. A
model appointment letter and joining report form are given.
PLACEMENT
INTRODUCTION:
Placements are a credit bearing part of a degree course and all placements optional. If a
student opts out of a placement or there is no placement available, this means that placement is
not guaranteed.
DEFITION: State of being placed or arranged.
IMPORTANCE PLACEMENTS:
The school of service management believes that taking a placement is one of the most
important decisions you can make in your university carrier. Not only will you benefit from
building personal confidence during your placement year but you will also establish contacts in
your chosen sector which may provide invaluable for graduate opportunity.
An increase in salary
An increase in
A better future
prestige
FACTORS
IMPLYING
An upward movement in
Additional supervisory the hierarchy of jobs
responsibility
NATURE AND SCOPE OF PROMOTION:
Seniority versus merits: There has been great deal of controversy over the relative values of
seniority and merit in any system of promotion. Seniority will always remain a factor to be
considered, but there be much greater opportunity for efficient personnel, irrespective of their
seniority, to move up speedily if merit is used as the basis for promotions. It is often said that at
least for the lower ranks, seniority alone should be the criterion for promotion. One cannot agree
with this. The quality of work is more important in the lower ranks as in the higher.
There are some who argue against this plea and advocate the merit policy for the following
reasons:
1) They believe that mere length of service evidence only of continued service but are surely
no indication of vast experience.
2) Promotion on the basis of seniority saps the initiative of the employees. Once they realize
that promotions in the organization are on the basis of seniority alone, they lose all
enthusiasm for showing better performance. Therefore, in terms of getting the best out of
employees, the merits of the individual employee will have to be considered.
3) There are individual differences amongst persons working o the same of them are most
efficient, some barely average and some below average. If their differences are not
distinguished and they are uniformly rewarded, all individual will gradually sink to the
level of the below-average employee.
PROMOTION POLICY:
The promotion policy is one of the most controversial issues in every organization. The
management usually favors promotion on the basis of merits, and the unions vehemently
opposite by saying that management resort to favoritism. The unions generally favor promotions
on the basis of seniority. However, in practice, both seniority and ability criteria should be taken
into consideration; but in order to allay the suspicious of the trade unions, there should be written
promotion policy which should be clearly understood by all.
Promotion policy may include the following:
1) Charts and diagrams showing job relationships and ladder of promotion should be prepared.
Those charts and diagrams clearly distinguish each job and connect various jobs by lines and
arrows showing the channels to promotion. These lines and arrows are always based on
analysis of job duties. These charts do not guarantee promotion but do point out various
avenues which exist in an organization.
2) There should be some definite system for making a waiting list after identification and
selection of those candidates who are to be promoted as and when vacancies occur.
3) All vacancies within the organization should be notified so that all potential candidates may
complete.
4) The following eight factors must be the basis for promotion:
Outstanding service in terms of quality as well as quantity
Above average achievement in patient care and for public relations
Experience
Seniority
Initiative
Recognition by employee as a leader
Particular knowledge and experience necessary for a vacancy and
Record of loyalty and cooperation
In some instances, it may be possible to use pre-employment test, to determine eligibility for the
vacant position.
5) Though the department heads may initiate promotion of an employee, the final approval
should be with top management because a department head can think only of the
repercussions of the promotion in his department while top management looks at it from the
point of view of the organizations a whole. The personnel department can help at the stage by
proposing the names of prospective candidates out of the existing employees in the
organization and also submit their performance appraisal record of the last few years to the
department head.
6) All promotion should be for a trail period. In case the promoted person is not found capable
of handling the job. Normally, during this trail period, he draws salary at the higher pay-
scale, but it should specially be made clear to him in writing that if his performance is not
found up to the work, he will be reverted to his former post at the former scale.
7) In case of promotion, the personnel department should carefully follow the progress of the
promoted employees. A responsible person of the personnel department should hold a brief
interview with the promoted person and his department head to determine whether
everything is going on well or not. The promotional post should be continued after the
satisfactory report of the department head.
RETENTION
NURSE RETENTION
By Lee Ann Runy
An Executive’s Guide to Keeping One of Your Hospital’s Most Valuable Resources
With no end in sight for the nation‘s nursing shortage, hospitals are placing greater
emphasis on retaining their current RN staff. It‘s a complex process, requiring in-depth
knowledge of the needs and wants of the nursing staff and lots of creativity. ―You have to know
what motivates nurses to stay,‖ says Pamela Thompson, CEO of the American Organization of
Nurse Executives. To that end, many hospitals regularly conduct retention or exit surveys to
understand what‘s on nurses‘ minds.
―The stresses of the job can be compounded by responsibilities outside of the workplace.
Hospitals are doing what they can to support nurses on a personal level, which is where
creativity mostly comes into play. From concierge services that help nurses with errands to day
care to flexible scheduling, hospitals are doing whatever it takes to allow nurses to focus on their
work and keep them in their jobs for years to come.
DEFINITION:
Staff choose to stay for long periods within a cost centre, turnover is under is 10% annually.
IMPORTANCE OF STAFF RETENTION:
The advantages of staff retention are fairly clear. Most importantly perhaps, key skills, ideas,
knowledge and experience remain within your organization. Client relationships and
networks are also preserved in conjunction with all the income that these areas generate.
Conversely, losing your key employees lays open the possibility that these people will than
assume roles with your direct competitors. As a result those invaluable skills, ideas,
knowledge, experience, relationships and networks are all transferred to another
organization.
On top of all these there are also direct costs involved in losing key employees. The cost of
replacing such an individual includes advertising, recruitment agency fees and the time spent
conducting actual interview process. Further more it is also worth considering the time and
expense spent on the induction new employees and lost revenue during the recruitment and
bedding in process.
All though an element of employee churns is both inevitable and healthy. It is nevertheless
clear that retention brings substantial benefits to your organization. Whilst attrition involves
significant direct and indirect financial costs.
PERSONNEL POLICIES
2. Policies in general, they are guidelines to help in the safe and efficient achievement of
organizational objectives.
Personnel Policy-
1) A set of rules that define the manner in which an organization deals with a human
resources or personnel-related matter. A personnel policy should reflect good practice, be
written down, be communicated across the organization, and should adapt to changing
circumstances.
2) Personnel policy is an integrated function which encompasses many aspects of the
personnel management.
3) The written statement of an organization‘s goal and intent concerning matters that effect
the personnel working in an organization.
4) Personnel policies are the statements of the accepted personnel principles and the
resulting course of administrative action by which a specific organization pattern
determines the pattern of its employment conditions.
IMPORTANCE:
―The nursing service administration of believes that its supreme objective ; the best
possible patient care, can be achieved only by the full cooperation of all who are privileged to
take part in that care‖.
―It seeks to establish a team dedicated to the protection of health and well being of the
patient in an environment that will enable every member of the team to obtain as well as give
satisfaction in his or her work‖.
OBJECTIVES:
1) To employ those persons best fitted by education, skill and experience to perform
prescribed work.
2) Guarantee fairness in the maintenance of the discipline
3) Upgrade and promote existing staff wherever possible.
4) Take all practical steps to avoid excessive hours of work.
5) Ensure the greatest practicable degree of permanent and continuous employment.
6) Maintain standards of remuneration
7) Provide and maintain high level of physical working conditions.
8) Maintain effective methods of regular consultation between administration and
employees.
9) Provide suitable means for the orientation, on the job training and evaluation of
employees.
10) Encourage social and recreational facilities for employees.
11) Develop appropriate schemes for employees welfare.
TYPES OF POLICIES
a) Implied Policy:
It is the policy which is not directly voiced or written but is established by pattern
of decision.
They may have either favourable or unfavorable effects
It is the policy neither written nor expressed verbally have usually developed over
time and follow a presendent.
If you have people who are accountable to you, you don‘t need to formally issue
policy statements to create policy.
Parents, bosses, boards, government administrations, etc. are producing implied
policy all of the time.
For Example: Imagine that an employee comes to the boss and asks,
―What should I do about this?‖ If the boss responds by giving an instruction, that
employee will assume that this is how to cope with all similar situations. They
will interpret the instruction in terms of the implied values or the general policy
that would result in the instruction.
b) Expressed Policy:
These are delineated verbally or in writing.
Oral policies are more flexible than written ones and can be easily adjusted to
changing circumstances.
Most of the organization have many written policies that are readily available to
all people and promote consistency in action. It may include:
Formal dress code
Policy for sick leave or vacation time
Disciplinary procedures
Operating Procedures
The statement details the company's operating procedures, including how employees should
accomplish their assigned tasks; punctuality, work hours, and breaks; payment structure;
personal appearance and dress code; drug and alcohol policies; benefits; and other employee
guidance and responsibilities.
Employee Conduct
The statement defines the company's policies and guidelines about such matters as
professional conduct with other employees and clients.
Employee use of office equipment is another key item. If personal or non-work-related use of
computers, telephones, other equipment, and office supplies is prohibited, this should be
outlined.
Professionalism
With an employer personnel policies statement in effect, business owners, managers, and
employees are afforded a greater air of professionalism, according to the National Restaurant
Association's guidelines for writing an employee manual.
Employer Authority
One of the principal functions of an employee statement is that it offers the employer a point
of reference in the event that an employee is reprimanded or terminated, thereby protecting
the employer from wrongful termination lawsuits.
Every organization should have a complete set of well developed personnel policies before it
begins to function. The existing ones also need to be revised. At times, the policies may be
formulated simultaneously from the top management as well as the lower division management.
The stages and sequences of events in the process of development of policy are:
Fact Finding
PROCESS
i) Law of the country: The various laws and labor legislation govern the various
aspects of personnel matters. Policies should be in conformity with the laws of the
country
ii) Social values and customs: there are codes of behavior of any community which
should be taken in account in framing policies.
iii) Management philosophy and values: Management cannot work together for any
length of time without clear broad philosophy and set of values which influence their
actions on matters concerning the work force.
iv) Stage of development: All changes such as size of operations, scale of technology,
innovations, fluctuations in the composition of workforce, decentralization of
authority and change in financial structure influence the adoption of personnel
policies.
v) Financial position of the firm: The personnel policies cost money which will be
reflected in the price of the product. Because of this, prices set the absolute limit to
organization‘s personnel policies.
vi) Type of work force: The assessment of characteristics of workforce and what is
acceptable to them is the responsibility of the effective personnel staff.
TERMINATION
STAFF DEVELOPMENT PROGRAMME: IN-SERVICE AND CONTINUING
EDUCATION
INTRODUCTION:
Staff development is the process directed towards the personal and professional growth of
nurses and other personnel while they are employed by a health care agency. It is essential for
the upliftment of professional as well as administrative field. Staff development programme
helps in updating the knowledge and practice of professionals. It is applicable not only to the
nursing field but also to all the professional fields.
DEFINITION:
GOAL:
To assist each employee to improve performance in his or her present position and to
acquire personal and professional abilities that maximizes the possibility of career
advancement.
To meet social change and scientific advancement. It causes rapid changes in nursing
knowledge and skills.
To provide the opportunity for nurses to continually acquire and implement the
knowledge, skills and attitudes, ideas and values essential to maintain high quality
nursing care.
To meet job related learning needs of the nurse – (eg, continuing education, in-service
education, extramural education and post basic education).
Fill the gaps between theory and knowledge.
To achieve personal or professional development eg, promotion.
To prepare for future tasks or trends.
Staff development model is based on the aforementioned philosophical statement, that the
activities within a health care agency are directed towards achieving a high quality care through
the mutual goal oriented efforts of the health care agency, nursing profession and its
practitioners.
Education
Experience
Socio-economics
The educational component assumes that the nurse is motivated to continue learning
through involvement in educational activities endorse by a health care agency and the nursing
profession. It may take the form of continuing education – in service education and extramural
education or post basic nursing education. Staff nurse is self-motivated for learning. She may
accept any type of staff developmental activity, comes under local agency or outside agency.
Nursing practice and experience in daily life are integral parts of staff development.
Planned approach to the daily assignment of nursing responsibilities is both a benefit to the
development of the nurse practitioner and prerequisites to high quality patient care. For quality
care – experiences may be planned or unplanned. Experiences are curricular and co-curricular
and self.
Socio-economic component:
It involves health care agency, the nurse and nursing association in management,
planning, counseling and employee – employer relations.
The effectiveness of man power planning depends on needs assessment, which is
influenced by the standards set by the nursing profession and the job commitment made
between the health care agency and the nurse.
Counseling includes career planning as well as performance evaluation for the benefit
of both the health care agency and the nurse.
Employee-employer relations are reflected in the personal practices, form the basics of
policies underlying staff development in any agency.
The interrelationship of the components provides the framework for purposeful staff
development structured to meet the needs of both a health care agency and the nurse.
Staff development includes formal and informal group and individual training and
education. Staff development activities include the following:
Induction
training
In service
education
Induction training (3 days): Is a brief standardized introduction to an agency‘s philosophy,
purpose policies and regulations given to each worker during her or his first two or three days of
employment in order to ensure his or her identification with agency‘s philosophy, goals and
norms.
Continuing education: Is a planned activity directed towards meeting the learning needs of the
nurse following basic nursing education, exclusive of full time formal post basic education.
Extramural education: Is a community based education directed towards meeting the job related
learning needs of the nurse and other personal. Exclusive of full time formal study at a degree
granting institution.
The major factors that determine the administrative structure of an agency-wide staff
development programme are:-
Orientation Programme
Skill Training Programme
Leadership and management development
Continuing education
1. Orientation Programme:
Is the process of acquiring anew staff with the existing work environment so that
he/she can relate quickly to his/ her new surroundings.
It is assigned for new staff. It is given at the initial stage of employment or when a
staff takes new responsibilities.
2. Skill Training Programme:
Skill training may be a manual or technical skill of doing for people or skill in
dealing and working well with people.
It provides the nursing staff with the skills and attitude required for job and to
keep them abreast of changing methods and new techniques.
Often it is the continuation of the orientation programme.
It is designed to new and older staff.
3. Leadership and management development:
To improve the managerial abilities of persons at every management level as well
as potential managers to produce the greatest degree of organizational progress.
It should be begin by establishing agreement among top and middle level
managers as to proper authority, responsibility and accountability for managers at
every level.
Need can identified by incident reports, turnover rates, patient audits and quality
control reports.
4. Continuing education:
Formal, organized, educational programme designed to promote the knowledge,
skills and professional attitude of nurses.
OTHER ACTIVITIES OF STAFF DEVELOPMENT
Preceptorship:
In most of the hospitals have a staff development coordinator who is responsible for
continuing and in-service education programmes. A staff nurse is selected as a preceptor
to assist the new nurse in the unit based on their skill and competence. The role of the
preceptor are:
As an orienteer
As a teacher
As a resource person
As a counselor
As a role model and evaluator
IN-SERVICE EDUCAION:
DEFINITION:
In-service education aims at developing the ability for efficient working and the capacity
for continuous learning, so that one may adapt to changes with judgment and produce profitable
services which become an important tool for the health care of the society and nation.
Help a person‘s
performance effectively
as a personal work Concept
In hospital nursing services, it becomes the process of helping the nurse to carry out the
functions with their obligations for nursing services. It helps to develop their skills necessary to
reach the ultimate goals of health agency. i.e. (i) The highest quality of the patient care, and (ii)
to keep abreast of changing technique and use of sophisticated tools and equipment.
CHARACTERISTICS
The economic, social, medical and technological sciences which affect that society will
affect nursing in-service education. The related factors affect the in-service education
programmes are:-
Centralized Approach
Decentralized Approach
Co-ordinated Approach
Advantages:
Budget control
Evaluation of programme can be facilitated
Prior decision on resources, people, places and things
Committees are directed to work on specific problems identified by administration.
Disadvantage:
In this approach, control in planning for an in-service is a responsibility of employees and the
qualities which are valued more are self direction, initiative and participation.
Advantages:
Individuals are working in the same unit and confront problems are common
Share the responsibilities for meeting the in-service needs
Proper contribution of the participants is expected
Disadvantages:
Lack of leadership
Conflicts
Inefficiency
Less or no budget
Advantages:
CONTINUING EDUCATION
DEFINITION:
1. Continuing education is ―any extension of opportunities for reading, study and training to
any person and adult following their completion of or withdrawal from full time school
and /or college programmes.‖
2. Continuing education is an ―educational activity, primarily designed to keep
the registered nurses abreast of their particular field of interest and do not lead to any
formal advanced standing in the profession.‖
It has been believed that the system of higher education which provides the basic
preparation or the members of a profession must also provide opportunities for practitioners to
keep abreast of advances in their field.
Planning is the key stone for the administrative process. Without adequate planning,
continuing education offerings are fragmented, haphazardly constructed, and often unrelated. A
successful continuing education programme is the result of careful and detailed planning.
Effective planning is required at all levels, local, state, regional and 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.
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 you have at your disposal.
2. Why is it necessary?
When breaking the units into separate jobs think of 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 n terms of the utilization ofmen,
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.
Applies adult learning principles when helping employees learn new skills or information
Uses teaching techniques that empower staff
Sensitive to the learning deficits of the staff and creatively minimize these difficulties
Prepare employees readily regarding knowledge and skill deficits.
Actively seeks out teaching opportunities
Frequently assess learning needs of the unit
FUNCTIONS:
DEFINITION OF EVALUATION:
Evaluation is the process of finding out how the development or training process has
affected the individual, team and the organization. or
Evaluation is a value judgment on an observation, ―performance test‖ or indeed any data whether
directly measured or inferred
TYPES OF EVALUATION
LEVELS OF EVALUATION
An Evaluation Framework
The four stages of evaluation are intended to measure: (1) Reaction, (2) Learning, (3) Behavior
and actions, and (4) Results.
INTRODUCTION:
Nursing and non nursing personals in hospitals plays an important role in patient care and
the development of the hospital. Their entire role is very important to improve the standard of
care.
ADMINISTRATOR:
A hospital administrator is usually an individual responsible for the day to day operational
running of the health care institution. Specific duties include recruitment and retention of
physicians, overseeing quality, improvement of processes for efficient delivery of patient care,
setting standards, oversight of budgets, creating financial and business strategies to assure fiscal
viability and health.
MANAGER:
The nurse plans, gives directions, develops staff, monitors operations, gives rewards fairly,
and represents both staff members and administration as needed. The nurse manages the nursing
care of individuals, groups, families and communities. The nurse manager delegates nursing
activities to ancillary workers and other nurses and supervises and evaluates their performance.
COUNSELOR:
In most organizations counselors' play an important role in the induction of new employees.
At this stage counselors can do much to help new employees. They take new employees round
the hospital, show them different departments and explain their functioning, explains rules and
regulations of hospital and of cafeteria, issue lockers and uniforms, and introduce them to the
administrator and medical superintend.
1. Emotional Problem
2. Behavioral Problem
3. Personal Problem
4. Environmental Problem
5. Organizational Problem
1. Emotional Problem
Unpleasant emotions like fear, anger, and jealousy, which are harmful to the well-being and
development of individual employee in hospital setting.
2. Personal Problems
Major organisational problems are lack of group cohesiveness, role conflict, feeling of
inequality, role ambiguity, role over load, lack of supervisory support, constraints of rules and
regulations, job mismatch, inadequacy of role authority, absenteeism, job dissatisfaction, labour
turnover and job stress.
CHANGE AGENT
The nurse initiates changes and assist the client make modifications in the lifestyle to
promote health. This role involves, identifying the problem, assessing the client‘s motivations
and capacities for change, determining alternatives, assessing resources, determining appropriate
helping roles, establishing and maintaining a helping relationship, recognizing phases of the
change process, and guiding the client through these phases.
RESEARCHER
The nurse participates in scientific investigation and uses research findings in practice. The
nurse helps develop knowledge about health and promotion of health over the full life span; care
of person with health problems and disabilities; and nursing actions to enhance people‘s ability
to respond effectively to actual or potential health problems.
CASE MANAGER
The nurse coordinates the activities of other members of health care team, such as nutritionists
and physical therapist, when managing a group of client‘s care.
COLLABORATOR
The nurse works in a combined effort with all those involved in care delivery, for a mutually
acceptable plan to be obtained that will achieve common goals. The nursing initiates nursing
actions within the health team
HEALTH EDUCATORS
Work to encourage healthy lifestyles and wellness through educating individuals and
communities about behaviors that can prevent diseases, injuries, and other health problems.
After assessing their audiences' needs, health educators must decide how to meet those needs.
Health educators have a lot of options in putting together programs. They may organize an event,
such as a lecture, class, demonstration or health screening, or they may develop educational
material, such as a video, pamphlet or brochure. Often, these tasks require working with other
people in a team or on a committee. Health educators must plan programs that are consistent
with the goals and objectives of their employers. For example, many nonprofit organizations
educate the public about one disease or health topic, and, therefore, limit the programs they
issue.
ADVICER:
Specific responsibilities:
1. Act as advisor in Tech-Serve project on matters relating to hospital management
improvement in provincial hospitals, based on previous experience.
3. Work closely with the other national and international Tech-Serve Hospital Management
Advisors concerning the Tech-Serve Hospital Management Improvement Initiative, reviewing
and developing MOPH policies and active participation in the MOPH Hospital Management
Task Force.
4. Provide technical assistance to EPHS workshops conducted at the provincial and central level
as well as participate in visits to provincial hospitals for purposes of training, conducting quality
standards assessment or preparing necessary workshops of Tech-Serve.
5. Travel regularly to the provincial hospitals for the purpose of supporting, training,
and monitoring the activities of the hospital leadership.
8. Collect statistical data as needed for the purposes of monitoring hospital performance
and providing comparative information on hospital performance to peer facilities and MSH.
9. Advocate for external support as needed by the hospitals, both within MSH and at the MOPH
through the Hospital Management Task Force.
10. Any other duties, as requested by the Chief of Party, Program Directors, or Program
Manager for Capacity Building.
ADVOCATOR:
A patient advocate may be charged with a cadre of duties, from gathering information from
doctors and hospitals to helping discuss and decide treatment options.
IMPLEMENTER:
The nurse should implement all of the hospital policies. They should implement patient
care according to their planning.
EVALUATOR:
The nurse evaluator should evaluate staff performance and give feedback about their
work. It helps the staff to improve their knowledge and practice.
DUTIES OF NURSING PERSONALS IN HOSPITAL:
A nursing superintendent supervises the nursing staff. The nursing superintendent, who is
also called the director of nursing, is responsible for the running and supervision of a nursing
department. Depending on the size of the facility, she may control subsidiary departments, such
as housekeeping. Nursing superintendents generally report to the hospital director or medical
director of their facility.
The top priority of a nursing superintendent is to ensure that the nursing staff members are
providing the best care for patients. She makes sure that individual nurses and nurses aides are
carrying out care plans and ensures that communication between shifts happens smoothly and
thoroughly. The superintendent also monitors stock and supplies to make sure that nurses have
the equipment they need to provide quality care.
The nursing superintendent is responsible for the hiring and training of new staff. She must
search for nurses that complement the existing team, design training programs and make sure
that nursing instructors and trainers are adequately preparing new staff for the workplace. Often
this includes hearing an evaluation of new nurses from the floor staff during the training period.
Patient care
Although the nursing superintendent does not have a high level of direct patient care, she is
responsible for the well-being of patients at the facility. This means that the superintendent must
monitor nurses' care and the attitude and health of the patients. In cases where the family requests
alternate care, the nursing superintendent must hear the request and make the final decision.
Each pay period, the nursing superintendent is responsible for setting the work schedules for
the entire department. She must take into account holidays, hear requests for time off, and create
a schedule that gives the appropriate number of hours to each nurse. As part of the process, the
nursing superintendent assigns duties and floor responsibilities to each nurse.
Make disciplinary decisions
In situations where a nurse, nurse's aide, or other staff member is involved in a dispute, the
nursing superintendent must handle disciplinary actions. In extreme cases like patient abuse or
staff coming to work under the influence, the nursing superintendent is responsible for
terminating contracts as needed.
In a large facility, the nursing superintendent may be responsible for directing the activities
of the housekeeping, linen, and kitchen facilities. She must handle any problems that arise,
communicate with department leaders, and address any supply issues.
Because the nursing superintendent is responsible for the supply of equipment and medical
necessities, she often negotiates with vendors for the new contracts. In large facilities, a
purchasing manager may handle these duties and report to the superintendent.
Essential Functions/Responsibilities:
1. Take responsibility for a group of activities or subcontractors and manage the work to be
done. Provide liaison between field engineering, estimating, and subcontractors to ensure
compliance of construction with drawings and specifications.
3. Monitor work performance and productivity of crafts to ensure project rules, procedures,
safety requirements, etc. are maintained.
4. Advise senior level supervision and project management of potential problems, work
interferences, schedule difficulties, etc. Assist in circumventing/resolving such problems as
required.
5. Maintain liaison with other departments, i.e., Purchasing, Accounting, Engineering, etc. as
required to support construction schedule. May provide assistance to the Superintendent in
resolving problems.
Functions:
A. Clinical Activities:
1. Assesses the situation of given unit in relation to different types of patient‘s care,
facilities provided by the nursing personnel.
2. Identifies the patient‘s need/problem in the unit.
3. Assigns the patient‘s care and others activities to nursing personnel.
4. Evaluates the patient‘s care given by nurses.
5. Attends Doctor‘s round and Matron and Assistant Matron‘s Clinical rounds.
6. Checks and caries out and delegates Doctor‘s instruction and order after round.
7. Participates and refers the patient for rehabilitation therapy.
8. Guides and conducts health education activities to client as required including MCH/FP
disease control and health promotion.
B. Supervisory Activities
1. Guides and supervises all staff for giving bed side nursing care.
2. Maintains regular records, report concerning the patient‘s care.
3. Provides direct guidance and supervision of nursing and non-nursing personnel for the
efficient running of the wards and in carrying out nursing routines, bearing in mind the
individual needs of patients.
4. Encourages motivates, assesses the effectiveness of their own works and develops their
potential for giving good nursing care.
5. Uses the standard guideline and manual for supervision.
C. Administrative Activities
D. Educative Activities
Perioperative registered nurses provide surgical patient care by assessing, planning, and
implementing the nursing care patients receive before, during and after surgery. These activities
include patient assessment, creating and maintaining a sterile and safe surgical environment, pre-
and post-operative patient education, monitoring the patient‘s physical and emotional well-being,
and integrating and coordinating patient care throughout the surgical care continuum.
During surgery, the perioperative registered nurse may assume any of the following
responsibilities:
Scrub nurse – works directly with the surgeon within the sterile field by passing
instruments, sponges, and other items needed during the surgical procedure.
Circulating nurse – works outside the sterile field. Responsible for managing the nursing
care within the O.R. by observing the surgical team from a broad perspective and
assisting the team in creating and maintaining a safe, comfortable environment.
Those who are suffering from skin disorders or in need of skin care may seek the services
of a dermatology nurse. Dermatology nurses are registered nurses who specialize in treating skin
disorders and may administer treatments for their patients. In some cases, they may prescribe
medication. The nurse may also educate their patients on maintaining healthy skin.
A geriatric nurse is a registered nurse who specializes in the care of elderly people.
Geriatric nurses must have the same educational background as registered nurses, including a
bachelor's degree from an accredited college or university. Duties of a geriatric nurse, however,
differ from other fields of nursing due to the unique problems that can arise in elderly patients.
Assess Problems
1. Geriatric nurses must be able to assess medical problems of their elderly patients. Often,
it is the geriatric nurse who must decide if his patient can preform every day tasks on her
own. Assessments may be in activities like driving, walking and taking medications.
Communication Skills
2. Geriatric nurses must be able to determine, through both verbal and non-verbal
communication, the health of patients by knowing symptoms, ailments and medications
being taken by patients. Geriatric nurses are the liaison between doctors, patients,
patients' families and other health-care facility workers.
3. Patient Relationships
Geriatric nurses often spend large amounts of time with their patients, causing them to
have close-knit relationships with the patients and their families. Geriatric nurses,
because of the time spent with their elderly patients, must be able to cope with the death
of patients as well as the decline of a patient's mental and physical health.
Provide preventive care and treat patients with a variety of illnesses and injuries in
physicians' offices or in clinics. Some ambulatory care nurses are involved in telehealth,
providing care and advice through electronic communications media such as videoconferencing,
the Internet, or by telephone.
Critical care nurses provide care to patients with serious, complex, and acute illnesses or
injuries that require very close monitoring and extensive medication protocols and therapies.
Critical care nurses often work in critical or intensive care hospital units.
ICU nurses are specialized, trained nurse professionals working with patients who have life-
threatening situations that required an extended hospital stay in an intensive care or critical care
unit of the hospital. The ICU nurse must be skilled to make complex assessments, give the
patient intense therapy and provide intervention care. The nurse may also perform ongoing duties
for a patient in ICU unit during his stay.
Assessment
Individualized assessment is made by the ICU nurse to determine the immediate needs of the
critical care patient. Ongoing assessment is then established to keep tabs on the patient's
condition and make any changes in treatment based on hospital policy, procedure and protocol.
Assessment helps the nurse and other hospital staff determine what plan of action to take in care
of the patient. Assessment also allows the ICU nurse to educate the patient and her family on
what to expect in the days, weeks and months following ICU treatment.
Patient Care
Following doctor or head nurse instructions, the ICU nurse performs treatments and therapies for
the patient. She gives the patient all necessary medication. If the patient lapses into cardiac arrest
or another condition that requires resuscitation, the nurse follow hospital protocols and
administers life-saving techniques. When a patient's condition changes rapidly, the nurse makes
quick decisions to treat the patient effectively. As shift changes occur, it is the nurse's duty to
inform the relief nurse of all patient care information. If the patient requires special procedures,
the ICU nurse acts as an assistant to the doctor or head nurse.
Administrative
Documentation of assessments and drug therapy is recorded by the ICU nurse. She also makes
documentation of physical therapy and other treatments given. The nurse must also keep all
patient clinical records with doctor orders confidentially secure. The ICU nurse must be non-
discriminative and nonjudgmental when dealing with patients.
Transport nurses:
Transport nurses will provide medical care to patients who are transported by helicopter or
airplane to the nearest medical facility.
Holistic nurses:
Holistic nurses will provide care such as acupuncture, massage and aroma therapy, and
biofeedback, which are meant to treat patients' mental and spiritual health in addition to their
physical health.
Home health care nurses:
Home health care nurses will provide at-home nursing care for patients, often as follow-up
care after discharge from a hospital or from a rehabilitation, long-term care, or skilled nursing
facility.
Hospice and palliative care nurses work in collaboration with other health providers (such
as physicians, social workers, or chaplains) within the context of an interdisciplinary
team. Composed of highly qualified, specially trained professionals and volunteers, the team
blends their strengths together to anticipate and meet the needs of the patient and family facing
terminal illness and bereavement.
Infusion nurses:
Infusion nurses administer medications, fluids, and blood to patients through injections into
patients' veins. Infusion nurses specialize in administering parenteral fluids, blood & blood
components, pharmacological agents, nutritional solutions and pain medications.
Long term care nurses provide healthcare services on a recurring basis to patients with chronic
physical or mental disorders, often in long-term care or skilled nursing facilities.
Surgical nurses are a vital part of the health care team that provides care for patients before,
during and after surgical procedures. They work both inside and outside of the sterile field to
provide both direct patient care and support to the surgical staff.
General Duties
Surgical nurses are RNs who work in the operating, pre-surgical or recovery areas of a
hospital, outpatient surgical center or emergency ward, under the supervision of the operating
physician. They perform many functions that allow surgeries to proceed smoothly, including
preparing patients for surgery, assisting the surgeon during procedures and following up with
patients during recovery.
Recovery nurses
Surgical prep and recovery nurses are RNs who care for individuals before surgery and
during recovery. They prepare patients for surgical procedures by starting intravenous lines,
administering medication, taking a complete health history, completing additional tests such as
blood work, and performing pre-surgical preparations such as shaving.
Scrub Nurses
Scrub nurses are RNs who work within the sterile field to assist the surgeon. The scrub
nurse has scrubbed with antimicrobial soap and is outfitted in a sterile suit. Scrub nurses prepare
the needed instruments and other supplies for surgery and hand them to the surgeon during the
procedure. Typically, scrub nurses acquire their position only after they have gained extensive
nursing experience.
Circulating Nurses
Circulating nurses assist the surgical team in various ways but do not work within the sterile
field. Some of the duties of a circulating nurse include obtaining additional equipment or
instruments for the team, monitoring the condition of the patients, preparing tissue samples for
transport to a lab, and disposing of biohazardous material..
Registered nurse first assistants (RNFA) have extensive additional training and clinical
experience that qualifies them to assist surgeons by performing basic surgical procedures. An
RNFA must take coursework in perioperative care and surgical procedures and pass the CRNFA
(Certified Registered Nurse First Assistant) professional board exam. Duties of a RNFA may
include suturing, exposing a wound, controlling bleeding and assisting surgeons in holding or
operating other instruments.
The prevention of health problems, promotion of healthy living and working conditions
Understanding the effects of work on health and health at work
Basic first aid and health screening
Workforce and workplace monitoring and health need assessment
Health promotion
Education and training
Counseling and support
Risk assessment and risk management
Perianaesthesia nurses:
Mental health nurses help psychiatrists, psychologists and other mental health professionals
counsel and treat patients with a variety of emotional and psychiatric issues, from substance
abuse oriented problems to paranoid-schizophrenia. Mental health nurses also help with the
dispensing of medication for patients. Psychiatric nurses with an advanced education may be
able to prescribe medication on their own.
Radiology nurses:
Radiology nurses provide care to patients undergoing diagnostic radiation procedures such as
ultrasounds, magnetic resonance imaging, and radiation therapy for oncology diagnoses.
Radiology nurses routinely start or check peripheral i.v.s, assess infusaports, administer
medications, monitor vital signs, suction patients, insert foleys and help patients with their
personal needs.
Rehabilitation nurses:
The goal of the rehabilitation nursing profession is to treat patients who require a broad range
of medical services for their recovery. People who need rehabilitation nursing care may have
suffered from such things as work injuries, car accidents, strokes, head trauma, drug or alcohol
abuse, gunshot wound or other severe trauma. These nurses find work in general hospitals,
rehabilitation centers, drug and alcohol recovery facilities, mental hospitals, senior citizen
facilities, or private homes. Rehabilitation nurses are able to provide a broad range of services
depending on the facility they work in.
Transplant nurses:
Transplant nurses care for both transplant recipients and living donors and monitor signs of
organ rejection.
Addictions nurses:
Addictions nurses care for patients seeking help with alcohol, drug, tobacco, and other
addictions.
• Liaise with mental health team, addictions team, psychology dept, social workers, medical
staff and general health team;
• Promoting healthy living and harm reduction initiatives to clients, eg safer injecting;
• Provide support and counseling for blood borne virus testing as required;
• Liaise with community agencies from a client‘s admission through to preparation for
and release from prison.
This post has a diverse range of responsibilities and excellent communication and interpersonal
skills are essential.
Intellectual and developmental disabilities nurses provide care for patients with physical,
mental, or behavioral disabilities; care may include help with feeding, controlling bodily
functions, sitting or standing independently, and speaking or other communication.
Genetic nurses:
Genetic nurses provide early detection screenings, counseling, and treatment of patients with
genetic disorders, including cystic fibrosis and Huntington's disease.
HIV/AIDS nurses:
HIV/AIDS nurses care for patients diagnosed with HIV and AIDS. They should give proper
care, education, psychological support and counseling to the patients.
Oncology nurses:
Oncology nurses care for patients with various types of cancer and may assist in the
administration of radiation and chemotherapies and follow-up monitoring.
The following discussion on the role of the oncology nurse focuses on patient assessment,
patient education, coordination of care, direct patient care, symptom management, and
supportive care. To illustrate how varied the role may be and its importance across the
continuum of cancer care, examples related to the role of the oncology nurse in direct patient
care, symptom management, and supportive care are provided.
Wound, ostomy, and continence nurses treat patients with wounds caused by traumatic
injury, ulcers, or arterial disease; provide postoperative care for patients with openings that allow
for alternative methods of bodily waste elimination; and treat patients with urinary and fecal
incontinence.
Cardiovascular nurses:
Cardiovascular nurses treat patients with coronary heart disease and those who have had
heart surgery, providing services such as postoperative rehabilitation.
Pre-Operative Responsibilities
Pre-operative care includes evaluating a patient's readiness for surgery by taking a detailed
medical history and performing a complete physical examination. This is followed by ordering
appropriate tests for assessment and prescribing necessary medications for surgery.
Operative Responsibilities
Operative responsibilities include assisting in preparation of the patient by positioning the patient
on the operating room table and applying appropriate draping for the surgical procedure.
Assisting the general operation as needed by a surgeon is also required.
Post-Operative Responsibilities
Post-operative care includes evaluating the patient's recovery process by checking vital signs,
administering intravenous lines, ordering medications and laboratory tests as needed and
monitoring the patient to ensure there are no complications after surgery.
Gynecology nurses:
Gynaecology nurses provide care to women with disorders of the reproductive system,
including endometriosis, cancer, and sexually transmitted diseases.
Nephrology nurses:
Nephrology nurses care for patients with kidney disease caused by diabetes, hypertension, or
substance abuse.
Before dialysis, the nurse assists the patient in seeking information about his disease,
prognoses and treatments. The nurse is responsible for ensuring that appropriate care is available.
Prior to the actual treatment, the nephrology nurse must evaluate if it's safe for treatment to
begin. If the patient has no new acute health issues, the nurse continues with the preparation for
dialysis.
Neuroscience nurses:
Neuroscience nurses care for patients with dysfunctions of the nervous system, including
brain and spinal cord injuries and seizures.
Ophthalmic nurses:
Ophthalmic nurses provide care to patients with disorders of the eyes, including blindness
and glaucoma, and to patients undergoing eye surgery.
Orthopedic nurses:
Orthopedic nurses care for patients with muscular and skeletal problems, including arthritis,
bone fractures, and muscular dystrophy.
Otorhinolaryngology nurses:
Otorhinolaryngology nurses care for patients with ear, nose, and throat disorders, such as
cleft palates, allergies, and sinus disorders.
Respiratory nurses:
The role of respiratory nurses is to promote good pulmonary (lung) health within
individuals, families and communities. By building close relationships with doctors and patients
in their community, respiratory nurses educate the public on the importance of healthy breathing
and proper exercise in people of all ages.
Urology nurses:
Urology nurses care for patients with disorders of the kidneys, urinary tract, and male
reproductive organs, including infections, kidney and bladder stones, and cancers.
A urology nurse cares for patients with urinary tract problems in a hospital, urology clinic, or
private doctor's office. A nurse performs initial evaluations of symptoms, assists doctors with
diagnostic and treatment procedures, and provides expert patient education and counseling
services. Professionals see patients who have urinary tract infections, kidney stones, cancers,
prostatitis, or any of a number of other specific conditions.
Clinical nurse specialists provide direct patient care and expert consultations in one of
many nursing specialties, such as psychiatric-mental health.
Nurse anesthetist:
Nurse anesthetist provides anesthesia and related care before and after surgical, therapeutic,
diagnostic and obstetrical procedures. They also provide pain management and emergency
services, such as airway management.
Nurse midwives:
Nurse midwives provide primary care to women, including gynecological exams, family
planning advice, prenatal care, assistance in labor and delivery, and neonatal care.
Nurse practitioners:
Nurse practitioners serve as primary and specialty care providers, providing a blend of nursing
and healthcare services to patients and families. The most common specialty areas for nurse
practitioners are family practice, adult practice, women's health, pediatrics, acute care, and
geriatrics. However, there are a variety of other specialties that nurse practitioners can choose,
including neonatology and mental health.
Forensics nurses:
Forensics nurses participate in the scientific investigation and treatment of abuse victims,
violence, criminal activity, and traumatic accident.
Main function of a forensic nurse is to collect information about crime and investigate details
about it but it is not the only work that they do. Forensic nurses even provide medication and
relief to the victims of any crime, they even provide counseling to offenders and even children
who at times go off track and start indulging in unethical activities.
An infection control nurse has one primary role, and that is to prevent hospital infections in
their patients by carrying out infection prevention protocols diligently. nurses can play an
important role in controlling and preventing the spread of infectious diseases in health care
facilities. In fact, several nurse duties are aimed solely at infection control.
Nurse educators:
Nurse educators plan, develop, implement, and evaluate educational programs and curricula
for the professional development of student nurses and RNs.
Nurse informaticists:
Nurse informaticists manage and communicate nursing data and information to improve
decision making by consumers, patients, nurses, and other healthcare providers. RNs also may
work as healthcare consultants, public policy advisors, pharmaceutical and medical supply
researchers and salespersons, and medical writers and editors.
Work environment. Most RNs work in well-lit, comfortable healthcare facilities. Home health
and public health nurses travel to patients' homes, schools, community centers, and other sites. .
RNs may be in close contact with individuals who have infectious diseases and with toxic,
harmful, or potentially hazardous compounds, solutions, and medications. RNs must observe
rigid, standardized guidelines to guard against disease and other dangers, such as those posed by
radiation, accidental needle sticks, chemicals used to sterilize instruments, and anesthetics. In
addition, they are vulnerable to back injury when moving patients.
INTRODUCTION
Motivation is an action that stimulates an individual to take a course of action, which will
result in an attainment of goals, or satisfaction of certain material or psychological needs of the
individual. Motivation is a powerful tool in the hands of leaders. It can persuade convince and
propel people to act.
DEFINITION
Motivation is ―an inner impulse or an internal force that initiates and directs the individual to act
in a certain manner to satisfy a need.‖
Motivating force is a need that comes from within an individual, e.g. to make a living, gain status
and respect or to remove a source of frustration (Review of Maslow‘s Hierarchy of Needs).
―Motivation refers to the way in which urges, drives, desires, aspirations, striving or needs direct,
control or explain the behavior of human beings‖. -Dalton E. McFurland,
The nurse manager must realize that nurses have different personalities, work habits, and
what motivates one nurse may not motivate others. Meanwhile, some nurses are skilled,
confident, and capable of self-direction and seem to motivate themselves, while other nurses lack
self-confidence; they do their jobs poorly and have little motivation. The nurse manager is
responsible to motivate the second group and to improve their performance.
Researchers have revealed that job performance is the result of the interaction of two
variables; the ability to perform the task and the amount of motivation.
Job dissatisfaction:
Job dissatisfaction contributes to higher turnover rates and decreased productivity and
considerable time and money are required to recruit and select a replacement for someone who
leaves the organization, it also takes time to socialize new employee to the organizational
culture, which is expensive time, beside that, other employees will need to carry more load to
cover the needs, and at last the kind of interruptions that results from the loss of this employee.
For all those reasons the manager should be concerned about job satisfaction of employee, and to
do that there is a need to look at the different theories.
TYPES OF MOTIVATORS
1) Intrinsic motivation: Refers to motivation that comes from within the person, driving
him or her to be productive. It is related to a person‘s level of inspiration. The motivation
comes from the pleasure one gets from the task itself or from the sense of satisfaction in
completing or even working on the task rather than from external rewards.
2) Extrinsic motivation: It refers to motivation that comes from outside an individual, i.e.
enhanced by the work environment or external rewards such as money or grades. The
rewards provide a satisfaction and pleasure that the task itself may not provide. An
extrinsically motivated person will work on a task even when they have little interest in it
because of the anticipated satisfaction they will get from the reward. e.g.- reward for a
student would obtain good grade on an assignment or in the class.
TYPES OF MOTIVATION
1) Achievement motivation
It is the drive to peruse and attain goals. An individual with achievement
motivation wishes to achieve objectives and advance up the ladder of success. Hence,
accomplishment is important for his/her own sake and not for the rewards that accompany
it.
2) Affiliation motivation
It is a drive to relate to people on a social basis. Individuals with affiliation
motivation perform work better when they are complimented for their favourable attitude
and co-operation.
3) Competence motivation
It is the drive to be good at something, allowing the individual to perform high
quality work. Competence/skill motivated individuals seek job mastery, take pride in
developing and in using their problem solving skills and strive to be creative when
confronted with obstacles. They learn from their experiences.
4) Power motivation
It is the drive to influence people and change situations. Power motivated people
wish to create an impact on their organisation and are willing to take risks.
5) Attitude motivation
Attitude motivation is how people think and feel. It is their self-confidence, their
belief in themselves and their attitude to life. It is how they feel about the future and how
they react to the past.
6) Incentive motivation
It is where the people are motivated through external rewards. Here, a person or
team reaps a reward from an activity. It is the type of rewards that drive people to work
harder.
7) Fear motivation
Fear motivation coercions a person to act against will. It is instantaneous and gets
the job done more quickly. Fear motivation is helpful in the short run.
Nature of motivation
Unending process: human wants keep changing & increasing.
A psychological concept: deals with the human mind.
Whole individual is motivated: as it is based on psychology of the individual.
Motivation may be financial or non-financial: Financial includes increasing wages,
allowance, bonus, etc.
Motivation can be positive or negative: positive motivation means use of incentives -
financial or non-financial. E.g. of positive motivation: confirmation, pay rise, praise etc.
Negative motivation means emphasizing penalties. It is based on force of fear. Eg.
demotion, termination.
Motivation is goal-oriented behaviour.
Motivation is an internal feeling of an individual. It can‘t be observed directly; we can
observe an individual‘s action and interpret his behavior in terms of underlying motives.
This leaves a wide margin of error. Our interpretation may not reveal the individual‘s true
behavior.
Motivation is a continuous process that produces goal directed behavior. The individual
tries to find alternatives to satisfy his needs.
Motivation is a complex process. Individual may differ in their motivation even though
they are performing the same type of job. For example, if two men are engaged in cutting
stones for constructing a temple, one may be motivated by the amount of wages he gets
and the other by the satisfaction he gets by performing the job.
COMPONENTS OF MOTIVATION
Direction
Effort
Persistence
We start off by deciding what we want, which is our direction as we know where we want to
go and what we have to achieve. Then we make an effort towards our goal. We start to do things
and we continue our making the efforts for some time and give it everything that we have. Now
comes the part where we have to be persistent with our efforts and keep doing them.
SOURCES OF MOTIVATION
REQUISITES TO MOTIVATE
We have to be Motivated to Motivate
Motivation requires a goal
Motivation once established, does not last if not repeated
Motivation requires Recognition
Participation has motivating effect
Seeing ourselves progressing Motivates us
Challenge only motivates if you can win
Everybody has a motivational fuse i.e. everybody can be motivated
Group belonging motivates
In the initiation, a person starts feeling lacknesses. There is an arousal of need so urgent,
that the bearer has to venture in search to satisfy it. This leads to creation of tension, which urges
the person to forget everything else and cater to the aroused need first. This tension also creates
drives and attitudes regarding the type of satisfaction that is desired. This leads a person to
venture into the search of information. This ultimately leads to evaluation of alternatives where
the best alternative is chosen. After choosing the alternative, an action is taken. Because of the
performance of the activity satisfaction is achieved which than relieves the tension in the
individual.
Leadership Roles:
The nurse manager while managing the nursing unit will have to choose a combination of the
following measures to facilitate nurses‘ motivation.
Encouragement means helping and reassuring nurses regardless of the type of problems.
Develop a supportive environment by reducing physical stresses associated with the job.
Support means removing obstructions and providing nurses with satisfying work
environment which include personnel and facilities and suitable learning materials needed to do
their job.
a) Give recognition for successful achievement of the job. Praise frequently and informally.
It can be in front of other staff.
b) Reward includes: Pay increase, promotion, training for advancement to a higher level
within a job.
c) Thank you is a type of reward that helps to increase self-confidence.
The word motivation theory is concerned with the processes that describe why and how
the human behaviour is activated and directed. It is considered as one of the most important areas
of study in the field of organizational behaviour. There are two different categories of motivation
theories- the content theories and the process theories.
In an individual, more than one need may be operative at the same time.
If a higher need goes unsatisfied than the desire to satisfy a lower need intensifies.
When the higher level needs is frustrated; people will regress to the satisfaction
of the lower-level needs. This phenomenon is known as frustration-regression
process
The motivation factors create opportunities for high satisfaction, high motivation and
high performance. Absence of motivation factors causes a lack of job satisfaction.
4) David McClelland(1961)
David McClelland has developed a theory on three types of motivating needs:
Need for Power
Need for Affiliation
Need for Achievement
People with high need for power are inclined towards influence and control. They like to
be at the center and are good orators. They are demanding in nature, forceful in manners and
ambitious in life. They can be motivated to perform if they are given key positions or power
positions.
In the second category are the people who are social in nature. They try to affiliate
themselves with individuals and groups. They are driven by love and faith. They like to build
a friendly environment around themselves. Social recognition and affiliation with others
provides them motivation.
People in the third category are driven by the challenge of success and the fear of failure.
Their need for achievement is moderate and they set for themselves moderately difficult tasks.
They are analytical in nature and take calculated risks. Such people are motivated to perform
when they see atleast some chances of success.
McClelland observed that with the advancement in hierarchy the need for power and
achievement increased rather than Affiliation. He also observed that people who were at the
top, later ceased to be motivated by this drives.
5) McGregor‟s Theory X and Theory Y
Douglas McGregor proposed two different motivational theories- theory X and theory Y.
He states that people inside the organization can be managed in two ways. The first is
basically negative, which falls under the category X and the other is positive, which falls
under the category Y.
Assumptions of theory X:
Employees inherently do not like work and whenever possible, will attempt to avoid it.
Because employees dislike work, they have to be forced, coerced or threatened with
punishment to achieve goals.
Employees avoid responsibilities and do not work until formal directions are issued.
Most workers place a greater importance on security over all other factors and display little
ambition.
Assumptions of theory Y:
Physical and mental effort at work is as natural as rest or play.
People do exercise self-control and self-direction and if they are committed to those goals.
Average human beings are willing to take responsibility and exercise imagination,
ingenuity and creativity in solving the problems of the organization.
That the way the things are organized, the average human beings brainpower is only partly
used.
On analysis of the assumptions it can be detected that theory X assumes that lower-order
needs dominate individuals and theory Y assumes that higher-order needs dominate
individuals. An organization that is run on Theory X lines tends to be authoritarian in nature-
―power to enforce obedience‖ and the ―right to command.‖ In contrast Theory Y
organizations can be described as ―participative‖, where the aims of the organization and of
the individuals in it are integrated; individuals can achieve their own goals best by directing
their efforts towards the success of the organization
7) Attitude theory
Focuses on favorable attitudes of job satisfaction and job involvement leading to high
performance.
8) Attrition/self-efficacy theory
Focuses on explanations for events or behaviour. Perceptions of self efficacy and self
esteem affect performance.
The needs of an individual are important motivators. These make the person work with
enthusiasm & interest. The significant individual needs are:
* Need for Power: Which results in a strong desire to influence staff, stimulate them to
work, making them achieve positions of leadership e.g. making the nursing supervisor
wholly responsible to take care of whole ward.
* The need for achievement results in a desire to do something better or more efficiently than
others. People with a high need of achievement have an intense desire for success & equally
intense fear of failure. They want to be challenged, prefer to assume personal responsibility
to get work done and like to work for long hours. Training and orientation (refresher) course
increase this need. All the staff working in a particular area should be given equal chance to
attend the refresher courses related to that particular area.
* Need for affiliation: - Some people derive pleasure from being loved and tend to avoid the
pain of being rejected by social group. They enjoy social relationships, intimacy, empathise and
help others in trouble. There is close intimacy when a staff nurse is allowed to plan and decide
patient care along with ward supervisor.
In order to satisfy the employees, a manger can also use Maslow's Motivation Theory in these
ways:
* Improving physical working conditions to satisfy needs e.g. grilled door and escorts to
secure the nursing staff at night, providing rest rooms for lunch and dinner.
* Increasing the level of training, development and skill in order to meet the self esteem needs
e.g. uniform, leave facilities, vacation to nursing students. If these facilities are inadequate it
harms their self esteem.
* Having congenial social group and peer group interaction to fulfill affiliation needs.
* Placing the person in position which match their self concept to fulfill the self actualization
need.
Job Design
Job design is another motivator to satisfy, signify and give value to employees encouraging them
to perform well.
Koul Jyoti conducted a study on job satisfaction of 126 staff nurses of different hospitals in J&K
State and showed that only 8% were highly satisfied. Maximum satisfaction was found for the
work itself and with the competency of supervision. The areas of best satisfaction were
concerned with material rewards and individual agency. The older age group and experienced
persons were found more satisfied.
Work Environment
There are many conditions in the environment which could possibly effect the motivation of
staff. It is seen by Behaviour Modification Theorist that employees perform positively if
environment is favorable which is made by pay/ reward policies, democratic leadership style,
peer group interaction etc.
To effect the performance of employees, their input (e.g. efforts, training, experience, skill,
education, seniority) should be equitable to their output e.g. pay, rights, benefits, job-status,
status symbol's (vacation, clothing, satisfactory superior).
The employees feel inequity if unrewarded or if given undesirable placement. The employees
always respond to the environment & these responses influence their behaviour. A nursing
Manager can accomplish this by using following motivational techniques.
* Positive Reinforcement: Annual reward for better performance in the form of money,
recognition, praise, promotion etc. Give reward to the most clean and best patient care ward
on Annual days.
* Avoidance Learning: Some staff nurses improve their behaviour in order to avoid criticism of
Nursing. Superintendent or to avoid any disciplinary action against her.
* Be sure to tell a person she / he is doing wrong and what type of behaviour is desired e.g. RT
feeding given with force by use of piston should be corrected and demonstrated so that goes
with gravity.
* Making the staff participate in different activities which give them affiliation, acceptance and
recognition, e.g. in conferences, Nurses'-Day, Hospital Annual Day etc.
* Warmth, support and identity motivate the staff to perform better. Every staff member has her
own potential. Respect their individual capabilities. Don't scold if she is performing badly in
other field. Let her develop potential gradually.
It is generally conceded that while rewards can offer workers a variety of incentives which can
not only motivate them to work harder but also produce feelings of good-will towards
management, punishment often functions only to cultivate feelings of hostility between managers
and workers, which can directly and negatively effect productivity.
Personal Satisfaction vs. Financial Satisfaction
One of the most successful ways of fostering a productive and motivated workforce is to ensure
that workers are satisfied with their jobs, not just with their pay. It is interesting to note that
people are quite often more concerned with how much they like their job than they are with how
much money they actually make. Making employees feel important in the workplace can make
them feel like part of the team, which makes them feel personally invested in the health of a
business.
By appealing to a worker's sentiments and reason a manager can persuade a worker to take
initiative and build their morale, which are internal drivers of motivation. However, by appealing
to fear and coercion a manager may actually cause a decline in internal motivation, leaving
instead feelings of hostility or anxiety which can negatively effect production.
Involvement
One of the top things leading workers to feel productive and motivated in the workplace is
knowing that they have a good management team. When people feel close to their managers they
oftentimes do not want to disappoint, and may even feel the desire to win approval. By being
invested in workers, managers can get workers to feel reciprocally invested in their workplace
and their work. Fostering motivation in the workplace is first and foremost about fostering good
management practices.
2. Job enlargement: is a motivation technique used for employees that perform a very few
and simple tasks. It increases the number and variety of tasks that the employee performs,
resulting in a feeling of importance
3. Job enrichment: this method increases the employees control over the work being
performed. It allows the employees to control the planning, execution and evaluation of
their own work, resulting in freedom, independence and added responsibility.
4. Flexible time: this allows the employees to choose their own work schedule to a certain
extend.
5. Job sharing: a less common method but very effective in preventing boredom. It allows
employees to share two different jobs
6. Employee involvement: people want to feel like they are a part of something. Letting the
employees to be more active in decision-making related to their job makes them feel
valued and important to the company and increases job motivation.
7. Variable pay programs: merit based pay, bonuses, gain sharing, and stock ownership
plans are some good motivators for employees. They should be offered as an incentive or
reward for outstanding performance.
INTRODUCTION:
Nurse Managers are required to be aware of the techniques that can help them ensure
effective management of educational/service unit. Communication is one of the most important
activities in the nursing management. It is the foundation upon which the manager achieves
organizational objectives.
MEANING OF COMMUNICATION:
DEFINITION OF COMMUNICATION:
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 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
moulding 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:
ELEMENTS:
Source idea
Message
Encoding
Channel
Receiver
Decoding
Feedback
Source idea:
The Source idea is the process by which one formulates an idea to communicate to another
party. This process can be influenced by external stimuli such as books or radio, or it can come
about internally by thinking about a particular subject. The source idea is the basis for the
communication.
Message:
The Message is what will be communicated to another party. It is based on the source idea,
but the message is crafted to meet the needs of the audience. For example, if the message is
between two friends, the message will take a different form than if communicating with a
superior.
Encoding:
Encoding is how the message is transmitted to another party. The message is converted into
a suitable form for transmission. The medium of transmission will determine the form of the
communication. For example, the message will take a different form if the communication will
be spoken or written.
Channel:
The Channel is the medium of the communication. The channel must be able to transmit
the message from one party to another without changing the content of the message. The channel
can be a piece of paper, a communications medium such as radio, or it can be an email. The
channel is the path of the communication from sender to receiver. An email can use the Internet
as a channel.
Receiver:
The Receiver is the party receiving the communication. The party uses the channel to get
the communication from the transmitter. A receiver can be a television set, a computer, or a
piece of paper depending on the channel used for the communication.
Decoding:
Decoding is the process where the message is interpreted for its content. It also means the
receiver thinks about the message's content and internalizes the message. This step of the
process is where the receiver compares the message to prior experiences or external stimuli.
Feedback:
Feedback is the final step in the communications process. This step conveys to the
transmitter that the message is understood by the receiver. The receiver formats an appropriate
reply to the first communication based on the channel and sends it to the transmitter of the
original message.
CHARACTERISTICS OF COMMUNICATION:
1. Clarity:
2. Aim or Goal:
3. Precision:
* Be precise & exact in your approach. Neither be too deep nor be too short.
* Include some good facts acknowledging your topic.
5. Linkage :
* Try to maintain a logic link between your sayings.
* Don't put two opposite faces of coin at a same time.
* Deliver in a structured & planned way.
* Try to explain the broader aspects but not on the cost of local values.
* Aggregation of local values should result into global and broader aspects.
7. Style of Expressing:
* Control various speech parameters like pitch, tone, intensity etc. according to the environment.
* Don't be too fast or too slow.
* Light Humor at the right time is always accepted.
* Look straight & forward. Keep a light smile on your face.
* Avoid using words that show arrogance.
* Feel what you say.
* Avoid being too formal, be natural and practical.
9. Do a good Homework.
* 25% confidence and 25% Respect from audiences comes automatically, if you have dressed
up well.
* Be neat, clean, ironed and polished irrespective of the fact that you have dressed up formally
or informally.
* Do a good hair styling; avoid any casual or unethical looks.
PROCESS OF COMMUNICATION:
Ideation:
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:
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.
Transmission:
The third step, transmission of the message, must overcome interference such as garbled
speech, unintelligible use of words, long complex sentences, distortion from recording devices,
noise and illegible handwriting.
Receiving:
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:
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 depend on the
receiver‘s understanding of the information.
Response or feedback:
It is the final step. It is important for the manager or sender to know that the message has
been received and accurately interpreted.
PRINCIPLES OF COMMUNICATION:
Listening
Broad openings
Restating
Clarification
Reflection
Focusing
Sharing perceptions
Silence
Humor
Informing
Suggesting
Listening:
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 e.g. 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 is 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 e.g. 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 e.g. 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.
Informing:
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.
TYPES OF COMMUNICATION:
Communication
One-way communication:
The flow of communication is one way from the communicator to the audience. Example
receive method.
Drawbacks are:
Knowledge is imposed.
Learning is authoritative.
Little audience participation.
No feedback.
Does not influence human behavior.
In this both the communicators and the audience take place. The process of communication
is active and democratic. It is more likely to influence behavior than one way communication.
FORMAL V/S INFORMAL COMMUNICATION:
Communication has been classified into formal (follows lines of authority) and informal
(group line) communication.
Formal communication:
Informal network:
Gossip circles such as friends internet group, like minded people and casual groups.
Communication is very faster here. The informal channels may be more active. It follows
grapewine route. It may be a fact but more in native of rumor. It does not reach every one
informal communications are quite fast and spontaneous.
Physiological communication:
It is a stimulus received by the body immediately the brain receives the information and
transmits to the respective organs through the nervous, where it has to be passed.
Psychic communication:
Extra sensory perception occurs, i.e something which will occur in future. The person
pertains and predicts that in advance is called psychic communication.
Serial communication:
Person to person the message will be passed line a chain. Sender passes the message to one
person, then that receiver passes information to other and so on.
Symbolic communication:
Visual communication:
The visual forma of communication comprise charts and graphs, pictograms, tables, maps,
posters etc.
VERBAL V/S NONVERBAL COMMUNICATION:
The traditional way of communication has been by word of mouth language is the chief
vehicle of communication. Through it, one can interact with other can be passes through. Direct
verbal communication by word of mouth may be loaded with hidden meanings. The important
aspects if verbal communications are as follows.
Vocabulary:
Communication is unsuccessful if senders and receivers cannot translate each others word
and phrases when a nurses cases for a client who speaks another language an interpret may be
necessary.
A single word has several meaning. Individuals who use a common language share the
denotative meaning, baseball has the same meaning for everyone who speaks English, but code
denotes cardiac arrest primarily to health care providers.
Pacing:
Adoptability:
Spoken messages need to be altered a according with behavioural due from the receiver.
Intonation:
Tone of voice dramatically affects a meaning. The nurse must be aware of voice line to
avoid sending unintended messages.
Brevity is achieved by using short sentences and words that expresses an idea simply
and directly.
Credibility:
Timing is critical in communication. Even though message is clear, poor timing can
prevent it from being effective. Often the best time for interaction is when a client express an
interest in communication. If message are relevant of important to the situation at hand, they are
more effective.
Oral communication:
Oral communication is a transmitting message orally either by meeting the person through
artificial media of communication such as telephone and intercom systems.
Written communication:
Personal appearance:
Nurse learn to develop a general impression of clients health and emotion status through
appearance and clients develop a general expression of the nurse‘s professionalism and caring in
the same way personal appearance includes physical characteristics, facial expression, manner of
dress and grooming first impressions are largely based on appearance.
Poster and gait are forms of self expressions. The way people sit, stand and more reflect
attitudes, emotion and self concept and health status.
Facial expression:
The face is the most expressive part of the body. Facial expression convey emotion such as
surprise, fear, anger, happiness and sadness. People can be unaware of the messages their
expression convey doing procedure and the client may interpret. This is anger or disapproval.
Eye contact:
Maintaining eye contact during conversation shows respect and willingness to listen, lack
of eye contact may indicate anxiety, discomfort or lack of confidence in communicating.
MECHANICAL COMMUNICATION:
By using mechanical devices the communication will be sent. For e.g. internet, radio,
T.V. etc.
ADVANTAGES OF COMMUNICATION:
Oral communication:
Written communication:
DISADVANTAGES OF COMMUNICATION:
Oral communication:
STRATEGIES OF COMMUNICATION:
Think about the purpose of your communication. What do you hope to accomplish with
your words or actions? Are your comments about something you are responsible for doing, such
as parenting or managing someone or about an activity you are doing together with the other
person? Or, is it an opinion about something that is not your business, maybe even something
that the other person has already asked you to stop discussing?
"Before you speak, ask yourself: Is it kind? Is it necessary? Is it true? Does it improve
on the silence?" . Also, think about the structure of your communication.
Listening:
The most effective leaders know when to stop talking and start listening. This is especially
important in three particular situations: when emotions are high, in team situations and when
employees are sharing ideas.
First, listening is crucial when emotions are high. Extreme emotions, such as anger, resentment
and excitement, warrant attention from a personal and a business standpoint. On a personal level,
people feel acknowledged when others validate their feelings. Managers who ignore feelings can
create distance between themselves and their employees, eroding the relationship and ultimately
affecting the working environment.
Questioning:
Many leaders need information but aren't sure how to get it. Similarly, their employees may have
information but don't know how to impart it. Managers can open the lines of communication by
asking good questions. Note that different kinds of questions yield different kinds of results.
Here is a short primer on questioning:
* Closed questions are those that elicit yes/no answers. These are beneficial when a manager
simply needs to check the status of an issue. Has the report been completed? Do you know what
to do? Can you get that to me by Friday? These are examples of closed questions that are
perfectly appropriate in the right situations.
* Open questions are those that elicit longer responses. They are useful almost anytime a
manager wants more than a yes/no answer--for instance, when seeking input from others,
looking for information about a particular topic or exploring a problem. What do you think
would be the best way to go about this? How are you doing on that project? What went wrong?
These kinds of questions give others the chance to give all of the information they have and to
avoid the innumerable consequences that can come when leaders make assumptions without
becoming well-informed.
* Personal questions have a special role in leadership. Inappropriate personal questions can
alienate employees. Asking direct reports if they are dating anyone or why they haven't bought a
house can be perceived as prying, even if the questions are well intended. Appropriate personal
questions, however, can create a sense of camaraderie between employee and boss.
Using Discretion:
Knowing when not to speak as a leader is just as important as speaking. Managers must
understand that the moment they don a new title, they become a leader--one whom others look to
for guidance, direction and even protection. Good leaders adopt a policy of discretion, if not
confidentiality, with their employees. Only then can they develop the trust that is so vital to
productivity.
Confidential situations may arise in a number of areas, personal and professional. Here are some
topics that may warrant discretion:
* An employee wants genuine advice on how to excel but doesn't want to be seen as cozying up
to the boss.
Directing
Notice that directing comes last on the list of communication strategies. It may not be the least
important, but it is definitely one to use less often. Many managers direct their employees
because they believe it's the only way to get things done. It is not.
But directing has its place. Directing means giving directions clearly and unequivocally, such
that people know exactly what to do and when. It is best used in times of confusion, or when
efficiency is the most important goal. Although it can be effective, directing also can lead to
complacency on the part of employees who may adopt an "I just do what they tell me" attitude.
Use it sparingly
CHANNELS OF MANAGERIAL COMMUNICATION:
Downward communication.
Upward communication.
Lateral communication.
Diagonal communication.
Downward communication:
This is the traditional and most used communication, where the management gives orders to
the subordinates at the bottom level to carry out the orders as per the organizational hierarchy.
Management
Subordinates Subordinates
All the written and oral communication which are carried out from the top management
to the employees by various means in order that the employees carry out their duties in the
organization in achieving its goals.
Upward communication:
Upward communication in the management levels from staff, lower and middle
management personnel and continuous up to the organizational hierarchy. It provides a means
for motivating satisfying personnel by encouraging employees input.
Management
Subordinates Subordinates
Lateral communication:
Management
Subordinates Subordinates
Diagonal communication:
Diagonal communication occurs between two individuals or departments that are not on
the same level of the hierarchy.
Management
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.
1. The attitude exhibited by the supervisor are sometimes a hurdle in two way
communication. One common illustration is non listening habit. A supervisor may guard
information for:
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:
a. not seeking clarification on instructions which are subject to different interpretations; and
b. acting as screen for passing only such information which may please the boss.
3. semantic barriers:
Semantic is the science of meaning. Words seldom mean same thing to two person. 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.
4. Tendency to evaluate:
A major barrier to the communication is the natural tendency to judge the statement of the
person or other group. Every one 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.
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.
Inattention:
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 send 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 sometime 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.
THEORIES OF COMMUNICATION:
Related to management:
It argues that the best way to get the message across is to state one‘s point loudly and
frequently. its effectiveness over a period of time is nil, but many of us still need to be reminded
that shouting only makes poor communication louder.
It lays down that the total burden of communication is on the communicator while the
receiver is passive and pliable. One of the problem created by this approach is that it tends to
increase the barriers between the individuals and thus reduces the chances of hearing each other.
It assumes that the receiver probably is not much interested in what is being communicated.
By telling an individual what he needs to know, he will have little to object and little to question.
4. PUBLIC RELATIONS
INTRODUCTION:
Public relation is an essential and integrated component of public policy or service. The
professional public relation activity will ensure the benefit to the citizens, for whom the policies or
services are meant for. An effective public relations can create and build up the image of an individual or
an organization or a nation. At the time of adverse publicity or when the organization is under crisis an
effective public relations can remove the "misunderstanding" and can create mutual understanding
between the organization and the public.
OBJECTIVES:
On completion of the seminar the participant will be able to:
Explain public relation concept and its importance.
Explain the importance of organizational image.
Develop public relation programmes in the hospital.
Explain about the methods of maintaining public relation in the community.
Tell about the public relation in an educational institution.
Understand the role of dean in public relation.
TERMINOLOGIES:
(1) Fortitude: Happening by chance.
(2) Composite: Made up of different part or material.
(3) Humility: Quality of being humble
(4) Persuasive: Able to give good reason for doing something.
―Public relation in Government is the composit of all the primary and secondary
contacts between the bureaucracy and citizens and all the interactions of influences and attitudes
established in these contracts‖. - J.L MeCamy,
―Public relation means the development of cordial, equitable and therefore mutually
profitable relations between a business industry organization and the public it serves‖. - W.T. Parry‘
―Public relations are the process whereby an organization analyses the needs and desires of all
interested parties in order to conduct itself more responsively towards them‖. - Rex Harlow,
NEED OF PUBLIC RELATION:
Not many years ago, management decisions took no consideration of public attitudes but today
management cannot ignore the views of employees, and the community in making – policy decisions. It
has been estimated that eighty per cent of the problems confronting management have public relations
implications. Management has to foresee the impact of policy decisions on the opinion of the public.
There is normally four distinct reasons for ever increasing necessity of public relations:
(1) Increased governmental activities.
(2) Population explosion creating communication problems.
(3) Increased educational standards resulting in rise in expectations.
(4) Progress in communication techniques.
Well-executed public relations will
Increase visibility for the hospital, employees, programs and services.
Position the hospital as a health care leader and authority within the community or
region.
Expand awareness of the hospital‘s entire range of programs and services.
Enhance the hospital‘s image.
Aid in recruitment and retention of employees.
Support efforts to raise funds for new programs and services or assist with the passage
of levies and bonds.
Act as a foundation when negative news about the hospital occurs.
Boost employee morale.
Functions of public relation:
Public Relation is establishing the relationship among the two groups
(organization and public).
Art or Science of developing reciprocal understanding and goodwill.
It analyses the public perception & attitude, identifies the organization policy with
public interest and then executes the programmes for communication with the
public.
Community relations:
It is the function of actively planning and participating with and within a community for the benefit
of the community and the hospital. Tactics within this category include community events, volunteer
activities and co-sponsorship opportunities with other community organizations. Community relations
may also include fundraising and development activities.
Government relations:
It is a function of relating to government officials and agencies about issues that impact the hospital
and its audiences. Hill climb events in Olympia, letter writing campaigns, and op-ed placements in the
newspaper are often part of government relations.
Media relations:
It is often considered synonymous with public relations, is the function of working with the media
to communicate news. Media relations can be active – seeking positive publicity for a newsworthy topic at
the hospital – or reactive – responding to a news inquiry about a positive or negative story of interest to
the media and its readers or viewers.
Goals:
Public relations goals help direct the strategies and tactics in future public relations endeavors. The
goals should clearly support hospital mission statement. While a mission statement may include what the
hospital wants to accomplish, a public relations goal should be focused on what you want the public to
think and know about the hospital
Examples:
General Washington Hospital is a community leader committed to providing high quality
health care for the people of Carter, Key and Kangley counties.
Highland Valley Medical Center provides superior primary care services in a comfortable, safe
environment for people in the Highland Valley region.
Ivy River Hospital, with its friendly, helpful physicians and nurses, is the most dependable
health care service provider in the state.
Objectives:
Objectives help determine specific outcomes from your public relations efforts. Objectives should be
clear and concise, and include timing.
Examples:
Increase awareness of the technology and medical advances used at the hospital within Evergreen
County over the next six months.
Build the reputation of the hospital in the next three to four years as a cornerstone of the
community that provides health care services, jobs and community leadership.
Encourage renewed interest in specialty hospital services such as childbirth classes over the next
two years.
Target Audiences:
Detail the groups of people that are important to inform or influence, and why.
Examples:
Patients: They purchase health care services and generate revenue for the hospital.
Physicians: They use hospital facilities and generate revenue for the hospital. They control where
patients go for care in the hospital or outside of the community.
Media: They write both positive and negative stories about the hospital, its staff and services. They
have considerable influence and access to all of the hospital‘s target audiences.
Other audiences to consider may include employees, board members, community leaders, local
government officials, state legislators, vendors and suppliers.
Tactics:
It‘s easy for busy hospital professionals to think about tactics first, but it is critical to have a solid
strategy in place. Only pursue the tactics that will help achieve the goals. Here are some ―best uses‖ for
specific tactics.
Brochure/Collateral – To inform patients and community members about programs and services
provided at the hospital for promotional use only. It may be provided to media for background, but
not to be used instead of effective media tools, such as press releases or fact sheets.
Direct mail – To help create awareness for programs or services with target audiences. Message is
controlled.
Letters – Good for personal or business communication. Adjustable length (1-2 pages).
Postcards – Good for event invitations or welcome cards. Inexpensive postage.
Direct mail packages – Good for inclusion in new neighbor welcome packages or community
coupon envelopes. Consider including brochures or inserts. Costs are typically part of an
advertising or sponsorship package. Production of materials likely not included.
Specialty mailings – Good for awareness efforts, such as a child safety campaign sponsored by
the hospital. Mailing may include a magnet with safety tips and local emergency contact
information.
Distribution Methods:
How you distribute materials is often as important as what the organization send. It is a good idea
to know which methods the target audiences, especially reporters, prefer.
Mail – Good to use when timing is less sensitive (one to three days). Good for newsletter mailings,
new neighbor welcome packets, media kits, and other materials that are difficult to fax or e-mail.
Mail can also be certified to verify receipt or insured to avoid loss.
Fax – Good for timely communication (faster than mail). Good for press releases, event reminders,
and some forms of newsletters (such as weekly news notices). Less effective for documents with
images or graphics.
E-mail – Good for timely and direct communication with an individual. Good for press releases,
media reminders, media personnel questions, and pitch letters. Access to e-mail and electronic
document size can be limitations.
Face-to-face meetings – Best way to make a personal connection. It allows for detailed
explanation of a point-of view or complicated subject. Best way to demonstrate excitement,
concern, tolerance, empathy, etc.
Phone conference call – Allows for personal contact when face-to-face is not possible. Good for
back-and-forth communication. Inexpensive method for communicating with large groups in
different locations (cities/states).
Web site – Web pages allow interested parties to pull information thereby facilitating distribution.
Directing people to a web site may be done through mailings, publicity or other notices.
Newsletter – To regularly update a variety of target audiences about the happenings at the
hospital. Good way to establish and maintain community support for the hospital and services.
Public service announcement (PSA) – To create awareness of a problem or issue through radio
or television.
Press release – To distribute straightforward news to the media.
Press kit – To provide extensive information about a topic. It may precede an event or new
program launch.
Press conference – To disseminate time sensitive and critical news to multiple media contacts at
once. It should be rarely used.
Special event – To make a personal connection with target audiences in a positive environment. It
is good way to recognize people for good work or launch new programs of facilities.
Speaking engagement – To reach a target audience, establish the speaker as an expert and build
credibility for the speaker and the hospital.
Video – To communicate messages with emotion through visuals. It is good for town meetings,
new employee education, fundraising projects, special events, etc.
Web site – To provide 24-hour access to information about the hospital. It may include health
information or links to health information depending on site design. It is good for general
information about the hospital, its services and staff.
Budgets:
Public relations budgets may come in a variety of ways. It may be pre-determined and passed down
from the overall hospital budget. It may include general guidelines but is open to the tactics decided upon.
It may be non-existent, in which case the tactics will need to rely on investments in staff time, instead of
materials. All of these factors will determine where budgeting fits into the overall public relations
planning. Regardless of where budgeting fits into the plan, consider the following:
Nothing is free Consider all of the direct and indirect costs. Even a press release, one of the
least expensive tactics, has a price tag, the time spent writing and editing the release, the paper it is
printed on and the postage it‘s mailed with at a minimum.
Don’t underestimate time investments-------- Every public relations activity has time investments
and opportunity costs and don‘t just consider the time investments for the PR staff. Administrative
oversight and involvement, interview source preparation and even volunteer efforts all play into
the opportunity costs of public relations. When planning and prioritizing projects, consider all
necessary staff time and what else they would be doing with their time if not promoting the
hospital.
Shop around---------When producing brochures or printed materials; be sure to get more than one
estimate. Printing shops with more capacity at certain times may discount their rates.
Evaluate options--------- Another way to save money when producing materials is to consider
design options. For example, two-color brochures are far less expensive than their four color
counterparts. Specialty work, such as die-cuts for holding business cards or layered stair-steps for
handouts, are nice features, but may carry a hefty price tag. Designers and printers can be allies in
determining options. Just be sure to have your budget in mind.
Be prepared for the unexpected opportunities--------Reserve 10 to 15 percent of the overall public
relations budget for unexpected activities. There may be some great opportunities to do events,
community outreach activities or other projects that you didn‘t anticipate.
General:
High quality patient care by the hospital is the theme of any public relation programme. No amount
of smile, cheers and propaganda will compensate for bad administration and poor professional care in the
hospital.
Physical facilities:
Well planned hospital with sufficient waiting area for the patient and its relation in the hospital,
optimum floor space for each department of t e hospital, logical layout of the department and work areas,
provision of adequate facilities like toilets, public utility services like canteen, drinking water facility and
so on go a long way in improving the image of the hospital.
Staff:
In a hospital the staff consists of variety individuals drawn from different status of the society with
different levels of education and background. Imbibing a team spirit in all these groups of people for the
patient care will lead to a general satisfaction foe the patients in the hospital.
Importance of Color:
Color affects many of our moods and emotions. Proper choice of color can transform depressing and
monotonous atmosphere into pleasing and exciting one. It stimulates employee‘s productivity. Hospital is
one area where color can be used with measured success not only in appearance but for the psychological
uplifting which it brings to patients.
Operating facility:
The operating efficiency in an organization like, hospital is the outcome of its soundness of
objectives, policies, procedures, programmes and standing orders. The clear cut policy and procedure in
writing and their periodic promulgation to the staff specially, clear order regarding organizational
structure, defining their duties, authorities and accountability of the staff.
Waiting time:
The waiting time in the OPD is invariably the sore point of public grievances. Introduction of
appointment system, staggering of OPD timings for the registration, punctual attendance by doctors are
some of the remedies which can be introduced to reduce waiting time and have successfully been
implemented in many hospitals.
Delay in Admission:
Anxiety and distress is the result of delays in admission due to long waiting list. In allotting priorities
for admission, hospitals consider the physical state of the patients but forget the social background and as
a result, social emergencies have to wait. Adequate facilities in efficient use of present resources can
resolve this problem to some extent.
Ward Reception:
Patients are generally vulnerable to anxiety and fear on arrival in the ward. The reception they get
tends to leave a deep impression. Prompt reception improves the morale of the patients.
Privacy:
It is normally observed that majority of the patients are dissatisfied with the type of privacy provided
in the ward. Provision of screens around each bed would afford greater privacy. To have the privacy and
at the same time provide the advantage of companionship of other patients in the ward would go a long
way in creating a feeling of warmth and understanding.
Food:
Good food, well prepared and attractively served to patients, makes a very favorable impression.
Presence of dietician or a nurse at the time of service creates good impact on the patients.
Cleanliness:
Cleanliness is much a desired thing in a hospital. It not only enhances the image of the hospital but also
helps in controlling hospital infection. Frequent cleaning and liberal use of detergents and deodorants
eliminates the stink which is most dissatisfying.
Information about Illness:
The most important thing to a patient is to know as to what is wrong with him and how long will it
take to recover. Information in this respect will always be associated with fear, anxiety and thus, will help
in building patients confidence. A doctor or a nurse should be available in the ward during visiting hours
to furnish information regarding illness of the patients to their relatives.
Visitors:
Relatives and friends come rushing to the hospital the moment they learn about the illness of their
near and dear one. This is to show their loyalty, affection and strength of ties. It also satisfies emotional
needs of the patient. The relatives etc. are allowed to visit their patients for a short while. The visiting hour
policy should be more liberal for the visitors to the serious patients and relatives coming from distant
places. Too rigid visiting policy makes the public critical of the hospital.
Operative methods:
These methods are essentially connected with every aspect of community operation including
those are carried out by such workmen as health personnel, office personnel, enquiry, media personnel etc.
The fundamental ingredients of community operation are:
i. Cheerful and courteous behavior.
ii. Prompt and efficient treatment.
iii. Clear surroundings and well appearance of the workers.
Some operations of improving operation of primary health care in the community level are:
i. A high quality patient care is the key of good public relation
ii. Adequate physical facility with good functional layout. Waiting room with benches or
chairs, water, refreshment facility in the outpatient department.
iii. To make others happy one must be happy himself. Good morale of workers not only
increases efficiency, but workers with high morale interact in a positive manner with
one another and also with the patients in the community.
iv. Operating efficiency with effective coordination among all clinical departments and
other supportive services stem from good administration, organization structure,
policies, procedures and authority and accountability should be clearly understood by
each staff.
Communicative methods:
These methods employ means of communication in all possible forms to enable the primary
health centre to convey its message to the public. Some of these are also intermixed in a way with intra-
mutual functions of the hospital or health centers and the operative methods may be used in the following
ways:
a. Making the available appropriate information to the patients, their relatives and visitors.
b. A provision to listen to verbal complains instead of insisting on written one.
c. Prompt reply to questions.
d. Provision of suggestion box at appropriate place.
e. Visual communication, film shows, exhibitions and hospital Boucher are to be displayed.
f. Hospital tours can be conducted by the school teachers, students, housewives and members
of women‘s organization and religious leaders.
g. Holding an annual hospital day or open day house where public can be shown every aspect
of the hospital operation including some of the highly technical functions.
h. Using mass media would be helpful to improve public relation.
PUBLIC IMAGE:
An idea or mental picture about the organization by the public.
Advertising:
The main forms of advertising are------
Brochures or flyers
Direct mail
E-mail messages
Magazines
Newsletters
Newspaper(major)
Online discussion and chat groups
Posters and bulletin boards
Radio and television announcements
Publicity:
Publicity is the spreading of information to gain public awareness for a product, person, service,
cause or organization, and can be seen as a result of effective PR planning.
Propaganda:
Propaganda is a form of communication that is aimed at influencing the attitude of a
community toward some cause or position. Propaganda, in its most basic sense, presents information
primarily to influence an audience and change in their attitude.
Public diplomacy:
Public diplomacy, broadly speaking, is the communication with foreign publics to establish a
dialogue designed to inform and influence. It is practiced through a variety of instruments and methods
ranging from personal contact and media interviews to the Internet and educational exchanges.
Campaign:
Effective public relations require a knowledge, based on analysis and understanding, of all the
factors that influence public attitudes toward the organization. While a specific public relations project
or campaign may be undertaken proactively or reactively to manage some sort of image crisis.
Promotion:
Commercialization of publicity.
Annual reports:
They are ripe with information if they include an overview of your year's activities,
accomplishments, challenges and financial status.
ROLE OF DEAN:
Deans are expected to support and promote the highest quality educational programs, research,
public service, and economic development activities of their respective colleges and schools. Each dean
must be an effective advocate for his/her college, both within the University and externally. Deans have
ultimate accountability for their colleges‘ sound management of resources: fiscal, facilities, and human.
They are responsible for collegiate planning, including alignment of plans for educational, research, and
other activities in their colleges. The Deans have direct responsibility for:
Faculty:
The academic dean is responsible for the hiring of most department chairs and faculty selection. She often
acts as a bridge between the academic and bureaucratic sides of education. Often the dean will delegate
responsibility to trusted department heads but still oversee all the activity within each department.
Finance:
The academic dean may also be responsible for fund-raising and financial decisions made in
regard to the school. Because of the complexities of the financial responsibilities of the dean, the job
strongly resembles that of the chief executive officer of a mid-sized business or enterprise.
The academic dean is responsible for overseeing course scheduling and the introduction of new
courses into the curriculum of the school. She also plays an integral role in maintaining good relationship
with alumni and the general public and garnering financial support for the institution. An academic dean
must have excellent social skills, as he is called upon to interact with the public as a representative of the
college or university.
The academic dean may also be responsible for much of the decision making in regards to
campus upkeep and the regular care of campus grounds. He delegates the responsibility for care and
upkeep of the grounds, but makes the financial decisions regarding upkeep and general funding allotted to
the physical appeal of the university or college.
Faculty Communication:
Because all faculty report directly to the academic dean, she is often looked to for problem-
solving and conflict resolution. For this reason he must have an active interest in and knowledge of the
academic side of this jurisdiction, as well as a basic understanding of all areas of education. She must
likewise be persuasive, an effectual listener, and collaborative. The authority of the academic dean is
consistently being challenged, and thus she must possess humility, patience, and fortitude.
Fee Accounts:
Stipulate the fee structure in respective zones under instructions of the management.
Extending concessions on discretion to students being confirmed, registered or enrolled –
keeping in view merit and other criteria that demand concession.
Monitor the fee dues of students and educate parents in clearing the same within the time
stipulated.
Maintain healthy public relations with parents in the interest of the organization.
Keep in touch with parents of students already studying in your zone.
Make efforts to identify merit students at the earliest and extend academic support to them.
Take a feedback from students on the performance of the staff attached to the campuses in your
zone.
Ask parents of exceptional students for feedback on the performance of respective campuses in
academic and administrative areas.
Communicate any significant information about campus performance to management and staff
for improvement.
Sick room:
The health of a student is important since it also reflects on the academic performance. A student
in good health can perform up to potential, whereas a student who is ill cannot. Besides, the welfare of a
student studying on residential campus is of primary concern to the organization. It is for this reason that
every residential campus has a Doctor attending to sick students with special rooms to keep them in, and
under the care of Sick-in-charges.
CONFLICT MANAGEMENT
INTRODUCTION
Conflict is generally defined as the internal or external discord that results from
differences in ideas, values, or feelings between two or more people. Because managers have
interpersonal relationships with people having a variety of different values, beliefs, backgrounds,
and goals, conflict is an expected outcome. Conflict is also created when there are differences in
economic and professional values and when there is competition among professionals.
TYPES OF CONFLICTS
Conflict has been described and studied from the standpoint of its context, or where it
occurs. 3 types of conflicts are
Intrapersonal conflict: an intrapersonal conflict occurs within an individual in situations in
which he or she must choose between two alternatives. Choosing one alternative means that he
or she cannot have the other; they are mutually exclusive. E.g. we might internally debate
whether to complete an assignment that is due the next day or watch a favorite television
programme.
Interpersonal conflict: is conflict between two or more individuals. It occurs because of
differing values, goals, action, or perceptions. For e.g. when you want to go to a science fiction
movie, but your partner may prefer to attend an opera. Interpersonal conflict becomes more
difficult when we are involved in issues relating to racial, ethnic and life style 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 function of the organization. Typically, aspects of the organizations style of
management, rules, policies and procedures give rise to conflict..
Two areas responsible for conflict in organizations are role ambiguity and role conflict.
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.
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. E.g. 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.
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.
THE CONFLICT PROCESS
Before managers can or should attempt to intervene in conflict, they must be able to
assess its five stages accurately
1. Latent conflict (also called antecedent conditions).
2. Perceived conflict
3. Felt conflict
4. Manifest conflict
5. Conflict resolution
6. Conflict aftermath.
Manifest conflict
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 organisation more closely for
antecedent conditions.
Perceived conflict
If the conflict progresses, it may develop into the second stage: 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
It is also called as 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 often directly affect how
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 to 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 there 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.
Outcomes of conflict
We often hear people hear about conflict situation resulting in win-win, win-lose and lose-
lose. Filley (1975) identified these 3 different positions or outcomes of conflict.
Win-lose outcome: occurs when one person obtains his or 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: 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.
EFFECTS OF CONFLICT IN ORGANIZATIONS
• Stress
• Absenteeism
• Staff turnover
• De-motivation
• Non-productivity
SIGNS OF CONFLICT BETWEEN INDIVIDUALS
1. Colleagues not speaking to each other or ignoring each other
2. Contradicting and bad-mouthing one another
3. Deliberately undermining or not co-operating with each other, to the downfall of the team
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
conflict 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, the
urgency of the decision, the power and status of the players, the importance of the issue, and the
maturity of the people involved in the conflict.
1. Discipline
2. Consider Life Stages
3. Communication
4. Active Listening
5. Assertiveness Training
6. Assessing the Dimensions of the Conflict
Issues in Question
Size of the Stakes
Interdependence of the Parties
Continuity of Interaction
Structure of the Parities
Involvement of Third Parties
Discipline: In using discipline to manage or prevent conflict, the nurse manager must know and
understand the organization‘s rules and regulations on discipline. If they are not clear, the nurse
manager should seek help to clarify them. The following rules will help in managing discipline:
1. Discipline should be progressive.
2. The punishment should fit the offense, be reasonable, and increase in severity for
violation of the same rule.
3. Assistance should be offered to resolve on-the-job problems.
4. Tact should be used in administering discipline.
5. The best approach for each employee should be determined. Managers should be
consistent and should not show favoritism.
6. The individual should be confronted and not the group. Disciplining a group for a
member‘s violation of rules and regulations makes the other members angry and
defensive, increasing conflict.
7. Discipline should be clear and specific.
8. It should be objective, sticking to facts.
9. It should be firm, sticking to the decision.
10. Discipline produces varied reactions. If emotions are running too high, a second meeting
should be scheduled.
11. The nurse manager performing the discipline should consult with the supervisor. One
should expect to be overruled sometimes. Knowing the boundaries of authority and the
supervisor will avoid most overrules.
12. A nurse manager should build respect, trust, and confidence in his or her ability to
handle discipline.
Consider Life Stages: Most organizations will have nurses at all life stages in their employ.
Conflict can be managed by supporting individual nurses in attaining goals that pertain to their
life stages. Three developmental stages are as follow.‖
1. In general, in the young adult stage, nurses are establishing careers. Nurses at this stage
may be pursuing knowledge, skills, and upward mobility. Conflict may be prevented or
managed by facilitating career advancement.
2. In general, during middle age, nurses become reconciled with achievement of their life
goals. These nurses often help develop the careers of younger nurses.
3. In general, after age 55 years, nurses think in terms of completing their work and retiring.
Egos and ideals are integrated with accomplishments.
Communication: Communication is an art that is essential to maintaining a therapeutic
environment. It is necessary in accomplishing work and resolving emotional and social issues.
Supervisors prevent conflict with effective communication and should make it a way of life. To
promote communication that prevents conflict, do the following.
1. Teach nursing staff members their role in effective communication.
2. Provide factual information to everyone: be inclusive, not exclusive.
3. Consider all the aspects of situations: emotions, environmental considerations, and verbal
and nonverbal messages.
4. Develop these basic skills;
a. Reality orientation, by direct involvement and acceptance of responsibility in
resolving conflict.
b. Physical and emotional composure.
c. Positive expectations that generate positive responses.
d. Active listening.
e. Giving and receiving information.
Active Listening: Active or assertive listening is essential to managing conflict. In order to be
sure that their perceptions are correct, nurse managers can paraphrase what the angry or defiant
employee is saying. Paraphrasing clarifies the message for both. Paraphrasing can help cool off
the situation because it gives the employee time and the opportunity to hear the supervisor‘s
perceptions of the emotions expressed.
Active assertive listening is sometimes called stress listening. Powell suggest these techniques
for stress listening.
1. Do not share anger; it adds to the problem. Remain calm and matter-of-fact.
2. Respond constructively in both verbal and nonverbal language. Be cheerful but sober.
Maintain eye contact. Prevent interruptions. Bring problems into the open. Make the
employee comfortable. Act serous. Always be courteous and respectful.
3. Ask questions and listen to the answers. Determine the reasons for the anger.
4. Separate fact from opinion, including your own.
5. Do not respond hastily. Plan a response.
6. Consider the employee‘s perspective first.
7. Help the employee find the solution. Ask questions and listen t responses. Do not be
paternalistic.
Assertiveness Training: Assertive nurse, including managers, will stand up for their rights
while recognizing the rights of others. They are straightforward and know that they are
responsible for their thoughts, feelings, and actions. Assertive nurses also know their strengths
and limitations. Rather than attack or defend, assertive nurses assess, collaborate, support, and
remain neutral and nonthreatening. They can accept challenges and prevent conflict by helping
others deal with their own anger.
Assertiveness can be taught through staff development programs. In these programs
nurses are taught to make learned, thoughtful responses and to know when to say no, even to
boss. They learn to hold people to a standard and to know when to accept responsibility rather
than to blame others. When they are dissatisfied, they do something to increase their satisfaction.
Most assertive behaviours can be learned with the use of case studies, role playing, and group
discussion.
When they finish their training, assertive nurses will use positive comments to reinforce
expectations that others do their jobs. They will use praise and consideration to promote wellness
and positive individual behaviour. Nurse Managers learn that direct communication of support to
staff members increases staff job satisfaction.
Assertive nurses focus on data and issues when offering constructive cretinism to the
boss or constructive feedback to the staff, which encourages dialogue and produces solutions to
problems rather than conflict. They ask for assistance or delay when it needed.
People generally respond positively to assertion and negatively to aggression; however,
some people respond negatively to assertion.
Assessing the dimensions of the conflict
Greenhalgh has developed a system for assessing the dimensions of conflict. His view is
that conflict may be considered to be managed when it does not interfere with ongoing functional
relationships. Participants in a conflict have to be persuaded to rethink their views. A third party
must understand the situation empathetically from the participants‘ view points. The conflict
may be the result of a deeply rooted antagonistic relationship.
Greenhalgh‘s Conflict Diagnostic Model has seven dimensions, each with a continuum
from ―difficult to resolve‖ to ―easy to resolve.‖ Once the dimensions of the conflict have been
assessed, those should be shifted to the easy-to-resolve domain.
The issue in question
It has already been stated that values, beliefs, and goals are difficult issues to bring to a
reasonable compromise. Principles fall into the same category, since they involve integrity and
ethical imperatives. The third party must persuade the conflicting parties to acknowledge each
other‘s legitimate point of view. How can principles be maintained and the organization and
employees be saved?
The size of the stakes
The size of the stakes can make conflict hard to manage. If change threatens somebody‘s
job or income, the stakes are high. The third party must try to keep egos from being hunt,
postponing action if necessary. What will the parties settle for? Precedents create potential for
future conflicts: If I give in now, what will I have to give up in the future?
Interdependence of the parities
People must view resources in terms of interdependence. If one group sees no benefits
from the distribution of resources, they will be antagonistic. A positive-sum interdependence of
mutual gain is needed.
Continuity of interaction
Long-term relationships reduce conflict. Managers should opt for continuous, not
episodic, interaction.
Structure of the parties
Strong leaders who unify constituents to accept and implement agreements reduce conflict.
When informal coalitions occur, involve their representatives to find and implement agreements.
Involvement of third parties
Conflicts are difficult to resolve when participants are highly emotional and resort to
distorting nonrational arguments, unreasonable stances, impaired communication, or personal
attacks. Such conflicts can be solved with a prestigious, powerful, trusted, and neutral third
mediator, or arbitrator. The inside manager who acts as judge or arbitrator polarizes; inviting a
third party makes it public. Third parties have to be involved when the nurse manager, as party to
a conflict, cannot resolve it.
Viewpoint Continuum
Accommodation/Accommodating (lose/win):
Working toward a common purpose is more important than any of the peripheral
concerns; the trauma of confronting differences may damage fragile relationships.
Cooperating is the opposite of competing. In the cooperating approach, one party
sacrifices his or 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. The 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.
Competition/Competing (win/lose):
Associates "winning" a conflict with competition.
The competing approach is used when one party pursues what it wants at the expense of
the 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.
Compromise/Compromising (win some/lose some):
Winning something while losing a little is OK. 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.
1. Collective bargaining
Especially in workplace situations, it is necessary to have agreed mechanisms in place for
groups of people who may be antagonistic (e.g. management and workers) to collectively discuss
and resolve issues. This process is often called "collective bargaining", because representatives
of each group come together with a mandate to work out a solution collectively.
2. Conciliation
he dictionary defines conciliation as "the act of procuring good will or inducing a friendly
feeling". It is the synonymous terms that refer to the activity of a third party to help disputants
reach an agreement.
3. Negotiation:
This is the process where mandated representatives of groups in a conflict situation meet
together in order to resolve their differences and to reach agreement. It is a deliberate process,
conducted by representatives of groups, designed to reconcile differences and to reach
agreements by consensus. The outcome is often dependent on the power relationship between the
groups.
4. Mediation:
When negotiations fail or get stuck, parties often call in and independent mediator. This
person or group will try to facilitate settlement of the conflict. The mediator plays an active part
in the process, advises both or all groups, acts as intermediary and suggests possible solution.
5. Arbitration:
Means the appointment of an independent person to act as an adjudicator (or judge) in a
dispute, to decide on the terms of a settlement. Both parties in a conflict have to agree about who
the arbitrator should be, and that the decision of the arbitrator will be binding on them all.
COLLECTIVE BARGANING
INTRODUCTION
Other than the continuing argument about the appropriate education for nurses, collective
bargaining is the most controversial and divisive issue in nursing. Some believe that collective
bargaining reduces the professionalism of nursing; others view it as a mechanism to prevent
employers from exploiting nurses. It has been seen as a complex legal issue, but dealt with by
attorney and other experts specifically trained to handle the problem it presents.
MEANING
DEFINITION:
(Tudwig Teller)
1. It is a group process, wherein one group, representing the employers, and the
other, representing the employees, sit together to negotiate terms of
employment.
2. Negotiations form an important aspect of the process of collective bargaining
i.e., there is considerable scope for discussion, compromise or mutual give and
take in collective bargaining.
3. Collective bargaining is a formalized process by which employers and
independent trade unions negotiate terms and conditions of employment and the
ways in which certain employment-related issues are to be regulated at national,
organizational and workplace levels.
4. Collective bargaining is a process in the sense that it consists of a number of
steps. It begins with the presentation of the charter of demands and ends with
reaching an agreement, which would serve as the basic law governing labor
management relations over a period of time in an enterprise. Moreover, it is
flexible process and not fixed or static. Mutual trust and understanding serve as
the by products of harmonious relations between the two parties.
5. It a bipartite process. This means there are always two parties involved in the
process of collective bargaining. The negotiations generally take place between
the employees and the management. It is a form of participation.
6. Collective bargaining is a complementary process i.e. each party needs
something that the other party has; labor can increase productivity and
management can pay better for their efforts.
7. Collective bargaining tends to improve the relations between workers and the
union on the one hand and the employer on the other.
8. Collective Bargaining is continuous process. It enables industrial democracy to
be effective. It uses cooperation and consensus for settling disputes rather than
conflict and confrontation.
9. Collective bargaining takes into account day to day changes, policies,
potentialities, capacities and interests.
UNION/LABOUR ORGANIZATION:
This will normally include procedures in respect of individual grievances, disputes and
discipline. Frequently, procedural agreements are put into the company rule book which provides
information on the overall terms and conditions of employment and codes of behavior. A
substantive agreement deals with specific issues, such as basic pay, overtime premiums, bonus
arrangements, holiday entitlements, hours of work, etc. In many companies, agreements have a
fixed time scale and a collective bargaining process will review the procedural agreement when
negotiations take place on pay and conditions of employment.
1. Prepare: This phase involves composition of a negotiation team. The negotiation team
should consist of representatives of both the parties with adequate knowledge and skills
for negotiation. In this phase both the employer‘s representatives and the union examine
their own situation in order to develop the issues that they believe will be most important.
2. Discuss: Here, the parties decide the ground rules that will guide the negotiations. A
process well begun is half done and this is no less true in case of collective bargaining.
An environment of mutual trust and understanding is also created so that the collective
bargaining agreement would be reached.
3. Propose: This phase involves the initial opening statements and the possible options that
exist to resolve them. In a word, this phase could be described as ‗brainstorming‘. The
exchange of messages takes place and opinion of both the parties is sought.
4. Bargain: negotiations are easy if a problem solving attitude is adopted. This stage
comprises the time when ‗what ifs‘ and ‗supposals‘ are set forth and the drafting of
agreements take place.
5. Settlement: Once the parties are through with the bargaining process, a consensual
agreement is reached upon wherein both the parties agree to a common decision
regarding the problem or the issue. This stage is described as consisting of effective joint
implementation of the agreement through shared visions, strategic planning and
negotiated change.
STEP
S
Selection of a bargaining agent.
Certification to contract.
Contract administration.
The nurse manager‘s role.
Decertification.
The process of establishing a union in any setting begins with the selection
of a bargaining agent certified to conduct labour negotiations for a group of individuals. This
process is known as a representative election and is presided over by the national labour
relationship board. For an election occurs, the union must demonstrate that interest is shown by
at least 30% of the employees affected by this action. Once the 30% level is reached, the union
can petition the national labour relations board to conduct an election. At the conclusion of this
meeting the board will have determined three things:
- Who is eligible to participate in the union: - This is problematic issue and not
easily resolved, because registered nurses employed as staff nurses are eligible for
collective bargaining but registered nurses employed as management are not.
- Whether the signatories are employees of the organization.
- A date for union election: - the election is conducted by the board within 45 days,
using a secret ballot. All individuals eligible for represent action by the union are
notified of the election time and date. On Election Day, eligible employees are
asked to choose not only whether they wish to be representatives of the union but
also which union they want to represent.
Many unions represent registered nurses in collective bargaining; therefore the ballot may
contain several choices for the bargaining agent. In addition to various state nurses associations
(SNAs), other major unions representing nurses are:
The process of selecting a bargaining agent produces a tense, emotional climate that
affects everyone in the organization. It is important for both nurse and managers and staff nurses
to remember that during this period, the rules of unfair labour practice apply. Staff nurses also
must be careful that their discussions regarding collective bargaining take place away from the
work site and not on work time.
Certificate to contract:
The actual contract and its provision must be written and voted on by the union
membership a process that may take some time. Issues considered mandatory subjects of
bargaining are rates of pay, wages, hours of employment and grievance procedures.
Additionally, the contract may specify other areas provided that both parties agree
they should be included. These can include:
Contract administration:
The role of administrating the contract then falls to an individual designated as the
union representative. The individual may be an employee of the union or a member of the
nursing staff. It is the duty of the union representative to provide fair and equal representation to
all members of the unit. The role of the union representative is explain the provisions of the
contract to the union membership and be available to help in the grievance process.
The nurse manager in a health care organization where nurses are organized into a
collective bargaining unit participates in resolving grievances, using the agreed upon grievance
procedure.
CLASSIFICATION OF GRIEVANCE:
Symptomatic grievances are simply a means for the employee to show dissatisfaction or
frustration and stem from the human element in management / labour relationship.
Step 1:- the employee talks informally with her or his direct supervisor, usually as soon
as possible after the incident has occurred. A representative of bargaining agent is allowed to be
present. A written request for the next step is given to the immediate supervisor within ten work
days. The employee, supervisor, and agent will be present for any discussion.
Step 2:- if the response to step 1 is not satisfactory, a written appeal may be submitted
within 10 work days to the director of nursing. The employee, agent, grievance chairperson and
the top nursing administrator or designs can be provided in 5 work days subsequent to these
meetings.
Step 3:- the employee, agent, grievance chairperson, nursing administrator and director
of human resources meet for discussion. The 10 and 5 day time limits for appeal and answer are
again observed.
Step 4:- the final step is arbitration, which is invoked when no solution suggested is
acceptable. An arbitrator who is a neutral third party is selected and is present at these meetings.
The submission of grievance may be required within 15 days after step 3 is completed.
The objective of the grievance process is not to achieve conquest. You have to
work with one another after resolution of the grievance, so treat each other with
courtesy and respect.
Do not, whatever your position, allow disagreements or disputes among members
of your team to be public.
Expedience is a must; delaying tactics serve only to heighten emotions. However
allow time to consider the facts.
Stay objective: emotionalism usually leads to further problems.
Implementing decisions or filing grievances requires planning. Get all the facts
and information‘s, evaluated and anticipates the other party‘s response. Seek
guidance from those higher in administrative positions.
Never refuse to meet with the grievant representatives.
The bargaining unit representative, though in a unique position, is not immune
from reprimand or discipline.
Integral to bargaining are solutions that may also accommodate future changes
and needs.
Be prepared to give or take acceptable compromises and alternate solutions
within the framework of the contract, no matter which party suggests them.
Pat formulas do not settle grievance or solve problems.
Observe the time limits. If you do not, the bargaining unit may lose the right to
continue the grievance to the next level.
In adjusting a grievance, knowledge is very important.
Gloating over a ‗nursing‘ is human but remember that you may ‗lose‘ the next
one; don‘t become overconfident.
THE GRIEVANCE HEARING
Decertification:
Occasionally, members of a particular may decide that the union they want or that
no union at all is needed. In such a case, the members of the bargaining unit have the right to
either change their union affiliation or remove the union by using a process known as
decertification. This process is essentially the same as that following by the NLRB for a
representation election.
TYPES OF STRIKES:
Jurisdictional Recognition
Strikes strikes
Illegal Unfair
Economic strikes:
Employee‘s attempt to get their employer to meet their demands by their services. An
employ cannot be fired for participating in an economic strike but can be replaced.
Sympathy strikes:
Employees of one employer strike in support of another. Workers can refuse to cross to
picket lines.
Jurisdictional strike:
In jurisdictional strike there is a work stoppage over the assignment of work to two or
more unions. Employees may strike because the employer assigned a particular job to another
union.
Recognition strikes:
Illegal strikes:
The category of illegal strike comprises violent strikes, boycott or secondary strikes and
wildcat or surprise strikes that are not authorised by the union.
BARGAINING FORM AND TACTICS
Distributive bargaining:
It involves haggling over the distribution of surplus. Under it, the economic issues like
wages, salaries and bonus are discussed. In distributive bargaining, one party‘s gain is another
party‘s loss. This is most commonly explained in terms of a pie. Disputants can work together to
make the pie bigger, so there is enough for both of them to have as much as they want, or they
can focus on cutting the pie up, trying to get as much as they can for themselves. In general,
distributive bargaining tends to be more competitive. Also known as conjuctive bargaining
Integrativebargaining:
This involves negotiation of an issue on which both the parties may gain, or at least neither
party loses. For example, representatives of employer and employee sides may bargain over
the better training programme or a better job evaluation method. Here, both the parties are
trying to make more of something. In general, it tends to be more cooperative than
distributive bargaining. This type of bargaining is also known as cooperative bargaining.
Attitudinalrestructuring:
This involves shaping and reshaping some attitudes like trust or distrust, friendliness or
hostility between labor and management. When there is a backlog of bitterness between both
the parties, attitudinal restructuring is required to maintain smooth and harmonious industrial
relations. It develops a bargaining environment and creates trust and cooperation among the
parties.
Intra-organizationalbargaining:
It generally aims at resolving internal conflicts. This is a type of maneuvering to achieve
consensus with the workers and management. Even within the union, there may be
differences between groups. For example, skilled workers may feel that they are neglected or
women workers may feel that their interests are not looked after properly.
As 3 levels
1. National level
2. Sectoral/ industrial level
3. Company/ enterprise level
Economy-wide (national) bargaining is a bipartite or tripartite form of
negotiation between union confederations, central employer associations and
government agencies. It aims at providing a floor for lower-level bargaining on
the terms of employment, often taking into account macroeconomic goals.
Collective bargaining includes not only negotiations between the employers and unions but
also includes the process of resolving labor-management conflicts. Thus, collective
bargaining is, essentially, a recognized way of creating a system of industrial jurisprudence.
It acts as a method of introducing civil rights in the industry, that is, the management should
be conducted by rules rather than arbitrary decision making. It establishes rules which define
and restrict the traditional authority exercised by the management.
Importance to employees
Importance to employers
1. It becomes easier for the management to resolve issues at the bargaining level rather
than taking up complaints of individual workers.
2. Collective bargaining tends to promote a sense of job security among employees and
thereby tends to reduce the cost of labor turnover to management.
4. Collective bargaining plays a vital role in settling and preventing industrial disputes.
Importance to society
It provides a method or the regulation of the conditions of employment of those who are
directly concerned about them.
Advantages:
o Equalization of power
o Viable grievance procedure
o Equitable distribution of work
o Professionalism promoted
o Nurses control practice
Disadvantages:
o Adversary relationship
o Strikes may not be prevented
o Leadership may be difficult to obtain
o Unprofessional behaviour
o Interference with management
Since its inception, the ANA has had an active interest in the economics security of nurses.
The original purposes of ANA was ―to promote the usefull and honor, the financial and
other interest of the nursing profession‖- Flannigan-1976. Although this statement was
useful in helping to shape the role of the profession in supporting collective bargaining
for nurses, the ANA did not officially adopt an economic security program that included
collective bargaining for nurses through the Economics and General welfare program,
which currently is called the Department of labor Relations and work place advocacy.
The ANA is a registered labor organization, but it does not engage in direct collective
bargaining. The actual certification of units, negotiation of contracts, and administration
of contracts is conducted by the SNA.
The SNA have the freedom to independently decide their own level of participation
regarding collective bargaining.
In 1983, the nursing leaders established their first orgsnisation, the American Society of
Superintendents of Training Schools for Nurses, one of whose purpose was a
commitment to promote the general welfare of nurses.
In early 1900s, working conditions and salaries for nurses were extremely poor.
In 1929, some nurses began to recognize that protest and collective action were necessary
if the conditions of the nurse were to improve.
In 1945, Shirley Titus, then the executive director of the California nurses association,
chaired a committee to study the employment conditions of nurses; as a result of the
findings of this committee, ANA adopted what was called the economic security
program.
In 1974, the health care amendments referred to earlier made it possible for nurses to use
legal sanctions if necessary to ensure bargaining related to conditions of employment.
Since the passage of these amendments, many state nurses associations (SNAs) have
qualified as a legal bargaining agents for nurses.
In 1982 ANA changed structure to become a federation of state association. This change
has rendered the state associations more direct representation of their member nurses.
INTRODUCTION:
All occupational fields have their own hazards. There are variety 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:
By ―occupational environment‖ is meant the sum of external conditions and influences
which prevail at the place of the work and which have a bearing on the health of the working
population. Basically there are three types of interaction in the working environment:
a. Man and physical, chemical and biological agents.
b. Man and machine.
c. Man and man.
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 comprises a large number of chemicals, toxic dust and gases
which are the potential hazards 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.
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, lack of safety measures are the cause of accidents which is the major problem in industries.
OCCUPATIONAL HAZARDS:
An industrial worker may be exposed to five types of hazards, depending upon his
occupation:
1) Physical hazards.
2) Chemical hazards.
3) Biological hazards.
4) Mechanical hazards.
5) Psychosocial hazards.
Physical hazards:
Heat and cold: the common physical hazard in most industries is heat. The direct effects
of heat exposure are burns, heat exhaustion, heat stroke and heat cramps; the indirect
effects are decreased efficiency, increased fatigue and enhanced accident rates. Important
hazards associated with cold work are chilbans, erthrocynosis, immersion foot, and
frostbite as a result of cutaneous vasoconstriction. General hypothermia is not unusual.
Light:.The acute effects of poor illumination are eye strain, headache, eye pain,
lachrymation, congestion around the cornea and fatigue. The chronic effects on health
include ―miner‘s nystagmus‖. Exposure to excessive brightness or ―glare‖ is associated
with discomfort and annoyance and visual fatigue.
Noise: The effects of noise are of two types : auditory effects which consist of temporary
or permanent hearing loss and non auditory effects which consist of nervousness, fatigue,
interference with communication by speech, decreased efficiency and annoyance.
Vibration: Vibration usually affects the hands and arms. After some months or years of
exposure, the fine blood vessels of the fine fingers may become increasingly sensitive to
spasm (white fingers). Exposure to vibration may also produce injuries of the joints of the
hands, elbows and shoulders.
Chemical hazards:
There is hardly any industry which does not make use of chemicals. The chemical hazards
are on the increase with the introduction of newer and complex chemicals. Chemical agent acts
in three ways: local action, inhalation and ingestion. The ill-effects produced depend upon the
duration of exposure, the quantum of exposure and individual susceptibility.
Local action: some chemicals cause dermatitis, eczema, ulcers and even cancer by primary
irritant action; some causes dermatitis by an allergic action.
Inhalation: Dusts are produced in a number of industries- mines, foundry, quarry, pottery,
textile, wood or stone working industries. The most common dust disease in this country are
silicosis and anthracosis.
Gases: Gases are sometimes classified as simple gases(eg; oxygen, hydrogen), asphyxiating
gases (e.g. carbon monoxide, cyanide gas, sulphur dioxide, chlorine) and anesthetic gases
(eg; chloroform, ether, trichloroethylene) carbon monoxide hazards is frequently reported in
the coal-gas manufacturing plants and steel industries.
Metals and their compounds: a large number of metals and compounds are used throughout
industry. The chief mode of entry of some of them is by inhalation as dust or fumes. Metals
may be of antimony, arsenic, beryllium, cadmium, cobalt, manganese, mercury, phosphorus,
chromium, zinc and others.
Biological hazards: workers may be exposed to infective and parasitic agent of the place of
work. The occupational disease in this category are brucellosis, leptospirosis, anthrax,
hydatidosis, psittacosis, tetanus, encephalitis, fungal infections, schistosomiasis and a host of
others. Persons working among animal products(eg; hair, wool, hides) and agricultural
workers are specially exposed to biological hazards.
Psychosocial hazards: the psychosocial hazards arises from the worker‘s failure to adapt to
the alien psychosocial environment. Frustration, lack of job satisfaction, insecurity, poor
human relationship, emotional tension are some of the psychological factors which may
undermine both physical and mental health of the workers.
The health effects can be classified in two main categories: psychological and behavioral
changes- including hostility, aggressiveness, anxiety , depression, tardiness, alcoholism, drug
abuse, sickness, absenteeism. Psychosomatic illhealth: including fatigue, headache, pain in the
shoulders, neck and back; propensity to peptic ulcer, hypertension, heart disease and rapid
ageing.
OCCUPATIONAL DISEASE:
Occupational diseases are usually defined as diseases arising out of or in the course of
employment.
Occupational cancer:
Cancer of the skin, lungs, bladder.
Occupational dermatosis:
Dermatitis, eczema
Pneumoconiosis: Dust within the size of 0.5 to 3 micro is a health hazard producing, after a
variable period of exposure, a lung disease known as pneumoconiosis, which may gradually
cripple a man by reducing his working capacity due to lung fibrosis and other complications. The
hazardous effects of dusts on the lungs depend upon a number of factors such as:
a) Chemical composition
b) Fineness
c) Concentration of the dust in the air
d) Period of exposure
e) Health status of the person exposed.
Silicosis: among the occupational disease, silicosis is the major cause of permanent disability
and mortality. It is caused by inhalation of dust containing free silica or silicon dioxide.
Pathologically, silicosis is characterized by a dense ―nodular‖ fibrosis, the nodules ranging from
3 to 4mm in diameter. Some of the early manifestations are irritant cough, dyspnoea on exertion
and pain in the chest.
Anthracosis: Anthracosis exhibits two general phases in coal miners pneumoconiosis: the first
phase is labeled as simple pneumoconiosis which is associated with little ventilator impairment.
This phase may require 12 years of work exposure for its development. The second phase is
characterized by progressive massive fibrosis; this causes severe respiratory disability and
frequently results in premature death.
Byssinosis: it is due to inhalation of cotton fibre dust over long periods of time. The symptoms
are chronic cough and progressive dyspnoea, ending in chronic bronchitis and emphysema.
Bagassosis: is the name given to an occupational disease of the lung caused by inhalation of
bagasse or sugar-cane dust. It was first reported in India by Ganguli and Pal in 1955 in a
cardboard manufacturing firm near Kolkata. The sugarcane fiber which until recently went to
waste is now utilized in the manufacture of paper, cardboard and rayon. The symptoms consists
of breathlessness, cough
Asbestosis:
Asbestos are silicates of varying composition(magnesium, iron, calcium, sodium,
aluminium). Asbestos is of 2 types – serpentine (hydrated magnesium silicate) and amphibole
type (contain magnesium). Asbestos is used in the manufacture of asbestos cement, fire proof
textiles, roof tiling, brake lining, etc.
Asbestos enters the body by inhalation, and fine dust may be deposited in the alveoli. The
disease is characterized by dyspnoea, clubbing of fingers, cardiac distress and cyanosis. Chest x-
ray shows a ground-glass appearance in the lower two third of the lungs. It causes pulmonary
fibrosis leading to respiratory insufficiency and death, carcinoma of the bronchus and gastro
intestinal tract.
Preventive measures:
1. Use of safer types of asbestos(chrysolite and amosite)
2. Substitution of other insulants – glass fiber, mineral wood, calcium silicate, plastic foams.
3. Dust control and biological monitoring(x-ray, lung function)
4. Periodic examination of workers and continuing research.
FARMER‟S LUNG:
It is due to the inhalation of mouldy hay or grain dust which contains micropolyspora
faeni , the main cause of farmer‘s lung. Its growth is encouraged by moist hay or grain dust. The
disease is characterized by respiratory symptoms and finally leads to pulmonary fibrosis and
pulmonary damage.
OCCUPATIONAL CANCER
1. SKIN CANCER:- Skin cancer is a main occupational hazard among gas workers, oven
workers, tar distillers, oil refiners, dye-stuff makers, road makers and in industries associated
with the use of mineral oil, tar and related compounds.
2. LUNG CANCER:- It is an occupational hazard in gas industry, asbestos industry, nickel and
chromium work and in mining of radio-active substances. The main carcinogens in these areas
are nickel, chromates, asbestos, coal tar, etc.
3. BLADDER CANCER:- The industries associated with bladder cancer are the dye-stuffs and
dyeing industry, rubber, gas, and the electric cable industries. The major bladder carcinogens are
benzidine, auramine, beta-naphthylamines, etc.
4. LEUKAEMIA:- Exposure to benzol, roentgen rays and radio-active substances give rise to
leukaemia. Benzol is a dangerous chemical and is used as a solvent in many industries.
OCCUPATIONAL DERMATITIS:
Occupational dermatitis is a big problem in many industries. The causes may be
Physical- heat, cold, moisture, friction, pressure, x-rays
Chemical- acid, alkalies, dyes, solvents, grease, tar, chlorinated phenols
Biological- living agents such as bacteria, virus, fungi, parasites.
Plant products- leaves, vegetables and its dust , flowers and pollen grains.
PREVENTION:
Pre-selection - the workers should be medically examined before employment.
Protection – protecting clothing, long leather gloves, aprons, boots, barrier creams.
Personal hygiene – supply of warm water and adequate washing facility, soap, towels.
Periodic inspection – medical checkup and early detection, transfer from risky area,
proper education of workers to identify skin irritation.
RADIATION HAZARDS:
A number of industries use radium and other radio-active substances. X-rays are used both in
medicine and industry. Exposure to ultraviolet rays occurs in arc and other electric welding
processes. Infrared rays are produced in welding and glass blowing. The main effects of radiation
are acute burns, dermatitis malignancies, genetic effects etc.
Preventive measures:
Shielding of workers in x-ray field, so that direct contact to skin can be avoided.
The employees should be monitored at intervals not exceeding 6 months.
Suitable protective clothing
Adequate ventilation in work place to prevent inhalation of harmful gases and dust.
Replacement and periodic examination of workers in every 2 months.
Pregnant women should not be allowed to work in risky areas.
LEAD POISONING:
Lead is used in variety of industries such as manufacture of storage batteries, glass
manufacture, ship building, printing and potteries, rubber industry etc. Thousands of tons of lead
every year is exhausted from automobiles. All lead components are toxic – lead oxide, lead
carbonate, lead arsenate, etc. Lead has an effect on membrane permeability. Mode of absorption
is of 3 ways – inhalation, ingestion and absorption through skin. Normal adult ingest about 0.2 to
mg of lead per day from food and beverages. Confirmation of lead poisoning
shows a blood count more than 70 mue gm./100 ml and urine lead more than 5mg/lt.
The toxic effect of inorganic lead exposure are abdominal colic, constipation, loss of
appetite, blue-line on the gums, anaemia, wrist drop and foot drop. The toxic effects of organic
lead compounds are mostly on the CNS- insomnia, headache, mental confusion, delirium, etc.
Preventive measures:
Substitution of lead with less toxic materials.
Isolation of all processes which gives rise to lead dust and fumes.
Local exhaust ventilation.
Personal protection, personal hygiene and good housekeeping
Periodic examination of workers and health education.
Medical management- saline stomach wash if ingested, d-penicillamine.
1. NUTRITION:
In many developing countries malnutrition is an important factor contributing to poor
health among workers and low work productivity. Malnutrition may also affect the metabolism
of toxic agents and also the tolerance mechanisms. Under the Indian Factories Act, every
industry should provide a canteen when the numbers of employees exceed 250. The aim is to
provide balanced diets and snacks at reasonable cost under sanitary control. It is important to
combine this action with the education of the workers on the value of a balanced diet.
2. COMMUNICABLE DISEASE CONTROL:
The industry provides an excellent for early diagnosis, treatment, prevention and
rehabilitation. There should be an adequate immunization program against preventable
communicable diseases. The communicable diseases of special importance in India are
tuberculosis, typhoid fever, viral hepatitis, amoebiasis, intestinal parasites, malaria and venereal
diseases.
3. ENVIRONMENTAL SANITATION:
Within the industrial establishment , the following needs attention for the prevention of
spread of communicable diseases;
Water supply
Food
Toilet
General plant cleanliness
Sufficient space
Lighting , ventilation , temperature
Protection against hazards
Housing
4. MENTAL HEALTH:
Industrial workers are susceptible to the effects of love, recognition, rejection, job
satisfaction, rewards and discipline. The goals of mental health in industry are;
To promote the health and happiness of the workers
To detect the signs of emotional stress and strain and to secure relief
The treatment of employees suffering from mental illness
Rehabilitation of those who become ill
Expectant mothers are given maternity leave for 12 weeks, of which 6 weeks precede the
expected date of confinement they are allowed maternity benefit with cash payment.( ESI
act, 1948)
Provision of free antenatal, natal and postnatal services.
Night work between 7 pm to 6 am is prohibited.(Factories Act)
Provide crèches in factories where more than 30 women workers are employed.
The Indian Mines Act 1923, prohibits work under ground.
No child below the age of 14 shall be employed to work in any factory or mine or
engaged in any other hazardous employment.
6. HEALTH EDUCATION:
The various measures for the prevention of occupational diseases may be grouped
under 3 headlines:
Medical measures
Engineering measures
Legislative or statutory measures
1. MEDICAL MEASURES:
Pre-placement examination
Periodical examination
Medical and health care services
Notification
Supervision of working environment
Maintenance and analysis of records
Health education and counseling
2. ENGINEERING MEASURES:
3. LEGISLATION:
Planning
Top management establishes OHS policy, standing health and safety objectives and commitment
to continual improvement of health and safety performance and comply with OHS legislation
and requirements.
policy
Checking and
corrective action
Audit Feedback from measuring performance
Management review
Evaluate, monitor and control OHS hazards through corrective and preventive actions.
Checking and corrective action
Checking and
Internal factors corrective action external factors
OHS policy
Undertake management review to monitor progress of OHSMS implementation.
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 issues relating to
the personal safety and protection of its workers is a very important Environmental Health
concern for hospitals.
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 (i) sealed
sources containing radioactive material such as isotopes of radium, cobalt and strontium, and (ii)
linear accelerators emitting short wave length gamma waves.
Licensing users of this technology is strictly controlled (i) appropriate training, certification and
credentialing of users (ii) demonstrated implementation of safety precautions related to storage,
use and shielding of non target personnel (iii) regular inspection, maintenance and certification
of equipment by the Department of Physics within Queensland Health, and (iv) ongoing
monitoring of radiation exposure of staff using the equipment.
Back 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 wards 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 Theatres.
Where 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 Theatres 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.
Patient Protection
Nosocomial Infection Control
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.
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.
2. SPECIALIST:
3. MANAGER:
Management - In some cases the occupational health nurse may act as the manager of
the multidisciplinary occupational health team, directing and co-ordinating the work of
other occupational health professionals. The OH nurse manager may have management
responsibility for the whole of the occupational health team, or the nursing staff or
management responsibility for specific programmes.
Administration - The occupational health nurse 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 occupational health nurse 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
4. CO-ORDINATOR:
Occupational health team - The occupational health nurse, 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 occupational health nurse has a role in worker
education. This may be within existing training programmes or those programmes that
are developed specifically by occupational health nurses to, for example, inform, educate
and train workers in how to protect themselves from occupational hazards, workplace
preventable diseases or to raise awareness of the importance of healthy practices.
Environmental health management - The occupational health nurse can advise the
enterprise on simple measures to reduce the use of natural resources, minimise the
production of waste, promote re-cycling and ensure environmental health.
5. ADVISER:
6. HEALTH EDUCATOR:
7. COUNSELLOR:
Counselling and reflective listening skills - Where the nurse has been trained in using
counselling or reflective listening skills they may utilise these skills in delivering care to
individuals or groups.
Problem solving skills - Due to the close working relationship which occupational health
nurses have with the working population, and because of the nurses‘ position of trust,
occupational health nurses are often approached for advice on personal problems.
8. RESEARCHER:
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, occupational health nurses working at the enterprise level, are more
likely to use simple survey techniques, or semi-structured 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.
Occupational health nurses 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.
CONCLUSION:
Occupational diseases should not be neglected and should give proper attention at
time. It is the main role of a nurse to work as an educator and protector in the field of
occupation. Early detection and timely management can control occupational diseases.
Unit VII
MATERIAL Concepts, principles and proceDURes
MANAGEMENT Planning and proCURement proceDURes :
Specifications
ABC analysis,
VED (very important and essential daily Use)
analysis
Planning eqUIpments and SUpplies for NURsing
care: UNIT and
hospital
Inventory control
Condemnation
Application to NURsing service and eDUCation
MATERIAL MANAGEMENT
CONCEPTS
Material management is concerned with providing the drugs, supplies and equipment needed by
health personnel to deliver health services. The right drugs, supplies and equipment must be at
the right place, at the right time and in the 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 upto expectation.
Definition
Planning and control of the functions supporting the complete cycle (flow) of materials, and the
associated flow of information. These functions include (1) identification, (2) cataloging, (3)
standardization, (4) need determination, (5) scheduling, (6) procurement, (7) inspection,(8)
quality control, (9) packaging, (10) storage, (11) inventory control, (12)distribution, and (13)
disposal. Also called as materials planning.
To get
1. The right quality
2. Right quantity of supplies
3. At the right time
4. At the right place
5. For the right cost.
Material planning
Purchasing
Receiving & warehousing
Store keeping
Inventory control
Value analysis
Standardization
Production control
Transportation
Material handling
Disposal scarp
PROCEDURE
Identification of need
Establishment of standards and specification, character, quality with full description
Preparation of requisition or indents in the predesigned
Selection of the right source that is supplier
Determine right price, availability and delivery time
Placement of purchase order
Follow up
Arranging of receipt, inspection, rejection replacement for defective pieces.
Verification of invoices
Payment of bills
Maintenance of record.
"Material planning is the scientific way of determining the requirements that goes into
meeting production needs within the economic investment policies‖.
It is done at all stages and all levels of management. Material planning is based on certain
feedback information and reviews.
To get:
Primary objectives
Right price
High turnover
Low procurement and storage cost
Continuity of supply
Consistency in quality
Good supplier relations
Secondary objectives:
Development of personnel
Good information system
Forecasting
Inter-departmental harmony
Product improvement
Standardization
Make or buy decision
New materials and products
Favorable reciprocal relationships
Planning
Organizing
Staffing
Directing
Controlling
Reporting
Budgeting
Sound purchasing methods
Skillful and hard poised negotiations
Effective purchase system
Should be simple
Must not increase other costs
Simple inventory control programme
Demand estimation
A large number of items are used in the hospital. The advisory committee for
development of surgical instruments, equipment and appliances (1963) identified 3200
items of instruments, equipments and appliances being used in the hospital.
PROCUREMENT
Most organizations have a detailed set of rules and regulations regarding the procedure
for ordering for materials. In the Government systems DGHS play a crucial role in purchasing
materials of heavy cost.
Procurement cycle
Review selection
Determine needed quantities
Reconcile needs and funds
Choose procurement method
Select suppliers
Specify contract terms
Monitor order status
Receipt and inspection
Open tender
Public bidding, resulting in low prices
Published in newspapers
Quotations must be sent in the specific forms that are sold, before the time and date
mentioned in the tender form
Technical bid
Financial bid
Negotiated procurement
Buyer approaches selected potential Suppliers and bargain directly
Fix at a rate acceptable to both parties
Used in long time supply contracts
Direct procurement
Purchased from single supplier, at his quoted price
Prices may be high
Reserved for proprietary materials, or low priced, small quantity and emergency
purchases
Rate contract
Firms are asked to supply stores at specified Rates during the period covered by the
Contract
Spot purchase
It is done by a committee, which includes an officer from stores, accounts and
purchasing departments
Risk purchase
If supplier fails, the item is purchased from other agencies and the difference in cost
is recovered from the first supplier
Latest technology
Availability of maintenance and repair facility, with minimum down time
Post warranty repair at reasonable cost
Upgradeability
Reputed manufacturer
Availability of consumables
Low operating costs
Installation
Proper installation as per guidelines
Storage
Inventory control
It means stocking adequate number and kind of stores, so that the materials are available
whenever required and wherever required. Scientific inventory control results in optimal balance
To provide maximum supply service, consistent with maximum efficiency and optimum
investment.
To provide cushion between forecasted and actual demand for a material
ABC ANALYSIS
DEFINITION
ABC analysis helps us in segregating the items from one another and tells us how much valued
the items is and controlling it to what extent is in the best interest of the organization.
It 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.
OBJECTIVE
The main objective is to frame policy guidelines regarding control of items. First of all
the items are classified into three classes viz A items, B items and C items. Expensive items are
to be branded as A items, which constitute 10% of overall items but whose percentage in terms
of value is around 70%. The least expensive items are to be branded as C items, whose number
items will be 70% of total number of items but its value will be around 10% of the total items of
inventory. The in-between are to be branded as B items whose number of items will be
Also called as Pareto analysis. In ABC analysis, the entire lot of inventory is classified into three
groups based on their annual value and not on their individual cost given as:
Class A: High value items, which accounts for major share of annual inventory value.
Stricter control must obviously be applied on these items right from the initial stages of
estimating requirement, fixing the minimum stocks, lead time.
A items:
2. Rigid estimates
Class B: Medium value items, which do not belong to either of the classes and not so
strict control procedures, need be followed in regard to the items in this group.
B items
1. Moderate controls
C items
When carrying out an ABC analysis, inventory items are valued (item cost multiplied by quantity
issued/consumed in period) with the results then ranked. The results are then grouped typically
into three band. These bands are called ABC codes.
Step 1:
List down item-wise annual consumption of inventory with its unit price and determine the
annual consumption of each item.
Step 2:
Rewrite the above list in descending order of money value with additional column to enter
‗cumulative % value‘.
Step 3:
a. From the list prepared, mark the serial number of items against which the
cumulative % value of annual consumption reaches a figure of 70%
approximately. These are called class A items and compute the number of class A
items as a percent of total items.
b. Continue this process down the list and note the serial number of items against
which the cumulative % value reads approx. 90%. These additional items
constitute class B.
c. The remaining items in the list form class C items and determines quantity in
percent of total number of items.
Step 4:
Plot a curve with cumulative percentage of annual usage on quantity terms on X-axis and money
value on Y-axis.
CONTROL
Class A items are controlled and purchased only on as-required basis to minimize
carrying cost. Higher level control is exercised, these being high value items.
Class C items can be purchased in bulk for the requirement of the entire year,
being of low value. The control is exercised at lower level.
ADVANTAGES
Provides a mechanism for identifying items that will have a significant impact on overall
inventory cost
It helps to segregating those items which ought to be given priority to maximize results.
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.
LIMITATION
When number of items runs into several thousands, it is not convenient to compute and
carry out this analysis.
More chances of deterioration in storage exist since class c items are purchased in bulk
and inventory on these piles up.
ABC focuses on money value and not on functional importance of such items,
resulting in shortages of critical items.
ABC does not take into account variation of prices of items as time goes.
In VED Method (vital, essential and desirable) , 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.
In VED analysis, the inventory is classified as per the functional importance under the following
three categories:
Vital (V)
Essential (E)
Desirable (D)
Vital:
Items without which treatment comes to standstill: i.e. non- availability cannot be tolerated. The
vital items are stocked in abundance, essential items and very strict control.
Essential:
Items whose non availability can be tolerated for 2-3 days, because similar or alternative items
are available. Essential items are stocked in medium amounts, purchase is based on rigid
requirements and reasonably strict watch.
Desirable:
Items whose non availability can be tolerated for a long period. Desirable items are stocked in
small amounts and purchase is based on usage estimate.
Although the proportion of vital, essential and desirable items varies from hospital to hospital
depending on the type and quantity of workload, on an average vital items are 10%, essential
items are 40% and desirable items make 50% of total items available.
PURPOSES
In a manufacturing organization, there are number of items which are very vital or critical
in production.
Their availability must be ensured at all times for smooth production, so need to be
strictly controlled.
Desirable items are least importance in terms of functional considerations, which are
loosely controlled at the lower level.
There can be combination of these two categories like a matrix combining ABC and VED
categories. This matrix is more relevant in the hospitals. The AV category becomes the most
important for inventory control because the items are very much cost consuming being a
category and also vital for uses. These items can be controlled by the top-level management. The
CD category items are not very costly and at same time of desirable category. These items can be
controlled at the lower level.
V E D
A AV AE AD
B BV BE BD
C CV CE CD
CONTROL OF VED ITEMS
a. Category I items: these items are the most important ones and require control by the
administrator himself.
b. Category II items: these items are of intermediate importance and should be under control
of the officer in charge of the stores.
c. Category III items: these items are of least importance which can be left under the control
of the store keeper.
d. The grouping will essentially depend upon the strategy of management and the
environment of functioning. However these simple techniques can be effective in
material management system.
e. Items with high criticality (V), but required in small quantity (A) should receive highest
priority. Items with low criticality (D) and which are required in big quantity should
receive least priority.
Demand estimation
Stocking
Inventory control
Distribution
Hospital supplies and equipments are dealt with under material management. Supplies are those
items that are used up or consumed ; hence the term consumable is used for supplies. The
supplies in hospital include drugs, surgical goods (disposables, g;lass wares), chemicals,
antiseptics, food materials, stationeries, the linen supply etc. The term equipment is used for
more permanent type of article and may be classified as fixed and movables. Fixed equipment is
not a structure of the building, but it is attached to the walls or floors.(sterilizer) Movable
equipment includes furniture , instruments etc.
Disinfecting items
Computers, telephone and fax
Food and beverage materials
Anesthetic equipment
Electro medical equipment
Glass ware, dental machines
Surgical dressing utensils
Artificial limbs,bandages, cots for
patient, furniture
Engineering items and many others
1. General store
2. Dietary department and
3. Pharmacy department
When planning for the purchase of articles, budgeting is done not only for the actual price of
articles but also for the additional costs that are involved such as :
Selection of article:
While buying articles it has to meet the standards. Indian Standards Institution is the
national agency set up to bring standardization of articles in India. Articles that meet the criteria
specified by the Indian Standard Institution will be marked by ISI markings. The articles bought
should safety to the patient and personnel. Faulty instruments and equipments cause not only
inconvenience in the patient care, but also it may cause the loss of life.
Purchasing article:
The material used for any equipment should be durable, non-corroding, non- toxic and
safe for use.
Should have standard shapes and dimensions to fit into various situations
Reparability and spare part availability of the article
Interchangability of the article
All surgical instruments used in a hospital should be sterilisable and they should stand
the tests for leakage, hydraulic pressure tests for bursting etc
Should have accuracy in measurements
Should have ease of operation
The central supply service
Most hospital have a central department where equipments and supplies are stored and from
which they are distributed to the units. The type of materials that is kept in the central supply
room varies from hospital to hospital . OIn some hospital the central soppy room deals only the
sterile supplies and ward trays. In other hospitals all types of equipment such as oxygen, suction,
ward trays, catheters, syringes etc are stored here.
Linen supply:
a) Departmentalised system
b) Centralised linen supply
1) Scope of services
Essential clinical services- medicine, surgery, pediatrics, OBG, and acute
psychiatry( when necessary)
Optional clinical services – Oral surgery, orthopedic surgery, otolaryngology,
neurology and psychiatry
Essential clinical support- anesthesia, radiology and clinical laboratory
Optional clinical support services- pathology and rehabilitation including
physiotherapy.
2) Essential medical equipment
Diagnostic imaging equipment –It includes x-ray and ultrasound equipment. X-
ray equipment can be stationery in one room or mobile.
Laboratory equipment-
o Microscope
o Blood counter
o Analytical balance
o Calorimeter
o Centrifuge
o Water bath
o Incubator/oven
Refrigerator
Instillation and purification apparatus
3) Electrical medical equipment
Portable electrocardiograph
Defibrillator(external)
Portable anesthetic unit
Respirator- it should be applicable for prolonged administration during post
operative care.
Dental chair unit- a complete unit should be available to carry out standard dental
operations.
Suction pump- one portable and one other suction pump are required.
Operating theatre lamp- one main lamp with at least 8 shadows lamp and an
auxillary of 4 lamp units.
Delivery table-it should be standard and mainly operated.
Diathermy unit- a standard coagulating unit which is operated by hand or foot
switch, with variable poor control.
4) Other equipment
Autoclave – for general sterilization
Small sterilizers- for specific services.eg. Stabiliser
Cold chain and other preventive medical equipment
Ambulance
5) Small, inexpensive equipment and instruments
Equipment and instruments, such as BPapparatus, oxygen manifolds, stethoscope,
diagnostic sets and spotlights.
Introduction
Many products generally available and routinely used in healthcare facilities may also be
used in emergency preparedness/safety planning. Other specialized items – for example, Level C
equipment like powered respirators – are used primarily in emergency preparedness. The Safety
Institute's emergency preparedness products file, lists products and equipment that may be
considered when developing an emergency preparedness supply inventory. This file is intended
to serve only as an example and may not include all items and contracted suppliers that should be
considered.
Healthcare facilities purchase many of the supplies and materials needed for safety and
emergency preparedness on a regular basis from a variety of companies. Some of these routine
supplies may also be designated for a disaster supply inventory. In addition, emergency
preparedness requires specialized equipment and supplies. Many companies with comprehensive
emergency-preparedness, safety-related equipment offers catalogs, some of which are available
online.
Product categories
The following table provides some sample categories and subcategories of search terms that may
be useful in locating specific healthcare products, equipment, and training services for
emergency preparedness.
Category Subcategories
Personal protective
equipment (PPE)
Detection; monitoring Detection instruments; personal alarm kits; gas detection instruments
Monitoring
Operations; traffic Crowd control, flashlights, signs, barricades
safety
Training resources Health & training services; respiratory protection training, hearing and
biological screening
1. Department Head or designee will call in their own personnel as needed after reporting
to Command Center.
2. Be prepared to supply all departments with needed supplies.
3. Director will designate assistant to supply runners or volunteers to deliver supplies.
4. Have an up-to-date list of suppliers who can quickly supply extra materials.
5. Have Kardex in Storeroom up-to-date.
1. Large paper or plastic bags are available in the treatment Areas and the storeroom
for patient's clothing and valuables.
1. Department head or designee will call in their own personnel as needed after reporting
to Command Center.
2. Be sure all hallways or traffic areas are clear of cleaning carts, equipment and etc.
e. Operating Room, CSR, PAR, Anesthesia, & OP
g. Laboratory
1. Have arrangements made to obtain additional blood, equipment and supplies from
area agencies.
i. Pharmacy
j. Respiratory Therapy
1. Keep adequate supply of bubblers, cannulas, masks and flow meters available in
Respiratory Therapy Department.
2. Be prepared to obtain additional respirators and equipment as needed.
3. Keep resuscitation equipment in good operating condition and well marked.
Introduction
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 healthcare for CQI is done with Quality Assurance (QA).
Definition
―Quality assurance is a judgment concerning the process of care based on the extent to
which that care contributes to valued outcomes.‖ -Donabedian 1982
Quality improvement is not necessarily a replacement for existing quality assurance activities,
but rather an approach that broadens the perspectives on quality.
Public accountability- It provides evidence that the funds are being spend both
effectively resulting in optimum utilization of the resource resulting in operational
efficiency and efficiency of services provided.
To refine existing methods for ensuring optimal quality health care through an applied
research programme
(Decker, 1985 and Schroeder, 1984).
Purposes/ Need
Principles
Approaches
General approach
Specific approach
Specific approach: - These are methods used to evaluate identified instances of provider and
client interactions.
Elements/ components
According to Donabedian;
Structure Element- The physical, financial and organizational resources provided
for health care.
Process Element- The activities of a health system or healthcare personnel in the
provision of care.
Outcome Element- A change in the patient‘s current or future health that results
from nursing interventions.
According to Manwell, Shaw, and Beurri, there are 3A‘s and 3E‘s;
Access to healthcare
Acceptability
Appropriateness and relevance to need
Effectiveness
Efficiency
Equity
STANDARDS
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 systems
function, staff performance, and client care. The organizations providing quality indexes are;
Areas of QA
The assurance in various key areas are;
1. Donabedian Model (1985): It 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.
2. ANA Model: This first proposed and accepted model of quality assurance was given by Long
& 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.
Evaluate Identify
outcome of standards
structure
and criteria
, standard and criteria
System
(Individual,
Group/ organization)
Intervention Outcome
Client
(Individual, Family & Community)
4. Plan, Do, Study, Act cycle: It is an improvement model advocated by Dr. Deming which is
still practiced widely that contains a distinct improvement phase.
Use of 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.
5. Six Sigma: It 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.
Define: Questions are asked about key customer requirements and key processes to
support those requirements.
Measure: Key processes are identified and data are collected.
Analyze: Data are converted to information; Causes of process variation are identified.
Improve: This stage generates solutions and make and measures process changes.
Control: Processes that are performing in a predictable way at a desirable level are in
control.
Quality tools
Chart audits
It is the most common method of collecting quality data using charts as quality
assessment tool.
Failure mode and effect analysis: prospective view
It is a tool that takes leaders through evaluation of design weaknesses within their
process, enable 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 aimed at improving patient safety.
Root- cause analysis: retrospective view
It 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 4 categories: people, materials, policies and
procedures, and equipment.
Flow charts
These are diagrams that represent the steps in a process.
Pareto diagrams
It is used to illustrate 80/ 20 rule, which states that 80% of all process variation is
produced by 20% of items.
Histograms
It uses a graph rather than a table of numbers to illustrate the frequency of
different categories of errors.
Run charts
These 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
These 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.
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 Steps 1-3, or it may start with small-scale quality improvement activities
(Steps 5-10). Alternatively, the process may begin with monitoring (Step 4). The ten steps in the
QA process are discussed.
4. 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.
7. 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.
1. 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.
4. 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 i.e. sentinel events and rate-based. Indicators also differ
according to the type of event they usually measures (structure, process or outcome).
7. 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.
8. 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.
10. Communicate:
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
analysing through all the facilities , services rendered, measures involved in diagnosis, treatment
and other conditions and activities that affect the patients.
Definition
―Nursing audit refers to the assessment of the quality of clinical nursing.‖ - Elison
―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
Characteristics
It improve the quality of nursing care
It compares actual practice with agreed standards of practice.
It is formal and systemic.
It involves peer review.
It requires the identification of variations between practice and standards followed by the
analysis of causes of such variations.
It provides feedback for those whose records are audited.
It includes follow- up or repeating an audit sometimes later to find out if the practice is
fulfilling the agreed standards.
Objectives
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, lab 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 bed- side 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.
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
2. observe
3. compare
practice
with standards
changes
Advantages
Disadvantages
INTRODUCTION
A continual and troublesome question facing nurse managers today is why some employees
perform better than others. Making decisions about who performs what tasks in a particular
manner without first considering individual behaviour can lead to irreversible long term
problems. Each employee is different in many respects. A manager needs to ask how such
differences influence the behaviour and performance of the job requirements. Ideally, the
manager performs this assessment when the new employee is hired. In reality, however, many
employees are placed in positions without the managers having adequate knowledge of their
abilities and / or interests. This often results in problems with employee performance, as well as
conflict between employees and managers.
MEANING
Performance appraisal means the systematic evaluation of the performance of an expert or his
immediate superior.
DEFINITION
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 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.
OBJECTIVES OF APPRAISAL.
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.
4. To discover the aspirations of employees and to reconcile them with the goals of the
organisation,
IMPORTANCE
Now a day, the management uses performance appraisal as a tool. The scope of performance
appraisal is not limited to pay fixation and is enlarged to include many decisions.
1. Performance appraisal helps the management to take decision about the salary increase of
an employee.
2. The continuous evaluation of an employee helps in improving the quality of an employee
in job performance.
3. The Performance appraisal brings out the facilities available to an employee, when the
management is prepared to provide adequate facilities for effective performance.
4. It minimises the communication gap between the employer and employee.
5. Promotion is given to an employee on the basis of performance appraisal.
6. The training needs of an employee can be identified through performance
appraisal.
7. The decision for discharging an employee from the job is also taken on the basis
of performance appraisal.
8. Performance appraisal is used to transfer a person who is misfit for a job to the
right placement.
9. The grievances of an employee are eliminated through performance appraisal.
10. The job satisfaction of an employee increases morale. This job satisfaction is
achieved through performance appraisal.
11. It helps to improve the employer and employee relationship.
1. The philosophy, purpose, and objectives of the organisation are clearly stated so that
performance appraisal tools can be designed to reflect these.
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 utilised and is
accompanied by clear instructions for its use.
5. Evaluators are trained in the use of the tool.
7. Plans for policing the appraisal procedure and evaluation appraisal tools are developed
and implemented.
9. Performance appraisal is considered to be fair and productive by all who participate in it.
3. Evaluation biases and rating errors, which result in unreliable and invalid ratings.
1. Single employee is rated by two ratters. 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 he stands and where he should go.
6. The plus points of an employee should be recognised. At the same time, the minus points
should not be highlighted too much, but they may be hinted to him.
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.
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 his attitudes. The result approach refers to
appraising the employee on the basis of results of his accomplishments of a job.
1. Ranking method
This 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.
Example: if there are ten workers in the working group, the most efficient worker is
ranked as number one and the least efficient worker is ranked as number ten.
Advantages
Disadvantages
a. A big organization is not able to get sizable benefits from the ranking method.
b. Ranking method does not evaluate the individuality of an employee.
c. It lags objectivity in the assessment of employees.
Disadvantages
9. Essay 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.
COMPONENTS TO BE EVALUATED
Nurse engages in a variety of job related activities to reflect the multi dimensional nature
of the job. The performance appraisal form usually acquires a nurse manager to rate several
different performance dimension.
1. The employee selects peers to conduct the evaluation. Usually two to four peers are
identified through a pre determined process.
2. The employee submits self evaluation port folio. The port folio might describe how he or
she met objectives and/or pre determined standards during the past evaluation cycle.
Supporting materials are included.
3. The peer evaluates the employee. This may be done individually or in a group. The
individuals are group then submit a written evaluation to the manager.
4. Manager and employee meet to discuss the evaluation. The manager‘s evaluation is
included and objectives for the coming evaluation cycle are finalized.
APPRAISAL INTERVIEW
Once the manager completes an accurate evaluation of performance, he/she should arrange
an appraisal interview. The appraisal interview is the first step in employee development.
1. They provide feedback to an employee which enables him to improve his performance in
future.
2. They help management to ascertain and assess the training needs of individual
employees.
3. They enable management to know the problems and difficulties experienced by
subordinates in discharging their responsibilities and also their suggestions for removing
these difficulties.
There is no one performance appraisal system, which will work equally well in all work patterns,
a number of techniques are available to managers and occasionally more than one method is
used. An organisation must decide whether it wants to measure in terms of performance and
what method of measurement works best. It can then experiment with that method.
Several common methods of performance appraisal including their advantages and disadvantages
are described next.
When using the easy technique the evaluator writes a paragraph or more regarding a particular
employee‘s strengths and potential. Essay content should reflect the employee‘s performance in
relation to his job description. It may also include information about personal characteristics
which are pertinent to the employees job, such as the ability to work well with others or
motivation for professional growth. Well done essays have the advantage of providing an in-
depth analysis of performance. Essays are also especially suitable for identifying training and
development needs and problem areas.
4. They are difficult to combine or compare since different essays cover different aspects of
performance.
The graphic rating scale requires the rater to assign a numerical value or letter grade to each
dimensions of performance to indicate judgements ranging from superior to unsatisfactory. The
advantages of the graphic rating scale are that it is generally more consistence and reliable than
the essay, it is usually acceptable to raters, and it is easy to construct. The graphic rating scales
primary disadvantages are that it does not yield the depth of information attained in the essay
approach, and its validity can be challenged unless the factors to be rayed are chosen carefully
and comprehensively.
The critical incidence technique operated by supervisors collecting and recording instances of
their subordinates are performing in ways that are of critical importance to the success or failure
of the job. These critical incidents are reviewed with the employees during a scheduled feedback
interview. The advantage of the critical incident technique is that the evaluator rates performance
rather than personality traits. In addition, this method is useful in helping supervisors do a better
coaching job and communicate performance appraisal information to subordinates. The
disadvantage of the critical incident technique is that if requires the supervisors to write down
incidents daily, or at least weekly which can be very time consuming and sometimes difficult to
accomplish.
Supervision 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
To improve the
Helping
quality of work the person
/ performance
doing the work and develop the highest possible standard
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.
15. Supervision should encourage innovation allowing free flow of ideas and share positive
experiences of personnel.
COMMON SUPERVISORY METHODS
Supervision should be focused on the attainment of one goal, the giving of a high quality
of nursing care.
To make pattern for analysis and to analyze continuously her success in reaching the
objectives.
WHO IS SUPERVISOR?
• A supervisor is a person who is primarily incharge of a section & is responsible for both
quality & quantity of production, for the efficient performance of the equipment, & for
the employees in his charge & their efficiency, training & morale
• A supervisor drives authority from the departmental head for getting work done from the
workers by using the resources of the enterprises.
• He issues instructions to the workers, directs their activities & reports to the department
head on the performance of his section.
QUALITIES OF A GOOD SUPERVISOR:
• Trained person
• Good listener.
• Creative enthusiasm
• Helpful
SUPERVISION CONSIST OF
Communication
Leadership
Motivation
Evaluation
FUNCTIONS OF SUPERVISION:
A. Administrative B. Educative
C. Communicative
D. Evaluative
A. Administrative:
• Assignment of the work loads of individual and groups according to the level of physical
and mental competence (or) preparing the duty roaster.
• Identify the needs for supplies and equipment and providing materials and supplies to
facilitate the staff performance.
B. Educative:
• Orientation
• Teaching subordinates
• Plan and conduct in service education program
• Ensuring staff developments
C. Communicative
• The supervision act as a communicator between the staff and authorities and other health
team members.
• She facilitates communication
• She should encourage free communication among persons between worker and
community representatives and members of health team.
D. Evaluative:
Supervisor is supposed to carryout performance appraisal of all the staff this include
identify the cause of difficulty.
Providing C E and guidance.
OTHER FUNCTIONS ARE:
• Co-ordinates there of subordinates and agents and promote team worker.
• Promote social contact with in the team to bring staff together and increases
group cohesiveness.
• Develops mutual confidence
• Raises level of motivation
• Develops good IPR
• Maintains R & R
• Establish control over the subordinates
AS A MANAGER SUPERVISOR HAS TO PERFORM THE FOLLOWING
FUNCTIONS
Planning the work
Issuing orders
Providing guidance & leadership
Motivation
Preserving records
Controlling output – performance of the worker
Liaison between management & workers
Grievance handling
Industrial safety
STEPS IN SUPERVISION:
When supervision is needed the supr 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 programme has met
problem / objectives acc to plan.
Types of supervision:
Points to be considered:
- Be human in behavior
This includes:
Methods of supervision:
I. Technical – These are basic supervisory skills and which need to be trained – group
discussion and conference
For example: techniques of service study, record construction, time study etc.
Ex. Instead of orientation period of two week for each new staff member, a variable plan in
both contents and time according to the needs of each individual should formulated.
II. 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.
III. Scientific supervision – Relies on objective study and measurement than personal
judgment / opinion.
Employee oriented: Supervisors are more concerned about worker staff their needs and
welfare than assigned tasks.
Checklist
Rating scales
Nurses reports
Nursing rounds
Job descriptions
Personnel policies
Staff educations
TECHNIQUES OF SUPERVISION
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.
Any technique used for supervision must be based on sound democratic psychological
principles which takes account the nurse‘s individuality.
- Relevant problems
2. Study of document
3. Identification of priorities
Stage 2: supervision
- Task description
• Establish contact
• Identify the gaps & needs for follow up action based on feed back data attained through
the observation.
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:
4. Lack of clearly defined assignments, multiple responsibility and lack of planning on the
part of those to whom personnel is responsible
3. Grievances
6. Staff members who are inflexible and resist any type of change
14. Other issues can include anything from car rental, uniform allowance, security of the
staff within the community, need for supplies and equipment, duplication of services
provided by another organization.
DISCIPLINE
INTRODUCTION
One method by which a nurse manger can control subordinates behaviour is to invoke
official disciplinary procedure. Discipline can be self-control by which an employee brings his or
her behaviour into agreement with the agency‘s official behaviour code, or it can be a managerial
action to enforce employee compliance with agency rules and regulations.
DEFINITION
Discipline is defined as a training or moulding of the mind and character to bring about
desired behaviours.
Discipline refers to working in accordance with certain recognized rules, regulations and
customs, whether they are written or implicit in character.
AIMS AND OBJECTIVES OF DISCIPLINE
The basic pre-requisite for effective discipline is employee awareness of agency rules and
regulations governing employee behaviour. Behaviour rules should be written in clear and
concise language, incorporated in a hand-book and given to new employees during induction,
posted in each work unit and discussed with employees by manager of each unit. The
significance of code of conduct is that each employee should behave and perform in a way that
preserves the company values and commitments.
PENALTIES
Oral reprimands: For minor violations that may have occurred for the first time, managers
may opt give an oral warning in private. When oral warning is given, the nurse manager is
advised to make an anecdoctal record of time, place, occasion and gist of the reprimand.
Written reprimand: If the offense is more severe or repeated, the reprimand may be written.
The written notice should include the name of the employee, name of manager, nature of the
problem, the plan for correction, and consequences of future repetition. The employee has to
sign it, to indicate that the employee has read it. A copy should be given to the employee and
one retained for the personnel file. If again the terms are not met, other penalties will probably
be necessary.
Other penalties:
Fines may be charged for offences such as tardiness.
Loss of privileges might include transfer to a less desirable shift and loss of preference
for assignments.
Demotion is a questionable solution. It creates hard feelings which may be contagious
and more likely places offenders in a position for which they are overqualified.
Suspension: for a period of time
Withholding increment
Termination(dismissal): permanent termination of services.
APPROACHES OF DISCIPLINE
1. TRADITIONAL APPROACH
It emphasizes punishment for undesirable behaviour. The purposes of traditional discipline
are punishment for sin, enforce conformity to custom, and strengthen authority of the old over
the young. Here discipline is always applied by superiors to subordinates, the severity of
punishments is designed to be proportional to the severity of the offense, and when no single
individual admits to the violation, the whole group is punished to motivate group members to
identify the violator or punish him or her themselves
2. DEVELOPMENTAL APPROACH
It emphasizes discipline as a shaper of desirable behavior. The purpose of developmental
discipline is to shape behaviour by providing favourable consequences for the right behaviour
and unfavourable consequences for the wrong behavior; and avoidance of physical
punishment, protection of the rights of the accused and replacement of arbitrary individual
judgements of guilt.
SELF DISCIPLINE
It refers to one‘s effort at self-control for the purpose of adjusting oneself to certain needs and
demands. This form of discipline is based on two psychological principles. First, punishment
seldom produces the desired results. Often, it produces undesirable results. Second, a self-
respecting person tends to be a better worker than one who is not.
Constructive discipline (positive discipline) uses discipline as a means of helping the employees
grow, not as a punitive measure. The primary emphasis here is assisting employees to behave in
a manner that allows them to be self-directive in meeting organizational goals.
Destructive discipline (also called enforced or negative discipline): If employees are forced to
follow the rules and regulations of the organization by inducing fear in them, then it is termed as
negative discipline
2. DISCIPLINARY LETTER
It is a letter send to the nurse/employee immediately after the conference, documenting the
interview content from the managers viewpoint. It is needed as sometimes employee‘s anxiety
may block perception of the painful feedback offered by the manager.
A. Acts
1. Acts amounting to crimes
Eg. Bribery, corruption
2. Acts amounting to misdemeanor
Eg. Misbehavior, insurbordination, disobedience
3. Acts amounting to misconduct
Eg. Violation of conduct rules or standing orders
B. Omissions
Eg. Habitual late attendance, irresponsibility, negligence.
1. Preliminary enquiry
2. Decision to start formal departmental enquiry
3. Suspension
4. Charge sheet and its service
5. Appointment of enquiry officer
6. Written statement of defence
7. Recording of evidence by the enquiry officer
8. Personal hearing of charged official
9. Report of enquiry officer
10. Show cause notice by the disciplinary authority
11. Reply to show-cause notice and decision thereon
12. Review of punishment order
13. Appeal or revision
14. Reinstatement and restitution
15. Show-cause notice against withholding of emoluments for suspension period in the case
of a reinstated.
EVALUATION
INTRODUCTION
The realisation of goals and objectives is based on the accuracy of the judgements and
inferences made by decision-makers at every stage. To arrive at a good decision the test,
measurements and evaluation are being used in all situations. Thus evaluation has become a part
and parcel of every system to determine the achievement of goals in a given period.
MEANING AND DEFINITION
The term evaluation is derived from the word ‗valoir‘ which means ‗to be worth‘. Thus
evaluation is the process of judging the value or worth of an individuals achievements or
characteristics.
―It is an act or process that involves the assignment of a numerical index to whatever is being
assessed‖
―Evaluation is an act or process that allows one to make a judgement about the desirability or
value of a measure‖
SELF EVALUATION
DEFINITION
Self evaluation is defined as judging the quality of one‘s work, based on evidence and explicit
criteria, for the purpose of doing better work in the future.
1. Increased confidence in their own learning, in trying out new ideas, in changing their practice
and in their power to make a difference.
2. Enthusiasm for collaborative working, despite initial anxieties about being observed and
receiving feedback
3. Improved team-work and greater flexibility in their use of their skills
4. Increased awareness of new techniques and greater insight into thinking
5. Enhanced planning skills to ensure more effective task management.
Consumers of health care services demand quality care. Patient satisfaction has been used as an
indicator of quality services provided by health care personnel. The most important predictor of
patients overall satisfaction with hospital care is particularly related to their satisfaction with
nursing care. In recent years, the focus on consumerism in a highly competitive environment has
led to increased interest in measuring patient satisfaction with health care.
DEFINITION
―Patient satisfaction is defined as the extent of the resemblance between the expected quality
of care and the actual received care.‖
- Scarding (1994)
Data about patient satisfaction equips nurses with useful information about the structure,
process and outcome of nursing care
It is a requirement for therapeutic treatment and is equivalent to self therapy. Satisfied patients
help themselves get healed faster because they are more willing to comply with treatment and
adhere to instructions of health care providers, and thus have a shorter recovery time.
Medical audit
Quality assurance committee reviews
Indices of nursing performances
Judgemental method
1. Evaluation of the programs and activities of various departments including outpatient care,
inpatient care, overall health education activities of the hospital
2. Evaluation of the various resources available in the hospital for effective health care
3. Evaluation of effectiveness of hospital personnel including medical, paramedical, nursing as
well as non-medical employees of the hospital.
4. Services are relevant to the needs of the population it serves.
Patient satisfaction with nursing care is important for any health care agency because nurses
comprise the majority of health care providers and they provide care for patients 24 hours a day.
ULITILISATION REVIEW
The utilisation review program includes determining appropriate hospital length of stay and
necessary treatments for various illnesses and conditions and reviewing patient medical records
on admission and at intervals during hospitalisation to ensure that the patient receives
appropriate care.
1. The main aim is to curb the exploding health care costs with conservative use of
hospitalisation and expensive diagnostic and treatment procedures.
2. They work in liason with a business organisation to provide healthcare services to the
organisation‘s employees at discounted rates.
3. Cost containment to limit each patient‘s diagnostic and treatment measures to the fewest,
least expensive procedures that will relieve patient symptoms, avert costly complications,
and return the patient to fullest possible function in the shortest time possible.
A utilization review nurse is a registered nurse who reviews individual medical cases to
confirm that they are getting the most appropriate care.
They can work for insurance companies, determining whether or not care should be approved
in specific situations, and they can also work in hospitals.
Members of this profession do need to possess compassion, but they also need to be able to
review situations dispassionately to make decisions which are fair, even if they may be
uncomfortable.
At a hospital, a utilization review nurse examines patient cases if the hospital feels that a
patient may not be receiving the appropriate treatment.
In an insurance company, the utilization review nurse inspects claims to determine whether
or not they should be paid.
The nurse weighs the patient's situation against the policy held by the patient, the standards
of the insurance company, and the costs which may be involved in treatment.
To work in this field, it is usually necessary to hold a current nursing license, and to have
experience in the field.
Unit IX
FISCAL PLANNING Steps
Plan and non-plan, zero BUDGEting, mid-term
appraisal, capital and
revenUe
BUDGEt estimate, revised estimate, performance
BUDGet
AUDit
Cost effectiveness
Cost accOUnting
Critical pathways
Health care reforms
Health economics
Health insURance
BUDGEting for varioUS Units and levels
Application to NURsing service and eDUCation
FISCAL PLANNING (BUDGETING)
Introduction
Definition:
Feature of budget
Importance of budget
Budget is needed for planning for future course of action and to have a control over all
activities in the organization
Budget facilities co coordinating operation of various departments and sections for
realizing organizational objectives.
Budget serves as a guide for action in the organization
Budget helps one to weigh the values and to make decision when necessary on whether
one is of a greater value in the programme than the other
Principles of Budget
Budget is an operational plan for a definite period, usually a year, expressed in financial
terms and based on expected income and expenditure.
2. Budget should focus on objectives and policies of the organization. It must flow from
objectives and give realistic expression to the way of realizing such objectives.
3. Budget should ensure the most effective use of scarce financial and non financial resources.
5. Budgetary process requires consistent delegation for which fixed duties and responsibilities
are required to be allocated to managers at different level for framing and executing budget.
6. Budgeting should include coordinating efforts of various departments establishing frame of
reference for managerial decisions, and providing a criterion for evaluating managerial
performance.
7. Setting budget target requires an adequate checks and balance against the adoption of too
high or too low estimate. Utmost care is a must for fixing targets.
8. Budget period must be appropriate to the nature of business or service and to the type of
budget.
9. Budget is prepared under the direction and supervision of the administrator or finance officer.
10. Budget is to be prepared and interpreted consistently throughout the organization in the
communication of planning process.
11. Budget necessitates a review of the performance of the previous year and an evaluation of its
adequacy both in quantity and quality.
12. While developing a budget, the provision should be made for its flexibility.
STEPS IN BUDGETING
Take into consideration your payroll deductions (health insurance or other group benefits,
income taxes, union dues, pension) and other sources of income.
– Add together all income, less deductions. On a piece of paper record the resulting
figure as VALUE A.
Such as housing, utilities, food and transportation. Remember to allocate funds for
clothing, medical care, child care, personal expenses, recreation and emergencies/repairs.
– By subtracting your total expenses (B) from your total net income (A).
• The monthly payments and the balances. If you don‘t know your exact debt amount, now
is the time to determine it.
• If this figure is a negative number, you are not ready for Step 6 – setting goals.
Consult a personal financial counsellor and work on getting this figure into the
positive numbers
• Determine the requirements: inputs from all levels of hierarchy must be obtained
• Review the budget appropriation and actual expenditure for the current year
• Contemplated changes
• Salary fixation
• Requirement estimation
• Review of budget
• Ascertain changes
• Preparing requirements
4. implement
1. set
change
standards
3. compare 2. observe
with standards practice
changes
Introduction
Cost effectiveness and cost accounting are important aspects in the managerial level. If
these factors are not being monitored properly the profit of the organization may be drastically
affected. So each administrator should be aware of this. Thus it forms an important aspect in the
part of administration.
Cost accounting has long been used to help managers understand the costs of running a
business. Modern cost accounting originated during the industrial revolution, when the
complexities of running a large scale business led to the development of systems for recording
and tracking costs to help business owners and managers make decisions.
In the early industrial age, most of the costs incurred by a business were what modern
accountants call "variable costs" because they varied directly with the amount of production.
Money was spent on labor, raw materials, power to run a factory, etc. in direct proportion to
production. Managers could simply total the variable costs for a product and use this as a rough
guide for decision-making processes.
Some costs tend to remain the same even during busy periods, unlike variable costs,
which rise and fall with volume of work. Over time, the importance of these "fixed costs" has
become more important to managers. Examples of fixed costs include the depreciation of plant
and equipment, and the cost of departments such as maintenance, tooling, production control,
purchasing, quality control, storage and handling, plant supervision and engineering. In the early
twentieth century, these costs were of little importance to most businesses. However, in the
twenty-first century, these costs are often more important than the variable cost of a product, and
allocating them to a broad range of products can lead to bad decision making. Managers must
understand fixed costs in order to make decisions about products and pricing.
Definition
Cost accounting
Cost accounting is the process that supports the budget reporting system and the agency
efforts for cost containment.
Cost accounting is a set of techniques for associating costs with the purpose for which
obtained.
1. Raw materials
2. Labor
3. Indirect expenses/overhead
Elements of cost
In modern cost accounting, the concept of recording historical costs was taken further, by
allocating the company's fixed costs over a given period of time to the items produced during
that period, and recording the result as the total cost of production. This allowed the full cost of
products that were not sold in the period they were produced to be recorded in inventory using a
variety of complex accounting methods, which was consistent with the principles of GAAP
(Generally Accepted Accounting Principles). It also essentially enabled managers to ignore the
fixed costs, and look at the results of each period in relation to the "standard cost" for any given
product.
An important part of standard cost accounting is a variance analysis,, which breaks down
the variation between actual cost and standard costs into various components (volume variation,
material cost variation, labor cost variation, etc.) so managers can understand why costs were
different from what was planned and take appropriate action to correct the situation.
Classification of costs
Classification of cost means, the grouping of costs according to their common characteristics.
The important ways of classification of costs are:
Activity-based costing (ABC) is a system for assigning costs to products based on the
activities they require. In this case, activities are those regular actions performed inside a
company. "Talking with customer regarding invoice questions" is an example of an activity
inside most companies.
Accountants assign 100% of each employee's time to the different activities performed
inside a company (many will use surveys to have the workers themselves assign their time to the
different activities). The accountant then can determine the total cost spent on each activity by
summing up the percentage of each worker's salary spent on that activity.
A company can use the resulting activity cost data to determine where to focus their
operational improvements. For example, a job-based manufacturer may find that a high
percentage of its workers are spending their time trying to figure out a hastily written customer
order. Via ABC, the accountants now have a currency amount pegged to the activity of
"Researching Customer Work Order Specifications". Senior management can now decide how
much focus or money to budget for resolving this process deficiency. Activity-based
management includes (but is not restricted to) the use of activity-based costing to manage a
business.
While ABC may be able to pinpoint the cost of each activity and resources into the
ultimate product, the process could be tedious, costly and subject to errors.
As it is a tool for a more accurate way of allocating fixed costs into product, these fixed
costs do not vary according to each month's production volume. For example, an elimination of
one product would not eliminate the overhead or even direct labor cost assigned to it. ABC better
identifies product costing in the long run, but may not be too helpful in day-to-day decision-
making.
Lean accounting
Lean accounting has developed in recent years to provide the accounting, control, and
measurement methods supporting lean manufacturing and other applications of lean thinking
such as healthcare, construction, insurance, banking, education, government, and other
industries.
There are two main thrusts for Lean Accounting. The first is the application of lean methods
to the company's accounting, control, and measurement processes. This is not different from
applying lean methods to any other processes. The objective is to eliminate waste, free up
capacity, speed up the process, eliminate errors & defects, and make the process clear and
understandable. The second (and more important) thrust of Lean Accounting is to fundamentally
change the accounting, control, and measurement processes so they motivate lean change &
improvement, provide information that is suitable for control and decision-making, provide an
understanding of customer value, correctly assess the financial impact of lean improvement, and
are themselves simple, visual, and low-waste. Lean Accounting does not require the traditional
management accounting methods like standard costing, activity-based costing, variance
reporting, cost-plus pricing, complex transactional control systems, and untimely & confusing
financial reports. These are replaced by:
This method is used particularly for short-term decision-making. Its principal tenets are:
Revenue (per product) − variable costs (per product) = contribution (per product)
Total contribution − total fixed costs = (total profit or total loss)
Thus, it does not attempt to allocate fixed costs in an arbitrary manner to different products. The
short-term objective is to maximize contribution per unit. If constraints exist on resources, then
Managerial Accounting dictates that marginal cost analysis be employed to maximize
contribution per unit of the constrained resource
Throughput Accounting
Advantages
Disadvantages
It is the fact that it is difficult for a manager to justify the cost of a nursing care programme.
Cost effectiveness
Cost-effectiveness analysis
Cost-effectiveness analysis is a form of economic analysis that compares the relative
costs and outcomes (effects) of two or more courses of action. Cost-effectiveness analysis is
distinct from cost-benefit analysis, which assigns a monetary value to the measure of effect.
Cost-effectiveness analysis is often used in the field of health services, where it may be
inappropriate to monetize health effect. Typically the CEA is expressed in terms of a ratio where
the denominator is a gain in health from a measure (years of life, premature births averted, sight-
years gained) and the numerator is the cost associated with the health gain.[
It is a tool with great potential for the decision maker so long as he or she recognises 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.
A cost benefit ratio (z) is defined as the ratio of the value of benefits of an alternative to
the value of alternative cost.
Cost benefit analysis is designed to consider the social costs and benefit attributable to
the project. The benefits are expressed in monetary terms to determine whether a given
programme is economically sound and to select the best out of several programmes.
CRITICAL PATHWAY
Clinical Pathways: multidisciplinary plans of best clinical practice. Many synonyms exist
for the term Clinical Pathways including: Integrated Care Pathways, Multidisciplinary pathways
of care, Pathways of Care, Care Maps, and Collaborative Care Pathways.
Clinical Pathways were introduced in the early 1990s in the UK and the USA, and are
being increasingly used throughout the developed world. Clinical Pathways are structured,
multidisplinary plans of care designed to support the implementation of clinical guidelines and
protocols. They are designed to support clinical management, clinical and non-clinical resource
management, clinical audit and also financial management. They provide detailed guidance for
each stage in the management of a patient (treatments, interventions etc.) with a specific
condition over a given time period, and include progress and outcomes details.
Clinical Pathways have four main components (Hill, 1994, Hill 1998):
1. A timeline
Select a Topic .
Select a Team .
In this step, data, rather than anecdotal reports, are key to understanding current variation.
For systems with electronic medical records, this process may be more automated. For other
systems, a careful review of medical records is necessary to identify the critical intermediate
outcomes, rate-limiting steps, and high-cost areas on which to focus.
Evaluate Medical Evidence and External Practices .
After key rate-limiting steps have been identified, the critical pathway team must evaluate
the literature to identify evidence of best practices. For most rate-limiting steps, there are few
data available to define optimal processes of care. The critical pathway development team will
often lack answers to specific questions such as appropriate observation period or length of stay.
In the absence of evidence, comparison with other institutions, or "benchmarking," is the most
reasonable method to use.
The format of the pathway may vary widely. Important features include a task-time
matrix in which specific tasks are specified along a timeline. There is a spectrum of pathways
that range from a form that takes the place of the medical record to a simple checklist. A
reduction in charting that may occur with more complicated pathways is a benefit. However, if
the pathway format is too difficult to follow, it will not be used. Critical pathways have become
widely available in electronic format, where electronic charting and pathway compliance are
obtained simultaneously. One disadvantage to this method is the absence of a standard medical
record. This may result in duplication of efforts and possible noncompliance with the pathway.
This is particularly true among physicians who are likely to be resistant to novel charting
methods. For some systems, a simple checklist at the front of the paper chart may be an optimal
method for implementing the pathway. These checklists would have areas to be filled in by
different staff members active in patient care.
Variances are patient outcomes or staff actions that do not meet the expectation of the
pathway. In general, variance in clinical pathways is a result of the omission of an action or the
performance of an action at an inappropriate (often, a late) time period. Because the critical
pathway is a series of time-associated actions, this analysis of variance can be overwhelmed by
multiple data points. Computer-assisted pathway analysis can help with this issue. Another
approach is for the pathway team to concentrate on a few critical items in the pathway that have
been identified in advance, such as extubation time after cardiac surgery or length of stay in the
intensive care unit. These are critical intermediate outcomes that may have a substantial number
of important contributory factors. Arguably, the selection of areas to analyze and the analysis of
variance are among the most important processes in the critical pathway. Identification of factors
that contribute to variance and interventions to improve those factors are the key features in
process improvement.
As with Gantt Charts, Critical Path Analysis (CPA) or the Critical Path Method (CPM)
helps you to plan all tasks that must be completed as part of a project. They act as the basis both
for preparation of a schedule, and of resource planning. During management of a project, they
allow you to monitor achievement of project goals. They help you to see where remedial action
needs to be taken to get a project back on course.
Within a project it is likely that you will display your final project plan as a Gantt Chart
(using Microsoft Project or other software for projects of medium complexity or an excel
spreadsheet for projects of low complexity).The benefit of using CPA within the planning
process is to help you develop and test your plan to ensure that it is robust. Critical Path Analysis
formally identifies tasks which must be completed on time for the whole project to be completed
on time. It also identifies which tasks can be delayed if resource needs to be reallocated to catch
up on missed or overrunning tasks. The disadvantage of CPA, if you use it as the technique by
which your project plans are communicated and managed against, is that the relation of tasks to
time is not as immediately obvious as with Gantt Charts. This can make them more difficult to
understand.
A further benefit of Critical Path Analysis is that it helps you to identify the minimum
length of time needed to complete a project. Where you need to run an accelerated project, it
helps you to identify which project steps you should accelerate to complete the project within the
available time. .
PERT is a variation on Critical Path Analysis that takes a slightly more skeptical view of
time estimates made for each project stage. To use it, estimate the shortest possible time each
activity will take, the most likely length of time, and the longest time that might be taken if the
activity takes longer than expected.
Use the formula below to calculate the time to use for each project stage:
6
Importance
• Task priorities.
In 1957, DuPont developed a project management method designed to address the challenge of
shutting down chemical plants for maintenance and then restarting the plants once the
maintenance had been completed. Given the complexity of the process, they developed the
Critical Path Method (CPM) for managing such projects.
CPM models the activities and events of a project as a network. Activities are depicted as nodes
on the network and events that signify the beginning or ending of activities are depicted as arcs
or lines between the nodes. The following is an example of a CPM network diagram:
CPM Diagram
From the work breakdown structure, a listing can be made of all the activities in the project. This
listing can be used as the basis for adding sequence and duration information in later steps.
Some activities are dependent on the completion of others. A listing of the immediate
predecessors of each activity is useful for constructing the CPM network diagram.
Once the activities and their sequencing have been defined, the CPM diagram can be drawn.
CPM originally was developed as an activity on node (AON) network, but some project planners
prefer to specify the activities on the arcs.
The time required to complete each activity can be estimated using past experience or the
estimates of knowledgeable persons. CPM is a deterministic model that does not take into
account variation in the completion time, so only one number is used for an activity's time
estimate.
The critical path is the longest-duration path through the network. The significance of the critical
path is that the activities that lie on it cannot be delayed without delaying the project. Because of
its impact on the entire project, critical path analysis is an important aspect of project planning.
The critical path can be identified by determining the following four parameters for each
activity:
• ES - earliest start time: the earliest time at which the activity can start given that its
precedent activities must be completed first.
• EF - earliest finish time, equal to the earliest start time for the activity plus the time
required to complete the activity.
• LF - latest finish time: the latest time at which the activity can be completed without
delaying the project.
• LS - latest start time, equal to the latest finish time minus the time required to complete
the activity.
The slack time for an activity is the time between its earliest and latest start time, or
between its earliest and latest finish time. Slack is the amount of time that an activity can be
delayed past its earliest start or earliest finish without delaying the project.
The critical path is the path through the project network in which none of the activities
have slack, that is, the path for which ES=LS and EF=LF for all activities in the path. A delay in
the critical path delays the project. Similarly, to accelerate the project it is necessary to reduce
the total time required for the activities in the critical path.
As the project progresses, the actual task completion times will be known and the
network diagram can be updated to include this information. A new critical path may emerge,
and structural changes may be made in the network if project requirements change.
CPM Limitations
CPM was developed for complex but fairly routine projects with minimal uncertainty in
the project completion times. For less routine projects there is more uncertainty in the
completion times, and this uncertainty limits the usefulness of the deterministic CPM model. An
alternative to CPM is the PERT project planning model, which allows a range of durations to be
specified for each activity.
Benefits
There are many issues in critical pathway development and implementation that are of concern to
practitioners who care for patients with cardiovascular disease.
The first issue is that critical pathways address processes in the "ideal" patient and in
some cases do not address issues in the majority of patients who enter the path.
Identification of appropriate patients to enter the pathway is an important issue in
implementation. In general, critical pathways are more applicable to patients with
uncomplicated illnesses who are undergoing procedures or surgery. For patients treated
with medical conditions such as acute coronary syndromes, it is difficult to define
"appropriate" treatment for the majority of patients. Therefore, critical pathways will tend
to identify a great deal of variance in the care of these patients that may or may not be
wasteful or potentially harmful. The goal of placing most patients within pathways may
not benefit the individual patient.
A second issue is how to evaluate critical pathways as an effective tool in improving
patient care. As we have mentioned, little controlled research has been performed on the
effectiveness of pathways. One reason for this is that at any one medical center,
"pathway" care cannot be easily differentiated from "usual" care because of
contamination from the pathway intervention. Randomized trials with the unit of
randomization at the medical center would be the optimal evaluation method.
The real impact of critical pathways and appropriateness protocols is their use as tools for
collection of information. Pathways can serve as a screening test for inefficient care. The
danger is that a pathway with too many critical areas under review will be too sensitive,
resulting in the review of a large number of marginally appropriate cases.Review of
critical pathway data should be focused on the highest-impact areas in terms of either
cost, quality of care, or, preferably, both.
Health care reform is a general rubric used for discussing major health policy creation or
changes—for the most part, governmental policy that affects health care delivery in a given
place. Health care reform typically attempts to:
Broaden the population that receives health care coverage through either public sector
insurance programs or private sector insurance companies
Expand the array of health care providers consumers may choose among
Improve the access to health care specialists
Improve the quality of health care
Give more care to citizens
Decrease the cost of health care
We need a different approach to healthcare reforms in India
Goal
The goal of healthcare reform is to make healthcare more accessible and available to all
citizens. Currently, millions remain uninsured due to job loss, or because healthcare premiums
would simply be too costly. Ideally, healthcare reform would enable more, to become insured,
and also decrease the cost of healthcare. However, this is a goal that is not so easily obtained,
due to the complexities of the healthcare system , and the quality of care provided here.
The Ministry of Health and Family Welfare is the Indian government ministry charged
with health policy in India. It is also responsible for all government programs relating to family
planning in India.
The Minister of Health and Family Welfare holds cabinet rank as a member of the
Council of Ministers. The current minister is Shri. Ghulam Nabi Azad, who is assisted by a
Minister of States for Health and Family Welfare, Shri. Dinesh Trivedi & Shri. S. Gandhiselvan.
1 Department of Health
3 Department of AYUSH
1. Department of Health
The Department of Health deals with health care, including awareness campaigns, immunization
campaigns, preventive medicine, and public health. Bodies under the administrative control of
this department are:
10) National Vector Borne Disease Control Programme (NVBDCP) (vector-born disease)
11) Pilot Programme on Prevention and Control of Diabetes, CVD and Stroke (diabetes,
cardiovascular disease, stroke)
19) All India Institute of Physical Medicine and Rehabilitation (AIIPMR), Mumbai
The Department of Family Welfare (FW) is responsible for aspects relating to family welfare,
especially in reproductive health, maternal health, pediatrics, information, education and
communications; cooperation with NGOs and international aid groups; and rural health services.
The Department of Family Welfare is responsible for:
• 18 Population Research Centres (PRCs) at six universities and six other institutions
across 17 states
3. Department of AYUSH
The Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy
(AYUSH) deals with ayurveda (Indian traditional medicine), and other yoga, naturopathy, unani,
siddha, and homoeopathy, and other alternative medicine systems.
The department was established in March 1995 as the Department of Indian Systems of
Medicines and Homoeopathy (ISM&H).The department is charged with upholding educational
standards in the Indian Systems of Medicines and Homoeopathy colleges, strengthening
research, promoting the cultivation of medicinal plants used, and working on Pharmacopoeia
standards. Bodies under the control of the Department of AYUSH are:
Healthcare in India
India has a universal health care system run by the local (state or territorial) governments.
Government hospitals, some of which are among the best hospitals in India, provide treatment at
taxpayer expense. Most essential drugs are offered free of charge in these hospitals. However,
the fact that the government sector is understaffed, underfinanced and that these hospitals
maintain very poor standards of hygiene forces many people to visit private medical
practitioners.
The charges for basic in-hospital treatment and investigations are much less compared to
the private sector. The cost for these subsidies comes from annual allocations from the central
and state governments. For example, an outpatient card at AIIMS (one of the best hospitals in
India) costs a one-time fee of 10 rupees (around 20 cents U.S.) and thereafter outpatient medical
advice is free. In-hospital treatment costs depend on financial condition of the patient and
facilities utilized, but are usually much less than the private sector. For instance, a patient is
waived treatment costs if their income is below the poverty line. Another patient may seek an
air-conditioned room for an additional fee.
Primary health care is provided by city and district hospitals and rural primary health
centres (PHCs). These hospitals provide treatment free of cost. Primary care is focused on
immunization, prevention of malnutrition, pregnancy, child birth, postnatal care, and treatment of
common illnesses.[citation needed] Patients who receive specialized care or have complicated
illnesses are referred to secondary (often located in district and taluk headquarters) and tertiary
care hospitals (located in district and state headquarters or those that are teaching hospitals).
Now organizations like Hindustan Latex Family Planning Promotional Trust and other
private organizations have started creating hospitals and clinics in India, which also provide free
or subsidized health care and subsidized insurance plans.
In India, reforms can develop on sound principles on the basis of the learning of all available
systems, our strengths and needs. To make the common man healthy in the Indian scenario, we
need a different approach.
Funding models
Universal health care in most countries has been achieved by a mixed model of funding.
General taxation revenue is the primary source of funding, but in many countries it is
supplemented by specific levies (which may be charged to the individual and/or an employer) or
with the option of private payments (either direct or via optional insurance) for services beyond
that covered by the public system.
Almost all European systems are financed through a mix of public and private
contributions. The majority of universal health care systems are funded primarily by tax revenue
(e.g. Portugal, Spain, Denmark and Sweden). Some nations, such as Germany, France and Japan
employ a multi-payer system in which health care is funded by private and public contributions.
However, much of the non-government funding is by defined contributions by employers and
employees to regulated non-profit sickness funds. These contributions are compulsory and vary
according to a person's salary, and are effectively a form of hypothecated taxation.
A distinction is also made between municipal and national healthcare funding. For
example, one model is that the bulk of the healthcare is funded by the municipality, speciality
healthcare is provided and possibly funded by a larger entity, such as a municipal co-operation
board or the state, and the medications are paid by a state agency.
Universal health care systems are modestly redistributive. Progressivity of health care
financing has limited implications for overall income inequality.
Single payer
The term single-payer health care is used in the United States to describe a funding
mechanism meeting the costs of medical care from a single fund. Although the fund holder is
usually the government, some forms of single-payer employ a public-private system.
Public
Some countries (notably the United Kingdom, Italy, Spain and the Nordic countries)
choose to fund health care directly from taxation alone. Other countries with insurance-based
systems effectively meet the cost of insuring those unable to insure themselves via social security
arrangements funded from taxation, either by directly paying their medical bills or by paying for
insurance premiums for those affected.
Compulsory insurance
This is usually enforced via legislation requiring residents to purchase insurance, though
sometimes, in effect, the government provides the insurance. Sometimes there may be a choice
of multiple public and private funds providing a standard service (e.g. as in Germany) or
sometimes just a single public fund (as in Canada). The U.S. Patient Protection and Affordable
Care Act is a law based on compulsory insurance.
Private insurance
In some countries with universal coverage, private insurance often excludes many health
conditions which are expensive and which the state health care system can provide. For example
in the UK, one of the largest private health care providers is BUPA which has a long list of
general exclusions even in its highest coverage policy. In the USA (which tried to transition
towards universal health care, but is being challenged through the court systems as
unconstitutional, because of the mandatory purchasing requirement) dialysis treatment for end
stage renal failure is generally paid for by government and not by the insurance industry. Persons
with privatized Medicare (Medicare Advantage) are the exception and must get their dialysis
paid through their insurance company, but persons with end stage renal failure generally cannot
buy Medicare Advantage plans.
HEALTH INSURANCE
Health insurance is insurance against the risk of incurring medical expenses. By
estimating the overall risk of health care expenses, an insurer can develop a routine finance
structure, such as a monthly premium or payroll tax, to ensure that money is available to pay for
the health care benefits specified in the insurance agreement. The benefit is administered by a
central organization such as a government agency, private business, or not-for-profit entity.
The concept of health insurance was proposed in 1694 by Hugh the Elder Chamberlen
from the Peter Chamberlen family. In the late 19th century, "accident insurance" began to be
available, which operated much like modern disability insurance.This payment model continued
until the start of the 20th century in some jurisdictions (like California), where all laws regulating
health insurance actually referred to disability insurance.
Accident insurance was first offered in the United States by the Franklin Health
Assurance Company of Massachusetts. This firm, founded in 1850, offered insurance against
injuries arising from railroad and steamboat accidents. Sixty organizations were offering accident
insurance in the U.S. by 1866, but the industry consolidated rapidly soon thereafter. While there
were earlier experiments, the origins of sickness coverage in the U.S. effectively date from 1890.
The first employer-sponsored group disability policy was issued in 1911.
Before the development of medical expense insurance, patients were expected to pay
health care costs out of their own pockets, under what is known as the fee-for-service business
model. During the middle to late 20th century, traditional disability insurance evolved into
modern health insurance programs. Today, most comprehensive private health insurance
programs cover the cost of routine, preventive, and emergency health care procedures, and most
prescription drugs, but this is not always the case.
Hospital and medical expense policies were introduced during the first half of the 20th
century. During the 1920s, individual hospitals began offering services to individuals on a pre-
paid basis, eventually leading to the development of Blue Cross organizations.[5] The
predecessors of today's Health Maintenance Organizations (HMOs) originated beginning in
1929, through the 1930s and on during World War II
How it works
Premium: The amount the policy-holder or his sponsor (e.g. an employer) pays to the
health plan to purchase health coverage.
Deductible: The amount that the insured must pay out-of-pocket before the health insurer
pays its share. For example, policy-holders might have to pay a $500 deductible per year,
before any of their health care is covered by the health insurer. It may take several
doctor's visits or prescription refills before the insured person reaches the deductible and
the insurance company starts to pay for care.
Co-payment: The amount that the insured person must pay out of pocket before the
health insurer pays for a particular visit or service. For example, an insured person might
pay a $45 co-payment for a doctor's visit, or to obtain a prescription. A co-payment must
be paid each time a particular service is obtained.
Coinsurance: Instead of, or in addition to, paying a fixed amount up front (a co-payment),
the co-insurance is a percentage of the total cost that insured person may also pay. For
example, the member might have to pay 20% of the cost of a surgery over and above a
co-payment, while the insurance company pays the other 80%. If there is an upper limit
on coinsurance, the policy-holder could end up owing very little, or a great deal,
depending on the actual costs of the services they obtain.
Exclusions: Not all services are covered. The insured are generally expected to pay the
full cost of non-covered services out of their own pockets.
Coverage limits: Some health insurance policies only pay for health care up to a certain
dollar amount. The insured person may be expected to pay any charges in excess of the
health plan's maximum payment for a specific service. In addition, some insurance
company schemes have annual or lifetime coverage maximums. In these cases, the health
plan will stop payment when they reach the benefit maximum, and the policy-holder must
pay all remaining costs.
Out-of-pocket maximums: Similar to coverage limits, except that in this case, the insured
person's payment obligation ends when they reach the out-of-pocket maximum, and
health insurance pays all further covered costs. Out-of-pocket maximums can be limited
to a specific benefit category (such as prescription drugs) or can apply to all coverage
provided during a specific benefit year.
Capitation: An amount paid by an insurer to a health care provider, for which the
provider agrees to treat all members of the insurer.
In-Network Provider: (U.S. term) A health care provider on a list of providers preselected
by the insurer. The insurer will offer discounted coinsurance or co-payments, or
additional benefits, to a plan member to see an in-network provider. Generally, providers
in network are providers who have a contract with the insurer to accept rates further
discounted from the "usual and customary" charges the insurer pays to out-of-network
providers.
Prior Authorization: A certification or authorization that an insurer provides prior to
medical service occurring. Obtaining an authorization means that the insurer is obligated
to pay for the service, assuming it matches what was authorized. Many smaller, routine
services do not require authorization.
Explanation of Benefits: A document that may be sent by an insurer to a patient
explaining what was covered for a medical service, and how payment amount and patient
responsibility amount were determined.
Making a hospital budget is only second to medical delivery systems in for a hospital. In
fact, if a budget is not properly written, the hospital may be unable to deliver medical services at
all. So many expenses and sources of revenue must be taken into consideration, so the budget
process takes an expert to get through it successfully. Let's find out how to start.
Difficulty: Challenging
Instructions
Revenue can come from patient payments, tax dollars, donations, insurance credits.
Be sure to deduct a percentage of the patient bills that will remain uncollected,
the charity work expected by the hospital and the pro bono work it does.
4. Add all medical equipment costs, ongoing and expected expansion or replacement of
new diagnostic equipment.
How many staff hours are spent on each bed, occupied or not.
Use this figure as an average to get a cost per patient year.
Add to that the non medical costs per bed.
Include every possible cost that keeps that bed in the hospital.
Don't forget replacement costs per annum for any and all patient needs.
9. Write in an emergency expense fund. Disasters occur and the hospital must be
prepared for them when they arrive.
School should have a separate budget, i.e. principal in charge of the school of nursing
should be the drawing and disbursing officer and empowered to plan for operating the funds
in all different heads (as per government rules and regulations and as seemed necessary for
running an educational institutions).
Both the school/college and hospital should have separate budget. The budget for the
school or college is annually planned by the nursing director, principal and general manager
and approved by the managing director.
1. Revenue: It includes assets, fixed deposits, investments, loan, advances and income.
2. Expenditure: It includes capital, recurring annual mandatory and non recurring.
- Rent
- Salary
- Stationary items
- Contingency
- Guest relation
- House keeping indent
- Pharmacy indent
- AV aids
- Journals
- Books
- Maintenance: Repair, Replacement, Electricity, Phone, Drinking Water, Sewage
Disposal.
Non recurring expenditure includes:
- DME endowment
Endowment Fund (property or income left to someone like insurance) Rs 20,00,000/-
in two installments (before one year 10,00,000/ and second year Rs.10,00,000/) which is
paid to the DME office.
- Security fixed deposit Rs.10,00,000/ with the joint account of registrar of the university
and trustees.
- Solvency certificate(state of having more money than one owes) for Rs. 30,00,000/ from
nationalized bank for a period of 5 years.
- University endowment
Approximately the Revenue is Rs. 21,24,000/ and where as the Expenditure is Rs. 20,52,859/
Annual auditing is done to plan for the next year budget and to evaluate the current year
budget.
Unit X
NURSING Trends
INFORMATICS General PURpose
Use of compUTers in hospital and commUNIty
Patient record system
NUrsing records and reports
Management information and evALUATion
system (MIES)
E- NURsing, Telemedicine, telenURSing
Electronic medical records
NURSING INFORMATICS – CONCEPT AND TRENDS
Definitions:
Informatics (informatics comes from the French word informatique which means
computer science). Informatics is defined as computer science + information science. Used in
conjunction with the name of a discipline, it denotes an application of computer science and
information science to the management and processing of data, information, and knowledge in
the named discipline. Thus we have, medical informatics, nursing informatics, pharmacy
informatics and so on.
Hebda (1998 p. 3), defines nursing informatics as "the use of computers technology to support
nursing, including clinical practice, administration, education, and research."
American Nurses Association (ANA) (1994) has defined nursing informatics as "the
development and evaluation of applications, tools, processes, and structures which assist nurses
with the management of data in taking care of patients or supporting the practice of nursing."
Graves, J. R., & Corcoran, S. (1989). The Study of Nursing Informatics. Image: Journal of
Nursing Scholarship, 27, 227-231. Define nursing informatics as "a combination of computer
science, information science and nursing science designed to assist in the management and
processing of nursing data, information and knowledge to support the practice of nursing and the
delivery of nursing care."
The framework for nursing informatics relies on the central concepts of data, information and
knowledge:
Data is defined as discrete entities that are described objectively without interpretation
Information as data that is interpreted, organized or structured
Knowledge as information that has been synthesized so that interrelationships
are identified and formalized.
Resulting in decisions that guide practice
The management and processing components may be considered the functional components of
informatics.
Nursing Process
Because information management is integrated into the Nursing Process and Practice, some
Nursing Communities identify a 5th step in Nursing Process DOCUMENTATION
Automation of Documentation
Up-to-date, accurate information of each step of the Nursing Process is the Power behind safe,
high quality patient-centered care!
Successful Automation
Clinical Work
Information and
Communication technologies
Organisation of medicine and
health care (system)
Assesses and
2. understands the
context & identifies
consequences for
clinical work and
Selects and imperatives for 1.
prioritises change Respond Assesses and
opportunities, understands what
Respond
problems, [and for what key
imperatives and Identify impact
reasons] activities
requirements occur at each
for change level
Observe
& enquire
Identify Health care
impact
Clinical Tell
4. Relate &
check 5. Realise 6.
Creates an
information and Involves, informs Plans and
technology persuades, introduces new
strategy and prepares for these technologies
financial plan technologies and with other
other changes changes
The main point of nursing informatics is to use technology to enhance patient care and nursing
practice. Nursing informatics is a narrower, specialized field inside of the wider medical
informatics. Nursing informatics represents the way that nurses utilize technology in their daily
duties. This includes using the latest developments to help make nursing more modern and
efficient — while still providing excellent personalized patient care. Indeed, with nursing
informatics, it is often easier to give the proper individualized patient care because the vital
statistics that nurses need are often right at their fingertips.
Our future
• Technological advances are advantageous only if nurses find them useful and learn
how to use them
• Nurses may tend to focus on machinery rather than persons
• Information overload
Definition: In 2008, the American Nurses Association (ANA) defined this growing field in
its Scope and Standards for Nursing Informatics Practice as ―a specialty that integrates
nursing science, computer science, and information science to manage and communicate data,
information, knowledge and wisdom in nursing practice.‖
History: Early hospital computer systems developed from business computing systems in
the late 1950s and early 1960s, and were used for accounting, billing, inventory and similar
business-related functions. Others were developed during the 1960s primarily for storing
patient information to be used by medical staff. Nurses have worked in informatics roles for
over twenty-five years, but the phrase ―nursing informatics‖ was not seen in the literature
until 1984. Since 1984, nursing informatics has established itself as a specialty in the nursing
field. Nurses identified as informatics specialists numbered 15 in 1981; there were over
5,000 by 1991 (Saba& McCormick1996). In 1992, the American Nurses Association‘s
Congress of Nursing Practice supported the recommendation of the Council on Computer
Applications in Nursing to officially recognize NI as a nursing specialty.
Pulse Oximeter: Measure the arterial haemoglobin oxygen saturation of the patient's blood.
Intracranial Pressure Monitors: are connected to sensors inserted into the brain through a
cannula or bur hole.
Apnoea Monitors: Use electrodes or sensors placed to detect cessation of breathing, display
respiration parameters, and trigger an alarm.
Infusion Pumps: Employ automatic, programmable pumping mechanisms to supply the patient
with fluids intravenously or epidurally through a catheter.
Crash Carts: Also called resuscitation carts or code carts, are strategically located in the ICU for
immediate availability when a patient experiences cardio-respiratory failure.
Intra-Aortic Balloon Pump: Use a balloon placed in the patient's aorta to help the heart pump.
Clinical Information System: Consists of information technology that is Applied at the point of
clinical care. They include electronic medical records, clinical data repositories, decision
support programs, handheld devices for collecting data and viewing reference material, imaging
modalities and communication tools such as electronic messaging system.
Mobile Technology: Refers to portable devices to create, store, retrieve and transmit data in real
time between end users for the purpose of improving patient safety and quality care.
Wireless Area Networking: Mobile electronic health tools such as cell phones and telemedicine
technologies are rapidly transforming the face and context of health care service delivery.
Picture Archiving and Communication systems (PACS): Enables images as x-rays and scans
to be stored electronically and viewed on screen, creating a filmless process and improved
diagnosis.
Method Single Sign-On (SSO): Is a mechanism whereby single action of user authentication
and authorization can permit a user to access all computers and systems where he has permission
without the need to enter multiple passwords.
Computerized Provider Order Entry (CPOE): Are designed to replace a hospital‘s paper
based-ordering system.
Virtual Reality: Is the simulation of a real or imagined environment that can be experienced
visually.
Electronic health records (EHR): From paper to paper-less communication is the mantra
of Informatics. Repository of electronically maintained information about an individual's lifetime
health status and health care, stored such that it can serve the multiple legitimate users of the
record.
Computer information system: Computer based system that is designed for collecting, storing,
manipulating and making available clinical information important to the healthcare delivery
process.
Uses in community
Storage of Patient Data: For any organization proper and systematic storage of information is a
mandate requirement. Nurses can use computers to take down and store notes of the patients, as
they observe their condition while on rounds. As the supervised rounds involve a lot of patients
and a lot of information, using a computerized personal digital assistant makes it easier to access
the right medical information at the right time instead of carrying a bunch of paper work and
then take time to search the piece of paper to access information when you need to be quick,
efficient and accurate.
Computerized Presentations: We all would agree that computerized power point presentations
are much more efficient and has more impact on the receiver when it comes to presenting data.
Even in the field of nursing education, computers help the nursing tutors/educators to present the
large and complicated detailed form of data, which of course is a part of the medical study, in a
very simplified and effective form. When speaking of uses of computers in medicine, features
like power point presentations, slide shows, and videos are used to present medical procedures
and techniques for better understanding of complex medical procedures and their treatments.
Teaching nurses through Simulations: The field of medicine involves the concept of "hands-
on work". I mean be it a doctor or a nurse, countless procedures are done on patients regularly.
Nursing education therefore, must involve a lot of practice programs to make the students
efficient to face the real life scenario. Computer programs which enable simulate such
procedures therefore are of great use.
Computerized Self Evaluation: Computers also contribute and help the students know their
strengths and weaknesses. There are many computerized quiz and medical tests with immediate
feedback that can help you brush and develop your medical facts and requirements without any
delay. Your queries are solved, you know the answers and you know where you stand. A regular
use of such computer applications definitely makes you more equipped and well researched for
your field.
Interactive Learning: Among the uses of computers in education, the most appealing and
outstanding feature of computer based education is that it gives boost to interactive learning.
A computer system is an electronic device similar to TV, DVD, etc. It accepts the requests
through commands and processes the requests to output the results.
In any hospital we have a procedure of file system to keep the records of the patients visiting the
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
Automated hospital information systems can help 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.
In addition to alerting physicians to 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.
Computers and databases can be used to compare expected results with actual results and to help
physicians make decisions.
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.
hospital. These records will be stored in a department called Medical Records section for the
future follow-ups.
Uses of Computers in Hospitals
Computers are being included in hospitals and medical clinics throughout the world. Some uses
of computers in hospitals and clinics have been described in the following paragraphs. To know
more about the advantages of such advanced systems in hospitals, read on…
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's an explanation to all such systems, which work on computers…
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 now a day‘s 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 the 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 CT /MRI scan. 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
which is used during surgery and blood pressure monitors. Basically these medical tests and
tools provide significant convenience to medical practitioners. You will find that major
laboratory equipment and heart rate monitors have already been computerized in many
hospitals.
There are significant advantages of using computers in hospitals. The importance of computers
in hospitals has also increased drastically due to the fact that the procedures have to be speedy to
cater to a larger population and the medical services have to be more precise.
The possibility of computers uses in the medical field are endless, facilitating medical help to
hospitals and clinics all across the globe. I hope that the elaboration of the uses of computers in
hospitals is resourceful.
The EMR can be defined as the legal patient record created in hospitals and ambulatory
environments that is the data source for the EHR.
It is important to note that an EHR is generated and maintained within an institution, such as a
hospital, integrated delivery network, clinic, or physician office, to give patients, physicians and
other health care providers, employers, and payers or insurers access to a patient's medical
records across facilities.
If there's one constant in the healthcare industry, its change. Healthcare providers are
driven to find new ways to cut costs while improving care.
To meet these challenges, healthcare is turning to information systems to control costs,
improve overall efficiency and enhance patient care.
Need of an hour
A case in point in the medical records arena is the completion of patient charts. While greatly
improved through imaging, this remains a costly, laborious process which has a tremendous
impact on healthcare enterprises.
Systems must evolve to find a way to automate the identification of deficiencies in patient charts.
They must also enable electronic routing of incomplete documents to appropriate medical and
administrative personnel for on-line processing, completion and reporting and include advanced
features like electronic signature. Integrated health care delivery system-need of efficient and
accurate ways of capturing, managing and analyzing clinical data.
Payers and regulators asking the report card on clinical process and outcome
Health information and data: Having immediate access to key information - such as patients'
diagnoses, allergies, lab test results, and medications - would improve caregivers' ability to make
sound clinical decisions in a timely manner.
Result management: The ability for all providers participating in the care of a patient in
multiple settings to quickly access new and past test results would increase patient safety and the
effectiveness of care.
Order management: The ability to enter and store orders for prescriptions, tests, and other
services in a computer-based system should enhance legibility, reduce duplication, and improve
the speed with which orders are executed.
Decision support: Using reminders prompts, and alerts, computerized decision-support systems
would help improve compliance with best clinical practices, ensure regular screenings and other
preventive practices, identify possible drug interactions, and facilitate diagnoses and treatments.
Patient support: Tools that give patients access to their health records, provide interactive
patient education, and help them carry out home-monitoring and self-testing can improve control
of chronic conditions, such as diabetes.
21. In Western countries, the concept of a national centralized server model of healthcare
data has been poorly received. Issues of privacy and security in such a model have been
of concern.
22. Records that are exchanged over the Internet are subject to the same security concerns
as any other type of data transaction over the Internet.
ISSUES
1. Integrated systems require consistent use of standards in e.g. medical terminologies
and high quality data to support information sharing across wide networks
2. Ethical, legal and technical issues linked to accuracy, security confidentiality and access
rights are set to increase as national EMR systems come online.
3. Common record architectures, structures
4. Clinical information standards and communications protocols
5. Security and confidentiality of information
6. Patient data quality; data sets, data dictionaries
Storage of records
The required length of storage of an individual electronic health record will depend on
national and state regulations, which are subject to change over time.
While it is currently unknown precisely how long EHRs will be preserved, it is certain that
length of time will exceed the average shelf-life of paper records.
Ruotsalainen and Manning have found that the typical preservation time of patient data varies
between 20 and 100 years.
Synchronization of records
When care is provided at two different facilities, it may be difficult to update records at both
locations in a co-ordinated fashion.
Two models have been used to satisfy this problem: a centralized data server solution and a peer-
to-peer file synchronization program
Synchronization programs for distributed storage models, however, are only useful once record
standardization has occurred.
Merging of already existing public healthcare databases is a common software challenge. The
ability of electronic health record systems to provide this function is a key benefit and can
improve healthcare delivery.
Health information
Definition:
―Health information is any quantifiable and non-quantifiable information that can be used by
health decision-makers and clinicians to better understand disease processes and health care
issues, and to prevent, diagnose or treat health problems‖. (WHO)
HIS in India
In India, the health information exists at various levels, forms and systems.
A wide variety of data is collected by number of agencies mainly government both at the
central and state level through routine data collection and also periodic sample surveys.
―Information that is derived at regular intervals of a year or less through mechanisms designed to
meet predictable information needs‖
Examples:
Health service statistics for routine services reporting and special program reporting
(malaria, TB, and HIV/AIDS)
Administrative data (revenue and costs, drugs, personnel, training, research, and
documentation)
Epidemiological and surveillance data
Data on community-based health actions
Data on vital events (births, deaths and migrations).
An important strength of routine HISs is that decision makers and managers at all levels
of the health system have direct access to data.
Useful in health planning and management.
Empowers practitioners and managers to identify problems as they arise and solve them.
Uses:
- Support of Clinical and Medical Patient Care Activities in the Hospital
- Administration of the Hospital‘s Daily Business transactions (financial, personnel,
payroll, bed census etc.)
- Evaluation of Hospital Performance and Cost , and projection of the long-term
forecast
To develop capacity of the health staff to better deal with computers, health
information systems, and health indicators and targets.
Development of this capacity will lead to better governance of the health sector and
improved delivery of health care to the community.
Role of HIS
Guide mobilization and allocation of resources, prioritization of health programmes and
research, and improve efficiency and effectiveness of health programmes.
For information to influence management in an optimal way, it has to be used by decision
makers at each point of the management spiral.
This means that not only policy makers and managers need to make use of information in
decision making but also care providers including doctors, health technicians, and
community health workers.
How Does a Health Information System Work?
HISs generally evolves in an erratic way in response to different pressures faced by the
health system: administrative, economic, legal, or donor pressures. The result has been
health systems that are fragmented and have a dispersal and dilution of responsibility.
Programs that are disease-specific also contribute to the fragmentation in their efforts to
respond to donor requirements and international reporting of indicators. All these
factors result in an overburdened and uncoordinated HIS.
The performance of an HIS is linked not only to technical determinants such as data
quality, system design, or adequate use of information technology.
Other determinants are also involved, such as
(1) Organizational and environmental determinants that relate to the information culture within
the country context, the structure of the HIS, the roles and responsibilities of the different
actors and the available resources for HIS, and
(2) the behavioral determinants such as the knowledge and skills, attitudes, values, and
motivation of those involved in the production, collection, collation, analysis,
and dissemination of information
Hospital
: Inadequate human resources
Untrained coders
Patient record formats
No established Medical Record Departments in some hospitals
No unique ID
Repeated admissions counted as new cases
Use of IT is minimal
Public
Health:
Total system is manual
Behind time
Processing is difficult
No/weak data from
Estate sector
Occupational health
Nutrition surveillance
Health education
There are many Issues: (Other)
Poor Financial Information
No unit cost system
No Disease burden study
No routine NCD surveillance system
Other Systems:
Introduce a Unit cost system
Updating of Human Resource Information System
Mapping of Health Facilities (GIS)
Convincing Policy makers and decision makers on investment in IT in Health
The biggest challenge is ―get decision makers and policy makers to use information
for decision and policy making.‖
Therefore ―evidence based decision making culture‖ has to be promoted among them.
Security of HIS
Security of data
- Physical security (backup)
• Confidentiality of data
- System access security (password management)
- Web and network security (cryptography)
• Legislation and regulation
Privacy problems
Introduction:
Nursing profession is influenced by the changes and current trend in the health care delivery
system. Technological proficiency in nurses is a desirable attribute to function optimally in our
changing health care system: not as a substitute for nurses' care, but as an actual
enhancement of care. Nurses are encountering lot of challenges as the new technologies are
emerging. These trends in information technology challenge the nurses to focus on new areas. E
nursing and telenursing is one area which needs nurse‘s attention.
In just 10 short years, the face of technology, inside the classroom and out, has changed
dramatically.
• NOW: Mass volume storage drives and DVD‘s, double DVD, BLUERAYS.
• THEN: Technology via the classroom was limited to TV replay classes, distance
learning and PowerPoint presentations.
• Students obtained readings and syllabi via their local bookstore, in printed copy.
• NOW: Almost all students use the e-learning system to access their classes and have
some sort of Web-based component.
Many students have only online classes and many access all materials online.
• THEN: Taking pictures meant buying film and having it developed at local pharmacy.
• NOW: Digital cameras now allow instantaneous viewing of photos, downloading and
sharing them with millions on the Internet.
• NOW: Today, more than 190 million people own cell phones. 39% of these are smart
phones, which allow access to email, the Internet, videos, and academic course
content.
• THEN: Most students using computers at visited the campus and waited for open
stations.
• NOW: students are required to own a personal computer and have a Gatorlink email
address, which faculty use to regularly communicate with students.
•
E- Health
India where have we reached?
Health care delivery system is facing emerging revolutions in the field of information
and communication technology .
E-Health
E-health is a client-centered World Wide Web-based network where clients and health
care providers collaborate through ICT mediums to research, seek, manage, deliver, refer,
arrange, and consult with others about health related information and concerns.
E-health networks have developed on the Internet at an amazing rate over the
past decade.
Clients driven by the need and urge to become informed health consumers.
• Health (also written e-health) is a relatively recent term for healthcare practice
supported by electronic processes and communication, dating back to at least 1999.
• Usage of the term varies: some would argue it is interchangeable with health informatics
with a broad definition covering electronic/digital processes in health,
Forms of e-health
• The term can encompass a range of services or systems that are at the edge of
medicine/healthcare and information technology, including:
• mHealth or m-Health: includes the use of mobile devices in collecting aggregate and
patient level health data, providing healthcare information to practitioners,
researchers, and patients, real-time monitoring of patient vitals, and direct provision of
care (via mobile telemedicine);
• Medical research using Grids: powerful computing and data management capabilities
to handle large amounts of heterogeneous data.
• Healthcare Information Systems: also often refer to software solutions for appointment
scheduling, patient data management, work schedule management and other
administrative tasks surrounding health.
- Traditional Medicine}
- Preventive Medicine} At Primary care level
- Curative Medicine}
• Financial unavailability:
• Technical constraints :
• Quality aspect :
• Government Support :
• Biological consistency :
– Health advisors,
E-Strategy Goals
• Advocating for nurses; access to ICT and the resources required to integrate ICT
into nursing practice;
• Supporting the development and implementation of nursing informatics
competencies required for entry-to-practice and continuing competence;
(Nursing practice in the year 2003 is vastly different from the days of Florence Nightingale in the
1850's.
Today's nurses literally have at their fingertips the power of the Internet)
Issues of E-nursing
• Caring, (essence of nursing is contact and engagement with people, which involves
physical closeness, intimacy, and interpersonal sharing and caring that cannot be
approached with computer technology).
• Empowerment,
• Computer Literacy,
• Confidentiality,
• Bioethical Decisions,
• Networking,
• Cyber phobia
“E-Learning: Facilitating Learning through Technology
―The biggest growth in the Internet, and the area that will prove to be one of the biggest agents of
change, will be in on-line training, or e-learning.‖
John Chambers, CEO, Cisco
1. Audio/Video Conferencing
2. Virtual Classroom: * VIRTUAL REALITY
3. Threaded discussions
4. Other (Groove, etc.)
E-Learning Aliases
• Online learning/Training
• Web-based learning/training
• Virtual learning
• Distributed learning
• Distance learning
• Technology-Supported/Mediated/Facilitated Learning
• Networked Learning
• Electronic learning
• Workflow-based learning
• [Learning/Training]
Blended e-Learning
• While providing school administrators and faculty the resources to ensure they're
on track.
• Since 1996, E*Value™ has been used to ask over 150 million evaluation questions.
• Assessment Features:
– Clinical Evaluations
– The web and PDA-based PxDx Case Logger™ component helps nursing students
quickly log real and simulated patient encounters, procedures, interventions and
diagnoses
• Curriculum Mapping & Document Collections[+]
Issues of e-learning
• Availability of funds,
• Commitment and
• Access to knowledge about new developments in the field inhibits the process.
• NIC-ICMR (MEDLARS)
Most professional journals have world wide web (www) addresses to be viewed electronically,
enabling any nurse, anywhere, access to current data.
E-medicine
1. www.emedicine.medscape.com
2. www.emedicinehealth.com
3. www.mediabiznet.com
E-learning
1. www.efquel.org
2. www.elearning for kids.org
3. www.microsoft elearning.com
4. www.healthelearning .com
5. www.elearningcentre .co.in
E-nursing
www.dcu.ie/nursing/elearning.html
Benefits of Telehealth
There are many potential benefits to telehealth. These can be divided into benefits for the patient,
remote (sending) health care provider, central (receiving) health care provider and the health care
payer (insurer).
Benefits - Patient
• Quicker , more accurate diagnosis and treatment ---> improved patient outcomes
• Reduced travel
• Decreased stress
• Collaborative research
• "Electronic housecalls‖
• Benefits of Telehealth
• Improved follow-up
• Collaborative research
Benefits - Health Care Payer
• Human resources are used more efficiently, "Do more with less"
TELENURSING
• Telenursing is the branch of telehealththat involves actual nursing and client interaction
through the medium of information technology.
Evolution:
In the 1970s, several health maintenance organizations began utilizing nurses to give
telephone advice—in the role that physicians once served.
Beginning in 1974 with Mary Quinn, who documented her care with patients at Logan
Airport via telemedicine while she worked from a hospital in Boston, Massachusetts.
Since that time, creative nurses have used technology to advance healthcare in a variety
of ways. Many advanced practice nurses are now leaders in telenursing practice.
DEFINITION:
• It involves the use of electromagnetic channels (e.g. wire, radio and optical) to transmit
voice, data and video communications signals.
It has many points of contacts with other medical and non-medical applications, such as
telediagnosis
• Today nurses can offer consultation and comfort to patients whether they are in the same
city or thousands of kilometres away.
• Over the telephone, nurses can calm an anxious parent, evaluate an injury or
advise whether a person should go to an emergency unit.
• Telemonitoring, etc.
Telenursing
Objective:
The two key dimensions of telenursing are distance and electronic mediation. The distance
between participants may be very large or relatively small, but usually is greater than a public
distance of 6 to 8 feet and the electronic component may be evident or concealed.
• One part of telenursing involves the use of electronic networks, in the form of intranets,
such as hospital-and community-based local area networks and wide area networks, while
the other is found in Internet, which is a prime example of a global area network.
Types
• The information from a distant site is simultaneously received by the CPU or codec and
decompressed. The in-coming visual information is displayed on a monitor and the
auditory information sent to the speakers.
Examples of…
• Telehealth nursing
• Teletriage
• Telecare
• Telepresence
• Telephone nursing
• Telecare is a term given to offering remote care of old and physically less able people,
providing the care and reassurance needed to allow them to remain living in their own
homes.
• Telepresence refers to a set of technologies which allow a person to feel as if they were
present, to give the appearance that they were present, or to have an effect, via telerobotics at a
place other than their true location.
Telenursing technologies include activities such as
• Videoconferencing,
• Data transfer.
Mobile telemedicine
Videoconferencing uses telecommunications of audio and video to bring people at different sites
together for a meeting.
This can be as simple as a conversation between two people in private offices (point-to-point) or
involve several sites (multi-point) with more than one person in large rooms at different sites.
Videophone calls (also: 'video calls' and 'video chat') differ from videoconferencing in that they
expect to serve individuals, not groups.
Webcams are popular, relatively low cost devices which can provide live video and audio streams
via personal computers, and can be used with many software clients for both video calls and
videoconferencing.
• Faculty member keeps in touch with class while away for a week at a conference.
• Need to provide Cost effective, timely and quality healthcare (remote, rural people).
For E.g.) Immediate post-surgical situations (the care of wounds, atomies, handicapped
individuals).
Nurses can
Provideroutine assessment and follow-up care without the client having to travel
to the health care agency for an appointment.
• Home care – In normal home health care, one nurse is able to visit up to 5-7 patients per
day. Using telenursing, one nurse can ―visit‖ 12-16 patients in the same amount of time.
• Immobile patients, patients with chronic or degenerative diseases are "visited" and
assisted regularly by a nurse via videoconferencing, internet, videophone, etc.
• Scope of practice
• Nursing Teleconsultation,
• Examination of results of medical tests and exams.
• Telenursing is also used by call centers operated by managed care organizations which
are staffed by registered nurses who act as case managers or perform patient triage,
information and counseling as a means of regulating patient access and flow and
decrease the use of emergency rooms.
Advantages of telenursing:
• With all of the new diseases and health issues emerging this is a way to learn faster in an
effort to save lives and minimize risk or discomfort to the patient.
• Sharing valuable medical information with doctors and nurses in other countries
around the world and in all areas of the profession.
• Another valuable way telenursing can be of use is for military personnel. They are often
times located in areas of the world that telemedicine is the only way to diagnose and
treat them.
• The fact is that telenursing can go anywhere. It is both versatile and effective.
• First of all, one problem is that many fear that it will take away from personal one on
one time.
• Conferences and video can‘t replace valuable time between nurse and patient or more
personal discussion that nurses and clients might otherwise have with each other.
• Legal complications are raising another red flag. Laws and a set code of rules and ethics
will first need to be applied before telenursing can be used regularly in various capacities.
This alone might take some time.
• Services and how nurses get paid for them will all need to be resolved as
telenursing becomes a more fluent practice. This can prove to be a difficult
determination.
• False diagnosis
• Reliability of networks
• Then we have clinical risk and over dependence on this telenursing system.
• Due to the risks involved with what is reliable vs. unreliable information and over
dependence or over use of telenursing can easily get out of control until more
uniformed strategies and procedures are put into play.
• Telemedicine is not yet all worked out where it can be utilized constantly or flexibly.
• But, it has enormous potential to be a tremendous asset to the world and all its
civilizations.
• More time and effort will be needed to organize telenursing for it to be confidently
accepted.
• Telemedicine Infrastructure
Telemedicine
(more than 400 platforms)
TELEMEDICINE
Introduction
The state of health of a population is a direct determinant of development. Access to
better health services reduces poverty and increases productivity. Investment in health is a
prerequisite to economic and social progress. Developing countries face various problems in the
provision of medical services and health care, including funds, expertise and resources. To meet
this challenge, governments and private health care providers must make use of existing
resources and the benefits of modern technology.
Definition of telemedicine:
The definition adopted by an international consultation group convened by the WHO in
Geneva in December 1997 to draft a health telematics policy for the WHO is as follows:
Among the early telemedicine efforts was the research and development work into
telemetry undertaken by the National Aeronautics and Space Administration (NASA) in
the USA. Scientists at NASA demonstrated successfully that physicians on earth could
monitor the physiological functions of an astronaut.
1957: The first interactive video link between the Nebraska Psychiatric Institute in
Omaha and the Norfolk State Hospital 118 kms. away established by Dr. Cecil Wittson.
1961: The first radio telemetry for monitoring patients in an intensive care unit was
described in the journal of Anesthesiology.
1965: Live transmission of a open heart surgery performed by Dr. Michael Ellis DeBakey
of Methodist Hospital. Houston, Texas in the United States to the audience attending a
World Health Organization meeting in Geneva, Switzerland using Comsat‘s Early Bird
satellite.
1967: Physicians provide services for airline passengers at Boston‘s Logan International
airport clinic with an electronic link from the airport to Massachusetts General Hospital
(MGH).
1972 to 1975: The department of health education and welfare, NASA, Lockheed, and
the Indian Health Service combine to provide health care, to the Papago Indian
Reservation in Arizona known as the Space Technology Applied to Rural Papago
Advanced Health Care (STARPAHC).
1989: NASA established a Space Bridge to Armenia to extend medical consultations for
the victims of a massive earthquake in the Soviet Republic of Armenia.
7th September 2001: The first complete long distance surgery performed by a doctor
stationed thousands of kilometres away from the patient. The surgical team in New York
sent high-speed signals to robots operating on the patient in France.
Practice of telemedicine:
A telemedicine system can be as simple as a computer hook-up or as advanced as
―robotics-surgery‖ facility. Varied branches of medical specialities such as
cardiology, pathology, radiology, neurology, psychiatry, dentistry, nursing, geriatrics,
dermatology, ophthalmology, otolaryngology, endoscopy, emergency care, home health care and
rural tele- medicine are at present in practice in telemedicine. The telemed specialists make either
elective applications for making diagnosis or tackle medical emergencies by inter-physician
communication or by direct physician – patient contact.
Tele-Cardiology has been in practice for the last two decades and includes trans-telephonic
electro-cardiography, echocardiography, angiography, stethoscopy and tele-transfer of
haemodynamic, blood gas and bio-chemistry parameters for intensive cardiac care services.
Tele-cardiology centres are expanding all over the world including India.
Trans-Telephonic Electro-Cardiographic Monitoring (TTEM):
. Einthoven investigated transmission of an ECG over a telephone line in 1906.
SodiPallers in 1984, introduced this technique in Mexico using one-lead transmission. It is well
known that majority of deaths due to acute myocardial infarction are related to time factor as
60% of mortality is within first 4 hours of the event. The time-delay between onset of symptoms
to accurate diagnosis and initiation of therapy is the most important determining factor for
patient survival. For initiating pre-hospital care and thrombolysis, time is of essence as the best
results are obtained when cardiac muscle is salvaged within the ―Golden Hour‖.
TTEM was started at Escorts Heart Alert Centre (EHAC) at New Delhi, on 17 th May
1996. The accuracy of ECG recorded by cardio-beeper in comparison with conventional ECG
has been accepted. Life-long TTEM is recommended in patients with pacemakers to detect
possible battery depletion, lead or electrode malfunction that may need reprogramming or battery
replacement and to follow patients with Automatic Implantable Cardioverter Defibrillators
(AICD). Other applications are diagnoses of arrhythmias that are difficult to detect by Holter,
follow up of arrhythmia treatment, evaluation of syncope, transient symptomatic event detection,
patients with high risk of sudden cardiac death, home-rehabilitation programme, patients after
coronary artery bypass graft surgery (CABG) or after coronary angioplasty.
Tele-Echocardiography:
Tele-transmitting 2-D echocardiogram and color Doppler flow images, from remote areas to
referral centres has become possible with use of special technology, viz., broad band, Integrated
Services Digital Network (ISDN), fractional T-1 and standard phone lines. Video-conferencing
equipment utilizing ISDN technology is a reliable method for transmitting full echo-data, which
is particularly helpful in pediatric cardiology practice, where rapid and accurate diagnosis of
complex congenital cardiac lesions is lifesaving.
Tele-Pathology:
Tele-pathology services have enhanced the ability to confer, educate and communicate to
the referring physician, which in turn provides better service to increase the consultation base.
Equally important is the decreased expense and time investment. Earlier consultation could take
many days for reports to be prepared. Many times, the consult slides were lost, broken, mixed
up or not returned. Tele-pathology services provide a direct contact; the images can be stored
permanently and are available for repeat consultation. They can be sent to many experts at the
same time who can make real-time interactions among themselves.
Tele-Radiology:
Tele-radiology is claimed as most mature telemedicine application. In late 1950, the work
started in Montreal and by 1990 technology was largely tested and found acceptable for all but a
small subset of cases with very high-resolution demands such as mammography.
State-of-art is reflected in development of filmless direct-digital-technology (DDT); its
advantages are:
Elimination of films and processing chemicals.
No film processing delay.
Direct assession of images, which eliminates need for expensive film digitisers.
Tele-Psychiatry:
Increasing number of studies has identified, essential issues, related to the utility, quality and
reliability of video-conferencing i.e. interactive television in mental health care in Scandinavian
countries and in Australia.
Better resource utilization; have been established by saving expense and travel time of
patients and psychiatrists. The issue of ―diffusion‖ has been raised i.e. to what extent the
psychiatrist, will accept and integrate this technology in their day-to-day clinical practice.
Tele-Neurology:
20 channels, digital electro-encephalograms, using data compression have been successfully
transmitted telephonically. The guidelines to be followed for transmission, interpretation and
storage of EEG have been laid down by American electro-encephalographic society.
Tele-Dermatology:
The UK multicentre Tele dermatology trial, in which centres from Ireland, Manchester and New
Zealand participated, has recommended that clinical management of dermatological conditions is
possible via real-time tele-dermatology. The final phase of this trial is under process, which
aims for evaluating cost of management and mismanagement, both to the patient and National
Health Service.
Medical Video-Conferencing:
provides live interaction between physicians situated at distant hospitals.The equipment involves
video cameras at peripheral and referral institutions, linked by ISDN digital lines or satellite
links with a central station.
In 1998, National Health Service in UK has started medical video-conferencing
programmes for providing emergency care services. Seniors faculty provides ―face-to-
face‖ consultations from Royal Brompton hospital to the patients at Harefield hospital and to
hospitals in Greece and Portugal. This has ensured that patients receive expert advice irrespective
of distances from a centre of excellence.
Benefits of telemedicine:
Everyone benefits from telemedicine from the patient to the community, as well as the
physician team. Benefits can be classified according to the target group:-
Benefits to clinicians’ new opportunities to consult experts, broader base for decision making,
avoidance of the inconvenience of traveling, improved image quality and the opportunity to
manipulate images. Increased collegial support to medical personnel working in remote and
isolated areas (Continuing Medical Education), resulting in improved teaching and learning
possibilities and opportunities, access to virtual medical libraries and increased job satisfaction.
Benefits to hospital includes reduced risk of images getting lost, faster and more precise
diagnosis and treatment, better communication between sites, transport sites, transport savings,
more efficient use of equipment.
(4) Costs:
Much of the equipment used in telemedicine is still expensive (although costs are coming
down) and network costs can be significant. Though declining transmission costs and advances
in digitization and compression has made telemedicine applications more affordable, rural
consultations are not frequent and it may be difficult to operate telemedicine systems cost
effectively. At the same time high volumes of usage may not be possible in the initial phase of
any telemedicine projects.
(7) Acceptance:
The success of telemedicine depends upon how users-patients, doctors, hospitals and
governments accept it. But patients and doctors who are accustomed to personal visits may be
reluctant to alter the traditional methods of health care. Like many people, some physicians may
resist the use of a new technology, which they do not understand.
(8) Reimbursement
Since no difference is made between a conventional consultation and a teleconsultation,
secondary consultations cannot easily be reimbursed and investment and telecommunication
costs cannot easily be amortized. Also there are few insurance providers who will cover the
risks associated with telemedicine consultations.
Telemedicine cell at
SuperSpecialityHospit
Fibre Optic or
satellite links Telemedicine
Telemedicine
cell at District cell at District
Telemedicine
cell at District
Internet Based
Primary Health Links Primary Health
Centre (PHC) Centre (PHC)
Primary Health
Centre (PHC)
Objectives:
To enable advancements in medicine and speciality care to reach remote areas where medical
facilities are non-existent.
To enable the medical expertise to reach people who cannot afford the high costs involved in
speciality care.
To implement the national ―Health for All‖ policy on the basis of WHO‘s
principles: accessibility, continuity and comprehensiveness of primary health care.
To increase health awareness and bring about education and training of health professionals in
remote areas.
This model is based on hub-and-spoke concept. This concept was originally developed
for air services so that they could service a large area with the help of small regional/local air
services for short haul flights while the large distance flight routes were serviced by large
national/international carriers.
Network Architecture:
In this model, each Primary Health Centre (PHC) with basic telephone connection (POTS
or ISDN) is connected to a dedicated telemedicine cell in the district hospital. This district
hospital is in turn linked to other district hospitals through ISDN lines or any other available high
bandwidth links. The district level hospital is in turn connected to a dedicated telemedicine cell
in a super speciality hospital through broadband links (satellite links or fiber optic lines). This
super speciality hospital is in turn linked to other super speciality hospitals, medical universities
and libraries and national level health coordinating centre through broadband links.
Telecommunication Infrastructure:
A telephone link.
An Internet connection.
A Pentium PC with web camera or digital camera.
A modem.
A printer.
An Uninterrupted Power Supply (UPS).
Medical Infrastructure:
A digital stethoscope.
A trans-telephonic electrocardiograph.
Basic diagnostic kits.
A registered medical practitioner or a qualified health nurse or a paramedic trained to
handle the equipment and facilitate teleconsultation with the telemedicine cell in the
district hospital.
District Hospital:
Has a dedicated cell with medical practitioners and specialists for attending to call from
PHCs.
Has a mobile unit that can be dispatched to villages in case of emergencies and to areas
not having PHCs.
Has access to national medical universities and libraries.
Is linked to super speciality hospitals through broadband links.
Link to PHCs through web based links.
Has X-Ray machines, diagnostic labs and even CT and MRI.
Has a team of medical personnel to provide expert opinion to PHCs.
Has a team to advise rural health workers in PHCs about vaccination, nutrition etc.
Provides training through continuous medical education.
Provides guidelines and treatment advice during epidemics.
Has an expert team of specialists to provide opinions guidelines and diagnosis to district
level telemedicine cells.
Has access to other tertiary medical centres, medical research institutes and a national
level health-coordinating centre.
Has sophisticated medical equipments and capable of super speciality care.
Unit XI
LEADERSHIP Concepts, Types, Theories
Styles
Manager behavioUR
Leader behavioUR
Effective leader: Characteristics, skills
GrOUp dynamics
Power and politics
lobbying
Critical thinking and decision making
Stress management
Applications to NURsing service and eDUCation
LEADERSHIP
CONCEPTS
Leader is a part of management and one of the most significant elements of direction. A
leader may or may not be manager but a manager must a leader. A manager as a leader must lead
his subordinate s and also inspire them to achieve organizational goals. Thus leadership is the
driving force which gets the things done by others.
Leadership represents an abstract quality in a man. It is a psychological process of
influencing followers or subordinates and providing guidance to them. Thus the essence of
leadership is follower ship. It is the followers who make a person as leader. An executive has to
earn followers. He may get subordinates because he is in authority but he may not get a
follower unless he makes the people to follow him only willing followers can and will make him
a leader.
DEFINITON
LEADER
A person who demonstrates and exercise influence and power over others. Leaders have a vision
and influence others by their actions and comments.
LEADERSHIP
Leadership is the ability to influence other people
Lansdale
Leadership is the ability of a manager to induce subordinate to work with zeal confidence.
Koontz and O Donnell
Leadership as the ability to secure desirable actions from a group of followers voluntary, without
the use of coercion.
Afford and Beaty
Leadership is the activity to persuade others to seek defined objectives enthusiastically. It is the
human factor which binds a group together and motivate it towards goals
Keith Davis
Leadership is the lifting of mans vision to higher sights, the rising of mans performance to higher
standard, the building of mans personality beyond its normal limitation.
Peter Drucker
IMPORTANCE-
A leader creates confidence in his subordinates and gains their faith and
cooperation. Besides, the leader provides environment conductive to work which results
in team spirit.
FUNCTIONS OF LEADERSHIP-
TYPES OF LEADERSHIP
a) INTELLECTUAL LEADER
He is one who possesses rich knowledge and technical competence. All his
subordinates listen and follow his advice because of his specialized intellectual authority.
b) CREATIVE LEADER
Creative leader uses the technique of ‗circular response‘ to encourage ideas to
flow from group to him and vice versa. He draws out the best in his followers and
controls them with zeal to attain the goals.
c) PERSUASIVE LEADER
He gains faith and confidence from his followers. He possesses a magnetic
personality which attracts followers which helps to get work done by them effectively.
d) INSTITUTIONAL LEADER
When a person becomes a leader by virtue of his position, he is called an
institutional leader. e.g. - the principal of a college, managing director of a company
e) DEMOCRATIC LEADER
A democratic leader is one who does not lead but is lead by his followers. In other
words, he follows the opinion of the majority of his followers and delegates most of his
power to them.
f) AUTOCRATIC LEADER
He is one who dominates and drives his group through coercion and command.
He institutes a sense of fear among his followers. Such leaders love power and never
delegate their authority.
THEORIES:-
2. STYLE THEORY-
This focuses on what leaders do in relational and contextual terms. The achievement of
satisfactory performance measures requires supervisors to pursue effective relationships with
their subordinates, while comprehending the factors in the work environment that influence
outcomes.
3. TRANSACTIONAL/TRANSFORMATIONAL THEORY
This theory describes the relationship between leaders and followers. New concepts such
as empowerment, inspiration motivation and social learning are present. This refers to a process
whereby the leader attends to the needs and motives of followers so that interaction raises to high
levels of motivation and morality.
4. SITUATIONAL THEORY
STYLES OF LEADERSHIP
1. AUTOCRATIC LEADERSHIP:
Tleader assumes complete control over the decisions and activities of the group.
ADVANTAGES DISADVANTAGES
Efficient in time of crisis, easy to make Does not encourage the individuals growth
decision by one group and less time and does not recognize the potentials,
consuming imitativeness and creates less cooperation
among members
It is useful when there is only leader who is Leader lacks supportive power that results
experienced having new and essential in decision made with consultation
information, while subordinates are in although he may be correct
experienced and new
It is useful when the workers are unsure of Less job satisfaction leads to less
taking decision and expect the leader to tell commitment to goals of the organization
what to do
2. DEMOCRATIC LEADER
ADVANTAGES DISADVANTAGES
Encourages all employee in decision It takes more time for taking decision by
making the group than the leader alone
3. LAISSARE-FAIRE LEADERSHIP
Free- Rein, Anarchic and Ultraliberal style of leadership. The leader gives up all
power to the group.
CHARACTERISTIC FEATURES
ADVANTAGES DISADVANTAGES
4. BUREAUCRATIC LEADERSHIP
In this the leader function only with rules and regulations. Leader cannot be
flexible and does not like to take any risk out of the rules. E.g defense leader
Characteristics of leadership
1. It is a personal quality of character and behavior in man which enables him to exert
internal personal influence.
2. It is concerned with the lying down group objectives and polices for the followers,
motivating them coordinating their efforts to accomplish the objectives.
3. It pre – supposes the existence of a group followers.
4. Its style may differ from situation to situation.
5. It is the ability to perused others and motivate them to work for accomplishing certain
objectives.
6. It is process of influencing exercised by leader on members of a group.
7. It involves an unequal distribution of authority among leaders and groups.
LEADERSHIP SKILLS
GROUP DYNAMICS
INTRODUCTION
“Never doubt that a small group of thoughtful citizens can change the world. Indeed, it is the
only thing that ever has.‖ Margaret Mead
DEFINITION
GROUP:
A group may be defined as a number of individuals who join together to achieve a goal.
People join groups to achieve goals that cannot be achieved by them alone.
Johnson & Johnson (2006)
A collection of people who interact with one another, accept rights and obligations as
members and who share a common identity.
A group is an association of two or more people in an interdependent relationship with
shared purposes.
GROUP DYNAMICS:
A branch of social psychology which studies problems involving the structure of a group.
The interactions that influence the attitudes and behavior of people when they are
grouped with others through either choice or accidental circumstances.
A field of social psychology concerned with the nature of human groups, their
development, and their interactions with individuals, other groups, and larger
organizations.
TYPE OF GROUPS
Formal groups: refers to those which are established under the legal or formal authority
with the view to achieve a particular end results. Eg: trade unions.
Informal groups: refers to aggregate of personal contact and interaction and network of
relationship among individual. Eg: friendship group.
Primary groups: are characterized by small size, face to face interaction and intimacy
among members of group. Eg: family, neighbourhood group.
Secondary groups: characterized by large size, individual identification with the values
and beliefs prevailing in them rather than cultural interaction.
Eg: occupational association and ethnic group.
Task groups: are composed of people who work together to perform a task but involve
cross-command relationship. Eg: for finding out who was responsible for causing wrong
medication order would require liaison between ward in charge, senior sister and head
nurse.
Social groups: refers to integrated system of interrelated psychological group formed to
accomplish defined objectives. Eg: political party with its many local political clubs.
friendship group.
Reference groups: one in which they would like to belong.
Membership groups: those where the individual actually belongs.
Command groups: formed by subordinates reporting directly to the particular manager
are determined by formal organizational chart.
Functional groups: the individuals work together daily on similar tasks.
Problem solving groups: it focuses on specific issues in their areas of responsibility,
develops potential solution and often empowered to take action.
♪ The members of the group must have a strong sense of belonging to the group.
♪ Changes in one part of the group may produce stress in other person, which can be
reduced only by eliminating or allowing the change by bringing about readjustment in the
related parts
♪ The group arises and functions owing to common motives.
♪ Groups survive by placing the members into functional hierarchy and facilitating the
action towards the goals
♪ The intergroup relations, group organization and member participation is essential for
effectiveness of a group.
♪ Information relating to needs for change, plans for change and consequences of changes
must be shared by members of a group.
CONTENT VS PROCESS
When we observe what the group is talking about, we are focusing on the content.
When we try to observe how the group is handling its communication, i.e., who talks how
much or who talks to whom, we are talking about group process. In fact, the content of
group discussion often tells us what process issue may be on people's minds.
At a simpler level, looking at process really means to focus on what is going on in
the group and trying to understand it in terms of other things that have gone on in the
group.
DECISION
Many kinds of decisions are made in groups without considering the effects these
decisions have on other members. Some try to impose their own decisions on the group,
while others want all members to participate or share in the decisions that are made.
Some decisions are made consciously after much debate and voting. Others are made
silently when no one objects to suggestion.
INFLUENCE
Some people may speak very little, yet they may capture the attention of the
whole group. Others may talk a lot—but other members may pay little attention to them
TASK VS RELATIONSHIPS
The group's task is the job to be done. People who are concerned with the task
tend to:
♥ Make suggestions as to the best way to proceed or deal with a problem
♥ Attempt to summarize what has been covered or what has been going on in the
group
♥ Give or ask for facts, ideas, opinions, feelings, feedback, or search for
alternatives.
Relationships means how well people in the group work together. People who are
concerned with relationships tend to:
♥ Be more concerned with how people feel than how much they know
♥ Help others get into the discussion
♥ Encourage people with friendly remarks and gestures.
ROLES
Behavior in the group can be of 3 types:
♥ TASK ROLES (which helps the group accomplish its task)
Initiator: proposing tasks or goals; defining a group problem; suggesting ways to
solve a problem.
Information/opinion seeker: requesting facts; asking for expressions of feeling;
requesting a statement; seeking suggestions and ideas.
Information or opinion giver: offering facts; providing relevant information;
stating an opinion; giving suggestions and ideas.
Clarifier and elaborator: interpreting ideas or suggestions; clearing up
confusion; defining terms; indicating alternatives and issues before the group.
Summarizor: pulling together related ideas; restating suggestions after the group
has discussed them; offering a decision or conclusion for the group to accept or
reject.
Energizer; who stimulates and prods the group to act and raise the level of their
actions.
Coordinator: who clarifies and coordinates ideas, suggestions and activities of
the group members.
MEMBERSHIP
One major concern for group members is the degree of acceptance or inclusion
they feel in the group.
♥ Are there any sub-groupings? Sometimes two or three members may consistently
agree and support each other or consistently disagree and oppose one another.
♥ Do some people seem to be outside the group? Do some members seem to be
"in"? How those ―outside‖ are treated?
♥ Do some members move in and out of the group? Under what conditions do they
move in and out?
FEELINGS
During any group discussion, feelings are frequently generated by the interactions
between members. These feelings, however, are seldom talked about. Observers may
have to make guesses based on tone of voice, facial expressions, gestures and many other
forms of nonverbal cues.
NORMS
Standard or group rules always develop in a group in order to control the behavior
of members. Norms usually express the beliefs or desires of the majority of the group
members as to what behaviors should or should not take place in the group. These norms
may be clear to all members (explicit), known or sensed by only a few (implicit), or
operating completely below the level of awareness of any group members. Some norms
help group progress and some hinder it.
GROUP ATMOSPHERE
Something about the way a group works creates an atmosphere which in turn is
revealed in a general impression. Insight can be gained into the atmosphere characteristic
of a group by finding words which describe the general impression held by group
members.
GROUP MATURITY
Group maturity is defined as the ability and willingness of group members to set
goals and work toward their accomplishment. Characteristic of mature group:
♥ An increasing ability to be self-directed (not dependent on the leader).
♥ An increased tolerance in accepting that progress takes time.
♥ An increasing sensitivity to their own feelings and those of others.
♥ Improvement in the ability to withstand tension, frustration and disagreement.
♥ An increased ability to change plans and methods as new situations develop.
Assessing group maturity is especially important for a group leader. An immature
group needs direction. Directive leadership is usually best. If a group is very mature,
nondirective leadership is usually best. In between the extremes of very mature and very
immature, democratic leadership will be the best bet depending on the situation.
Stage 2: Storming (letting down the politeness barrier and trying to get down to the issues even
if tempers flare up)
Individuals in the group can only remain nice to each other for so long, as
important issues start to be addressed. Some people's patience will break early,
and minor confrontations will arise that are quickly dealt with or glossed
over. These may relate to the work of the group itself, or to roles and
responsibilities within the group. Some will observe that it's good to be getting
into the real issues, whilst others will wish to remain in the comfort and
security of stage 1. Depending on the culture of the organization and
individuals, the conflict will be more or less suppressed, but it'll be there, under
the surface. To deal with the conflict, individuals may feel they are winning or
losing battles, and will look for structural clarity and rules to prevent the
conflict persisting.
Stage 3: Norming (getting used to each other and developing trust and productivity)
As Stage 2 evolves, the "rules of engagement" for the group become
established, and the scopes of the group‘s tasks or responsibilities are clear and
agreed. Having had their arguments, they now understand each other better,
and can appreciate each other's skills and experience. Individuals listen to each
other, appreciate and support each other, and are prepared to change pre-
conceived views: they feel they're part of a cohesive, effective
group. However, individuals have had to work hard to attain this stage, and
may resist any pressure to change - especially from the outside - for fear that
the group will break up, or revert to a storm.
Stage 4: Performing (working in a group to a common goal on a highly efficient and cooperative
basis)
Not all groups reach this stage, characterised by a state of interdependence and
flexibility. Everyone knows each other well enough to be able to work
together, and trusts each other enough to allow independent activity. Roles and
responsibilities change according to need in an almost seamless way. Group
identity, loyalty and morale are all high, and everyone is equally task-
orientated and people-orientated. This high degree of comfort means that all
the energy of the group can be directed towards the task(s) in hand.
Ten years after first describing the four stages, Bruce Tuckman revisited his original
work and described another, final, stage in 1977:
Stage 5: Adjourning (mourning the adjournment of the group)
This is about completion and disengagement, both from the tasks and the group
members. Individuals will be proud of having achieved much and glad to have
been part of such an enjoyable group. They need to recognize what they've
done, and consciously move on. Some authors describe stage 5 as "Deforming
and Mourning", recognizing the sense of loss felt by group members.
In the real world, groups are often forming and changing, and each time that happens, they
can move to a different Tuckman Stage. A group might be happily Norming or Performing, but
a new member might force them back into Storming. Seasoned leaders will be ready for this, and
will help the group get back to Performing as quickly as possible. Many work groups live in the
comfort of Norming, and are fearful of moving back into Storming, or forward into Performing.
This will govern their behaviour towards each other, and especially their reaction to change.
II. M. SCOTT PECK developed stages for larger-scale groups (i.e., communities) which are
similar to Tuckman's stages of group development. Peck describes the stages of a community as:
► Pseudo-community
► Chaos
► Emptiness
► True Community
GROUP DYNAMICS PROCESS
A. GROUP FORMATION
A group is able to share experiences, to provide feedback, to pool ideas, to generate
insights, and provide an arena for analysis of experiences. The group provides a measure of
support and reassurance. Moreover, as a group, learners may also plan collectively for
change action. Group discussion is a very effective learning method.
► Participation
Participation is a fundamental process within a group, because many of the other
processes depend upon participation of the various members. Levels and degrees of
participation vary. Some members are active participants while others are more withdrawn
and passive. In essence, participation means involvement, concern for the task, and direct or
indirect contribution to the group goal. If members do not participate, the group ceases to
exist.
Factors which affect member’s participation are;
◘ The content or task of the group- is it of interest, importance and relevance?
◘ The physical atmosphere - is it comfortable physically, socially and psychologically?
◘ The psychological atmosphere - is it accepting, non-threatening?
◘ Member‘s personal preoccupations - are there any distracting thoughts in their mind?
◘ The level of interaction and discussions - is adequate information provided for everyone
to understand? - is it at a level everyone understands?
◘ Familiarity - between group members- do members know each other from before?
► Communication
Communication within a group deals with the spoken and the unspoken, the verbal
and the non-verbal, the explicit and the implied messages that are conveyed and exchanged
relating to information and ideas, and feelings.
Two-way communication implies a situation where not only the two parties talk to each
other, but that they are listening to each other as well. It helps in clarification of doubts,
confusions and misconceptions, both parties understanding each other, receiving and giving
of feedback.
Helpful hints for effective communication
◘ Have a circular seating arrangement so that everyone can see and interact with everyone
else
◘ If there are two facilitators, they should sit apart so that communication flow is not in one
direction
◘ Respect individuals- let everyone call everyone else by name respectfully
◘ Encourage and support the quiet members to voice their opinions
◘ Try and persuade the people who speak too much to give others a chance
◘ Ensure that only one person speaks at a time or no one else will be heard
◘ Discourage sub groups from indulging in side talk
► Problem solving
Most groups find themselves unable to solve problems because they address the
problem at a superficial level. After that they find themselves blocked because they cannot
figure out why the problem occurred and how they can tackle it.
► Leadership
Leadership involves focusing the efforts of the people towards a common goal and to
enable them to work together as one. In general we designate one individual as a leader. This
individual may be chosen from within or appointed from outside. Thus, one member may
provide leadership with respect to achieving the goal while a different individual may be
providing leadership in maintaining the group as a group. These roles can switch and change.
B. DEVELOPMENT OF GROUPS
The developmental process of small groups can be viewed in several ways. Firstly, it is
useful to know the persons who compose a particular small group.
◘ People bring their past experiences
◘ People come with their personalities (their perceptions, attitudes and values)
◘ People also come with a particular set of expectations.
The priorities and expectations of persons comprising a group can influence the manner
in which the group develops over a period of time
Stages
Viewing the group as a whole we observe definite patterns of behavior occurring within a
group. These can be grouped into stages.
► FIRST STAGE
The initial stage in the life of a group is concerned with forming a group. This stage is
characterized by members seeking safety and protection, tentativeness of response, seeking
superficial contact with others, demonstrating dependency on existing authority figures.
Members at this stage either engage in busy type of activity or show apathy.
► SECOND STAGE
The second stage in this group is marked by the formation of dyads and triads.
Members seek out familiar or similar individuals and begin a deeper sharing of self.
Continued attention to the subgroup creates a differentiation in the group and tensions across
the dyads /triads may appear. Pairing is a common phenomenon.
► THIRD STAGE
The third developmental stage is marked by a more serious concern about task
performance. The dyads/triads begin to open up and seek out other members in the group.
Efforts are made to establish various norms for task performance. Members begin to take
greater responsibility for their own group and relationship while the authority figure becomes
relaxed.
► FOURTH STAGE
This is a stage of a fully functional group where members see themselves as a group
and get involved in the task. Each person makes a contribution and the authority figure is
also seen as a part of the group. Group norms are followed and collective pressure is exerted
to ensure the effectiveness of the group. The group redefines its goals in the light of
information from the outside environment and shows an autonomous will to pursue those
goals. The long-term viability of the group is established and nurtured.
C. FACILITATING A GROUP
A group cannot automatically function effectively, it needs to be facilitated. Facilitation
can be described as a conscious process of assisting a group to successfully achieve its task while
functioning as a group. Facilitation can be performed by members themselves, or with the help
of an outsider.
To facilitate effectively the facilitator needs to:
◘ Understand what is happening within the group
◘ Be aware of his/her own personality and
◘ Know how to facilitate
INTRODUCTION
Power was once considered a taboo in nursing. In the earliest years, the exercise of power
was considered inappropriate, unladylike, and unprofessional. Many decisions about nursing
education and practice were often made by persons outside of nursing. Nurses began to exercise
their collective power with the rise of nursing leaders and the development of organizations that
evolved into the American Nurses‘ Association and the National League for Nursing. Power
gives one the potential to change the attitudes and behaviors of individual people and groups.
Power has a positive and a negative face. The negative face of power is the ―I win, you lose‖
aspect of dominance versus submission. The positive face of power occurs when someone exerts
influence on behalf of rather than over someone or something. Politics is the art of using power
wisely. It requires clear decision making, assertiveness, accountability, and the willingness to
express one‘s own views.
DEFINITIONS:
1) Power is derived from the Latin verb potere (to be able); thus power may be
appropriately defined as that which enables one to accomplish goals.
2) Power can also be defined as the capacity to act or the strength and potency to
accomplish something.
3) Power is the ability to influence others through the use of energy and strength.
LEVELS OF POWER:
The power to be (being)- The maintenance of a purely vegetative existence requires
minimum force (exist).
The power of self-affirmation- Efforts to define self and establish significance require
greater force than that required for existence.
The power of self-assertion- Compelling others to reckon with one‘s individuality and rights
requires greater force than that needed for self affirmation.
The power of aggression- Moving into and taking possession of another‘s territory requires
force beyond that needed to define personal identity and rights
The power of violence-Application of harmful force against another person or property
reflects a disturbed definition of self, other, and property.
POWER PRINCIPLES:
There are principles to guide a nurse manager in obtaining power and preventing its seizure by
others.
1. Power is dynamic and elusive and must be continuously replenished.
2. Power can be obtained only through active means; that is, it must be expressed against
resistance and wrested from opponents.
3. A power oriented manager uses any means of control that will manipulate circumstances in
her/his favour.
4. To win in the game of organizational politics requires a person‟s total commitment to
goals.
5. Restraint is needed to use power appropriate. A person should use only as much force as
needed to achieve desired objectives.
6. Power relations in an organization are situational, that is, a person‘s ability to apply force
to another is contingent on specific circumstances that would not exist at another place or
time. For example, a subordinate‘s power over a superior may result from the subordinate‘s
having held a leadership position in the past; having publicly defended the superior against
attack; or having knowledge of the superior‘s unwise or unsafe behaviour in a situation that
is unknown to others. A superior‘s power over a subordinate may result less from their
respective positions in the official table of organization than from the superior‘s membership
on the subordinate‘s thesis committee or office in a professional organization that the
subordinate has recently joined.
7. Power has spatial dimensions. That is, the amount of a person‘s power is relative to other
powers extant in the situation. A nurse manager who attempts to wield power forcefully will
encounter strong resistance from peers and subordinates, because excessive force engenders
counterforce as employees struggle for personal control and control over work life. This
counterforce limits the direction and distance through which the manager‘s power attempts
are effective.
8. All agency employees desire clear definitions of power and control relationships among
staff members but are reluctant to discuss power and control issues publicly; especially in the
presence of persons with high authority. Consequently, health workers are unlikely to
ventilate dissatisfaction about power distribution and use during regular staff meetings.
Resentments concerning power abuse are likely to accumulate, fester, and explode
unexpectedly.
TYPES OF POWER:
According to French and Raven (1959), the following are the types of power.
1. Reward power:
Reward power is obtained by the ability to grant favors or reward others with whatever
they value. The arsenal of rewards that a manager can dispense to get employees to work toward
meeting organizational goals is very broad. Positive leadership through rewards tends to develop
a great deal of loyalty and devotion toward leaders. Nurse Managers have a strong reward power
base.
2. Punishment or coercive power:
This is the opposite of reward power and is based on fear of punishment if the manager‘s
expectations are not met. The manager may obtain compliance through threats of transfer, layoff,
demotion, or dismissal. The manager who shuns or ignores an employee is exercising power
through punishment, as is the manager who berates or belittles an employee. The focus of
coercive power is not to assist others to improve or contribute more to the work team, but instead
specifically to hurt and punish others. This manager has reward power but chooses to use it in a
negative way. This is an unhealthy power base and must be avoided by nurse managers who wish
to be successful.
3. Legitimate power:
Legitimate power is position power. Authority is also called legitimate power. It is the
power gained by a title or official position within an organization. Legitimate power has inherent
in it the ability to create feelings of obligation or responsibility. The socialization and culture of
subordinate employees will influence to some degree how much power a manager has due to
his/her position.
4. Expert power:
Expert power is gained through knowledge, expertise, or experience. Having critical
knowledge allows a manager to gain power over others who need that knowledge. This type of
power is limited to a specialized area. For example, someone with vast expertise in music would
be powerful only in that area, not in another specialization.
5. Referent power:
Referent power is power a person has because others identify with that leader or with
what that leader symbolizes. Referent power also occurs when one gives other person feelings of
personal acceptance or approval. It may be obtained through association with the powerful.
People may also develop referent power because others perceive them as powerful.
Some theorists distinguish charismatic power from referent power. Willey (1990) state that
charisma is a type of personal power, whereas referent power is gained only through association
with powerful others.
6. Informational power:
This source of power is obtained when people have information that others must have
inorder to accomplish their goals. The person with the most information is listened and
respected. We need to determine if it is legitimate information coming from the person who is
sharing it. The information coming from someone in a management position should be valued
and recognized as a source of power as opposed to information from someone who does not have
legitimate right to the information.
SOURCES OF POWER
Type source
Association with others
Referent
Position
Legitimate
Fear
Coercive
Ability to grant favours
Reward
Knowledge and skill
Expert
Personal
Charismatic
The need for information
Informational
Self Maturity, ego strength
EMPOWERMENT:
Definition: Empowerment is a sense of having both the ability and the opportunity to act
effectively.
Empowerment is a process or strategy the goal of which is to change the nature and distribution
of power in a specific context. It is a group activity that increases political and social
consciousness, is based on the need for autonomy, and is accomplished with continuing cycles of
assessment and action. Nursing organizations seek to empower nurses; nurses endeavour to
empower patients to seek and adopt healthy lifestyles.
Empowered nurses have three required characteristics that enable them to participate in policy
development:-
1. The first is a raised consciousness of the social, political, and economic realities of their
situation or environment and society. They are aware of culture and diversity and of gender,
race, and class biases, prejudices, discrimination, and stereotyping that produce the need for
policy development or change. Such nurses can evaluate and understand the dynamics of a
situation or issue in which they themselves can more readily find or help to find remedies.
2. The second quality empowered nurses to have a positive sense of self and self-efficacy
regarding their ability to effect, or facilitate, change. They value themselves and have voice to
articulate and effect change. They can also contribute to the resolution of problems that affect
health at the community, state, and national levels.
3. Development of skills that allow active participation in change processes is the third
important characteristics. Empowered nurses know how to use traditional methods of power
and politics in policy making. Concrete knowledge and information are necessary, as is
understanding interpersonal communication skills, politics, and power and how to use them.
Empowerment ladder:
Self-confidence
Ability to control life situations
Refuse to be a victim
Value self and others
Be a risk taker
Be creative
Resolve conflict
Show initiative
Become empowered.
ABUSE OF POWER:
Abuse of power is the control of people by some kind of force. It is the use of power for
one‘s own benefit and can be present in families, organizations, and all levels of domestic and
international government. It is always unethical. Poor developing nations around the world are
obvious examples. Dictators abuse their people often to the point of genocide. Industrialized
nations engage in unfair trade and often exploit workers.
POWERLESSNESS:
Powerlessness is a horrible state. Personal powerlessness is a personal nightmare. It
brings about feelings of frustration that generally lead to anger; it saps energy levels and leaves
the person in a constant state of exhaustion from fighting to alter the balance of power; it defeats
the spirit and soul of a person. A person who exhibits powerless behaviour is someone who
needs immediate attention. Powerless people do not function well in their jobs, they lose their
motivation and drive to do well, and they are a negative influence in any work environment.
Such people should not be eliminated from the environment; they should be assessed and worked
with in an effort to alter the situation.
A person becomes powerless when:
Being threatened by the competence of others
Accepting a job without sufficient training or experience
Depending on others to meet own needs
Transferring feelings of inferiority to others while demanding perfection from subordinates.
―Nitpicking‖ over small things
Wanting to keep things predictable
Being trapped by roles and stereotypes
Devaluing the group process
POLITICS:
Definition: It is a process through which one tries successfully or unsuccessfully to reach a
goal.
Political nursing: Political nursing is defined as the use of knowledge about power processes
and strategies to influence the nature and direction of health care and professional nursing.
Anderson, Anderson & Glanze, 1998
Political Action Spheres:
The process of influencing others in order to achieve ends can be seen in relation to four arenas,
spheres or domains. These spheres are-
The workplace
Professional organizations
Community
Local, state and federal governments
The workplace:
Nurses work in organizations with varied characteristics- private or public; profit, non-
profit, or charitable; large, small or medium; and in large or small cities, towns, small towns, or
rural areas. In the work place, there are many issues with which nurses are involved. Power and
politics may be necessary to resolve issues. Some issues that may be found in some workplace
include the following:
1. Mandatory overtime work requirements
2. A nursing clinical ladder program that rewards excellence with promotions and pay
incentives.
3. Work scheduling length of shift, evening and night rotation, vacation priority.
4. A smoking ban in the entire facility; designation of smoking areas.
5. Visiting hours in special care units.
6. Identification and security procedures.
7. Authority to delay discharge from or admission to special care units based on professional
nurse assessment.
8. Decisions regarding substation of unlicensed personnel for Registered Nurses to provide
care.
Professional organizations:
Professional organizations have been essential to the ―professionalization‖ of nursing.
The modern nursing movement began in 1873 in response to the changing role of women.
Pioneers of this movement worked for a new profession for women and for better health for the
public. These women used political power to open nurse training schools, organize professional
associations, and participate in social issues such as women‘s suffrage, public health, and
integration. Professional organizations have made significant contributions in developing nursing
practice. They have set standards of practice, advocated for change in the scope of practice and
passage of nurse practice acts, and advocated for nurses in collective action in the workplace.
Such organizations have an ever-increasing role in the health policy development. A strong
professional or organization needs to be a visible force. Organizations can identify issues that
concern nursing and health care, bring them to public, and take a leadership role in advocating
for development of policies that improve health and ensure high-quality nursing care. To achieve
this, organizations need support of nurses through their membership and through their political
acumen.
Community:
Community is defined as a population, a neighbourhood, a state, a nation, and the world.
Nurses are members of a community with the responsibility to promote the wellbeing of the
community and its members. In exchange, the community provides important resources for
nurses‘ work in health promotion and health care-delivery. Many of the people who live in a
community, such as health-care administrators, corporate managers, industrial leaders, elected
and career government officials, and patient have power. These people can, and do, participate in
community activities; they have status, expertise, and connections. By building relationships
with community members, nurses can gain supporters to achieve goals. The connections they
make can transform into networks, and the people in the networks can be asked to support
agendas. In exchange, nurses should support community agendas to work to improve community
life. Nurses can help mobilize communities on issues such as recycling, environmental clean-up,
safety, energy conservation, health screening, and the like. This can affect professional life with
increased skills, knowledge, experience, and power development. In addition, nurses who are
active and form connections in their communities become role models and represent the whole
profession.
Government:
Government affects most aspects of our lives. We must document births, deaths,
marriages; and mandatory childhood immunizations. Government is needed to ensure that what
we need to get done is accomplished. Government plays an essential role in nursing and in health
care. Government influences and supports the current managed care arrangement, which
provides for reimbursement for health and nursing care. To a great extent, government
determines who has access to care and to what type of care. Federal, state, and local governments
make decisions about major health issues in our society. Recent decisions include:
1) The kinds of foods and snacks available to children at schools.
2) Prohibition of smoking in some public places
3) Provision of meals for the poorest children
4) The health services available at schools and whether schools may provide sexual
and reproductive information.
5) Whether public funds can be used to distribute clean needles to intravenous drug
users to reduce the spread of HIV and AIDS.
6) Whether women can receive full information about reproductive rights and who
can provide that information.
7) Whether violence is treated only as a crime or also as a public health issue and
whether to regulate the use of hand guns.
8) Allocation of funds for housing development and maintenance.
With the addition of an initial stage identified by Kalisch and Kalisch (1982), this
model can also be applied to the political development and activism of individual
nurses related to both professional and legislative political arenas:
1. Apathy: no membership in professional organizations; little or no interest in
legislative politics as they relate to nursing and healthcare.
2. Buy-in: recognition of the importance of activism within professional organizations
and legislative politics related to critical nursing issues.
3. Self-interest: involvement in professional organizations to further one‘s own career;
the development and use of political expertise to further the profession‘s self-interest.
4. Political sophistication: high level of professional organization activism (e.g.,
holding office at the local and state level) moving beyond self-interests; recognition of
the need for activism on behalf of the public.
5. Leading the way: serving in elected or appointed positions in professional
organizations at the state and national levels; providing true leadership on broad
healthcare interests within legislative politics, including seeking appointment to
policy-making bodies and election to political positions.
POLITICAL ANALYSES
Effective use of power and politics to facilitate strategy development for the policy
process requires systematic analysis of the issues.
COMPONENTS OF POLITICAL ANALYSIS:
POLITICAL STRATEGIES:
After the political analysis is completed, a plan of action with strategies is developed.
Strategies are the plans to achieve political and policy goals. To achieve goals it is useful to
follow these tactics.
Persistence- Change takes time; conflict is almost always part of policy change. Policy
change or new policy development and implementation is a long-term commitment and
requires commitment and endurance.
Look at big picture: Always prepare for the political process of policy development by
clarifying aspects of the issue. This includes knowing your position and possible
solutions supported by data, assessing your power base and that of others involved,
planning strategies, and knowing the opposition and their plans and rationales.
Understand the context of the issue.
Frame issue adequately: Understand the stakeholders and target audience to present the
issue in ways that are congruent with their values.
Develop and use networks: Use power that accrues through persona; connections,
which requires keeping track of what you have done for others and asking them to
reciprocate.
Assess time: Consider carefully when is the most opportune time to act. Knowing when
the time is right requires accurate assessment of the values, concerns, goals, and
resources of those you have to convince that your way is best.
Collaborate: Work with others to achieve policy goals. Collaboration usually achieves
goals more effectively than does individual action.
Prepare to take risks: Do a risk – and –benefit analysis of an action. This analysis
entails considerations of the benefits gained or goals achieved in relation to the
expenditure of all resources, including personnel, money, time spent that could have
been used on another endeavour, and coherence with values.
Understand the opposition: Put aside emotional positions, focus on the issues, and try
to understand the fears and concerns of the opposition. Educate the opposition to
appreciate the nursing position.
POLITICAL TACTICS
The effective functioning of an organization depends on the relationship between
individuals and groups. Effective use of politics in the workplace can facilitate achievement
of goals.
SKILLS AND TACTICS IN THE WORKPLACE:
The effective functioning of an organization depends on relationships between individuals
and groups. Often, problematic conflicts arise that are threatening to groups. Resolution of
these conflicts requires significant managerial skill. Effective use of politics can facilitate
conflict resolution and achieve goals. The following skills and tactics are useful and have a
high probability of success-
Build your own team: Executives, administrators, and managers are often defeated in
their roles because persons from the previous team are unhappy, jealous, and disgruntled
and do not support, or actively sabotage, the work of the new boss.
Choose your second-in command carefully. ―An aggressive, ambitious, upwardly
mobile number two man (or woman) is dangerous and often difficult to control‖
(McMurray, 1973).
Establish alliances with superiors and peers. Determine expectations and motivations
of others before you form true friendships. Alliances with superiors and peers are needed
to achieve goals.
Use all possible channels of communication. Develop and maintain open, effective
channels of communication to avoid isolation, pre-emption, and loss in power struggles.
Be fair, but learn to recognize aggressive, manipulative people.
Do not be naive about how decisions are made. Learn and understand the preferences
and the way powerful people act in the organization in order to predict how they will
make a decision; then plan accordingly.
Know priority. Know what the goals are and how the organization generally works to
achieve those goals. In other words, know the modus operandi.
Be courteous. Treat others with respect. Respect can prevent feelings that can lead to
sabotage and retaliation.
Maintain a flexible position and maneuverability. Identify what is ethically important
and nonnegotiable. Then you can maneuver confidently to change power.
Disclose information judiciously. In order to work effectively, it may be necessary not to
disclose how power strategies are used.
Use passive resistance when appropriate to gain time. Delay can be useful when time is
needed for gathering information.
Project an image of confidence, status, power, and material success. The image of
weakness conveys a lack of power and decreases ability to act and achieve goals.
Learn to negotiate and collaborate. Do not be ingratiating or conciliatory.
Nurses can take an active role in the legislative and political process to affect change.
They may become involved in influencing one specific piece of legislation or regulation, or
they can become involved more universally and systematically to influence health care
legislation on the whole.
DEFINITION-
LOBBYING:
Lobbying is the deliberate attempt to influence political decisions through various forms
of advocacy directed at policymakers on behalf of another person, organization or group.
Lobbying is the practice of private advocacy with the goal of influencing a governing
body by promoting a point of view that is conducive to an individual's or organization's
goals.
LOBBYIST:
1) A lobbyist is an individual who attempts to influence legislation on behalf of others, such
as professional organizations or industries.
2) Lobbyists are advocates. That means they represent a particular side of an issue.
3) A person who receives compensation or reimbursement from another person, group, or
entity to lobby.
TYPES OF LOBBYING:
Direct
Grassroots
DIRECT LOBBYING
Is communicating your views to a legislator or a staff member or any other government
employee who may help develop the legislation
To be lobbying, one must communicate a view on a "specific legislative proposal." Even if
there is no bill, one would be engaged in lobbying if one asked a legislator to take an action
that would require legislation, such as funding an agency. Asked one‘s members to lobby for
this bill is also considered as direct lobbying.
GRASSROOTS LOBBYING
Is simply citizen participation in government.
The key to successful grassroots lobbying efforts is assembling people who share
common goals and concerns. Grassroots communications are vital in educating legislators to the
concerns of the voting population in their state. If you do not share your views with your
representative, then your views will not be considered by your state representative when he votes
on an issue which affects you. You can make a difference by simply writing, calling, meeting, or
faxing your representative.
TYPES OF LOBBYISTS
The Lobbyists Registration Act identifies three types of lobbyists:
The consultant lobbyist:
The consultant lobbyist is a person who is gainfully employed or not and whose
occupation is to lobby on behalf of a client in exchange for money, benefits or other forms of
compensation. Consultant lobbyists may work for public relations firms or be self-employed. For
example, he or she might be a public relations expert, a lawyer, an engineer, an architect.
USEFUL TIPS-
Dos:
a. Do write legibly or type. Handwritten are perfectly acceptable so long as they can be read.
b. Do use persona stationary. Indicate that you are a registered nurse. Sign your full name and
address. If you are writing for an organization, use that organization‘s stationary and include
information about the number of members in the organization, the services you perform, and
the employment setting you are found in.
c. Do state if you are a constituent. If you campaigned for or voted for the official, say so.
d. Do identify the issue by number and name if possible or refer to it by the common name.
e. Do state your position clearly and state what you would like your legislator to do.
f. Do draft the letter in your own words and convey your own thoughts.
g. Do refer to your own experience of how a bill will directly affect you, your family, your
patients, and members of your organization or your profession. Thoughtful, sincere letters on
issues that directly affect the writer receive the most attention and are those that are often
quoted in hearings or debates.
h. Do contact the legislator in time for your legislator to act on an issue. After the vote is too
late. If your representative is a member of the committee that is hearing the issue, contact
him/her before the committee hearings begin. If he/she is not on the committee, write just
before the bill is due to come to the floor for debate and vote.
i. Do write the governor promptly for a state issue, after the bill passes both houses, if you want
to influence his/her decision to sign the bill into law or veto it.
j. Do use e-mails to state your points.
k. Do be appreciative, especially of past favourable votes. Many letters legislators receive
feedback from constituents who are unhappy or displeased about actions taken on an issue.
Letters of thanks are greatly appreciated.
l. Do make your point quickly and discuss only one issue per letter. Most letters should be one
page long.
m. Do remember that you are the expert in your professional area. Most legislators know little
about the practice of nursing and respect your knowledge. Offer your expertise to your
elected representative as an advisor or resource person to his or her staff when issues arise.
n. Do ask for what you want your legislator to do on an issue. Ask him/her to state his/her
position in the reply to you.
Don‟ts:
a. Do not begin a letter with ―as a citizen and a taxpayer.‖ Legislators assume that you are a
citizen, and all of us pay taxes.
b. Do not threaten or use hostility. Most legislators ignore ―hate‖ mail.
c. Do not send carbon copies of your letter to other legislators. Write each legislator
individually. Do not send letters to other legislators from other states-they will refer your
letter to your congressional representative.
d. Do not write House members while a bill is in the Senate and vice versa. A bill may be
amended many times before it gets from one house to the other.
e. Do not write postcards; they are tossed.
f. Do not use form letters. In large numbers these letters get attention only in the form that they
are tallied. These letters tend to elicit a ―form letter response‖ from the legislator.
g. Do not apologize for writing and taking their time. If your letter is short and presents your
opinion on an issue, they are glad to have it.
KEEP ABREAST OF LEGISLATION AND REGULATION:
When issues are important to your professional, contact the legislator and provide the important
facts that support your position and be sure to follow up routinely so your opinions stay fresh in
his/her mind.
Legislation: To keep in contact with the legislature, it is important to identify key committees
and subcommittees in the legislative bodies, and to identify and develop communication with the
members of those committees. Ways to keep abreast of new information include the following:
Volunteer for campaign work and develop contacts with
legislators. Obtain pertinent government documents using online
resources.
Get the general telephone number for the state government and the mailing addresses for
correspondence.
Develop liaisons with other health professionals and utilize them as information sources and
allies in lobbying for health care issues.
Register a member of your group as a lobbyist- the fee is generally small.
If possible, hire a lobbyist
Once you have notified your legislator about your interest in a particular issue, the
legislator‘s office may routinely send literature outlining his or her activities throughout the
sometimes arduous process.
Regulation: Because lobbying activities can significantly affect individuals and industry,
regulation is essential to avoid abuse. Lobbyists have created ethics codes, guidelines for
professional conduct and standards. The following will help you keep abreast o the newest
regulations and standards:
Subscribe to the state register (which contains all state regulations under consideration).
Identify and develop contacts with state agencies that exert control on or impact your practice
and ask to be added to their mailing lists. A limited list includes the following:
i. Nurse practice act: rules and regulations
ii. Medical practice act: rules and regulations
iii. Pharmacy act: rules and regulations
iv. Dental practice act: rules and regulations
v. Hospital licensing act: rules and regulations
vi. Ambulatory surgical center licensing act: rules and regulations
vii. Insurance statute: rules and regulations
viii. Trauma center statute: rules and regulations
ix. Department of Health
x. Podiatric Act: rules and regulations
CRITICAL THINKING
You assist an evil system most effectively by obeying its orders and decrees. An evil system
never deserves such allegiance. Allegiance to it means partaking of the evil. A good person will
resist an evil system with his or her whole soul. --Mahatma Gandhi
Meaning:
"Critical" as used in the expression "critical thinking" connotes the importance or centrality of
the thinking to an issue, question or problem of concern. "Critical" in this context does not mean
"disapproval" or "negative." There are many positive and useful uses of critical thinking, for example
formulating a workable solution to a complex personal problem, "Critical" as used in the expression
"critical thinking" connotes the importance or centrality of the thinking to an issue, question or problem
of concern. "Critical" in this context does not mean "disapproval" or "negative." There are many positive
and useful uses of critical thinking, for example formulating a workable solution to a complex personal
problem,
Definition:
Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing,
applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by,
observation, experience, reflection, reasoning, or communication, as a guide to belief and action.
Critical thinking is the skillful application of a repertoire of validated general techniques for
deciding the level of confidence you should have in a proposition in the light of the available
evidence.
-- Tim van Gelder
Critical thinking is reasonable, reflective thinking that is focused on deciding what to believe or
do.
-- Robert Ennis
Levels of Critical Thinking According To Bloom
Stage Two: We Reach the Second Stage When We Are Faced with The Challenge
Of Recognizing the Low Level at Which We and Most Humans Function as Thinkers.
For example, we are capable of making false assumptions, using erroneous information,
or jumping to unjustifiable conclusions. This knowledge of our fallibility as thinkers is
connected to the emerging awareness that somehow we must learn to routinely identify,
analyze, and assess our thinking.
Stage Three: We Reach the Third Stage When We Accept the Challenge and Begin
to Explicitly Develop Our Thinking
Having actively decided to take up the challenge to grow and develop as thinkers, we
become "beginning" thinkers, i.e., thinkers beginning to take thinking seriously.
Stage Six: We Reach the Sixth Stage When We Intuitively Think Critically at a
Habitually High Level Across all the Significant Domains of Our Lives. The sixth stage
of development, the Master Thinker Stage, is best described in the third person, since it is
not clear that any humans living in this age of irrationality qualify as "master" thinkers. It
may be that the degree of deep social conditioning that all of us experience renders it
unlikely that any of us living today are "master" thinkers. Nevertheless, the concept is a
useful one, for it sets out what we are striving for and is, in principle, a stage that some
humans might reach.
1. Perception
2. Assumption
3. Emotion
4. Language
5. Argument
6. Fallacy
7. Logic
8. Problem Solving
1. Perception: Perception refers to the way we receive and translate our experiences – how
and what we think about them. For some, plain yogurt is delicious, while for others it is
disgusting. For the most part, perception is a learned process. Eg: In the workplace, one
employee will perceive a co-worker to be a constructive decision-maker, while at the same
time, another sees the same employee as an adversarial roadblock to progress.
2. Assumptions: Trying to identify the assumptions that underlie the ideas, beliefs, values,
and actions that others and we take for granted is central to critical thinking. Assumptions
are those taken-for-granted values, common-sense ideas, and stereotypical notions about
human nature and social organization that underlie our thoughts and actions. Assumptions
are not always bad. For example, when you buy a new car, you assume that it will run
without problems for a while. When you go to sleep at night, you assume that your alarm
will wake you up in the morning.
Remember, assumptions depend on the notion that some ideas are so obvious and so taken
for granted that they don‘t need to be explained. Yet, in many cases, insisting on an
explanation reveals that we may need more factual evidence in order to develop well-
supported viewpoints and to come to sound decisions. The problem with assumptions is
that they make us feel comfortable without present beliefs and keep us from thinking about
alternatives.
3. Emotion: Emotions/feelings are an important aspect of the human experience. They are a
critical part of what separates humans from machines and the lower animals. They are part
of everything we do and everything we think. Emotions can affect and inspire thought,
stated William James, but they can also destroy it. We all have personal barriers
enculturation, ego defenses, self-concept, biases, etc.—shaped by our exposure to culture
and genetic forces. But to the critical thinker, personal barriers are not walls, merely
hurdles. Critical thinkers don‘t ignore or deny emotions; as with other forces of influence
on our thinking, they accept and manage them.
4. Language: Some say that language is the landscape of the mind. Others say that language
is the software of our brain. Whatever the metaphor, it is clear that thinking cannot be
separated from language. Furthermore, for the multitude that define thinking itself as
―expressed thought,‖ language carries the content and structures the form of the
entire thinking process.
5. Argument: Many people think that arguing means fighting or quarreling. In the context of
critical thinking, however, this definition does not fit. An argument is simply a claim, used to
persuade others, that something is (or is not) true and should (or should not) be done. When
someone gives reasons for believing something hoping that another person will come to the
same conclusion by considering those reasons the discourse is geared toward persuasion. An
argument contains three basic elements: an issue, one or more reasons called premises in
logic, and one or more conclusions. Arguments can be valid or invalid, based on how they
are structured. Arguments are not true or false only premises and conclusions are true or
false. The goal of a critical thinker is to develop sound arguments that have both validity (are
structured properly) and true premises. When we have a validly structured argument with
true premises, we have a sound argument. In sound arguments the conclusion must be true
and therein lies the beauty and usefulness of logic.
6. Fallacy: Since we use language for the three primary purposes of informing, explaining, and
persuading, we must be careful how we use it. We must make every effort to apply sound
reasoning, particularly when language is used to persuade. To be sound, reasoning must
satisfy three conditions:
If the reasoning fails to satisfy any of these three criteria, it is said to be fallacious.
A fallacy, then, is an incorrect pattern of reasoning.
Remember, finding a fallacy in your own or someone else‘s reasoning does not mean that the
conclusion is false. It means only that the conclusion has not been sufficiently supported
because one or more of the above three conditions were not satisfied. Fallacies can be
committed through any of our communication methods, especially in the print, visual, and
sound media.
8. Problem Solving: Solving ―logic‖ problems is like solving any problem that we encounter or
identify in life. The following general model for problem solving is suggested:
1. Read and heed the problem. What is it telling you? What is it asking? Define terms
that you do not understand.
2. Identify the unknown(s). It is helpful to name these with a symbol. Math uses a letter
known as a variable, but any symbol will do.
3. Identify the known‘s. Write down all the information that the problem tells
you. Even if you just repeat the givens in the problem, list them.
4. Start to identify the relationships between the known and the unknowns. This is the
critical and creative part of solving a problem. Create a visual aid like a diagram,
sketch, table, etc., that allows you to ―see‖ the relationships.
7. If something doesn‘t seem to work, repeat steps 1-6. The secret to problem solving is
continuing to try and learning something new on each successive iteration. The
solution will ultimately be reached.
The critical thinking process, as described by Wolcott and Lynch , includes four steps.
Students generally begin their critical thinking at step one and, with practice, progress
to step 2 and up the ladder.
Identify the problem, the relevant information, and all uncertainties about the
Step 1: problem. This includes awareness that there is more than one correct solution.
(low cognitive complexity)
Integrate, monitor, and refine strategies for re-addressing the problem. This
Step 4: includes acknowledging limitations of chosen solution and developing an ongoing
process for generating and using new information. (highest cognitive complexity)
EVALUATION
SYNTHESIS
ANALYSIS
APPLICATION
COMPREHENSION
KNOWLEDGE
The characteristic habits/attitudes {H} are the acquired behavior patterns that distinguish a
critical thinker from a non-critical thinker. These are approximately equivalent to what
Richard Paul has called the valuable intellectual traits of a critical thinker: intellectual
humility, intellectual courage, intellectual empathy, intellectual integrity, intellectual
perseverance, faith in reason, and fair-mindedness .
The set of values/commitments, for a critical thinker, has but one element: a commitment to
the truth, or in cases where the truth is unknowable, a commitment to the most defensible
opinion.
The relationships {R} between the elements in this model are shown graphically (see figure
to right). Values/commitments provide the foundation for critical thinking. It is the
commitment to searching for the truth that motivates the need for intellectual humility,
empathy, and the various other critical thinking traits, and these traits in turn regulate the
way in which cognitive skills are applied to form opinions, make decisions, and solve
problems.
1. Clarify.
State one point at a time. Elaborate. Give examples. Ask others to clarify or give examples. If
you‘re not sure what you‘re talking about, you can‘t address it.
2. Be accurate.
Check your facts.
3. Be precise.
Be precise, so you are able to check accuracy. Avoid generalizations, euphemisms, and other
ambiguity.
4. Be relevant.
Stick to the main point. Pay attention to how each idea is connected to the main idea.
5. Know your purpose.
What are you trying to accomplish? What‘s the most important thing here? Distinguish your
purpose from related purposes.
6. Identify assumptions.
All thinking is based on assumptions, however basic.
8. Empathize.
Try to see things from your opponent‘s perspective. Imagine how they feel. Imagine how you
sound to them. Sympathize with the logic, emotion, and experience of their perspective.
10. Be independent.
Think critically about important issues for yourself. Don‘t believe everything you read. Don‘t
conform to the priorities, values, and perspectives of others.
DECISION MAKING
Choose always the way that seems the best, however rough it may be. Custom will soon render it
easy and agreeable. -Pythagoras
Definition:
Decision making can be regarded as the mental processes ( cognitive process) resulting in the selection
of a course of action among several alternatives. –Wikipedia
Decision making is the process of selecting one course of action from alternatives.
Orientation stage- This phase is where members meet for the first time and start to get to
know each other.
Conflict stage- Once group members become familiar with each other, disputes, little
fights and arguments occur. Group members eventually work it out.
Emergence stage- The group begins to clear up ambigiuity in opinions is talked about.
Reinforcement stage- Members finally make a decision, while justifying themselves that
it was the right decision.
2. Inclusive, Not Exclusive. All parties with a significant interest in the issues should be
involved in the collaborative process.
7. Egalitarian. All parties have equal access to relevant information and the opportunity to
participate effectively throughout the process.
8. Respectful. Acceptance of the diverse values, interests, and knowledge of the parties
involved in the collaborative process is essential.
9. Accountable. The participants are accountable both to their constituencies and to the
processthat they have agreed to establish.
10. Time Limited. Realistic deadlines are necessary throughout the process.
11. Achievable. Commitments made to achieve the agreement(s) and effective monitoring
are essential.
STEPS IN DECISION MAKING:
The decision making task can be divided into 7 steps which are stated in order of
sequence are as
The 9 step decision making model is proposed by David Welsh in his book 'Decisions,
Decisions'.
The 9 step decision making model
Step 1 - Identify your objective
Besides the most obvious choices available to you, what other kinds of options can you think of?
Step 3 - Identify the implicated values
What values are at stake here? If it's an easy or unimportant decision you may not necessarily do
this step. But if the decision has a major impact on your wealth, your health or self-respect, then
it's useful to be aware of it.
Step 4 - Assess the importance of the decision
The importance of the decision will determine how much you invest in it in terms of time, energy
and money. The importance is determined by examining the implicated values.
You may also have to consider the context here as well, a different situation or environment can
mean that a decision that is often not very important can become very significant.
Having identified the main alternatives and the values, now decide on which time and energy to
spend making the decision itself. More important decisions are given more time and energy. He
suggests that busy people and nervous wrecks made worse decisions than other people.
This step of the 9 step decision making model involves making another decision. The time and
energy you plan to devote will affect the strategy you choose.
And because the strategy you choose may profoundly affect your decision it's important to
choose an appropriate one.
When you examine your options in more detail you may discover other options with different
implicated values. He points out that occasionally you may have to go back to step three to five
and make revisions.
This is where you compare the options available to you. Again he suggests that seeking advice
from an expert is often easier than making the decision on your own.
When you're finished doing the evaluation (only as much as it requires!), you make your choice.
He notes that people may still have difficulty at this stage because they fear the consequences of
making a bad decision.
Techniques and Tools of Decision Making
A. Judgmental technique
B. Operational research technique
C. Delphi technique
D. decision tree
A. Judgemental technique:
This is the oldest technique of decision making and is subjective in nature. As it is based
on past experiences or intuition about future, it is frequently used for making routine decisions. It
is cheap and can be quickly done. But it is hazardous as there is chance of taking a wrong
decision. So this technique is rarely used in large capital comminments.
Advantage is that it is free from another’s influence and does not require physical presence
which makes it appropriate for scattered group and limitation is that it is time consuming.
D. Decision trees: A decision tree is a graphic method that can help the supervisor in visualizing
the alternative available, outcomes, risks and information for a specific needs for a specific
problem over a period of time. It helps her to see the possible directions that action may take
from each decision point and to evaluate the consequences of a series of decisions. The process
begins with a primary decision having atleast two alternatives. Then the predicted outcome for
each decision is considered, and the need for further decisions is contemplated.
Rational
Intuitive
Recognition primed decision making
The ultimate decision making model
Rational
Rational decision making is the commonest of the types of decision making that is taught
and learned when people consider that they want to improve their decision making. These
are logical, sequential models where the emphasis is on listing many potential options and then
working out which is the best. Often the pros and cons of each option are also listed and scored
in order of importance.
Intuitive
The second of the types of decision making are the intuitive models. The idea here is that
there may be absolutely no reason or logic to the decision making process. Instead, there is an
inner knowing, or intuition, or some kind of sense of what the right
thing to do is.
Recognition primed...
Gather information from our environment in relation to the decision we want to make. Pick an
option that work. We rehearse it mentally and if we still think it will work, we go ahead. If it does not
work mentally, choose another option .If that seems to work, go with that one. Also points out
that as get more experience, recognise more patterns, and make better choices more quickly.
The ultimate...
Firstly, before you even make a decision, you establish how and who you want to be.
You obviously want to be in a good state so that you can make good decisions. But you also
want to be true to yourself, and that means knowing who 'yourself' is.
Irreversible
This are those type of decisions, which, if made once cannot be unmade. Whatever is
decided would than have its repercussions for a long time to come. It commits one irrevocably
when there is no other satisfactory option to the chosen course. A manager should never use it as
an all-or-nothing instant escape from general indecision.
Reversible
This are the decisions that can be changed completely, either before, during or after the
agreed action begins. Such types of decisions allows one to acknowledge a mistake early in the
process rather than perpetuate it. It can be effectively used for changing circumstances where
reversal is necessary.
Experimental
This types of decisions are not final until the first results appear and prove themselves to
be satisfactory. It requires positive feedback before one can decide on a course of action. It is
useful and effective when correct move is unclear but there is a clearity regarding general
direction of action.
MadeinStages
Here the decisions are made in steps until the whole action is completed. It allows close
monitoring of risks as one accumulates the evidence of out- comes and obstacles at every stage.
It permits feedback and further discussion before the next stage of the decision is made.
Cautious
It allows time for contingencies and problems that may crop up later at the time of
implementation. The decision-makers hedge their best of efforts to adopt the night course. It
helps to limit the risks that are inherent to decision- making. Although this may also limit the
final gains. It allows one to scale down those projects which look too risky in the first instance.
Conditional
Such types of decisions can be altered if certain foreseen circumstances arise. It is an
‗either or‘ kind of decision with all options kept open. It prepares one to react if the competition
makes a new move or if the game plan changes radically. It enables one to react quickly to the
ever changing circumstances of competitive markets.
Delayed
Such decisions are put on hold till the decision–makers feel that the time is right. A go-
ahead is given only when required elements are in place. It prevents one from making a decision
at the wrong time or before all the facts are known. It may, at times result into forgoing of
opportunities in the market that needs fast action.
1. Marginal theory
This theory stress on profit maximization .this theory focused on increases profit from the
decision. It related to health care cost and patient outcome
2. Psychological theory
The trust of this theory is on the maximization of customer satisfaction (patient). The
manager acts as a administrative man rather than economic man
3. Mathematic theory
This theory is based on the use of models. This is also known as operational research
theory. The techniques generally used include linear programming. Theory of probability
stimulation models etc
Accepts a world with bounded rationality and views the decision maker as acting
only in terms of what he/she perceive about a given situation
The behaviour decision maker faces a problem that is not clearly defined . has limited
knowledge of possible action alternatives and their consequences
Several statistical tools and methods are available to organize evidence, evaluate risks,
and aid in decision making. The risks of Type I and type II errors can be quantified
(estimated probability, cost, expected value, etc.) and rational decision making is improved
HEURISTICS: it is a rule which guides the search for alternative into areas that have a
high probability for yielding solution. Here the decision makers look for obvious solution
or previous solution that worked in similar situation
Experience and knowledge are two of the major factors affecting decision making.
Decision making within practice disciplines, such as nursing, involves more than the application
of theoretical knowledge. A deep understanding of the situation is required if treatment
approaches are to address the experience of illness as it relates to a particular patient. This
understanding evolves from knowledge and experience. Experience increases the cognitive
resources available for interpretation of data, resulting in more accurate decision making.
Creative thinking
Problem solving involves organisation of new and previously learned information to form
new responses to novel situations. The promotion of creative thinking through education calls for
teachers to endorse the creative thinkers' self-worth, listen to them, challenge learners to develop
new ideas and to question their taken-for-granted ideas, demonstrate critical thinking ability,
encourage breadth of reading, invite learners to talk about what they think and feel, and to adopt
a conversational approach
Self Concept
Perceptions of being less intelligent, less educated and less competent result in
relinquished authority to those perceived as being better. Those with an internal locus of control
believe in their ability to influence results, whereas, those possessing an external locus of control
believe that events are contingent upon the actions of others. Locus of control refers to the extent
to which a person believes they can control events and outcomes
Interpersonal Conflict
The stressors involved with interpersonal conflict constitute another barrier to decision
making. Clinical decision making is a social activity involving health care team members and the
patient. The social context in which the clinician functions impacts upon decision making
Inadequate Staffing
That it is stressful to work when staffing levels are inadequate for the tasks required
would be disputed by few. Most nurses have frequently encountered circumstances when
experienced staff are replaced with novices. This situation places stress on staff of all levels and
influence the decision
Only hearing and seeing what we want. Each individual has their own unique set of
preferences or biases which blinker them to certain information. The best way to deal
with this problem is to identify your preferences and biases whilst attempting to be open
to the information around you.
Placing too great a reliance on the information you receive from others. Often we rely on
certain individuals to provide support and guidance. This may be a suitable course of
action in many cases. However, if the individual is not closely involved in the problem
situation they may not have the necessary information or knowledge to help make the
decision.
Placing too little emphasis on the information you receive from others. This issue can
easily occur in a team situation. In many cases the team members are the people who are
most closely involved in a problem situation and they often have the most pertinent
information in relation to the problem. The best way to deal with this issue is to ensure
that team members are involved in the decision making process.
Ignoring your intuition. On many occasions we are actually aware at a subconscious level
of the correct course of action. Unfortunately, we often tend to ignore our intuition.
STRESS MANAGEMENT
INTRODUCTION
Right from the time of birth till the last breath drawn, an individual is invariably exposed
to various stressful situations. The modern world which is said to be a world of achievement is
also a world of stress and has been called the ― Age of Anxiety and Stress‖. The word stress was
originally used by Selyle in 1956 to describe the pressure experienced by a person in response to
life demands. These demands are referred to as stressors. Stress can be positive or negative.
Perception plays a key role in interpreting how stressful situations are.
DEFINITION
STRESS
According to Selye (1956), ―Stress is defined as the pressure experienced by a person
in response to life demands. These demands are referred to as ‗stressors‘ and include a
range of life events, physical factors (eg: cold, hunger, haemorrhage, pain),
environmental conditions and personal thoughts.‖
According to Selye (1976), ―Stress is a process of adjusting to or dealing
with circumstances that disrupt or threaten to disrupt a person‘s physical or psychological
functioning.
Stress is tension, strain, or pressure from a situation that requires us to use, adapt, or
develop new coping skills.
STRESSOR
Stressor is the stimuli proceeding or precipitating a change. It may be internal (fear, guilt)
or external (trauma, peer pressure, etc).
TYPES OF STRESS
♪ Distress: Stress due to an excess of adaptive demands placed upon us. The demands are
so great that they lead to bodily and mental damage. eg: unexpected death of a loved one.
♪ Eustress: The optimal amount of stress, which helps to promote health and growth. eg:
praise from an superior for hard working.
TYPES OF STRESSORS
Physiological stressors:
a. Chemical agents
b. Physical agents
c. Infectious agent
d. Nutrition imbalances
e. Genetic or immune disorders
Psychological stressors:
a. Accidents can cause stress for the victim, the person who caused the accident and the
families of both
b. Stressful experiences of family members and friends
c. Fear of aggression or mutilation from others such as murder, rape, terrorist and
attacks.
d. Events that we see on T.V. such as war, earthquake, violence
e. Developmental and life events
f. Rapid changes in our world, including economic and political structures and
technology
SOURCES OF STRESS
There are many sources of stress, these are broadly classified as:
Internal stressors: they originate within a person eg: cancer, feeling of depression.
External stressors: it originates outside the individual eg: moving to another city, death
in a family.
Developmental stressors: it occurs at predictable times throughout an individual‘s life.
eg: child- beginning of school.
Situational stressors: they are unpredictable and occur at any time during life. It may be
positive or negative. eg: death of family member, marriage/ divorce.
INDICATORS OF STRESS
It may be physiological, psychological and cognitive:
Physiological indicators: the physiological signs and symptoms of stress result from
activation of sympathetic and neuro- endocrine systems of body.
♥ Pupils dilate to increase visual perception
♥ Sweat production increases
♥ Heart rate and cardiac output increases
♥ Skin is pallid due to peripheral blood vessel constriction
♥ Mouth may be dry
♥ Urine output decreases
Psychologic indicators: the manifestations: of stress includes anxiety, fear, anger,
depression and unconscious ego defense mechanism.
PADMASHREE INSTITUTE OF NURSING. M.Sc. NURSING II yearS (2009-2011
batch)
d of rest, the individual is able to prepare for and meet a new threat or challenge
The individual appraises whether the event is a threat or a challenge
THEORIES OF STRESS
STRESS MODELS
The adaptation of the concept of stress by the biological and behavioural sciences
resulted in the formulation of a number of models to describe stress and its effects. They are,
STIMULUS BASED MODELS:
In this model, stress is defined as a stimulus, a life event or a set of circumstances that
arouses physiologic or psychologic reactions may increase the individual‘s vulnerability to
illness. In this model person is viewed as being constantly exposed to environmental stressors
in their daily life, eg. the demand of work, family responsibilities, disablement or to more
specific stressors such as smell or poor lighting.
Here stress is a state that can generally be empirically observed, measured and
evaluated and which can potentially be removed or altered to reduce the individual stress.
BIOSPHERE
SOCIETY
COMMUNITY
GROUP
FAMILY
INDIVIDUAL
BODY SYSTEM
ORGAN
TISSUE
CELL
Second assumption of the model is that nursing care is provided within a biological,
psychological, socio-cultural, environmental and legal- ethical context. The nurse
must understand each of them to provide holistic nursing care.
Third assumption of the model is that health/ illness and adaptation / maladaptation
are 2 distinct continuums: The health/illness continuum comes from a medical world
view, the adaptation/ maladaptation continuum comes from a nursing world view.
This means that a person with a medically diagnosed illness may be adapting well to
it. In contrast a person without a medical illness may have adaptative coping
resources.
Fourth assumption is that the model includes the primary, secondary, and tertiary
levels of prevention by describing four stages of psychiatric treatment: crisis, acute,
maintenance and health promotion. For each stage of treatment, the model suggests a
treatment goal, a focus of nursing assessment, nature of interventions and expected
outcomes of nursing care.
Fifth assumption is based on the use of nursing process and standards of care
professional performance. Each step of the process is important and it is a local
response to injury or infection. It helps to localize and prevent the spread of infection
and promote wound healing.
During positive breaths, one inhales, holds one's breath, and then exhales. The emphasis
is in keeping one's lungs full of air. Positive breaths increase the oxygen in one's blood.
Although not always taught, continuing to breathe into the chest at the same time can
provide an ever more "fulfilling" exercise. The goal is to have the entire torso move in &
out when breathing, as if one is surrounded by an expanding and contracting inner tube.
YOGA NIDRA
Yoga-nidra may be rendered in English as "yoga sleep". It is a sleep-like state that occurs
with some practitioners of meditation, details of which have been handed down by guru-to-
disciple transmission (parampara) within the Indian religions. These aspects may include
relaxation and guided visualization techniques as well as the psychology of dream, sleep and
yoga. Yoga-nidra should not be confused with hypnotic states, known as "yoga tandra". The
practice of yoga relaxation has been found to reduce tension and anxiety. The autonomic
symptoms of high anxiety such as headache, giddiness, chest pain, palpitations, sweating,
abdominal pain respond well.
NOOTROPICS
Nootropics also referred to as smart drugs, memory enhancers, and cognitive enhancers,
are drugs, supplements, nutraceuticals, and functional foods that are purported to improve mental
functions such as cognition, memory, intelligence, motivation, attention, and concentration.
Nootropics are thought to work by altering the availability of the brain's supply of
neurochemicals (neurotransmitters, enzymes, and hormones), by improving the brain's oxygen
supply, or by stimulating nerve growth. However the efficacy of nootropic substances, in most
cases, has not been conclusively determined.
RELAXATION TECHNIQUES:
Relaxation technique (also known as relaxation training) is any method, process,
procedure, or activity that helps a person to relax; to attain a state of increased calmness; or
otherwise reduce levels of anxiety, stress or anger. Relaxation techniques are often employed as
one element of a wider stress management program and can decrease muscle tension, lower the
blood pressure and slow heart and breath rates, among other health benefits.
FRACTIONAL RELAXATION:
Fractional relaxation is a method of releasing muscular tension in one small part of the
body at a time, such as relaxing one finger, then relaxing another, then adding another... Then the
whole hand is relaxed, followed by the forearm, and then the upper arm... The other arm is
relaxed next, starting with a finger... Then the legs (each starting with a toe)... and so on,
including all body parts (including all the parts of the head) until the entire body is relaxed. The
fractional relaxation approach is often used in preparation for trance induction and hypnosis, but
is very useful as a relaxation technique by itself. The theory behind this tension release method is
that it is easier to relax a fraction of the body than it is to relax the whole body all at once.
„ABC‟ OF STRESS MANAGEMENT
CODE OF ETHICS
Definition;
1. A code of ethics is a set of ethical principles that are accepted by all members of a profession.
-Potter and Perry
2 Code of ethics is a guideline for performance and standards and personal responsibility.
-Lillie M S and Juanita Lee
3. Code of ethics provides a frame work for decision making for the profession and should be oriented
toward the day to day decisions made by members of the profession.
- Chitty K K
4. A code of ethics is a set of ethical principle
that A} is shared by members of a
group
B} reflects their moral judgments over time
C} serves as a standard for their professional actions.
-Barbara Kozier
Nursing Ethics
It‘s a branch of applied ethics that concerns itself with activities in the field of nursing. Its
refers to ethical standards that govern and guide nurses in every day practice such as
―being truthful with clients ―, ―respecting client confidentiality‖, and advocating on behalf of the
client.
Right Duties
Goals Goals
Duties Rights
Acceptable Unacceptable
Consequences consequences
Dilemma resolution
PROFESSIONAL CONDUCT
Code of professional conduct (for nurses in India)
1. Professional responsibility and accountability
To maintain professional responsibility and accountability, the nurse
Appreciates a sense of self-worth and nurtures.
Maintains standards of personal conduct, reflecting credit upon the profession.
Carriers out responsibilities within the framework of the professional
boundaries is accountable for maintaining practice standards set by the Indian
Nursing Council.
Is accountable for his/her own decisions and actions.
Is compassionate.
Is responsible for the continuous improvement of current practices
Provides adequate information to individuals these allows them to make
informed choices.
Practices healthful behavior.
2. Nursing Practice
In the course of practice of nursing, the nurse
Provide care in accordance with set standards of practice
Treats all individuals and families with human dignity in providing the physical,
psychological, emotional , social and spiritual and aspects of care
Respects individuals and families in the context of traditional and cultural practicing,
promoting healthy practices and discouraging harmful practiced
Presents realistic practices truthful in all situations for facilitating autonomous decisions
making by individuals and families
Promote participation and individuals and significant others in the care
Ensures safe practice
Consults, co-ordinates, callboards and follow p approximately when an individuals care
needs exceed the his or her competence
3. Communication and interpersonal relationships
This plays a key role in the interaction of the nurse with his or her clients. To effect optimal
interaction the nurse
Establishments and maintains effective interpersonal relationships with individuals
families and communities
Upholds the dignity of team members and maintains effective interpersonal relationship
with them
Appreciates a and nurtures the professional role of team members
Co-operates with other health professionals to meet the needs of individuals , families
and communities
4. Valuing human being
The nurse values human life. He or she
o Takes appropriate action to protect individuals from harmful unethical practices
o Considers relevant facts while taking cons… decisions in the best interest of individuals
o Encourages and supports individual in heir right to speak for themselves on issues
affecting health and welfare
o Respects and supports choices made by individuals.
5. Management
Proper management of resources and unfortunate is essential for improving the over all
efficiency of the nurse. Hence the nurses
Ensures appropriate allocation and utilization of available responses
Participates in supervision and education of students and other formal providers
Uses judgment in relation to individual competence which accepting and delegating
responsibility
Facilitates conducive work culture in order to achieve institutional objectives
Communicates effectively following appropriate channels if communication
Participates in performance appraisal
Participates in evaluation of nursing services
Participates in policy decision, following the principles of equity and accessibility of
service
Works individuals to identify the needs and sensitizes policy makers and funding
agencies for resource allocation
Professional Advancement
To escape that he or she is at part with contemporaries in the nursing field the nurse must.
a. Ensures the protection of human rights, while pursuing the advancement of knowledge
b. Participate in determine and implementing quality
c. Take responsibility for updating one‘s own knowledge and competencies
d. Contribute to the core of professional knowledge and conducting and participating in
research
2. NURSING PRACTICE
a. In the course of practice of nursing, the nurse
b. Provide care in accordance with set standards of practice.
c. Treats all individual and family with human dignity in providing the physical, psychological,
emotional, social and spiritual aspects of care.
d. Respects individuals and families in the context of traditional and cultural practices,
promoting healthy practices, and discouraging harmful practices.
e. Presents realistic pictures truthful in all situations for facilitating autonomous decisions
making by individuals and families.
f. Promote participation of individuals and significant others in the care.
g. Ensures safe practice.
SOURCES OF LAW
Constitutional law: - it is a judgmental law. Law that governs the state. It determines
structure of state, power and duties.
Common law:- it is a body of legal principles that evolved from court decisions
Administrative law: - rules and regulations established by administrative agencies made
by executives of government.
PURPOSES
* To help the nurse to understand that they do have legal responsibilities in nursing practice.
* To make them understand by which authority these legal responsibilities can be enforced.
* To make them understand what areas of nursing practice can mostly create legal problems.
* To describe and protect the rights of clients and nurses
* Law is there for the protection of nursing practice
* Law is there for the identification of the risk of liability
* Law is there to assist in the decision-making process involved in nursing practice
* Nurses have more responsibility
*another important purposes are
Safeguarding the public
Safeguarding the nurse
Safeguarding the public
1) The public safety is guaranteed because the practice of nursing is restricted to those
accredited practitioners who would seek to provide highest possible level of
comprehensive care for the individual and the community taking in to account the total
need
2) The individual is secure to the event of sickness or disability with no fear of anxiety of
being cared for by a competent person
Safeguarding the nurse
1) Licensure:-
All nurses who are in nursing practice have to possess a valid licensure, issued by
the respective state nursing council/Indian nursing council
2) Good Samaritan laws:-
In response to health professionals, fear of malpractice claims, most states enacted
Good Samaritan Laws that exempt doctors and nurses from liability when they render
first during emergency. These laws limit liability and offer legal legal immunity for
people helping in an emergency
3) Good rapport: -
Developing good rapport with the client is very important to prevent malpractice.
The ability to develop good rapport with client is dependent on the nurse having good
interpersonal communication skills e.g. listening
4) Standards of care:-
All professional practicing in the medical field are held to certain standards when
administering care. It is always better to follow standards of care to avoid malpractice
and do not attempt anything beyond the level of competence.
5) standing orders:-
Although a nurse may not legally diagnose illness or prescribe treatment, she or
he may after assessing patients condition apply standing orders or treatment guideline
that have been established by the physician or doctor as appropriate for certain problems
and conditions
6) consent for operation and other procedures:-
A patient coming in to hospital still retains his rights as a citizen and his entry only
denotes his willingness to undergo an investigation or a course of treatment. Any
investigation or treatment of a serious nature, or an operation in which an anesthetic is
used, requires the written consent of the patient.
7) correct identity:-
The nurse or the midwife has the great responsibility to make sure that all babies
born in the hospital are correctly labeled at birth and to ensure that at no time they are
placed in the wrong cot or handled to the wrong mother.
8) Counting of sponge instrument and needles:-
Nurses advocate that sponge, instrument and needle counts be performed for all
surgical procedures taking place in operation theatre. When an instrument left in a patient
body the nurse will probably t=liable for any patient injury caused by the presence of
foreign body.
9) Contracts:
A contract is a written or oral agreement between 2 people in which goods or services are
exchanged.
10) Documentation:-
Documentation is by far the best once a lawsuit field. The medical record is a legal
document admissible in court as evidence.
LAW AFFECTING NURSES
Nurse practice laws
Describes and designs the legal boundaries of nurse practice act within each state
Administrative law
Created by administrative bodies such as state board of when they pass rules and
regulations. Developed by groups who are appointed to governmental administrative
agencies. E.g. Food, Drug & Cosmetic Act; Social Security Act; Nurse Practice Act
Statutory law
Created by elected legislative bodies such as state legislatures
Enacted law
Include all bills passed by legislative bodies whether local, state, and national
LAW IN NURSING
Common law
Created by judicial decisions made in courts when individual cases are decided
Felony
Is a crime of serious nature that has a penalty of imprisonment for greater than one year or
even death
Misdemeanor
Is a less serious crime that has a penalty of a fine or imprisonment of less than one year
Civil law
Protects the rights of individual persons within our society and encourage fair and equitable
treatment among people
Contract Law
It is the enforcement of agreements among private individuals. Employment Contracts is an
example of contract law under civil law
Criminal law
Prevent harm to society and provides punishment for crimes
TYPES OF LAW
There are many ways in which a body of law, or the principles of law-making, can be divided
into categories for the purposes of simplification.
- Comparative Law : The comparative lawyer works with international relations in trade
and commerce, travel, government business, and many other areas depending upon the
breadth of his/her knowledge and the needs of his/her employer. The field of comparative
law is one in which there is a great deal of opportunity for advancement and challenging
work.
- Public law : Public law is the body of law that governs the relationship between the
individual and the state, as distinct from civil law (or `private' law) which governs the
relationships between individuals. Public law is often taken to be divided into `criminal',
`constitutional' and `administrative' branches, although these are not distinct in all
jurisdictions.
- Family law: Family law attorneys deal specifically with laws having to do with family
matters. There are multiple facets to each instance of representation required and
knowledge of individuals and their family histories are necessary. Family law lawyers
must interview each family member involved, or mediate for families so agreements can
be made in an amiable or restructuring way. The most common family law attorneys are
the divorce lawyers, but other aspects of family law are represented as well. Child
support claims and those stipulations, custody and who gets custody, visitation and length
of visitation. Adoption proceedings, who can adopt, the rights of fathers, mothers, and the
different statutes of each state, paternity and how it is determined, domestic abuse
charges, who was abused, spousal abuse, child abuse, sexual abuse and the court's
rulings, annulments of marriages and what are considered avoidable marriages, are all
represented by the family law attorney. How these cases are decided by the courts and for
what reasons are determined by the knowledge and representation of the family law
attorney.
- Criminal Law : Criminal Law involves just what the label implies - people accused of
crimes. Lawyers who specialize in criminal law may work on either side of the adversary
process - defense or prosecution. There are many more types of law from which to
choose; what you choose will depend upon your present interests and your interests as
they develop in law school. There is no reason to make your decision before begin.
Types of liability
Product liability
Product liability is the area of law in which manufacturers, distributors, suppliers, retailers,
and others who make products available to the public are held responsible for the injuries those
products cause. Although the word "product" has broad connotations, product liability as an area
of law is traditionally limited to products in the form of tangible personal property. Products
Liability distinguishes between three major types of product liability claims:
manufacturing defect,
design defect,
a failure to warn (also known as marketing defects).
Strict liability
In law, strict liability is a standard for liability which may exist in either a criminal or
civil context. A rule specifying strict liability makes a person legally responsible for the damage
and loss caused by his or her acts and omissions regardless of culpability (including fault in
criminal law terms, typically the presence of mens rea). Strict liability is prominent in tort law
(especially product liability), corporations law, and criminal law.Rather than focus on the
behavior of the manufacturer (as in negligence), strict liability claims focus on the product itself.
Under strict liability, the manufacturer is liable if the product is defective, even if the
manufacturer was not negligent in making that product defective.
Vicarious liability
The word 'vicarious' derives from the Latin word for 'change' or 'alternation' or 'stead' and
in tort law refers to the idea of one person being liable for the harm caused by another, because
of some legally relevant relationship.
Public liability
Public liability is part of the law of tort which focuses on civil wrongs. An applicant (the
injured party) usually sues the respondent (the owner or occupier) under common law based on
negligence and/or damages. Claims are usually successful when it can be shown that the
owner/occupier was responsible for an injury, therefore they breached their duty of care.
The duty of care is very complex, but in basic terms it is the standard by which one
would expect to be treated whilst one is in the care of another.
Once a breach of duty of care has been established, an action brought in a common law
court would most likely be successful. Based on the injuries and the losses of the applicant the
court would award a financial compensation package.
Classification of accounting liabilities
Current liabilities
These liabilities are reasonably expected to be liquidated within a year. They usually include
payables such as wages, accounts, taxes, and accounts payables, unearned revenue when adjusting
entries, portions of long-term bonds to be paid this year, short-term obligations (e.g. from purchase
of equipment). Current liabilities are the financial obligations payable within a short period of time,
normally within one year. It is a balance sheet item, which is equal to the sum of dues within one
year and all the money indebted to the establishment. Current liabilities are the short-term financial
obligations.
Some of the distinguishable examples of current liabilities include accrued expenses as
wages, taxes and due interest payments.
Long-term liabilities
Long-term liabilities — these liabilities are reasonably expected not to be liquidated within
a year. They usually include issued long-term bonds, notes payables, long-term leases, pension
obligations, and long-term product warranties. Long-term liabilities are liabilities with a future
benefit over one year, such as notes payable that mature longer than one year. In accounting, the
long-term liabilities are shown on the right wing of the balance-sheet representing the sources of
funds, which are generally bounded in form of capital assets.
As a nurse it has become an important necessity to be aware of the legal aspects associated
with caring and helping people in the health industry today .Unfortunately, the more and more
negligence cases there are the less and less people want to get in to the health care field fearing
legal aspects and the inevitable law suites. The first nursing law created was that of nursing
registration in 1903 and they have only evolved and expanded over the years to create a thick
book which must be studied today by aspiring nurses.
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 judgment 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.
CHARITABLE IMMUNITY:
In some states, non-profit hospitals have charitable immunity. This means that the non profit
hospital cannot be held legally liable for harm done to a patient by its employees.
The employees of that nonprofit hospital are still legally for their own actions. The trend in
legislation is toward the repeal of laws providing for charitable immunity. Those active in the
consumer movement have argued that no institution should be relieved of responsibility in such a
blanket fashion. If you are employed by a non profit institution, it is important that you know
whether the law in your state provides charitable immunity for the institution.
SUPERVISORY LIABILITY:
When a nurse is in the role of charge nurse ,head nurse, supervisor or any other role which
involves supervision or direction of other people ,the nurse is potentially liable for the actions of
others .The supervising nurse is responsible for good exercising good judgment in a supervisory
role .This includes making appropriate decisions about assignments and delegation of tasks .If an
error occurs and the supervising nurse is shown to have exercised sound judgments in all
decisions made in that capacity, the supervising nurse may not be held liable for the error of the
subordinate .If poor judgment was used in assigning an inadequately prepared person to an
important task the supervisory nurse might be liable for resulting harm.
A nurse who is caring for the patient has legal duty to ensure that the patient receives safe
and competent care .This duty requires that the nurse maintain an appropriate standard of care
and also that the nurse take action to obtain an appropriate standard of care from other
professionals when that is necessary. The nurse has a duty to continue all efforts to obtain
appropriate medical care for the patient.
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.
Nurses must obtain a patient consent for nursing measures undertaken. This does not mean that
exhaustive explanations need to be given in each situation because courts have held that patients
can be expected to have some understanding of usual care. Consent for nursing measures may be
verbal or implied.
The nurse should remember that the patient is free to refuse any aspect of care offered.
However, like the physician, the nurse is responsible for making sure that the patient is informed
before making a decision.
WITHDRAWING CONSENT:
Consent may be withdrawn after it is given. People have the right to change their minds.
Therefore, if after one IV infusion a patient decides not to have a second one started that is his or
her right. As a nurse, you have an obligation to notify the physician if the patient refuses to
medical procedure or treatment.
The consent of minor is usually given by a parent or legal guardian. You should also obtain the
minor consent when he or 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.
CONSENT IN EMERGENCY:
If a true emergency exists, consent for care is considered to be implied. The law holds that if a
reasonable person were aware that the situation was life threatening, he or she would give
consent for care. An exception to this made, if the person has explicitly rejected such as care in
advance and any such information may be identified from patient wallet. \
FRAUD:
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(falsely) 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 sub standard 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:
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:
1. Intentional torts
2. Quasi-intentional torts
3. Unintentional torts
INTENTIOAL TORTS:
Assault:
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:
Battery is un-consented 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 cannot later charge battery,
saying that he 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 the
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 behaviour to your supervisor and the physician.
QUASI-INTENTIONAL TORTS
1. Invasion of privacy:
MEANING:
Invasion of privacy n. 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.
Intrusion of solitude, seclusion or into private affairs is a subset of invasion of privacy earmarked
by some spying on or intruding upon another person where that person has the expectation of
privacy. The place that the person will have an expectation of privacy is usually in a home or
business setting. People who are out in a public place do not have the same expectation for
privacy, according to most state laws, than do people who are inside their own homes.
For instance, journalist, investigators, law enforcement and others may not place wiretaps on a
private individuals telephone without his or her consent. However, law enforcement, may at
times circumvent this law by obtaining permission from the courts first. In rare cases, law
enforcement may even obtain permission after-the-fact for the wiretaps.
The appropriation of a private person's name, likeness or identity by a person or company for
commercial gain in prohibited under the invasion of privacy laws. This law pertains to a private
figure and not a public figure or celebrity, who have fewer and different privacy rights.
This law was born from a couple of court decisions in the early 1900's where a private person's
photograph was being used without consent for advertising purposes and without the person
receiving any money for using their pictures in print. The courts recognized the common law
right to privacy including a person's identity had been violated by the unauthorized commercial
use. In later cases, a person's voice was also included.
Public figures, especially politicians do not have the same right to privacy in regards to
appropriation of name, likeness or identity since there is much less expectation of privacy for
public figures. Celebrities may sue for the appropriation of name, likeness or identity not on
grounds of invasion of privacy, but rather on owning their own right to publicity and the
monetary rewards (or damages) that come from using their likeness.
Public disclosure of embarrassing private facts is an invasion of privacy tort when the disclosure
is so outrageous that it is of no public concern and it outrages the public sense of decency. In this
invasion of privacy tort, the information may be truthful and yet still be considered an invasion if
it is not newsworthy, the event took place in private and there was no consent to reveal the
information. Divorce situations and relationship breakups may involve this kind of invasion of
privacy tort.
LAW OF PRIVACY
Privacy law is the area of law concerned with the protection and preservation of the privacy
rights of individuals. Increasingly, governments and other public as well as private organizations
collect vast amounts of personal information about individuals for a variety of purposes. The law
of privacy regulates the type of information which may be collected and how this information
may be used and stored.
Specific privacy laws
These laws are designed to regulate specific types of information. Some examples include:
UNINTENTIONAL TORTS
1. Negligence:
Definition
Breach of Duty
Injury
For an injury to be considered caused by negligence, records must show that the nurse
failed to perform 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.
Performance 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.
Proof
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, and (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.
2. Malpractice:
Definition
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
- Medication errors – giving a patient the wrong medication or the wrong dose, or dispensing
medication to the wrong patient
-Documentation error
The consequences of nursing malpractice can range from minor to potentially fatal, and may
include:
Medication overdose
Not all unfortunate events in medicine are caused by malpractice. Despite what may be a
common societal belief, not all unexpected, unintended, or even undesired medical results can be
attributed to the fault of the healthcare provider. The law recognizes that much of nursing care
requires clinical judgment. Consequently, a patient must prove 4 requisite elements to establish a
malpractice case.
First, the patient must establish that there was a nurse-patient relationship. It is out of the
nurse-patient relationship that a nurse‘s duty to the patient arises. Rarely can it be said that a
particular nurse had a duty to the patient if such a relationship cannot be shown. Most often, this
element will be satisfied by reliance on the hospital record documenting the nurse‘s involvement
with some aspect of patient care. Once this is established, a duty is created.
Second, the patient must establish the scope of the duty that was owed by the nurse; this
is usually done though an expert witness testifying about the care that was required.
Third, the patient must establish that there was a departure from "good and accepted
practice." Good and accepted practice is most often defined as care that would have been
provided by the ordinarily prudent nurse practicing in the particular circumstances. The care need
not have been the best care or even optimum care. Furthermore, when there is more than 1
recognized method of care, a nurse will not be deemed negligent if an approved method was
chosen, even if that method later turns out to be the wrong choice. As long as the defendant nurse
provided care that was consistent with accepted practice, the nurse will not be found negligent,
regardless of outcome.
Lastly, there must be a causal relationship between the act or acts that departed from
accepted nursing care and the patient‘s injury. This link must be established not by possibility,
but by probability; thatis, it must be proved that if the nurse had not been negligent, then more
likely than not, the patient would not have suffered harm. This element must also be proved by
expert testimony.
Other common causes of malpractice cases against nurses include failure to properly monitor
and assess the patient‘s condition and failure to properly supervise a patient resulting in harm.
Typically, negligent monitoring cases arise from a nurse‘s failure to perform an assessment and
notify the treating physician of changes. Thus, a nurse‘s failure to obtain vital signs and report a
patient‘s deteriorating condition was held to constitute negligence.3 Similarly, when a nurse
observed that a patient‘s arm was swollen, black, and foul-smelling but failed to advise the
treating physician of other clinical findings, including delirium and arm drainage, the nurse was
held liable.4 Negligent supervision cases usually involve a patient who falls while getting out of
bed, while ambulating, or while using the bathroom.
A nurse who concludes that an attending physician has misdiagnosed a condition or has
not prescribed the appropriate course of treatment may not modify the course set by the physician
simply because the nurse holds a different view. To permit that conduct would allow the nurse to
perform tasks of diagnosis and treatment denied to the nurse by law. However, the nurse is not
prohibited from calling on or consulting with nurse supervisors or with other physicians on the
hospital staff concerning those tasks when they are within the ordinary care and skill required by
the relevant standard of conduct.
Therefore, a nurse has an obligation to advocate on behalf of the patient when issues arise
about the course of care or treatment being provided. Merely documenting in the chart that the
order was discussed and confirmed with the ordering care provider is not enough. The issue in
these cases is not about allocating the responsibility of healthcare, but instead arises from the
hospital‘s and nurse‘s duty to keep the patient safe.
Generally speaking, a principal is responsible for the acts of its agents. In law, this is
known as respondeat superior. Therefore, a hospital has vicarious liability for the negligence of
its nurses, which allows a patient to bring a lawsuit against either the nurse individually, or the
hospital as the employer, or both.
In addition to liability arising out of respondeat superior, a hospital may also have
separate institutional or corporate liability. Among its responsibilities, a hospital has a duty to the
patient to ensure the competency of its nursing staff and the physicians who maintain privileges
at its institution. Furthermore, the hospital is responsible for ensuring that proper drugs and
equipment are available for use, and that they are not defective. The hospital also has a general
duty to patients and visitors to maintain the hospital premises in a reasonably safe condition.
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.
1. Assessment
2. Problem/need identification
3. Planning
4. Implementation
5. 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 Rs 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.
1. Document, document, document...correctly. We've all heard the maxim, "If it wasn't
documented, it wasn't done." But simply documenting something isn't enough; we must
document it precisely and thoroughly. Otherwise, gaps in our charting leave us vulnerable
to malpractice charges.
No "one-size-fits-all" note suits all patients. Using your experience and knowledge, tailor your
notes to each individual, predicting possible complications and adverse outcomes and
documenting with that patient in mind. For surgical patients, include notes about your
assessment of postoperative complications; for obstetric patients, add notes on fetal and maternal
complications; for head-injury patients, document your frequent neurologic assessments, and so
on. Include normal as well as abnormal findings.
In a lawsuit, the timing of your findings can be crucial. When did you observe a patient first
move her fingers after hand surgery? What did the fetal heart monitor indicate during
contractions throughout the entire second stage of labor? If the patient has a neurologic disorder,
what's his level of consciousness from one assessment to the next?
When you discover deviations from normal findings-the fingers are immobile, prolonged fetal
heart decelerations are noted with delayed return to baseline, the Glasgow coma scale has
decreased from 15 to 13-document what time you communicated this information and to whom.
If you repeatedly report this information, your documentation must include this, along with
whatever other efforts you made to bring your findings to the provider's attention.
When unusual incidents occur, make sure you notify the appropriate people, according to facility
policy. For example, you should immediately advise your nurse-manager and risk management
about any incidents that have liability potential. Keep an eye on forms: Complete all flow sheets
or checklists, leaving no blanks; chart all given medications; and clearly mark discontinued
medications or changed doses on the medication administration record.
2. Specifically identify individuals. Nursing entries such as, "MD aware," "nursing supervisor
advised," and "visitor in room" don't help protect you. Which physician was aware? How can
you prove you informed a provider when you can't identify her? What visitor was in the room?
How can a witness be called to testify on your behalf when no one knows who he was? Always
include at least the person's last name so he can be identified and contacted if needed.
3. Date, time, and sign every entry-and write legibly. Many plaintiffs' claims are based on the
timing of events. The findings of what happened (or didn't happen), when, and in what order can
determine the outcome of a case. When working in hospitals that have computerized charting,
the technology helps confirm and preserve that information because the computer automatically
stamps, dates, and inserts your "signature" into each entry. But in facilities that still keep paper
records, you need to time and date every entry. That's because as charts are taken apart for
copying, pages can get separated and mixed up. Be sure to use a complete date, including the
year, and record time on a 24-hour clock or specify a.m. or p.m. Make sure that your watch is in
sync with the hospital's clock and that you record the time accurately. Sign every entry using a
complete signature, including your license (RN, LPN, and so on). If one entry is incomplete or
broken by pages, sign it anyway and write "contd." Continue it at another point and refer to the
incomplete note by writing "contd. from 6/7/04, 10:15 a.m." and sign that note as well.
Working in a unit that uses flow sheets that open into several pages? If so, make sure each page
has the correct date on it.
Legible handwriting is important too. Sloppily written notes convey an impression-rightly or not-
that your work is sloppy as well. You may save a few minutes by writing quickly, but do you
really want to risk having your sloppily written notes misread? In particular, make sure your
signature and status are legible so those who need you can find you easily.
4. Make sure you're aware of the facility's policies and practices. As a travel nurse, you may
be in a different location as often as every few weeks, so you'll be very dependent on a thorough
orientation to each facility. Review the policies and procedures manual on day one-or before you
start working, if that's possible-so you have a solid understanding of the facilities' practices.
Look to your nurse-manager and other staff nurses to fill you in on current practices and keep
your recruiter informed if you aren't getting the direction you need.
5. Don't let understaffing drive you to adopt careless habits. Without a doubt, understaffing
can contribute to errors: The Joint Commission on Accreditation of Healthcare Organizations
indicates that it's a factor in 24% of its sentinel event reporting. But understaffing is no excuse,
legally or ethically, for substandard nursing practice. If you're working in an understaffed unit,
be meticulous about your practice. Don't make exceptions because you're busy or you're working
in an unfamiliar or short-staffed unit. If a patient is injured from a medication error that you
made while taking a shortcut, no one will care about a nursing shortage. All that matters is that
you departed from the standard of care and that your departure caused an injury.
So check ID bands when administering medications, avoid leaving medications at the bedside,
observe the "five rights" (right patient, right medication, right dose, right route, and right
time), document injection sites, label intravenous lines, and so on. That way, if you're involved
in a lawsuit, you can say you followed the standard of practice for the profession. It means you
did check the patient's ID band before giving him his medication, even if you'd been taking
care of
him for 4 days. You did so because it's part of your standard practice to do so, and you don't
deviate from it.
6. Don't drop the advocacy ball and get too task oriented. The hallmark of nursing is patient
advocacy. Our education encourages us to be critical thinkers who study beyond the "hows" and
understand the "whys." We assess and analyze, rather than just following routines.
Make a conscious effort to keep your holistic hat on. If a patient was on a medication at home
that hasn't been ordered with admission orders, ask if it should be continued in the hospital.
Remember to check relevant lab values before giving medications. Push for psychiatric or social
work consults if you think they're needed. Don't get so lost in what has to be done that you stop
being a patient advocate.
7. Develop good relations with your patients. Bashing lawyers may be "fashionable," but
lawyers don't sue hospitals, providers, and nurses; patients do. Long before lawyers get
involved, a provider/ patient relationship exists, and the quality of that relationship plays a large
role in the patient's decision to seek out an attorney.
You can shape your relationship with patients in a manner that protects you or in a manner than
endangers you. From your own perspective, if someone causes you harm, whom are you more
likely to sue? Someone you had a good relationship with, who made you feel she cared about
you, and who treated you with dignity and respect? Or someone who was dismissive, took no
personal interest in you, disregarded your privacy, and treated you coldly?
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.
3. Fosters nurse-patient relationships that are respectful, caring and honest thus reducing
the possibility of future lawsuits
9. Increases staff awareness of intentional torts and assist them in developing strategies
to reduce their liability in these areas
10. Provides educational and training opportunities for staff on legal issues
affecting nursing practice.
PATIENT CARE ISSUES, MANAGEMENT ISSUES, EMPLOYMENT ISSUES AND
MEDICO LEGAL ISSUES
INTRODUCTION
Nursing is defined as providing care to the healthy or sick individuals for preventive,
promotive, curative and rehabilitative needs. The Consumers are patients with complex needs.
With increased awareness of health care, health care facilities and consumer protection Act,
patients/clients are getting awareness about their rights. Nurses also have now the expanded role,
with the result the legal responsibility is increased. Hence, it is important for nursing personnel
working in hospital, community and educational field to develop understanding of Legal and
Ethical issues of Nursing.
Issues need deliberations and common consensus. They need to be reviewed periodically.
Issues which seem not feasible, and ideal, may become practice with the change of time. Some
of these issues threaten nurses who do not keep up with the changing development. These issues
are base for the future trends in care.
Nurse migration has attracted a great deal of political as well as media attention in recent years.
The rights to healthcare as well as workers‘ rights are paramount to understanding the interests
of health sector stakeholders, including the consumer or patient, the government or employer,
and the worker or health professional. In this section a discussion on the right to work and the
right to practice is, by necessity, followed by a warning that cases of exploitation and
discrimination often occur when dealing with a vulnerable migrant population. Additionally,
international migration policy issues addressing the somewhat conflicting sets of stakeholders'
rights are presented, and ethical questions related to nurse migration are noted.
Professionally active nurses are important players in an increasingly competitive and global labor
market. Unable to meet domestic need and demand, many industrialized countries are looking
abroad for a solution to their workforce shortages; the magnitude of current international
recruitment is unprecedented (ICN, 2005).
For nurses to practice their profession internationally, they need to meet both professional
standards and migration criteria. The right to practice, e.g., to hold a license or registration, a
professional criteria, and the right to work, e.g. to hold a work permit, a migration criteria, are
sometimes linked. Yet they often require a different set of procedures with a distinct set of
competent authorities.
In the interest of public safety, nurses' qualifications must be screened in a systematic way to
ensure they meet the minimum professional standards of the country where they are to deliver
care. This may be in the form of a paper screen, for example automatic recognition of
qualifications received from a given country or school; tests, such as the NCLEX licensing
exam; supervised clinical practice, as seen in an adaptation period; and/or successful completion
of an orientation course/program.
Language is a crucial vehicle for the vital communication needed both between the patient and
care provider, and also between members of the health team. It is not surprising that in many
countries, a nurse's right to practice is limited if the foreign-educated nurse's language skills do
not support safe care practices. Passing specific language tests are required in certain countries.
In others, the employer is held responsible for ascertaining the language competence of the
employees/health professionals. Clearly, history has demonstrated a tendency for migrant flows
to be the strongest between source and destination countries that share a common language
(Kingma, 2006). For example, nurses wishing to migrate from Morocco will tend to go to France
while nurses from Ghana will be attracted by the United Kingdom. As the pools of nurses willing
to migrate change, and as language competency becomes a professional advancement
requirement, language barriers may prove to be less of a constraint, and we may see Chinese
nurses working in Ireland and Korean nurses going to the US.
Foreign nurses also need to meet national security and immigration criteria in-order-to enter the
country and to stay on a permanent or temporary basis, with or without access to employment.
There is no doubt that nurse mobility will be affected by national security concerns and decisions
on how fluid the borders will be maintained. For example a tightening of border restrictions after
terrorism attacks or the opening of borders with new economic agreements, such as the
expansion of the European Union, will continue to influence nurse migration patterns.
One of the most serious problems migrant nurses encounter in their new community and
workplace is that of racism and its resulting discrimination (Chandra & amp; Willis, 2005).
Incidents are, however, often hidden by a blanket of silence and therefore difficult to quantify
(Kingma, 1999). Migrant nurses are frequent victims of poorly enforced equal opportunity
policies and pervasive double standards. Some migrant nurses are experiencing dramatic
situations on the job where colleagues purposefully misunderstand, undermine their professional
skills, refuse to help, and sometimes bully them, thus increasing their sense of isolation (Allan &
amp; Larsen, 2003; Hawthorne, 2001; Kingma, 2006). If we recognize that international
migration will continue and probably increase in coming years, the protection of workers is a
priority issue and should be safeguarded in all policies and practices that affect migrant health
professionals.
The Courts have time and again reiterated that employees enjoy security of tenure of
employment. The maxim "easy to hire difficult to fire" is a truism even in the case of
probationers. No employer having hired a person at considerable cost and having exposed the
person to training, formal or otherwise, will want to terminate the person. However, when an
employee has an attitude problem or whose work performance is not up to the expectations he
cannot be terminated by the employer simply by invoking the termination clause in the
employment contract. The employer has to follow certain rules and procedures and only at the
end of it can he terminate the services of a non-performing employee. Even then, there are no
iron clad assurances that the termination will not be challenged by the employee at the
Industrial Court. How does an employer ensure that he minimizes the risk of being challenged
in Court over a termination of employment due to unsatisfactory work performance? This talk
will attempt to take you out of the labyrinth.
g. Misconduct and imposition of punishment
It has long been held that the employer has the inherent right to discipline his workers. Should
misconduct be committed, the employer after a proper inquiry has been instituted can impose a
suitable punishment, including dismissal if the offence committed was of a serious nature. The
decision on the type of punishment to be imposed is under all circumstances a subjective one.
The Courts will interfere if, among others, the action taken by the management was perverse,
baseless or unnecessarily harsh or was not just or fair. There have been occasions where
employers have imposed the punishment of dismissal for misconduct which they have assessed
as serious but these cases have been reviewed by the Industrial Court and the decision of the
employer substituted. Given that imposition of punishment is a subjective matter, what factors
or criteria should an employer apply in determining appropriate punishment for misconduct
committed in employment. This talk, among others, will examine some of the issues to be taken
into account.
i. Sexual harassment at the workplace
Sometime ago this subject matter received a great deal of attention especially with the launching
of the Code of Practice on the Prevention and Eradication of Sexual Harassment at the
Workplace by the Ministry of Human Resources. However, the response to the adoption of the
Code by employers was not encouraging. Some NGO's have called for the introduction of
statutory measures to deal with the problem. Some recent judicial pronouncements appear to
make it difficult to prove sexual harassment had indeed taken place. Regardless of all these what
is the proper attitude that ought to be taken by employers in this matter. Do employers have a
legal responsibility to safeguard their employees from sexual harassment at the workplace? To
what extent can employers dictate without being accused of encroachment into a person's private
life and social interaction. How is an employer to deal with sexual harassment cases and what
standard of proof is called for when usually harassments are .private and confidential incidents'.
j. Renewal of nursing registration
So that registration office is updated with nurses in practice. Of course re- registration may
qualify its periodicity and qualifications of nurses e.g. clinical experience, attendance at
continuing education etc.
k. Diploma vs degree in nursing for registration to practice nursing
This issue need indepth study of merits and demerits as well as its feasibility before it could
come on the surface.
l. Specialization in clinical area
It could be either through clinical experience or education. Specialization in cure and
specialized care required for patients demand that nurses be highly skilled in the unit.
Generalization of care seems remote and unacceptable for patients under specialized treatment.
m. Nursing care standards
Standards must be laid down and followed so that clients understand the quality of care expected
from the nurses.
D. MEDICO LEGAL ISSUES
Nurses face legal issues daily. Those issues may be in connection to negligence, administering
medication and advocating for the patient. The Nurse Practice Act lists all of the duties and role
of a nurse, except the legal and ethical issues. If these duties and regulations are not followed, the
nurse is at risk of losing his license and facing a malpractice suit.
a. Legal Issues Specific to Nursing
Duty to seek Medical Care for the patient
It is the legal duty of the nurse to ensure that every patient receives safe and competent care. The
nurse cannot guarantee the patient will receive medical care that the nurse be a strong advocate
for the patient and use every resource to ensure medical care is received. If you determine that a
patient in any setting needs medical care, and you do not do everything within your power to
obtain that care for the patient, you have breached your duty as a nurse.
Confidentiality
It is a privilege to care for other people. At times, your patients will relate to you in a personal
way. One of the outcomes of your relationship is that you may be told information of a personal
nature.in addition to what a patient may share with you, you have access to the person‘s hospital
records. The law requires you to treat all such information with strict confidentiality. This is also
an ethical issue. Unless a patient has told you something that indicates danger to self or others,
you are bound by legal and ethical principles to keep that information confidential.
Permission to treat
When people are admitted to hospitals, nursing homes, and home health services, they sign a
document that gives the personnel in the organization permission to treat them. Every time the
nurse provides nursing care to person, however, permission must be obtained. The courts have
ruled that people are expected to have some understanding of basic care, which means the nurse
should explain briefly what he or she is about to do. The concept of permission to treat should be
in your mind as you give nursing care. For example, most personnel who pass food trays
automatically ask, ―Are you ready to go for a walk now? These automatic questions actually are
permission to treat questions. When you are giving medication, you may say, ―Here are
your pills,‖ Here is the new medication the doctor ordered for you.‖ If the patient takes the
medication, he or she has given you permission to treat.
Informed consent
The concept of permission to treat is closely tied to the concept of informed consent. The law
states the persons receiving health care must give permission to treat based on informed consent.
The principle of informed consent states that the person receiving the treatment fully understands
the possible outcomes, alternatives to treatment, and all possible consequences.
The physician is responsible for obtaining informed consent for medical procedures, such as
surgery, whereas the nurse is responsible for obtaining informed consent for nursing procedures.
Each institution has forms for informed consent for complex or serious procedures, such as
surgery, chemotherapy, or electroshock therapy. Check with your institution and review the
forms available for informed consent.
Surgical procedures commonly require informed consent. Although the law states that either
verbal or written consent is acceptable, most institutions require written consent because it is the
most legally binding. It is the physician‘s responsibility to give the surgical patient the
information necessary to meet the requirements for informed consent. It often is the
responsibility of the nurse to get the surgical consent from signed.
Advance Directives
Although the Patient Self – Determination Act was passed by the U.S. Congress in 1990, it
was not implemented until 1992. The act states that all the health care institutions are required to
give clients or patients an opportunity to determine what lifesaving measures or life-prolonging
actions they want implemented. This requirement applies to all hospitals, long term care
facilities, and home health agencies and is to be done at the time of admission. The institution is
required to give adequate information to the person and assist in completing any forms. In most
situations, the nurse is responsible for educating patients if there is not enough information to
make an informed decision.
The purpose of advanced directives is to give the person an opportunity to make decisions
regarding healthcare before an illness or a need for treatment that would prohibit making such
critical decisions.
Negligence
The law requires nurses to provide safe and competent care. The measure of safe and
competent care is the standards of care. A standard of care is the level of care that would be
given by a comparable nurse in a similar situation. Negligence occurs when a person fails to
perform according to the standards of care or as a reasonably prudent person would perform in
the same situation.
It is the responsibility of the nurse to monitor the patient. If a patient calls for a nurse to come
and assist him in going to the restroom for example, the nurse is to assist, or if the is busy with
another patient, have another nurse assist the patient. Ignoring the patient or responding after a
lengthy delay could be considered negligence, and if the patient is hurt from trying to move
himself, the nurse could face legal suits. Also, it could be considered negligence if a physician
orders the nurse to administer a prescription, and the nurse did not do so.
Requirements to establish Negligence
There are four legal requirements that must be met for negligence to be proved:-
A standard of care exists.
A breach of duty or failure to meet the standard of care has occurred.
Damages or injury has resulted from the breach of duty. (This could be commission of
an inappropriate action or omission of a necessary or appropriate act).
The injury or damage must result from the nurse‘s negligence.
I have never met a nurse whose goal was to be negligent, but it doesn‘t happen. Examples of
negligent acts are:-
Leaving a patient‘s bed in high position with the side rails down and the patient
gets confused during the night and falls out of bed.
Committing medications errors of either omission (not giving the drug) or commission
(giving the wrong drug).
Breaking sterile technique when changing a dressing, with a resultant wound infection.
Mistakenly ambulating a patient who is on bed rest.
Nurses are not supposed to make mistakes, yet the best educated and well intentioned nurse can.
To avoid neglect, you need to pay attention to the details of your assignment and focus on
managing your workload efficiently. It is important to practice such skills now while you are a
student and have an instructor to help you determine the most effective way to get your work
done.
Malpractice
Malpractice is a term used for negligence. Malpractice specifically refers to negligence by a
professional person with a license. You can be sued for malpractice once you have your LPN
license. If you are a nursing assistant right now, you may be negligent, but it wouldn‘t be
malpractice because you are not licensed.
Fraud
Few cases of fraud exist in nursing, but it does need to be mentioned. Fraud is a deliberate
deception for the purpose of personal gain and usually is prosecuted as a crime. Most courts are
harder on cases of fraud compared with cases of negligence or malpractice because fraud is
deliberate and results in personal gain.
Assault and Battery
It is found that most nurses do not understand the definitions for assault and battery. It is
important to your practice that you do understand them.
Assault is the threat of unlawful touching of another, the willful attempt to harm someone.
Battery is the unlawful touching of another without consent, justification, or exercise. In legal
medicine battery occurs if a medical or surgical procedure is performed without patient consent.
In both situations, it is not necessary for harm to occur. The events simply need to happen. If you
understand and practice the caring and empowering concepts shared in this test, you should
never have to be concerned about assault and battery.
Assault can be verbally threatening a patient. Rather than threaten a patient, you need to use your
creative tactics to assist the patient in whatever is his or her choice in the matter. You do not
have to hurt the person. If you practice transpersonal caring, however you should not have to be
concerned with these legal issues.
False Imprisonment
Preventing movement or making a person stay in a place without obtaining consent is false
imprisonment. This can be done through physical or non physical means. Physical means include
using restraints or locking a person in a room.Insome unique situations, restraints and locking
patients in a room are acceptable behaviours.This is the case when a prisoner comes to the
hospital for treatment or when a patient is a danger to self or others. In these situations, be sure
you know the standards of care and the institution‘s policies regarding physical restraints. To
restrain a person is a serious decision. It requires a physician‘s order and permission of the
patient or the patient‘s family members.
It used to be common practice to use restraints on nursing home residents who wandered or had
other behaviours that were difficult to manage. This is no longer an acceptable standard of care.
The best approach to avoiding a charge of false imprisonment is to work closely with patients
who seem at risk for confinement. Talk to them, do an ongoing assessment, assign extra staff to
assist the person, or implement some other creative way to manage the problem. To resolve such
complex issues is truly practicing the art of nursing.
Invasion of privacy
Clients have claims for invasion of privacy‘, e.g. their private affairs, with which the public has
no concern, have been publicized. Clients are entitled to confidential health care. All aspects of
care should be free from unwanted publicity or exposure to public scrutiny. The precaution
should be taken sometimes an individual right to privacy may conflict with public‘s right to
information for e.g. in case of poison case.
Nurse Practice Act
Each state has what is called a Nurse Practice Act. The guidelines and laws outlined in the act
pertain to all nurses who are licensed in that particular state. Nurse limitation is one of those
laws. Each nurse has a limitation on what he is allowed and trained to do. He must follow the
chain of command, especially with the care of a patient. If he does not have the authority or
knowledge to give a prescription, analyze a lab report, or advise the patient on treatment, he may
not legally do so. Any wrong information or practice he commits is punishable by the law and
the patient or family may file a suit against him and the health agency or hospital he works for.
Patient's Advocate
A nurse has a legal obligation to act as the patient's advocate in case of emergency. The nurse is
to act as the liaison between the patient and the health care provider, such as a physician. The
nurse will monitor the patient, ensuring that if any complications or abnormalities arise, a
physician notified immediately. The nurse is legally obligated to keep the personal data and
information of the patient private; not doing so is a violation of the code of ethics for nurses.
Administering Medication
Nurses are responsible for administering the correct doses and medications to patients. If the
nurse gives a fatal dosage amount, she may face legal malpractice suits. It is also the
responsibility to research the patient's records, or ask the patient and family members if there are
any allergies or complications that may pose a risk if a certain medication is administered.
Report It or Tort It
Allegations of abuse are serious matters. It is the duty of the nurse to report to the proper
authority when any allegations are made in regards to abuse (emotional, sexual, physical, and
mental) towards a vulnerable population (children, elderly, or domestic). If no report is made, the
nurse is liable for negligence or wrongdoing towards the victimized patient.
The nurse is responsible for keeping all patient records and personal information private and only
accessible to the immediate care providers, according to the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). If records get out or a patient's privacy is breached, the
liability usually lies on the nurse because the nurse has immediate access to the chart.
It is the nurse's responsibility to make sure everything that is done in regards to a patient's care
(vital signs, specimen collections, noting what the patient is seen doing in the room, medication
administration, etc.), is documented in the chart. If it is not documented with the proper time and
what was done, the nurse can be held liable for negative outcomes. A note of caution: if there
was an error made on the chart, cross it out with one line (so it is still legible) and note the
correction and the cause of the error.
S.N Process
INTRODUCTION
The standard of nursing care delivery is set by certain regulations of nursing practice
called ―nurse practice acts‘. Nurse practice acts are legally defined and describe regulations
of nursing actions by an administrative board such as a state board of nurse examiners. These
boards generally have the authority to regulate nursing practice and education within the states.
The regulatory bodies that define the laws and regulations in nursing practice are the nursing
councils at the international national and state levels. Such as
ACCREDITATION
National agencies
National accrediting agencies are concerned with appraising the total activities of the institutions
of higher learning, and with safe guarding the quality of liberal education, the foundation of
professional programs in colleges and universities. Each agency establishes criteria for the
evaluation of institutions in its region it reviews those institutions periodically, and it publishes
from time to time a list of those agencies which it has accredited.
These professional groups aim to foster research, to improve service to the public and the
number of individuals admitted to the profession. Controlling admissions is vital to a
professional group particularly in the early stages when the professional is struggling for status.
In India, particularly in the field of health, national professional accrediting agencies have
existed.
NURSING LICENSURE
The registry of nurses initiated by Nightingale provided institutions and clients with the
means to ascertain the skills and knowledge of graduates. However, this was not enough. As
nursing programs proliferated, variations developed among the programs. Educational programs
were structured to meet the needs of the host hospital. Another method was needed to distinguish
those trained in providing nursing care. This method led to nurses developing criteria for
licensure. The primary purpose of licensure was, and still is, the protection of the public.
All nursing practice acts include two essential components. First each includes statements
that refer to protecting the health and safety of the public. The second is protection of the title of
RN. This protection is ensured by describing those individuals covered by the regulations and
those excluded from the act. The legal title, registered nurse, is reserved for those meeting the
requirements to practice nursing in the state. A section of each nursing practice act describes the
requirements for licensure. An initial requirement is graduation from high school and an
accredited nursing program.
Each nursing practice act includes the requirements and procedures necessary for initial
entry into nursing practice. There are several steps necessary in obtaining a license to practice
nursing. Candidates for licensure must submit evidence of graduation as defined by each state.
Frequently a transcript of course work, a diploma or letter from the dean of the program attesting
to the graduation of the applicant is necessary.
A temporary permit may be available for nurses moving from one state to another. The process
of obtaining a license in another state is to apply for licensure by endorsement. Nurses licensed
in one jurisdiction apply for licensure in a second jurisdiction by submitting a letter to the second
state board of nursing. Typically evidence for the new license is similar to that for initial
licensure. In addition, proof of the nurse‘s current license to practice will be required.
RENEWAL OF LICENSURE
In addition to outlining requirements for initial licensure, each nursing practice act
includes information on renewal of licensure requirements. These regulations define the period; a
license is valid and any additional requirements for renewal of licensure. All nurses are expected
to remain competent to practice through various means of continuing education.
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 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 to 4 months.
Consumer protection laws are designed to ensure fair competition and the free flow of truthful
information in the marketplace. 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 marketplace.
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.
Consumer protection act (CPA in short) was enacted by Parliament in December 1986 and
came into force on 1 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 consumer protection Act 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
The District Forum can award compensation up to rupees five lakhs, while the state commission
can award compensation up to rupees twenty lakhs. 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 13-11-1995, the Supreme Court of India in its judgment in civil appeal no
688 of 1993, in case of IMA vs VP Shanta 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.
They are at two levels namely Central and State protection councils
The objectives of this council shall be to promote and protect the rights of consumer such as,
The right to be protected against the marketing of goods and services which are
hazardous to life and property
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
The right to be assured , wherever possible, access to variety of goods and services at
competitive prices
The right to be heard and to be assured that the consumers interest will receive due
consideration at appropriate forums
The right to seek redressal against unfair trade practices
The minister incharge of consumer affairs in the state Government, who shall be its
Chairman and
Such number of other official or non official members representing such interest as may
be prescribed by state Government
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
consumer
DEFINITIONS
CONSUMER
Consumer means any person who hires any services for a consideration, and includes any
beneficiary of such services other than the person who hires the services, when such services are
availed of with the approval of the first mentioned person
A person who avails himself of the facility of a government hospital is not a consumer because
the facility offered in government hospitals is not service hired for a consideration. For
deficiency of service in government hospitals, the aggrieved person will have to file a claim in
civil court. If the conduct of the hospital doctor amounts to criminal negligence, the patient can
cause to prosecute the doctor in criminal court.
COMPLAINT
The goods bought by him or agreed to be bought by him suffer from one or more defects
An unfair trade practice or restrictive practice has been adopted by any trade
DEFECT
Means any fault , imperfection or short comings in the quality, potency, purity or
standard which is required to be maintained by or under any contract or as is claimed by the
trader in any manner whatsoever in relation to goods.
DEFECIENCY
SERVICE
Service means service of any description but excludes free service and personal service.
Treatment in a hospital (excluding government hospitals) on payment amounts to hiring of
service for a consideration. Therefore, a complaint would lie if there is deficiency in service
rendered by a member of the medical profession
TIME LIMITATION
A claim for compensation under CPA must be filed at a Forum within three years of the
subject matter of the complaint (e.g.; death) having arisen
If an amendment to the act, presently under consideration of the government is passed, this
period is likely to be raised to one year
At the district forum, a case has to be heard within three months of being filed
The health care 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
health care 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 patients, care-
givers, and care-giving 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
1960‘s 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.
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:
Providing accurate information about present illness and past medical history and wishes
for your medical care.
Seeking clarification when necessary to fully understand health problems and the
proposed plan of care.
Following through on agreed plan of care.
Considering and respecting the rights of others.
Being courteous.
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.
Following visitation policies of University Hospital.
RESPONSIBILITIES AND ACCOUNTABILITY
Introduction
What makes one employee look forward to taking on more responsibility and accountability
while another one blames to avoid any responsibility? Is it all based solely on the employee, or
does management play a role in creating an environment that fosters accountability and
responsibility?
Tool 1: How to Hold People Responsible and Accountable Using the RACI Chart
The RACI chart is designed to help people define who is Responsible, Accountable,
Consulted, and Informed for the various tasks or decisions required either by individuals or
teams. By completing the RACI, the manager or project leader clarifies what is expected and by
whom.
Responsible
The person or position required to complete a task. Each task is required to have a responsible
person or position assigned to it. Multiple people or positions can be assigned responsibility for
completing a task.
Accountable
The person or position accountable for a task is responsible for insuring that it is completed
on-time and in a manner which meets all expectations for it. The Accountable (A) person or
position does not have to physically do the task. Accountability should be focused on the
"Responsible" person whenever possible. Accountability must be assigned to each task.
Consulted
The person or position assigned consulting status for a task is required to be consulted with by
the Responsible (R) person or party before performing a task. A task with a consulting position
assigned to it must be consulted with before the task is performed. Because of the delay caused
by consultations, their use should be minimized. The responsible party should be empowered to
do the required task with very few exceptions.
Informed
The person or position assigned informed status for a task is required to be informed that a
task has been completed. The person or position with the "I" can be informed before or after the
fact. The Informed (I) person or position is not being informed for permission or approval.
The RACI chart should initially be completed by the manager or sponsor of a team and then
shared with employees or team members. The RACI is a living document that changes over time
as people become more and more accountable for their results. In a team environment, the RACI
is typically reviewed at the same time the team charter is being updated with new goals.
The Situational Leadership Model suggests that employees develop over a long period of time
by building on two components: the competence (skill and ability) and the commitment (desire
and motivation) to do the task. According to Blanchard, employees typically fall into one of
these four categories:
Having examined the four developmental categories, it's easy to see that it doesn't make sense to
lead, manage, supervise or coach these four types of employees in the same way. Each
developmental level needs a different leadership approach to encourage responsibility and
accountability. If we empower the D1, the employee will get completely lost, without a clue
about what work to do or how to do it. If we direct the D4, we will be micromanaging a
competent employee and, as a result, completely discourage any creativity or initiative.
Instead, Situational Leadership suggests that there are four corresponding styles of leadership
that must occur to drive accountability and responsibility. Leadership is based on the degrees of
Directive behavior (telling and showing people what to do and providing frequent feedback) and
the degree of Supportive behavior (praising, listening, encouraging and involving); the S1-S4
corresponds to the D1-D4:
Many managers are very reluctant to praise positive behavior for fear it will go to the
employee's head and correct problem behavior for fear of conflicts. As a result, the manager
focuses on setting goals, crafting mission and vision statements, and completing job descriptions
as a way to get correct behavior. These items are what are called "antecedents." They come
before the desired behavior. Aubrey Daniels, through his research in performance management,
found that antecedents only cause behavior to occur once or twice. Furthermore, he discovered
that it is only the consistent pairing of antecedents with consequences that drive behavior change
and accountability.
Consequences are defined as the natural outcomes that "move" or "stop" behavior.
Positive reinforcement
An individual gets what he/she wants. Not that the individual gets what we think they want
(e.g., praise, a luncheon, a movie ticket). For positive reinforcement to work it must be personal;
in other words, what motivates you will not necessarily motivate me. When the employee is
given "what he/she wants," it will build commitment and from commitment comes
accountability. Timing is critically important here as a long delay between behavior and
reinforcement will make the reinforcement meaningless.
Negative reinforcement
An employee avoids what they don't want. The most common form of negative reinforcement
is to introduce fear into the environment. "Better get that report that John wants on his desk by 4
or he won't be happy." The employee "moves" his/her behavior in order to avoid the anticipated
wrath of John. These fear messages can be very subtle - body language in a meeting, how a
report is placed in an in-box, reading between the lines of emails, not returning phone messages.
It's important to realize that fear will cause behavior to move (in order to avoid the projected
consequences), however, the focus is on compliance, not commitment. The individual performs
the minimums to avoid punishment.
The definitions here are very important because positive reinforcement doesn't necessarily
mean praise or gifts or applause. The person must get something that they truly desire. For many
people, this could mean time with the manager to talk about personal growth, an afternoon off to
attend a child's soccer game, or being assigned to a prestigious project. Likewise, negative
reinforcement introduced an outcome that the person would like to avoid. Positive reinforcement
will build commitment; negative reinforcement will only build compliance -- both, however, will
move behavior. Positive reinforcement builds accountability; negative reinforcement builds
avoidance of accountability and a desire to "play it safe."
Omission
Here the employee "doesn't get something he/she wants" such as attention, recognition or
special privileges. Omission is often used effectively when someone is doing behaviors that
focus on getting attention or inappropriate recognition, such as clowning around, interrupting,
being aggressive or sarcastic, and lateness. By omitting reinforcement, the behavior stops
because the person was looking for attention and doesn't get it. The best example is of a two or
three-year old who has a tantrum in the store. If the mom or dad keeps telling the child to be
quiet and admonishing that he or she will go to the car, the child is getting lots of attention (albeit
scolding) and the behavior is being positive reinforced (I get what I want). If, on the other hand,
the parent walks away and omits reinforcement, the child will fuss for another minute or two and
the stop to go find the parent. Ironically, adults act the same way sometimes: those who seek
attention by complaining, blaming, requiring lots of reminders to get work in on time, lateness,
interrupting, etc.
Punishment
The employee "gets what he/she doesn't want." Punishment is based on getting something we
don't want. Typically, organizations use progressive discipline to administer punishment.
However, we could be much more creative with punishment than we typically are. There are
many things employees don't like to do (scribe notes, facilitate meetings, do paperwork,
monotonous tasks, make phone calls, even serve on a team). All of these, if applied as
punishment, would cause problem behavior to stop.
Accountability must never be used as a device for placing blame or designating a scapegoat.
Developing accountability does not mean relinquishing accountability on management's part. It
must be perceived as a partnership. In the beginning of a group's development, management
usually carries the lion's share of the accountability burden, absorbing the brunt of any
disappointments. However, as the group matures, members expect to be held more accountable
for their own results.
Accountability begins at home, working on the messages you send out to others. Do you
identify ways to hand off meaningful activities to employees using the RACI chart? Do you
know the developmental levels of your employees and actively work them around to D4s? Do
you appropriately use positive and negative reinforcement to "move" behavior and omission and
punishment to "stop" behavior? Would some "redirection" conversations help to get a few people
back on track?
A Basic Framework
Several people in the NGO world have produced simple accountability frameworks.]For most
NGOs, only a small part of this accountability is legally required but increasingly the bulk of it is
more professionally, commercially, politically and morally demanded. Although the
predominant metaphor of accountability is financial, the actual demands of NGO accountability
today are much wider than a financial procedure that ensures that figures tally. Accountability is
much more about reporting on relationships, intent, objectives, method and impact. As such, it
deals in information which is quantitative and qualitative, hard and soft, empirical and
speculative. It records facts and makes judgements. Also, current orthodoxy in accountability is
as keen to ‗embrace failure‘ and so learn from it, as it would be to celebrate success and repeat
it. The simple frameworks to date might be summarised as having four main dimensions to
them.
An accountability process should start by identifying the rights involved in any NGO
programme, the relevant rights-holders and duty-bearers related to that right and the content of
the duty in the situation. From this rights-duties analysis, an NGO can then identify its own
specific duty and set out to account for it, while making clear the responsibilities of others. It
can then account for what it does by being able to tell as true a story as possible about the piece
of work that it did in a given situation. This story will involve an angle on all the different
people involved, their experience of the work, the relationships that emerged, the quality and
standards expected, the money that was spent, the things that it was spent on. From these
perspectives, it should then be able to report on the overall impact that this combination of
people, relationships, money, things and time had on the rights concerned.
Accountability to Whom?
In any piece of work, an NGO will need to account to different groups of people as
stakeholders. These will be the targeted rights-holders, the various duty-bearers and those
secondary and tertiary stakeholders beyond the primary stakeholders who operate as interested or
critical observers.
Accountability How?
Different stakeholders will require accounting to in different ways. Some people will require
figures alone. Others will require figures and impact. Some will be literate, others will
not. Some will want to know a lot of detail. Others will want to know the main points. So
accountability will require diverse media. Accountability processes must also involve key
stakeholders through representative meetings, research, representative assemblies or voting
systems. But virtues common to all NGO accountability mechanisms must be veracity and
transparency. What an NGO is saying about itself, or what it reports others as saying about it,
must be reasonably true, easily available and accessible to all.
Accountability to Improve
NGO accountability mechanisms must show clearly how the agency is responding to what it
has learnt and what its stakeholders are telling it. The mechanisms chosen must demand and
show responsiveness by informing people about, and involving people in, new action taken.
The concept of responsibility
• Causal Responsibility
• Liability-Responsibility
• Role-Responsibility
• Moral-Responsibility
Causal Responsibility
―The operator was responsible for turning off the control switch‖
But for the occurrence of X, Y would not have happened For Example: But for the
operator turning the switch, the control would not have went off‖
Liability-Responsibility
Liability for one‘s actions means that one can rightly be made to pay for the adverse
effects of ones actions on others
Automobile liability insurance is intended to cover the costs of damage to other persons
or property
We are usually liable for such payments as long as we are causally responsible, even if
our actions were unintentional
Liability, does not necessarily involve moral responsibility for the action
Part of the debate about legal liability concerns where the line should be drawn when
assigning strict liability
Role-Responsibility
Moral-Responsibility
Moral Responsibility: Accountability for the actions one performs and the consequences
they bring about, for which a moral agent could be justly punished or rewarded. It is
commonly held to require the agent's freedom to have done otherwise (autonomy).
Accountability
Responsibility and blameworthiness are only a part of what is covered when we apply the
robust and intuitive notion of accountability
When we say someone is accountable for a harm, we may also mean that he or she is
liable to punishment (e.g., must pay a fine, be censured by a professional organization,
go to jail), or is liable to compensate a victim (usually by paying damages).
In most actual cases these different strands of responsibility, censure, and compensation
converge because those who are to blame for harms are usually those who must ―pay‖ in
some way or other for them.
Accountability as a tracing too that allows us, a posteriori, to identify the people involved
in accidents and damage-inducing errors, punish the responsible if necessary and
compensate the victims if possible
A Typology of Moral Accountability
Malice: to set out on a course of action with the deliberate aim of imposing harm or risks
to people
Recklessness: to act knowing that it will cause harm or risk, but not taking this properly
into account
Negligence: the failure to exercise in the given circumstances that degree of care for the
safety of others which a reasonable person would exercise under the same or similar
circumstances
Incompetence: not qualified or suited for a purpose; showing lack of skill or aptitude; "a
bungling workman"; "did a clumsy job"; "his fumbling attempt to put up a shelf"
Due Diligence: the exercise in the given circumstances that degree of care for the safety
of others which a reasonable person would exercise under the same or similar
circumstances
Dutiful: to know what the right thing to do is and to do it regardless of how it effects you
1. Self-Interest
2. Fear
3. Self-Deception
4. Ignorance
5. Egocentrism
6. Narrowness of Vision
7. Uncritical Acceptance of Authority
8. Groupthink
Responsibility and Accountability for special individual & group.
1. Introduction
The Occupational Safety and Health Policy, approved by the Vice-Chancellor, commits the
University to ensuring a safe and healthy workplace for staff, students, contractors and visitors.
This policy provides further information on the responsibilities and accountabilities for such.
To effectively implement this policy, staff at all levels are required to be made aware of their
responsibilities and also held accountable for their actions or inactions. This requires the ongoing
incorporation of occupational safety and health (OSH) principles into work practices, the
ongoing commitment of resources to OSH and communications between all levels of staff and
others.
All staff and students are responsible for their own safety and health and for that of others
whose activities they may influence or control. The degree of responsibility a person has will
depend on his or her level of influence or control. This concept is recognised in law.
2. All Managers
The following responsibilities are established in law and are the general responsibility of all
management staff. In addition to the general duties, specific responsibilities also apply.
It is management‘s responsibility to ensure that those issues that they cannot directly control
are passed onto the relevant person or persons.
All managers shall, as far as it is practicable, provide and maintain a working environment in
which staff, students and others are not exposed to hazards and shall
Provide and maintain workplaces, plant and systems of work such that as far as
practicable, staff, students, contractors and others are not exposed to hazards
Provide such information, instruction, training and supervision of staff and students as is
necessary to enable them to perform their work in such a manner that they are not
exposed to hazards
Consult and co-operate with safety and health representatives, employees and others at
the workplace regarding safety and health issues
Where it is not practicable to avoid the presence of hazards at the workplace, provide
staff and students with such adequate personal protective clothing and equipment as is
practicable to protect them against those hazards, without any cost to the staff and
student (as appropriate)
3. Deans, Heads of Schools, Directors of Centres / Sections
In addition to the general responsibility placed on all managers, Deans, Heads of Schools,
Directors of Centres / Sections are also responsible for the following within their work areas
4. Safety Committees
5. Supervisors
Supervisors are those who have responsibility for the control of other persons within a work
area or part of a work area of a Faculty/School/Centre/Section. In addition to the general
responsibilities, supervisors are also responsible for
Ensuring that all staff supervised within their area are aware of their responsibility to
work and act safely
Conducting regular safety inspections
Conducting and reporting incidents, injuries or near miss reports and/or investigations
and ensuring corrective action is taken as necessary
Making training recommendations, as they see necessary, to
the faculty/school/centre/section heads
Ensuring the proper induction of new staff, following university guidelines
Cooperating in the rehabilitation of injured employees
Cooperating in the implementation and administration of the university safety and
health policies, procedures and guidelines
All employees and students are responsible for working and acting safely. Specific
responsibilities include
Taking reasonable care of their safety and health and that of co-workers, students and
visitors
Cooperating with the implementation and administration of university safety
policies, procedures and guidelines
Observing all instructions and rules issued to protect their safety and health and that of
others
Using plant and equipment as instructed by their supervisor
Making proper use of all safeguards, safety devices, personal protective equipment
and other appliances for safety purposes
Using protective equipment and wearing personal protective clothing as instructed
7. Safety and Health Representatives
The functions of a safety and health representative are, in the interests of safety and health at the
workplace for which they are elected
The role of School Safety Officers is to assist Heads of Schools and Directors of Centres
/Sections and supervisors in fulfilling their safety and health related responsibilities. Specific
responsibilities include
Assisting with a management systems approach to safety and health within the School /
Centre /Section
Assisting with the appointment of safety personnel and ensuring they understand and
fulfil their responsibilities
Coordinating their activities with those of other safety personnel such as Safety and
Health Representatives, First Aid Officers, Building Wardens, Wardens and
designated School or Section Safety Officers (Biological, Chemical, Fieldwork,
Radiation)
Conducting or coordinating regular internal safety inspections
Discussing potentially hazardous processes and operations with staff, students and
visitors and obtaining their cooperation in reducing them as much as possible
Informing Heads of Schools and Directors of Centres/Sections in writing of remaining
hazards (responsibilities for carrying out risk assessments lies with the staff member
in control of the operation)
Familiarising themselves with any Statutory or University regulations, policies and
procedures which would normally be applicable and informing their Head of School
in writing in cases where this is not done
Periodically inspecting hazard, incident and injury reports, investigating
where appropriate, and taking appropriate action to achieve safe working and
prevent recurrences
Recommending to the Head of School any changes to avoid hazards
9. Wardens
The evacuation of buildings may be required in the event of fires, major spills, bomb threats or
earthquakes. Heads of School are primarily responsible for ensuring evacuation procedures are
developed and enforced within their work areas. Wardens are responsible for assisting in the
planning and the actual execution of building evacuations.
Wardens are required to be familiar with recognising and responding to alarms, ensuring the
building is evacuated, ensuring that all personal can be accounted for and for liasing with the
support services which are required to attend to the alarm. Each building should have a Building
Warden and a number of Wardens for areas within the building. It is essential that there be
deputy wardens to assist and in case of absences.
Nominated First Aid Officers have current Senior First Aid Certificates and have skills in
basic first aid as well as more complex life saving techniques such as expired air resuscitation
and cardio-pulmonary. First Aid Officers are required to be familiar with the specific hazards
and conditions of their workplace.
11. Contractors
Contractors includes principal contractors and their sub contractors, who may be engaged by
UWA Facilities Management, Faculties, Schools or Sections for construction, building and infra-
structure maintenance and repair, communication installations and deliveries on campus.
Contractors are required to comply with the UWA Contractor Safety and Health policy and are
responsible for:
Ensuring their staff are properly qualified and trained to safely undertake the work
Ensuring they and their staff are properly inducted to UWA specific standards
Submitting a completed Risk Management Checklist with proof of insurances
Submitting a Safety Management Plan for larger contract works
Obtaining permits to work as required prior to commencing any hazardous work such
as hot work, asbestos removal, demolition, confined spaces or electrical work.
12. Visitors
Visitors are responsible for cooperating with University safety and health requirements and
not interfering with any aspects of the safety and health management systems on campus.
13. UWA Safety and Health
The role of UWA Safety and Health is to develop, advise on and assist in the implementation
of the University's Occupational Safety and Health policy. This is achieved through
The primary responsibility for safety and health for employees, students, contractors and visitors
rests with the University's line management. UWA Safety and Health provides corporate services
for Faculties, Schools, Centres and Sections to assist them in complying with legislation
requirements and best safety practices. Services that are provided include
UWA Safety and Health provides the executive support for the University's central safety
committees which have been set up under legislation or similar obligations. The Office is
responsible to the Director, Human Resources.
Facilities Management Senior Managers in Planning and Design and Operations and
Maintenance are responsible for ensuring all University building structures and infra-structure
services and equipment comply with all statutory regulations,
Australian Standards and Codes of Practice requirements for OSH, environment, public health,
Commonwealth Gene Technology legislation and local government authorities.
The Security and Parking Office‘s role is to monitor and assist with the personal safety of
staff, students and visitors whilst on campus and to provide services to protect personal security
such as night transport, security officers and barriers. They are also responsible for
Providing a first aid response service to the campus
Coordinating the emergency response to fires, bomb threats, explosions, gas leaks,
storms and other dangerous incidents
Determining parking policy on campus including placement of barriers and signs in
shared pedestrian/vehicle zones.
The University Safety Committee comprises of elected Safety and Health Representatives
and representatives from University management. The purpose of the committee is to provide a
forum for safety and health issues to be discussed and to make recommendations at a senior
level.
Any misuses or interference with safety equipment or measures put in place to protect the
safety and health of staff, students and others will not be tolerated, and those identified as
misusing or interfering with safety equipment or measures will be dealt with as a breach of
conduct or discipline
INTRODUCTION
Hospital infection is also called Nosocomial infection.It is the single largest factor that
adversely affects both the patient and the hospital.The English word Nosocomial is derived from
the Greek NOSOKOMEION meaning ―hospital‖. Nosocomial infection is that which develops in
the patients after more than 48 hours of hospitalization. Bacterial infections, which appear within
first 48 hours of admission, are considered as community acquired.
DEFINITION OF INFECTION:
Once the infectious agent enters the host it begins to proliferate and reacts with the
defense mechanisms of the body producing infection symptoms and signs: pain, swelling,
redness, functional disorders, rise in temperature and pulse rate and leucocytosis
PRINCIPLES
CHAIN OF INFECTION
Breaking the chain of infection occurs by altering the interactive process of agent, host, and
environment, as shown
Breaking the Chain of Infection
Nurses focus on breaking the chain of infection by applying proper infection control practices to
interrupt the mode of transmission. The chain of infection can also be broken by interrupting or
blocking the agent, portal of exit, or portal of entry or by destroying the agent or decreasing the
host‘s susceptibility. Refer to Figure 31-3, which shows preventive measures that break the chain
of infection.
Modes of Transmission
The mode of transmission is the process that bridges the gap between the portal of exit
of the biological agent from the reservoir or source and the portal of entry of the susceptible
―new‖ host. Most biological agents have a primary mode of transmission; however, some
microorganisms may be transmitted by more than one mode. Almost anything in the
environment can become a potential means of transmitting infection, depending on the agent.
The most important and frequent mode of transmission is contact transmission, which involves
the direct physical transfer of an agent from an infected person to a host through direct contact
with a contaminated object or close contact with contaminated secretions. Sexually transmitted
diseases are examples of diseases spread by direct contact.
Airborne transmission occurs when a susceptible host contacts droplet nuclei or dust particles
that are suspended in the air. Vehicle and vectorborne transmission are indirect modes of
transmission, because transmission occurs by an intermediate source. Vehicle transmission
occurs when an agent is transferred to a susceptible host by contaminated inanimate objects such
as water, food, milk, drugs, and blood. Vectorborne transmission occurs when an agent is
transferred to a susceptible host by animate means such as mosquitoes, fleas, ticks, lice,and other
animals.
SURGICAL ASEPSIS
Korsolex:- it contains formaldehyde and glutaraldehyde. One part of the concentrate is mixed
with 9 parts of water to prepare 10% solution. For disinfection the solution should remain in
contact for 20 minutes and for sterilization for 4 hours.
Savlon: - it is a mixture of cetrimide, chlorhexidine gluconate and isopropyle alcohol. Use 1:100
solution for equipments and furniture and 1:30 solution for treating dirty wounds and
disinfecting catheters or thermometers.
Betadine: - it is 7.5% solution of povidone iodine and used for preparation of skin and
disinfection of wounds. For skin preparation, leave it to dry for 60 seconds before undertaking
the procedure.
I. Fumigation:-
In centers where excellent housekeeping and aseptic routines are maintained, fumigation does
not provide any additional benefit. Doors, windows, walls and floors are scrubbed thoroughly
with soap and water. The oxygen and central suction lines are shut off. The fans and air
conditioners are put off. The ventilator outlets, air conditioner vents and gaps in doors and
windows should be sealed airtight. For effective fumigation 30 ml of formalin
(40%formaldehyde) in 90ml water is needed for a room of 30 cubic metres (1000 cubic feet)
capacity. Formalin can be sprayed with the help of a vaporizer (Oticare) for 6 hours. After
fumigation, the doors and windows are kept open till all the formalin fumes are allowed to
escape. The left over formalin should be removed and 4-6 ounces of ammonium hydroxide is
poured in the vaporizer which is plugged on for faster elimination of formalin fumes. When
vaporizer is not available, formalin can be boiled or treated with 250 gm potassium
permanganate and allowed to evaporate for 12 hours. Formalin should not be poured over the
potassium permanganate as this may lead to explosion.
II. Isolation:-
Isolation technique is intended to confine the microorganisms within a given and recognized
area. There are number of isolation techniques and precautions used to prevent the spread of
infection.
Respiratory isolation
Respiratory isolation is indicated in situations where the pathogens are spread on droplets from
the respiratory tract. In this type of isolation, masks are generally worn by the nurses. Gowns are
also worn when caring for small infants because of the possibility of drooling by the infants.
When it is possible clients are taught to cover their noses and mouths with several layers of
tissue paper or handkerchief. If tissue paper is used they should be disposed properly. Restrict
the number of visitors. Precautions must be taken while collecting the sputum specimens from
the clients. The nurse suffering from respiratory diseases should not attend to the client.
Enteric isolation
Enteric isolation is indicated when the pathogens are admitted in the faeces. For this type of
isolation it is not necessary to wear a mask, but it is recommended that gloves and gowns be
worn while handing soiled articles.
Thorough hand washing should be emphasized both by the clients and nurses. The soiled articles
such as linen should be disinfected before it is sent to dhobi.
Wound and skin isolation
This type of isolation is for pathogens which are found in wounds and can be transmitted by the
contact with the wounds or by contact with the articles contaminated with the wound discharges.
Usually gowns and gloves are worn in this type of isolation. Important point to note is the safe
disposal of dressings and discharges from the wounds and the disinfection of articles. Strict
isolation techniques should be followed while caring for clients with abscesses, boils, infected
burns, gas gangrene anthrax, rabies, tetanus, veneral diseases, scabies etc. all the articles used for
these clients should be kept separate.
Great care should be taken by the nurses to prevent the cuts or abrasions on their hands. Frequent
and thorough washing reduces the chances of infection.
Blood isolation
This type of isolation is intended to prevent transmission of pathogens that are found in the
blood. Therefore, any equipment that comes in contact with the client‘s blood should be carefully
disinfected before touching another object or person. Use of mosquito nets are also emphasized
to prevent this type of infection.
III) BARRIER PROTECTION: Materials that protect the health care worker from infection.
Gloves
Mask
Apron
Eyewear
Footwear
Gloves: All skin defects must be covered with water proof dressing
Use well fitting, disposable / autoclaved
Change if visibly contaminated / breached
Remove before handling telephones, performing office work,
leaving workplace
Mask & Goggles: Facial protection – When splashing or spraying of blood / blood fluids
expected
Apron: Gowns/Special uniforms – in high risk areas
Foot wear: Feet should be well covered on all sides, especially while working in areas
where spillage of infectious material is common, like operation theatres, labour room,
laboratories. Soft shoes are preferred to sandals.
IV.HAND WASHING: Protects both health personnels and patients
A. Social handwashing – Done for simple cleaning of hands with soap and water.
Reduces the transient flora. A modification is careful handwashing which is done
immediately after touching a patient or after contamination. All areas of the hand upto
the wrist are cleaned by rubbing for at least 2 minutes.
B. Hygienic hand disinfection – After social hand washing, to get a more sustained
effect, especially while caring for infected patients in special care units like ICUs and
neonatal units. 70% ethyl alcohol hand disinfectants may be rubbed thoroughly over the
hands. This effectively kills all transient flora, the action is fast and short-lived, hence
has to be repeated after touching each patient.
C. Surgical hand disinfection – Preoperative washing hands by surgeon. Done with
antibacterial soap e.g containing chlorhexidine or an iodophore, followed by
70%alcohol rub. Hands are scrubbed thoroughly for 5-10 minutes upto the elbows,
taking care to scrub nails and interdigital areas.
Cross infection refers to the transmission of a pathogenic organism from one person to
another. It is a common and important mode of infection with many varieties of organisms,
including streptococcal and other bacterial diseases, viral hepatitis A and some other fecal-oral
infections, such as scabies, fungus infections, pinworms, and roundworms. The preventive
measures include constant surveillance, maintenance of sanitary conditions, and prompt
intervention whenever an infection is detected. The best way to prevent cross infections is by
rigorous observance of personal hygiene at all times, and through the use of barrier nursing,
sanitary practices, and other pertinent procedures.
Hospital waste is ―Any waste which is generated in the diagnosis, treatment or immunization of
human beings or animals or in research‖ in a hospital.
Colour codes and type of containers used for disposal of biomedical waste are as follows:
Colour
Type of Container Waste Category Treatment options
coding
Autoclave/ Microwave/
Blue/
Plastic bag, Puncture Waste sharps and solid waste Chemical Treatment
White/
proof container Destruction and
Transparent
Shredding
The main aim of the hospital infection programme is to lower the risk of an infection during the
period of hospitalization.
THREE ASPECTS :
BASIC ELEMENTS:
Providing a system of identification and reporting of infections and providing a system for
keeping records of infections
Providing for good hospital hygiene ,aseptic technique and sterilization and disinfection
practices.
Providing for personnel orientation and continuing education programme in infection
prevention and control .
Providing for co-ordination with all departments and with medical/ nursing audit
committee in quality assurance.
Responsibility of hospital administrator/head of health care facility
The hospital administrator/head of hospital should:
1. Chairperson- He is the head of the infection control team. The designation of chairperson
is he/she should be registered doctor may be microbiologist.
2. Coordinator- He is the member of infection control team. The designation of the
coordinator should be registered doctor, HOD of surgery and medicine preferably may be
HOD of other department.
3. Surviellent- He/she may be the Nursing superintendent of that hospital
Functions
1. Secretary of Infection Control Committee and responsible for recording minutes and
arranging meetings;
2. Consultant member of ICC and leader of ICT
3. Identification and reporting of pathogens and their antibiotic sensitivity;
4. Regular analysis and dissemination of antibiotic resistance data, emerging pathogens and
unusual laboratory findings;
5. Initiating surveillance of hospital infections and detection of outbreaks;
6. Investigation of outbreaks, and
7. Training and education in infection control procedures and practice.
The ICD must be a registered medical practitioner. In the majority of countries, the
role is performed either by a medical microbiologist or hospital epidemiologist. Hospital
consultants in other disciplines (e.g. infectious diseases) may be appointed. Irrespective of their
professional background, the ICD should have knowledge and experience in asepsis, hospital
epidemiology, infectious disease, microbiology, sterilization and disinfection, and surveillance. It
is recommended that one ICD is required for every 1,000 beds.
Serves as a specialist advisor and takes a leading role in the effective functioning of the ICT.
Should be an active member of the hospital Infection Control Committee (ICC) and may act
as its Chairman.
Assists the hospital ICC in drawing up annual plans, policies and long-term programmes for
the prevention of hospital infection.
Advises the chief executive/hospital administrator directly on all aspects of infection control
in the hospital and on the implementation of agreed policies.
Participates in the preparation of tender documents for the support services and advises on
infection control aspects.
5. Infection Control Nurse (ICN)
The day-to-day activities of surveillance can be best handled by a sufficiently senior and
experienced full-time nurse, with special training in hospital infection control activities. In very
large hospitals, there should be atleast one infection control nurse for every 250 beds.
She directly reports to the infection control officer (ICO) and briefs him every day on
occurrence of a case and related matters.
Early and complete reporting is the sheet anchor of any hospital infection control programme.
Therefore, the infection control sister must be authorized to report any actual or suspected
infection immediately, to initiate a culture and sensitivity test, institute appropriate isolation
procedure if it is so requires, and notify the physician incharge of the patient.
She should also have direct access to the hospital administrator on matters of serious breaches
of control practices discovered by her.
1. People
It is the people in hospitals rather than the physical environment which constitutes the
reservoir of infection.Nurses should follow hand washing techniques properly and they
should also guide other staffs, students to follow the procedure of hand washing which
includes social handwashing, followed by procedural hand wash. All the steps of hand
washing should be followed properly. Following the habit of procedural hand wash after
touching each child will helps to prevent cross infection. Always use liquid soap instead
of solid soap for hand washing
2. Aseptic Techniques
There must be a system for keeping the contaminated pieces of linen, sputum cups,
bedpans, urinals, and similar items separately to minimize chances of getting mixed up
with clean items.
4. Isolation policy
7. Sterilization Practices
An efficient CSSD ensures supply of properly sterilized articles to all users in the
hospital. Each sterilisation must be monitored through the use of heat- sensitive tapes. All
steam and ethylene oxide sterilizers should be checked at least once each week with a
suitable live spore preparation by the laboratory. Instruments which come in contact with
mucous membranes but are disinfected rather than sterilized before use, such as
endoscopes, and anesthesia equipment may be bacteriologically sampled on a spot check
basis to ensure adequacy of disinfection.
8. Prevention of Injuries.
After using the disposable needles, never recap them to potential risk of
injury they should be disposed off uncapped.
Injection files and cotton swabs should be used for breaking ampoules.
Scissors and blades should be handled with extreme care.
Needles should never be left on the bed, table, chair, nurse‘s station etc.
Heavy duty gloves should be used while handling and washing sharp
instruments and glass ware.
Don‘t panic.
Don‘t squeeze the injured site
Wash with soap and water immediately.
Report to the casualty and provide proper history of exposure for
immunization.
(Basic regimen)
(Expanded regimen)
If vaccinated no problem.
If not vaccinated previously take Immunoglobulin‘s immediately then
take hepatitis vaccine regimen for 6 months.
9. Outpatient Department
In outpatient department separate arrangements for receiving and examining patients
suspected of having significant acute communicable condition should be made.
Recommended Standards
This set of standards, adapted mainly from ―Guidelines for Perinatal Care, 4th Edition by the
American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists‖, focuses on the following areas:-
I. Physical Setup
I. Physical Setup
(with additional reference to ―Recommended Standards for Newborn ICU Design‖ by The
Committee to Establish Recommended Standards for Newborn ICU Design1
Space
1. Each infant care space in the Neonatal Intensive Care Unit shall preferably contain a minimum
of 11.2 square meters (120 square feet), excluding sinks and aisles
2. There shall be an aisle adjacent to each infant care space with a minimum width of 0.9 meters
(3 feet).
Ventilation.
1. A minimum of 6 air changes per hour is required for the NICU, with a minimum of 2 changes
being outside air.
2. The ventilation pattern shall inhibit particulate matter from moving freely in the space and
intake and exhaust vents shall be situated as to minimize drafts on or near the infant beds.
3. Ventilation air delivered to the NICU shall be filtered with at least 90 % efficiency.
4. Fresh air intake shall be located at least 7.6 meters (25 feet) from exhaust outlets of ventilating
systems, combustion equipment stacks, medical/surgical vacuum systems, plumbing vents, or
areas that may collect vehicular exhausts or other noxious fumes. [IB]
Scrub Areas
1. In the NICU, there should be at least 1 hands-free handwashing sink for 4 beds.
2. In single bedroom, a hands-free handwashing sink shall be provided within each infant care
room. [II]
3. Hand washing facilities that can be used by children and people in wheelchairs shall
be available in the NICU
4. Sinks for hand washing should not be built into counters used for other purposes
5. Sink location, construction material and related hardware (paper towel, covered trash
receptacle, and soap dispensers) should be chosen with durability, ease of operation and
noise control in mind
6. Minimum dimensions for a hand washing sink are 61 cm wide X 41 cm front to back X 25 cm
deep (24 in. X 16 in. X 10 in.) From the bottom of the sink to the top of its rim; so as to
minimize splashing.
1. Isolation rooms adequately designed to care for airborne infection should be available in any
hospital with an NICU. In most cases, this is ideally situated within the NICU; but, in some
circumstances, utilization of an isolation room elsewhere in the hospital would be suitable.
2. An area for handwashing, gowning, and storage of clean and soiled materials shall be
provided near the entrance to the room
3. Isolation rooms should have a minimum of 13.94 sq metre (150 square feet) of clear space,
excluding the entry work area. Single and multibedded configurations are appropriate based
on use.
4. Ventilation systems for isolation room(s) shall be engineered to have negative air
pressure with air 100% exhausted to the outside. Air exhaust to outside the building do not
need to be filtered but the exhaust vent needs to be away from air-intake vents, persons or
animals.
7. Isolation rooms should have observation windows with blinds for privacy. Choice and
placement of blinds, windows, and other structural items should allow for ease of operation
and cleaning.
II. Administrative arrangement
1. With appropriate resources allocated from the hospital/ HAHO, the infection control
committee of each hospital should work with perinatal care personnel to establish workable
definitions of nosocomial infection for
surveillance purposes, with particular reference to the definitions/ guidelines set out by this
Working Group.
2. The definition selected should be applied consistently to allow uniform reporting and analysis
of nosocomial infections
3. With appropriate resources from the Hospital/ HAHO, NICU personnel should cooperate with
hospital infection control personnel in conducting and reviewing the results of surveillance
programs for nosocomial infections in a confidential manner.
Staff Health
1. Health care workers should be immune to rubella, measles and chicken pox
Handwashing
1. Medical and hospital personnel must follow careful hand-washing techniques to minimize
transmission of disease
2. Personnel should remove rings, watches, and bracelets before washing their hands and
entering the neonatal nursery.
3. Fingernails should be trimmed short and no false fingernails or nail polish should be
permitted.
4. Antiseptic preparations (e.g. chlorhexidine 4 %) should be used for scrubbing before entering
the nursery, before providing care for neonates, before performing invasive procedures, and after
providing care for neonates
5. Before handling neonates for the first time, personnel should scrub their hands and arms to a
point above the elbow thoroughly with an antiseptic soap. After vigorous washing, the hands
should be rinsed thoroughly and dried with paper towels.
6. A 10-second wash without a brush, but with soap and vigorous rubbing, followed by thorough
rinsing under a stream of water, is required before and after handling each neonate and after
touching objects or surfaces likely to be contaminated with virulent microorganisms or hospital
pathogens.
7. Handwashing is necessary even when gloves have been worn in direct contact with the infant.
Handwashing should immediately follow removal of gloves, before touching another infant.
8. Alcohol-containing foams kill bacteria satisfactorily when applied to clean hands and with
sufficient contact (in accordance with manufacturers‘ recommendations). They can be used in
areas where no sinks are available or during emergency. [III] But they are not sufficient in
cleaning physically soiled hands, because transient organisms are not removed.
Sibling Visits
1. Guidelines for visits should be established to maximize opportunities for visiting and to
minimize the risks of nosocomial spread of pathogens brought into the unit by these young
visitors.
2. No child with fever or symptoms of an acute illness, including an upper respiratory tract
infection, gastroenteritis, or dermatitis, should be allowed to visit. Siblings who recently have
been exposed to a known communicable disease and are susceptible should not be allowed to
visit. These interviews should be documented in the patient‘s record, and approval for each
sibling visit should be noted
Dress Code
1. Dress codes should be established for regular and part-time personnel who enter the neonatal
unit
2. Sterile long-sleeved gowns to be worn by all personnel who have direct contact with the sterile
field during surgical and invasive procedures in the neonatal unit.
3. Gloves are to be worn when handling the neonate until blood and amniotic fluid have been
removed from the skin.
4. When a neonate is held outside the bassinet by nursing or other neonatal intensive care unit
personnel, a gown should be worn over the clothing and either discarded after use or maintained
for use exclusively in the care of that neonate. If one gown is used for each neonate, the gowns
should be changed regularly
5. Caps, masks and sterile gloves are to be used during surgical and invasive procedures.
General Housekeeping
1. Cleaning should be performed in the following order – patient areas, accessory areas and then
adjacent halls
2. In the cleaning procedure, dust should not be dispersed into the air.
3. Standard types of portable vacuum cleaners should not be used in the neonatal ICU or SCBU
because particulate matter and microbial contamination in the room may be disturbed and
distributed by the exhaust jet. Vacuum cleaners that discharge outside the patient care area (ie,
central vacuum cleaning systems or portable vacuums) should be used so that only the cleaning
wand, floor tool, and high-efficiency, particulate air filtered vacuum hose are brought into the
patient care area.
4. Once dust has been removed, scrubbing with a mop and a disinfectant/detergent solution
should be performed. Mop heads should be machine laundered and thoroughly dried daily.
5. Cabinet counters, work surfaces, and similar horizontal areas should be cleaned once a day
and between patient use with a disinfectant/detergent and clean cloths; as they may be subject to
heavy contamination during routine use. Friction cleaning is important to ensure physical
removal of dirt and contaminating microorganisms.
6. Surfaces that are contaminated by patient specimens or accidental spills should be carefully
cleaned and disinfected.
7. Walls, windows, storage shelves and similar non-critical surfaces should be scrubbed
periodically with a disinfectant/detergent solution as part of the general housekeeping program.
1. When the incubators, open care units or bassinets are being cleaned and disinfected, all
detachable parts should be removed and scrubbed meticulously
2. If the incubator has a fan, it should be cleaned and disinfected; the manufacturer‘s instructions
should be followed to avoid equipment damage.
3. The air filter should be maintained as recommended by the manufacturer.
4. Mattresses should be replaced when the surface covering is broken, because such a break
precludes effective disinfection or sterilization
5. Portholes and porthole cuffs and sleeves are easily contaminated, often heavily; cuffs should
be replaced on a regular schedule or cleaned and
6. Incubators not in use should be thoroughly dried by running the incubator hot without water in
the reservoir for 24 hours after disinfection
7. Infants who remain in the nursery for an extended period should be transferred periodically to
a different, disinfected unit so that the originally occupied unit can be cleaned
Clean Linen
1. Procedures for laundering, making up packs and delivering linen to the nursery should be
established by the medical, nursing, laundry and administrative staffs of the hospital
2. Each delivery of clean linen should contain sufficient linen for at least one 8-hour shift
3. Linen should be cleaned and transported in covered carts or laundry bags to the nursery areas
4. No new garments or linen should be used for neonates without prior laundering.
Soiled Linen
1. An established procedure for the disposal of soiled linen should be strictly followed
2. Chutes for the transfer of soiled linen from patient care areas to the laundry are not acceptable
unless they are under negative air pressure.
4. Sealed bags of reusable, soiled nursery linens should be taken to the laundry at least twice
each day.
5. Impervious bags of soiled diapers (reusable or disposable) and other linen should be sealed
and removed from the nursery at least every 8 hours.
6. All personnel should be aware that handling dirty diapers with bare hands can result in heavy
contamination and transient colonization of the hands with microorganisms that cannot be easily
eliminated with hand-washing and can be readily transmitted to the next neonate for whom they
provide care.
Laundering:
2. To avoid the hazards associated with the use of such chemicals or enzymes in the hospital
laundry, the physician in charge should be aware of all agents in use and should be informed
before any changes are made in laundry chemicals or procedures. Caution should be exercised
when new laundry or cleaning agents are introduced into the nursery or when procedures are
changed.
Catheter-related sepsis
1. Meticulous attention should be given to aseptic insertion and maintenance of the cannula and
to aseptic techniques of fluid administration.
2. All parenteral nutrition fluids should be mixed in the pharmacy, under a laminar flow hood.
3. If bottles of lipid emulsions are kept in the neonatal unit refrigerator, care should be taken to
prevent contamination, as they are susceptible to contamination with a wide variety of bacteria
and fungi that can proliferate to high concentrations within hours. Open bottles must be
discarded no later than 24 hours after the seal has been broken.
I dear friends here I tried my best with the help of my friends to update
you regarding NURSING MANAGEMENT, I hope this book will definitely help you
to understand and make easier for your studies and prepare well for exams. Here I
tried to cover most of the topics, which is according to INDIAN NURSING
COUNCIL syllabus, which was revised on 2009. This is not an ultimate but I am
sure it fulfills and meets the criteria of syllabus, which makes easier instead of
struggling for the content. This may be just a gathering of content but there was a
hard work, commitment and dedication of all my friends to bring out this book. I’m
specially dedicating this book to my mom, Kalavathi Krishnamurthy, who is a great
inspire behind my every success.
Here I request the readers to feel free to write your valuable feedback or
suggestion to make this book more effective.
Thank you
With regards
Deepak.K
M.Sc. PSychiatric NURSing
Mobil no: 09739866870
deepakkala_2007@rediffmail.com