Administeration Notes

PADMASHREE INSTITUTE OF NURSING. M.Sc.
Nursing II years (2009-2011 batch)

PREPARED BY: ANOOP, CHETAN, DEEPAK, LINGARAJ, SARATH CHANDRAN, MITHUN
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

PADMASHREE INSTITUTE OF NURSING. M.Sc. Nursing II years (2009-2011 batch)
Dedicated to all
M.Sc. Nursing
students

From:
M.Sc. (Nursing) II year
Batch: 2009-2011

PADMASHREE INSTITUTE
OF NURSING
Forward
It gives me an immense happiness to forward this Text Book of Nursing Management
written by budding authors Mr.Annop, Mr. Chetan.M.R, Mr. Deepak.K, Mr. Sarath
Chandran, Mr.Mithun Kumar, Mr.Lingaraj.C.M, studying in Padmashree Institute of
Nursing, Bangalore, Karnataka.
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.
It is not an easy task to deliver such excellent knowledge information on nursing
management topics. It is the effort, dedication and commitment of Mr.Deepak.K who was
the backbone, pillars and implanted the seed to initiate, organized arrange systematically
the flow contents of Mr.Anoop, Mr. Chetan Kumar. C.M, Mr.Sarath Chandran,
Mr.Mithun Kumar, Mr.Lingaraj.C.M has joined their efforts with Mr.Deepak.K in
delievering the sweet essence on the units they selected and written in simple language.
I hope this book will be benefitted to Postgraduate nursing students to develop
understanding and apply the nursing management services in clinical setting and
educational institution too.
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.

Mr. Ellakuvana Bhaskara Raj.D
Associate Professor
HOD of Psychiatric Nursing Department
Padmashree Institute of Nursing
Kommagatta village, Bangalore-60

Acknowledgement
Service to mankind is service to GOD. We believe in invisible power which guided us
throughout our success.

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.
An evergreen unforgettable memory is friendship. We express our deep sense of gratitude
and heartfelt thanks to all my classmates who are the main inspiration behind this book.


UNIT I:

Introduction
Philosophy, purpose, elements, principles and scope of
Administration

Indian Constitution, Indian Administrative system vis a
vis health care delivery system: National, State and Local

Organization and functions of nursing services and
education at National, State , District and institutions:
Hospital and Community

Planning process: Five year plans, Various Committee
Reports on health, State and National Health policies,
national population policy, national policy on AYUSH and
plans,

UNIT I: INTRODUCTION:
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 is the organization and direction of human and material resources to achieve
desired ends - Pfiffner and presthus
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
Management is distinct process consisting of planning, organising, actuating, activating
and controlling, performed to determine and accomplish the objectives by the use of
people and resources. - George
Management and Administration:
These two words are slightly similar and can employ interchangeable.
Management refers to private sector. Whereas administration refers to public sector.
Management or Administration is the process for exceeding the goal expected."
- Derek French and Heather Saward.

Difference between administration and management
Basis of difference Administration Management
Nature of work It is concerned about the
determination of objectives
and major policies of an
organization
It puts into action the policies
and plans laid down by the
administration.
Type of function It is a determinative function It is an executive function
Scope It takes major decisions of an
enterprise as a whole
It takes decisions within the
framework set by the
administration.
Level of authority It is a top-level activity. It is a middle level activity
Nature of status It consists of owners who
invest capital in and receive
profits from an enterprise.
It is a group of managerial
personnel who use their
specialized knowledge to
fulfill the objectives of an
enterprise
Nature of usage It is popular with government,
military, educational, and
religious organizations.
It is used in business
enterprises.
Decision making Its decisions are influenced by
public opinion, government
policies, social, and religious
factors.
Its decisions are influenced by
the values, opinions, and
beliefs of the managers.
Main functions Planning and organizing
functions are involved in it.
Motivating and controlling
functions are involved in it.
Abilities It needs administrative rather
than technical abilities.
It requires technical activities
Managerial Concerns:
Efficiency - Doing things right Getting the most output for the least inputs
Effectiveness - Doing the right things Attaining organizational goals
Efficiency and Effectiveness in management

Managerial levels

Who are Managers?
Someone who coordinates and overseas the work of other people so that organizational goals are
accomplished.
First-line Managers
Individuals who manage the work of non-managerial employees.
Middle Managers
Individuals who manage the work of first-line managers.
Top Managers
Individuals who are responsible for making organization-wide decisions and establishing plans
and goals that affect the entire organization.
Functions:
Planning - Defining goals, establishing strategies to achieve goals, developing plans to
integrate and coordinate activities.
Organizing - Arranging and structuring work to accomplish organizational goals.
Leading - Working with and through people to accomplish goals.
Controlling - Monitoring, comparing, and correcting work.
Role:
Interpersonal roles - Figurehead, leader, liaison
Informational roles - Monitor, disseminator, Spokesperson
Decisional roles - Entrepreneur, Disturbance handler, resource allocator, negotiator
Skills:
Technical skills - Knowledge and proficiency in a specific field
Human skills - The ability to work well with other people
Conceptual skills - The ability to think and conceptualize about abstract and complex
situations concerning the organization
Skills Needed at Different Management Levels

Importance of management:
The Value of Studying Management:
- The universality of management
- Good management is needed in all organizations.
- The reality of work
- Employees either manage or are managed.
- Rewards and challenges of being a manager
- Management offers challenging, exciting and creative opportunities for meaningful and
fulfilling work.
- Successful managers receive significant monetary rewards for their efforts.
Universal Need for Management

PHILOSOPHIES OF ADMINISTRATION
Philosophy is based on the following key points: Administration believes in:
Cost effectiveness
Execution and control of work plans
Delegation of responsibility
Human relations and good morale
Effective communication
Flexibility in certain situation
PRINCIPLES OF ADMINISTRATION
Meaning of management principles: Management principles are statements of fundamental truth
which act as guidelines for taking managerial action.
Management principles are derived and developed in the following two steps.
(a) Deep Observations
(b) Repeated experiments
Henri Fayol (1841 - 1925): Graduated from the National School of Mines in Saint Etrenne in
1860
Fayols 14 principles of management
1. Division of Work. Specialization allows the individual to build up experience, and to
continuously improve his skills. Thereby he can be more productive. Small task, Competent,
Specialization, Efficiency, Effectiveness

2. Principle of Authority and Responsibility Authority means power to take decisions.
Responsibility means obligation to complete the job assigned

3. Principle of discipline: General rules and regulations for systematic working in an
organization.
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.
6. Subordination of individual interest to general interest: Subordination of individual
interest to general interest the interest of the organization must supersede the interest of the
individuals.
7. Principle of remuneration of persons: Employees must be paid fairly or adequately to give
them maximum satisfaction
8. Principle of centralization and decentralization: Centralization refers to concentration of
power in few hands. Decentralization means evenly distribution of power at every level.
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.
12. Stability of tenure of personnel: Stability of tenure of personnel No frequent termination or
transfer.
13. Principle of Initiative: Principle of Initiative Employees must be given opportunity to take
some initiative in making and executing a plan
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:

Five Elements: management roles and actions
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 command - Maintain the activity among the personnel.
To coordinate - Binding together, unifying and harmonizing all activity and effort.
To control -Seeing that everything occurs in conformity with established rule and
expressed command.
ELEMENTS OF ADMINISTRATION:
POSDCORB
Planning
Organizing
Staffing
Directing
Co-ordinating
Reporting
Budgeting

SCOPE OF ADMINISTRATION
Political: Functions of the administration includes the executive legislative relationship.
Defensive: It covers the hospital protective functions.
Economic: Concerns with the vast area of the health care activities.
Educational: Its involves educational administration in its broadest senses.
Legislative: It includes most not mealy delegated legislation, but the preparatory work
done by the administrative officials.
Financial: It includes the whole of financial, budget, inventory control managements.
Social: It includes the activities of the department s concerned with food, social factors.
Local: It concerned with the activities of the local bodies.
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.
Evolution of the Constitution
Acts of British Parliament before 1935
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.
Government of India Act 1935
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.
The Cabinet Mission Plan
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.
Indian Independence Act 1947
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.

Preamble
Part I - Union and its Territory
Part II - Citizenship.
Part III- Fundamental Rights
Part IV - Directive Principles and
Fundamental Duties.
Part V- The Union.
Part VI- The States.
Part XII - Finance, Property, Contracts and
Suits
Part XIII - Trade and Commerce within the
territory of India
Part XIV - Services Under the Union, the
States and Tribunals
Part XV - Elections
Part XVI - Special Provisions Relating to
certain Classes.
Part VII - States in the B part of
the First schedule (Repealed).
Part VIII - The Union Territories
Part IX - Panchayat system and
Municipalities.
Part X - The scheduled and Tribal
Areas
Part XI - Relations between the
Union and the States.
Part XVII - Languages
Part XVIII - Emergency Provisions
Part XIX - Miscellaneous
Part XX - Amendment of the Constitution
Part XXI - Temporary, Transitional and
Special Provisions
Part XXII - Short title, date of
commencement, Authoritative text in Hindi
and Repeals
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.
Changing the constitution
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 of laws

This section requires expansion.
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.
HEALTH CARE DELIVERY SYSTEM IN INDIA
Introduction
Health is the birth right of every individual. Today health is considered more than a basic
human right; it has become a matter of public concern, national priority and political action. Our
health system has traditionally been a disease-oriented system but the current trend is to
emphasize health and its promotion.
Selected health care definitions:
Health: According to WHO, health is defined as a dynamic state of complete physical,
mental and social well-being not merely an absence of disease or infirmity.
Health care services: It is defined as multitude of services rendered to individuals,
families or communities by the agents of the health services or professions for the
purpose of promoting, maintaining, monitoring or restoring health.
Definitions of health care delivery:
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)

2. It implies the organization, delivery staffing regulation and quality control.
J.C.Pak(2001)
Philosophy of Health Care Delivery System:
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:
1. Supports a coordinated, cohesive health-care delivery system.
2. Opposes the concept that fee-for-practice.
3. Supports the concept of prepaid group practice.
4. Supports the establishment of community based, community controlled health-care
system.
5. Urges an emphasis be placed on development of primary care
6. Emphasizes on quality assurance of the care
7. Supports health care as basic human right for all people.
8. Opposes the accrual of profits by health-care-related industries.
Functions of Health Care Delivery System:
1) To provide health services.
2) To raise and pool the resources accessible to pay for health care.
3) To generate human and physical sources that makes the delivery service possible.
4) To set and enforce rules of the game and provide strategic direction for all the different
players involved.
Characters of Health Care Delivery System:
1) Orientation toward health.
2) Population perspective.
3) Intensive use of information.
4) Focus on consumer.
5) Knowledge of treatment outcome.
6) Constrained resources.

HEALTH CARE DELIVERY SYSTEM IN INDIA
In India it is represented by five major sectors or agencies which differ from each other
by health technology applied and by the source of fund available. These are:
I. PUBLIC HEALTH SECTOR
A. Primary Health Care
Primary health centres.
Sub- centres.
B. Hospital/Health Centres
Community health centres.
Rural health centres.
District hospitals/health centre.
Specialist hospitals.
Teaching hospitals.
C. Health Insurance Schemes
Employees State Insurance.
Central Govt. Health Scheme.
D. Other Agencies
Defence services.
Railways.
II. PRIVATE SECTOR
A. Private hospitals, polyclinics, nursing homes and dispensaries.
B. General practitioners and clinics.
III. INDIGENOUS SYSTEMS OF MEDICINE
Ayurveda
Sidda
Unani
Homeopathy
Naturopathy
Yoga
Unregistered practioners.

IV. VOLUNTARY HEALTH AGENCIES
V. NATIONAL HEALTH PROGRAMMES
ORGANIZATION AND ADMINISTRATION OF HEALTH SERVICES IN INDIA AT
DIFFERENT LEVELS.
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
1. Central level. 2. State level 3. District level

Synoptic view of the health system in India
1/80,000 1,20,000
1/30,000
1/3,000 5,000
1/1,000
Community Health
Centres
Sub-district/Taluka
hospital
PHC
Sub-centres
Health worker (M & F)
Village health
guide, trained dai
District health organisation and basic
specialities hospital/districts
States (28) an Union Territories (7)
Ministry of Health and Directorate of Health
National Level
Ministry of Health and Family Welfare
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.

I. Union Ministry of Health and Family Welfare
Organisation
The Union Ministry of Health and Family Welfare is headed by a Cabinet Minister, a
Minister of State, and a Deputy Health Minister. These are political appointment and have dual
role to serve political as well as administrative responsibilities for health.
Currently the union health ministry has the following departments:
1. Department of Health
2. Department of Family Welfare
3. Department of Indian System of Medicine and Homoeopathy
a. Department of Health
It is headed by a secretary to the Government of India as its executive head, assisted by
joint secretaries, deputy secretaries, and a large administrative staff.
Functions
Union list
1. International health relations and administration of port-quarantine
2. Administration of central health institutes such as All India Institute of Hygiene and
Public Health, Kolkata; National Institute for Control of Communicable Diseases, Delhi,
etc.
3. Promotion of research through research centres and other bodies.
4. Regulation and development of medical, nursing and other allied health professions.
5. Establishment and maintenance of drug standards.
6. Census, and collection and publication of other statistical data.
7. Immigration and emigration.
8. Regulation of labour in the working of mines and oil fields and

Concurrent list
The functions listed under the concurrent list are the responsibility of both the union and
state governments. The centre and states have simultaneous powers of legislation. They are as
follows:
1. Prevention of extension of communicable diseases from one unit to another.
2. Prevention of adulteration of food stuffs.
3. Control of drugs and poisons.
4. Vital statistics.
5. Labour welfare.
6. Ports other than major.
7. Economic and social health planning
8. Population control and family planning.
Department of Family Welfare
It was created in 1966 within the Ministry of Health and Family Welfare. The secretary
to the Government of India in the Ministry of Health and Family Welfare is in overall charge of
the Department of Family Welfare. He is assisted by an additional secretary and commissioner,
and one joint secretary.
The following divisions are functioning in the department of family welfare.
1. Programme appraisal and special scheme
2. Technical operations: looks after all components of the technical programme viz.
Sterilization/IUD/Nirodh, post partum, maternal and child health, UPI, etc.
3. Maternal and child health
4. Evaluation and intelligence: helps in planning, monitoring and evaluating the
programme performance and coordinates demographic research.
5. Nirodh marketing supply/ distribution
Functions
a. To organize family welfare programme through family welfare centres.
b. To create an atmosphere of social acceptance of the programme and to support all voluntary
organizations interested in the programme.
c. To educate every individual to develop a conviction that a small family size is valuable and to
popularize appropriate and acceptable method of family planning
d. To disseminate the knowledge on the practice of family planning as widely as possible and to
provide service agencies nearest to the community.
Ministry of Health and Family Welfare

3. The department of Indian system of medicine and homeopathy
It was established in March 1995 and had continued to make steady progress. Emphasis
was on implementation of the various schemes introduced such as education, standardization of
drugs, enhancement of availability of raw materials, research and development, information,
education and communication and involvement of ISM and Homeopathy in national health care.
Most of the functions of this ministry are implemented through an autonomous
organization called DGHS.

Minister of State
Deputy Ministers
Dept. of Family Welfare Dept. of Health Dept. of Indian
System of Medicine
and Homoeopathy
Secretary
JS
(ISM)
Director
Ayurveda & Sidha
Secretary
Secretary health
Additional Secretary
Joint Secretaries (9)
Director General of
Health Services
Addl. Director Generals (4)
Chief Director
(1)
Cabinet Minister
Joint Secretary
(3)
II. Directorate General of Health Services
Organisation
The DGHS is the principal adviser to the Union Government in both medical and public
health matters. He is assisted by a team of deputies and a large administrative staff. The
Directorate comprises of three main units:
i. Medical care and hospitals
ii. Public health
iii. General administration
Functions
1. General functions: The general functions are surveys, planning, coordination,
programming and appraisal of all health matters in the country.
2. Specific functions
a. International health relations and quarantine:
b. Control of drug standards
c. Medical store depots
d. Postgraduate training
e. Medical education
f. Medical research
g. Central Government Health Scheme.
Family welfare services
h. National Health Programmes.
i. Central Health Education Bureau
j. Health intelligence.
k. National Medical Library

III. Central Council of Health
The Central Council of Health was set up by a Presidential Order on August 9, 1952,
under Article 263 of the Constitution of India for promoting coordinated and concerted action
between the centre and the states in the implementation of all the programmes and measures
pertaining to the health of the nation. The Union Health Minister is the chairman and the state
health ministers are the members.
Functions
1. To consider and recommend broad outlines of policy in regard to matters concerning
health in all its aspects such as the provision of remedial and preventive care,
environmental hygiene, nutrition, health education and the promotion of facilities for
training and research.
2. To make proposals for legislation in fields of activity related to medical and public health
matters and to lay down the pattern of development for the country as a whole.
3. To make recommendations to the Central Government regarding distribution of available
grants-in-aid for health purposes to the states and to review periodically the work
accomplished in different areas through the utilisation of these grants-in-aid.
4. To establish any organisation or organisations invested with appropriate functions for
promoting and maintaining cooperation between the Central and State Health
administrations.

AT THE STATE LEVEL
Historically, the first milestone in the state health administration was the year 1919,
when the states (provinces) obtained autonomy, under the Montague-Chelmsford reforms, from
the central Government in matters of public health. By 1921-22, all the states had created some
form of public health organisation. The Government of India Act, 1935 gave further autonomy to
the states. The state is the ultimate authority responsible for health services operating within its
jurisdiction.
State health administration
At present there are 31 states in India, with each state having its own health
administration. In all the states, the management sector comprises the state ministry of Health
and a Directorate of Health.
1. State Ministry of Health
The State Ministry of Health is headed by a Minister of Health and FW and a Deputy
Minister of Health and FW. In some states, the Health Minister is also in charge of other
portfolios. The Health secretariat is the official organ of the State Ministry of Health and is
headed by a Secretary who is assisted by Deputy Secretaries, and a large administrative staff.

Organisational structure of the health and family welfare services at state level

Functions: Health services provided at the state level
- Rural health services through minimum needs programme
- Medical development programme
- M.C.H., family welfare & immunization programme
- NMIP (malaria) & NFCP(filarial)
- NLEP, NTCP, NPCB, prevention and control of communicable diseases like
diarrheal disease, KFD, JE,
- School health programme, nutrition programme, and national goitre control
programme
- Laboratory services and vaccine production units
Minister in charge of health and family welfare portfolio in the state
Secretary or commissioner, Department of Health and Family Welfare
Director
Health Services
Director
FW Services
Director
Medical education
& research
Director
ISM and
Homoeopathy
Additional/deputy
joint directors of
health services
dealing with one or
more programmes
Assistant Directors
health services
dealing with one or
more programmes
Principal/Deans of
medical colleges
Divisional set up in
some states
District health
organisation
Taluk Health
organisation
Block level health
organisation
- Health education and training programme, curative services, national Aids control
programme
2. State Health Directorate
The Director of Health Services is the chief technical adviser to the state Government on
all matters relating to medicine and public health. He is also responsible for the organization and
direction of all health activities. The Director of Health and Family Welfare is assisted by a
suitable number of deputies and assistants. The Deputy and Assistant Directors of Health may be
of two types
Regional
Functional.
The regional directors inspect all the branches of public health within their jurisdiction,
irrespective of their specialty. The functional directors are usually specialists in a particular
branch of public health such as mother and child health, family planning, nutrition, tuberculosis,
leprosy, health education, etc.
AT THE DISTRICT LEVEL
The district is the most crucial level in the administration and implementation of medical /health
services. At the district level there is a district medical and health officer or CMO who is overall
Subdivisions
i. Tehsils (talukas)
ii. Community development blocks
iii. Municipalities and corporations
iv. Villages
v. Panchayaths
Most of the districts in India are divided into two or more subdivisions, each in charge of
an assistant collector or sub-collector. Each division is again divided into tehsils in charge of a
Tehsildar. A tehsil usually comprises between 200 and 600 villages.
Finally, there are the village panchayaths, which are institutions of rural local self-
government.
The urban areas of the district are organised into the following local self-government:
Town area committee 5,000 10,000
Municipal boards 10,000 2,00,000
Corporations population above 2,00,000.
The towns area committees are like panchayaths. They provide sanitary services.
The municipal boards are headed by a chairman/president, elected usually by the
members.
Corporations are headed by mayors. The councilors are elected from different wards of
the city. The executive agency includes the commissioner, the secretary, the engineer, and the
health officer. The activities are similar to those of the municipalities but on a much wider scale.
Primary Healthcare Infrastructure of District Level

Sub-
Centre
T.B.A.
VHG
T.B.A.
VHG
T.B.A.
VHG
T.B.A.
VHG
T.B.A.
VHG
Primary
Health
Centre
Sub-
Centre
Sub-
Centre
Sub-
Centre
Sub-
Centre
Sub-
Centre
PHC
PHC
District Health and
Family Welfare
PHC
CEO
Zilla
parishad
Community
Health Centre
Covers 1,00,000 population
Covers
30,000
population
Covers
5,000
population
Covers
1,000
population
PANCHAYATHI RAJ
The panchayath Raj is a 3-tier structure of rural local self-government in India linking the
villages to the district. The three institutions are:
a. Panchayath at the village level.
b. Panchayath samithi at the block level.
c. Zilla parishad at the district level.
The panchayathi Raj institutions are accepted as agencies of public welfare. All
development programmes are channelled through these bodies. The panchayathi Raj institutions
strengthen democracy at its root and ensure more effective and better participation of the people
in the government.
At the village level
The panchayathi Raj at the village level consists of:
1. The gram sabha
2. The gram panchayath
3. The nyaya panchayath
At the block level
The panchayathi raj agency at the block level is the panchayath samithi. The panchayathi
samithi consists of all sarpanchs of the village panchayaths in the block. The block development
officer is the ex-officio secretary of the panchayath samithi.
The prime function of the panchayat samiti is the execution of the community
development programme in the block.
The block development officer and his staff give technical assistance and guidance to the
village panchayaths engaged in the development work.
At the district level
The zilla parishad is the agency of rural local self-government at the district level. The
members of the zilla parishad include all leaders of the panchayath samithis in the district, MPs,
MLAs of the district, representatives of SC, SD and women, and 2 persons of experience in
administration. The collector of the district is a non-voting member. Thus, the membership of the
zilla parishad is fairly large varying from 40 to 70.
The zilla parishad is primarily supervisory and coordinating body. Its functions and
powers vary from state to state. In some states, the zilla parishads are vested with the
administrative functions.

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
District
Level
Zilla Panchayat
(ZP)
Taluka
Level
Taluka Panchayat
(TP)
Village
Level
Gram Panchayat
(GP)
Gram
Sabha
Direct election @ 1:40,000
(except Uttara Kannada, Coorg
and Chickmagalore where it is
1:30,000). 20 months term for
Adhyakshas and Upadhyakshas
and 5 standing committees.
Direct election @ 1:10,000.
Voting rights to MPs, MLAs,
MLCs. One year membership to
1/5 of Gram Panchayat
Adhyakshas and 5 standing
committees.
Direct election @ 1:4,000. Ban on
political parties. 5 years term.3
standing committees.
Minimum of two meetings per
annum, under the chairmanship of
GP Adhyaksha, for approval of
Budget/accounts, review of
development programme
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 31
st
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

District
Level
Zilla Panchayat
(ZP)
Taluka
Level
Taluka Panchayat
(TP)
Village
Level
Gram Panchayat
(GP)
Gram
Sabha
Direct election @ 1:40,000
(except Uttara Kannada, Coorg
and Chickmagalore where it is
1:30,000). 20 months term for
Adhyakshas and Upadhyakshas
and 5 standing committees.
Direct election @ 1:10,000.
Voting rights to MPs, MLAs,
MLCs. One year membership to
1/5 of Gram Panchayat
Adhyakshas and 5 standing
committees.
Direct election @ 1:4,000. Ban on
political parties. 5 years term.3
standing committees.
Minimum of two meetings per
annum, under the chairmanship of
GP Adhyaksha, for approval of
Budget/accounts, review of
development programme

Organisational structure of health department at district level

DISTRICT HEALTH AND FAMILY WELFARE OFFICER
Dy. CMO/
Medical
Officer (FW
& MCH)
Asst. District
Health &
Family
Welfare
Officer (HQ)
Asst. District
Health and
Family
Welfare
Officer (Sub-
division
level/Dy.
CMOs)
District
Malaria
Officer
Senior
Malaria
Officer
Senior
Medical
Superin
tendent
Medical officers of
Dt. General
Hospital and other
Govt. Hospitals
District
Leprosy
Officer
District
Health
Education
Officer/
Dmeio
Medical
Officer
(District
Lab.)
District
Tubercul
osis
Officer
(TB
Centre)
Gazetted
Assistant
District
Nursing
Supervisor
Medical Officers
of Primary
Health centres
(Coordinators at
PHC level)
Assistant
Statistical
Officer
Lady
Medical
Officers/
11 MO of
Primary
Health
Centres
Service
Engineer
(Mobile
Workshop)
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
Additional DG (N) Additional DG (M) Additional DG (PH)
DDG (N)
ADG (Nursing education
& research)
ADG (Hospital nursing
service)
ADG (Community
nursing service)
DADG DADG DADG
Community &
nursing officer
PHN Supervisor
PHN
LHV
ANM
Principal tutor SON
Senior tutor
Tutor
Clinical instructors
Nursing superintendent
Deputy Nursing
superintendent
Assistant Nursing
superintendent
Ward sister
Staff nurse
Placement of nurses at state level
There is no proper and definite pattern of nursing structure in the state directorates except
the state of West Bengal. Usually one or two nurses are posted with varying designations, e.g., in
Tamilnadu there is one assistant director nursing who is responsible to Director, Medical
Services, and Director, Medical Education.
In Maharashtra, two nurses work, one each in the office of the Director, Medical
Education, and Director, Health Services.

Recommended organization at state level (union territory level)

Secretary (Health)
ADNS (Nursing
education & research)
ADNS (Hospital/
nursing service)
ADNS (Community
nursing)
DADNS Nursing Superintendent District Nursing
Officer
Public health
nursing officer
PHN at PHC
LHV (HSV)
LHV
ANM
Principal SON
Senior tutor
Tutor
Clinical instructors
Deputy Nursing
superintendent
Assistant nursing
superintendent
Ward sister
Staff nurse
Director, Nursing Services
Joint/Deputy Director, Nursing Services
DADNS (Nursing
education & research)
DADNS (Nursing
service)
DADNS (Community
health nursing)
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
officer
DHO DMO
Dist. P. N. O. Nsg. Superintendent/Dy.
Nsg. Suptd.
Asst. Nsg. Suptd.
Ward sister
Staff nurse
P. N. Supervisor
(CHC)
PN (PHC)
LHV/HS
ANM
Director, Nursing Services
Dy. Asst. Director, Nursing Services
Assistant Dist. Nsg. Officer
(Hosp. & Nsg. Edu)
Dy. Director, Nursing Services
Asst. Director, Nursing Services
Assistant Dist. Nsg. Officer
(Community)
LHV
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.

NATIONAL RURAL HEALTH MISSION
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..
To achieve these goals NRHM will:
Facilitate increased access and utilization of quality health services by all.
Forge a partnership between the Central, state and the local governments.
Set up a platform for involving the Panchayati Raj institutions and community in the
management of primary health programmes and infrastructure.
Provide an opportunity for promoting equity and social justice.
The Vision of the Mission
To provide effective healthcare to rural population throughout the country with
special focus on 18 states, which have weak public health indicators and/or weak
infrastructure.
18 special focus states are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal
Pradesh, Jharkhand, Jammu and Kashmir, Manipur, Mizoram, Meghalaya, Madhya
Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh.
To rise public spending on health from 0.9% GDP to 2-3% of GDP, with improved
arrangement for community financing and risk pooling.
To undertake architectural correction of the health system to enable it to effectively
handle increased allocations and promote policies that strengthen public health
management and service delivery in the country.
To revitalize local health traditions and mainstream AYUSH into the public health
system.
The Objectives of the Mission
Reduction in child and maternal mortality.
Universal access to public services for food and nutrition, sanitation and hygiene and
universal access to public health care services with emphasis on services addressing
womens and childrens health and universal immunization.
Prevention and control of communicable and non-communicable diseases, including
locally endemic diseases.
Access to integrated comprehensive primary health care.
Population stabilization, gender and demographic balance.
Revitalize local health traditions & mainstream AYUSH.
Promotion of healthy life styles.
The core strategies of the Mission
Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and
manage public health services.
Promote access to improved healthcare at household level through the female health
activist (ASHA).
Health Plan for each village through Village Health Committee of the Panchayat.
Strengthening sub-centre through better human resource development, clear quality
standards, better community support and an untied fund to enable local planning and
action and more Multi Purpose Workers (MPWs).
Provision of 30-50 bedded CHC per lakh population for improved curative care to a
normative standard. (IPHS defining personnel, equipment and management standards, its
decentralized administration by a hospital management committee and the provision of
adequate funds and powers to enable these committees to reach desired levels)
District and Block levels.
Programmes
Reproductive and Child Health Programme II (RCH-II) and the Janani Suraksha
Yojana (JSY) launched.
Polio eradication programme intensified cases reduced from 134 in 2004-05 to 63 (up
to now).
Accelerated implementation of the Routine Immunization programme taken up. Catch up
rounds taken up this year in the States of Bihar, Jharkhand and Orisaa.
Ground work for introduction of JE vaccine completed.
Ground work for Hepatitis vaccines to all States completed.
Auto Disabled Syringes introduced throughout the country.
State Programme Implementation Plans for RCH II appraised by the National Programme
Coordination Committee set up by the Ministry. Funds to the extent of 26.14% i.e. Rs.
1811.74 core have been released under NRHM Outlay.

Mission on nursing education:
The Mission would support strengthening of Nursing Colleges wherever required, as the
demand for ANMs and Staff Nurses and their development is likely to increase significantly.
Special attention would be given to setting up ANM training centers in tribal blocks which are
currently para-medically underserved by linking up with higher secondary schools and existing
nursing institutions.
ORGANISATION OF THE HEALTH CARE SYSTEM
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.
Organization of the public health system
The public health system is organised in too many levels in the
Federal,
State,
Local systems.
THE FEDERAL SYSTEM:
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
1) Union ministry of health and family welfare
2) Centre council of health
3) Centre family welfare council
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
Programme appraisal co-ordination and training and sterilization division
Technical operation division
Maternal child health division
Evaluation and intelligence division

Centre council of health

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
State ministry of health and family welfare
They have political responsibilities, responsibilities towards their constituencies as per
their political agenda, and responsibilities for administration and management of health and
family welfare services in their state.
Health secretariat
It is the official organ of the ministry. Major function of the secretariat include helping
minister in
Formulation, review and modification of board policy outlines
Execution of policies programmes etc.
Coordination with government of India and other state governments
Control for smooth and efficient functioning of administrative machinery.

State health directorate
Providing curative and preventive services
Provision for control of milk and food sanitation
Assumes for total responsibility for taking all steps in the prevention of any outbreak of
communicable diseases specially during festivals and special seasons
Establishment and maintenance of central laboratories for preparation of vaccines, etc
Promotion of health education
Collection, tabulation and publication of vital statistics
Apart from governmental actions it will be organized by state nursing councils and universities
Functions of university are
Organize the courses
Plan for the examinations
Setting question papers
Planning the examination date
Plan the curriculum
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
Head nurse / nursing tutor
A head nurse is assigned to a nursing unit, or ward, or a section of department. She works
under the general direction of the supervisor of the division.

Staff nurse / clinical instructor
Staff nurses are employed at the floor level for carrying out skilled bedside nursing.
This is the real work force of the hospital upon whose competency, state of training and
dedication depend the success of the nursing department.
Student nurse
Students nurse cannot be employed on nursing duties except under supervision of fully
qualified staff nurses.
Policies and procedures
In order that a good standard of nursing care be maintained, the nursing superintendent
should develop written policies and procedures to serve as a guides for nurses of the various
units of the hospital. Important topics that should be incorporated are as follows
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
As a basic function, to assist the individual patient in performance of those activities
contributing to his health or recovery that he would otherwise perform unaided has had
the strength will, or knowledge.
As an extension of the above basic function, to help and encourage the patients to carry
out the therapeutic plan initiated by the physician
As a member of health team, to assist other members of the team to plan and carryout the
total programme of care

AT COMMUNITY
PHCs (Primary Health Care)
Introduction
The PHC is the first contact point between the village community and the medical
officer. These are established and maintained by the state government under minimum needs/
basic minimum services programme. It acts as a referral unit for six sub centre and has 4-6 beds.
A PHC covers population of 30000 in plain area and 20000 in hilly remote and tribal area. The
activities of PHCs involve curative, preventive, promotive and family welfare services. The
number of PHCs functioning in the country is 22975.
Definition
Primary health centre is the basic structural and functional unit of public health services
for rendering primary health care in peripheral areas.
Elements of PHC
e- Ensure safe water supply
l- Locally endemic disease control
E- Education/ expanded programme on immunization
m- Maternal and child health
e- Environmental sanitation
n- Nutritional services
t- Treatment of minor aliments
s- School health services
Standards of PHC
The IPHHS for PHCs has been prepared keeping in view the resources available with respect to
functional requirement for PHCs with minimum standards such as-
Building
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 achieve and maintain an acceptable standards of quality of care
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
STAFF EXISTING RECOMMENDED
Medical officer 1 3(at least 1 female)
AYUSH practitioner - 1
Accountant manager - 1
Pharmacist 1 2
Nurse midwife(staff) nurse 1 5
Health worker 1 1
Health educator 1 1
Health assistant (m/f) 2 2
Clerks 2 2
Laboratory technician 1 2
Driver 1 OPTIONAL / vehicle
may be from out side
Class IV 4

Major role of nurse in PHC
Facilitative role
Developmental role
Clinical role
Supportive role
Functions of PHC
Medical care
Maternal and child health
Control of communicable diseases
Collection and reporting of vital statistics
Immunization services
Improvement in environmental sanitation
School health programmes
CHCs (community health centres)
Introduction
The community health centres are established and maintained by state government under
MNP/BMS programme. It has 30 indoor beds with x-ray labour room, operation theatre, and
laboratory facilities. It is managed by four medical specialists i.e. surgeon, physician,
gynecologist and pediatrician. On 31
st
march 2003, 3076 CHC were established each covering a
population of 80000 to 1.20 lakh.
Definition
Community health centres are the nonprofit community governed health organizations
that provide primary health care, health promotion and community development services, using
them inter disciplinary terms of health providers.
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.

SECOND FIVE YEAR PLAN (1956-1961)
The second five-year plan focused on industry, especially heavy industry. Unlike the First
plan, which focused mainly on agriculture, domestic production of industrial products was
encouraged in the Second plan, particularly in the development of the public sector.
The plan followed the Mahalanobis model, an economic development model developed by
the Indian statistician Prasanta Chandra Mahalanobis in 1953. The plan attempted to determine
the optimal allocation of investment between productive sectors in order to maximize long-run
economic growth.
The specific objectives were;
1. Establishment of institutional facilities to serve as a basis from which service could be
render to the people both locally & surrounding territory.
2. Development of technical man power through appropriate training programmes.
3. Intensifying measures to control widely spread communicable disease.
4. Encouraging active campaign for environmental hygiene.
5. Provision of family planning and other supporting services.
During this plan period the public sector outlay was Rs. 4,800 crore of which Rs. 225 crore were
allotted for health programs.

THIRD FIVE YEAR PLAN (1961-1966)
The third plan stressed on agriculture and improving production of rice
Many primary schools were started in rural areas. In an effort to bring democracy to the
grassroots level, Panchayat elections were started and the states were given more development
responsibilities.
State electricity boards and state secondary education boards were formed. States were made
responsible for secondary and higher education.
The specific objectives were in tuned with the 1
st
& 2
nd
five years plan except that integration of
public health with maternal & child welfare, nutrition & health education was planned.
During this plan period the public sector outlay was Rs. 7,500 crore of which Rs. 341.8 crores
were allotted for health programs.

FOURTH FIVE YEAR PLAN (1969-1974)
At this time Indira Gandhi was the Prime Minister. The Indira Gandhi government nationalized
Green Revolution in India advanced agriculture
Certain objectives of the Mudaliar committee were the base for this plan in relation to health.
1. To provide an effective base for health services in rural areas by strengthening the PHCs.
2. Strengthening of sub-division & district hospitals to provide effective referral services
for PHCs,
3. Expansion of medical & nursing education & training of Para medical personnel to meet
the minimum technical man power requirements.
During this plan period the public sector outlay was Rs. 16,774 crore of which Rs. 1,156 crore
FIFTH FIVE YEARS PLAN (1974-1979)
Stress was laid on employment, poverty alleviation, and justice. The plan also focused on self-
reliance in agricultural production and defense. In 1978 the newly elected Morarji Desai
government rejected the plan. Electricity Supply Act was enacted in 1975,
The emphasis of the plan was on removing imbalance in respect of medical facilities &
strengthening the health infrastructure in rural areas.
Specific objectives to be pursued during the plan were:
1. Increase accessibility of health services to rural areas.
2. Correcting regional imbalance.
3. Further development of referral services.
4. Integration of health, family planning & nutrition.
5. Intensification of the control & eradication of communicable diseases especially malaria
& smallpox.
6. Quantitative improvement in the education & training of health personnel.

During this plan period the public sector outlay was Rs. 37,250 crore of which Rs. 3,277 crores
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.

SEVENTH FIVE YEAR PLAN (1985-89)
The main objectives of the 7th five year plans were to establish growth in the areas of increasing
economic productivity, production of food grains, and generating employment opportunities.
The thrust areas of the 7th Five year plan have been enlisted below:
Social Justice
Removal of oppression of the weak
Using modern technology
Agricultural development
Anti-poverty programs
The objectives were
1. Eliminate poverty & illiteracy by 2000
2. Achieve near full employment secure satisfaction of the basic needs of food, cloth,
shelter
and provide health for all.
3. To provide an effective base for health services in rural areas by strengthening the PHCs.
4. universal immunization programme
5. Promotion of voluntary acceptance of contraceptives
During this plan period the public sector outlay was Rs. 1.80.000 crores of which Rs. 3,392
crores were allotted for health programs.
Period between 1989-91
P.V. Narasimha Rao was the twelfth Prime Minister of the Republic of India and head of
Congress Party
1989-91 was a period of political instability in India and hence no five year plan was
implemented. Between 1990 and 1992, there were only Annual Plans.

EIGHTH FIVE YEAR PLAN (1992-97)
India became a member of the World Trade Organization on 1 January 1995.This plan can be
termed as Rao and Manmohan model of Economic development. The major objectives included,
containing
1. population growth,
2. poverty reduction,
3. employment generation,
4. strengthening the infrastructure,
5. Institutional building,tourism management,
6. Human Resource development,
7. Involvement of Panchayat raj,
8. Nagarapalikas,
9. N.G.Os and
10. Decentralization and people's participation.
It is based on the national health policies.
1. Human development is the ultimate goal of this plan.
2. Employment generation, population control literacy, education, health, drinking water &
provision of adequate food &basic infrastructure.
3. Towards health for the underprivileged was the of the aim of this plan.
The PHCs were strengthened staff vacancies, by supplying essential equipment &drugs.
AIDS control program was initiated during this plan.

NINTH FIVE YEAR PLAN (1997-2002)
Ninth Five Year Plan India runs through the period from 1997 to 2002 with the main aim of
attaining objectives like speedy industrialization, human development, full-scale employment,
poverty reduction, and self-reliance on domestic resources.
Background of Ninth Five Year Plan India: Ninth Five Year Plan was formulated amidst the
backdrop of India's Golden jubilee of Independence.
The main objectives of the Ninth Five Year Plan India are:
to prioritize agricultural sector and emphasize on the rural development
to generate adequate employment opportunities and promote poverty reduction
to stabilize the prices in order to accelerate the growth rate of the economy
to ensure food and nutritional security
to provide for the basic infrastructural facilities like education for all, safe drinking water,
primary health care, transport, energy
During this plan, vertical health program were integrated horizontally with general health
services.
The Reproductive & child health program was improved under following guidelines;
1. Decentralize RCH to the level of PHCs.
2. Base planning for RCH services on assessment of the local needs.
3. Meet the needs of contraceptives
4. Involve the general practitioners & industries in family welfare work.

TENTH FIVE YEAR PLAN (2002-2007)
Reduction of poverty ratio by 5 percentage points by 2007;
Providing gainful and high-quality employment at least to the addition to the labour
force;*All children in India in school by 2003; all children to complete 5 years of
schooling by 2007;
Reduction in gender gaps in literacy and wage rates by at least 50% by 2007
This plan has laid down the following targets
Bring down the decadal growth rate by 16.2% in the decade from 2001 to 2011.
Reduce infant mortality rate to 35/1000 live births by 2007 & to 28/1000 live births by
2012
Reduce maternal mortality rate to 2/1000 live births by 2007 & 2/1000 live births by
2012.
To achieve the above, the government is planning to do the following
1. Restructure existing health infrastructure.
2. Upgrade the skills of health personnel
3. Improve the quality of reproductive & child health
4. Improve logistic supplies.
5. carry out the research on nutritional deficiency
6. Promote rational drug use.

ELEVENTH PLAN (2007-2012)
1. Income & Poverty
o Create 70 million new work opportunities.
o Reduce educated unemployment to below 5%.
o Raise real wage rate of unskilled workers by 20 percent.
2. Education
o Reduce dropout rates of children from elementary school from 52.2% in 2003-04
to 20% by 2011-12
o Develop minimum standards of educational attainment in elementary school, and
by regular testing monitor effectiveness of education to ensure quality
o Increase literacy rate for persons of age 7 years or above to 85%

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 its 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.
NATIONAL HEALTH POLICY - 2002
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.
Delivery of national public health programmes
Extending public health services
Policy of devolving programmes and funds in the health sector through different levels of
the Panchayati Raj Institutions.
Need for specialists in public health and family medicine
Use of generic drugs and vaccines
Urban health, Mental health, Womens health
Information, education and communication
Health research and National disease surveillance network
Health statistics and Medical ethics
Enforcement of quality standards for food and drug
Regulation of standards in para medical disciplines
Environmental and occupational health
Providing medical facilities to users from overseas
Globalization on the health sector
Objectives
- The main objective of this policy is to achieve an acceptable standard of good health
amongst the general population of the country.
- Decentralized public health system by establishing new infrastructure in deficient areas,
and by upgrading the infrastructure in the existing institutions.
- Ensuring a more equitable access to health services across the social and geographical
expanse of the country.
- Emphasis will be given to increasing the aggregate public health investment through a
substantially increased contribution by the Central Government.
- Strengthen the capacity of the public health administration at the State level to render
effective service delivery.
NHP-2002 - Policy prescriptions
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
Need for national health policy
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
Pharmacopoeial Laboratory for Indian Medicine (PLIM)
Homoeopathic Pharmacopoeial Laboratory (HPL)
Ayurved Hospital, Lodhi Road, New Delhi
National Population Policy of India
Population Policy pursues to achieve following Socio-Demographic goals by 2010:
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
Nursing
management
Concept, types, principles and techniques
Vision and Mission Statements
Philosophy, aims and objective
Current trends and issues in Nursing
Administration
Theories and models
Application to nursing service and
education
Management: Refer unit 1
Functions of administration: Refer unit 1
PLANNING AND CONTROL
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.
Essentials of good planning
Yields reasonable organizational objectives and develops alternative approaches to meet
these objectives.
Helps to eliminate or reduce the future uncertainty and chance.
Helps to gain economical operations.
Lays the foundation for organizing.
Facilitates co-ordination.
Helps to facilitate control.
Dictates those activities to which employers are directed.
Controlling
Controlling can be defined as the regulation of activities in accordance with the
requirements of plans.
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
3. Comparing the actual results with the standards.
4. Correcting deviations from standards.

CO-ORDINATION AND DELEGATION
CO-ORDINATION
Definitions
Co-ordination is the integrating process in an orderly pattern of group efforts in an organization
toward the accomplishment of a common objective.
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
Effective co-ordination is good management. Co-ordination is not a one-shot deal.
It is a never ending process of ensuring the achievement of organizational goals
effectively.
Important features of co-ordination
- Co-ordination is a integrity process.
- If subdivision of work is in escapable, co-ordination becomes mandatory.
- Undue confusion is a symptom of poor co-ordination.
- Co-ordination is a process. It is a process of achieving integration among different
organizational units.
- Unity of effort is the heart of co-ordination problem. The idea that co-ordination is a
fixed entity that either exists or does not exist is totally unrealistic.co-ordination is
present in all organizations but in varying degrees.
- The chief objective of co-ordination is a common purpose.
Principles of co-ordination
Co-ordination is a process whereby an executive develops an orderly pattern of group effort
among his subordinates and secures unity of action in the pursuit of common objectives. Co-
ordination is the continuous and dynamic process and emphasizes unity of efforts of achieve the
desired objectives. Co-ordination the managerial responsibility.
1. Principle of direct contact: co-ordination can be achieves by direct contact among the
responsible people concerned. Co-ordination can be easily obtained by direct
interpersonal relationships and direct personal communications.

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.

4. Principles of self co-ordination: in this when a particular department affects other
function or department or function in turn affected, may not have direct control over the
other department that is influencing the said department.

Importance of co-ordination
Co-ordination is crucial factor in the survival of any enterprise.
It resolves conflicts between line and staff inter-department, intra-departmental conflicts
and restores harmony in operations.
It results in the accomplishment of organizational goals
It helps to increase the effectiveness of management
Co-ordination helps to increase the effectiveness of management in the following ways
Co-ordination pulls all the function and activities together
Co-ordination brings unity of action and direction. it resolves effectively the dangerous
conflicts between individual and organizational goals.
Activities are dividing and sub-divide in organizations.
Modern organizations are considered as open system these open systems are
characterized by information flows, resource flows, and the flow of activities.
Co-ordination ensures the smooth flow of resources into productive units and brings
required quality output.

Techniques to achieve co-ordination
1. Co-ordination by rules or procedures
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.
2. Co-ordination by targets or goals
Most of the managers assign specific goals/ targets to their subordinates facilitate co-ordination.
3. Co-ordination through hierarchy
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.
4. Co-ordination through departmentalization
Departmentalization also serves as a technique to bring about effective co-ordination. Some
forms of departmentalization also facilitate co-ordination better than do others. a matrix
approach means each project has the continuous and undivided attention of its own project
manager and the project team.
5. Using a staff assistant for co-ordination
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 managers
ability to handle the problems and coordinate the work of his subordinates.
6. Using a liaison for coordination
In some big organizations where the volume of contacts between two departments grows, many
managers appoint a special liaison person to facilitate coordination.
7. Using committee for coordination
Another sound technique of coordination is to from committee for understanding various
functions and problems. Committees are increasingly useful for coordinating, planning and
executing programs and controlling the various activities..
8. Using independent integrators for coordination
In some special circumstances, independent integrator may be recruited by organizations. An
independent integrators job is to coordinate the activities of several interdependent
departments..
9. Conferences
Conferences at regular intervals also ensure better coordination. Conferences provide adequate
platform for discussion of various problems being encountered by different departments.
10. The techniques of communication
To promote coordination, communication system must be perfect. It must be well designed.
Communication is an artery through which the decisions flow top to bottom and reports flow
from bottom to top.
11. Miscellaneous
Other coordinating techniques include :grouping the similar activities, reorganization of
departments to ensure coordination, cross functioning of the departments, project management
organization hierarchy, planning techniques, creation of certain staff positions, periodical staff
meetings ect.
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.
1. Vertical and horizontal 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
Coordination may be internal or external to be organization. Coordination is internal when it is
achieved between different departments, sections, and units of an enterprise. It is both vertical
and horizontal.
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
Decision making- decentralization basic goals of decentralization.
Definition
Decision making is a systematic process of choosing among alternatives and putting the
choice in to action. -Lancaster and Lancaster
Decision making is a necessary component of leadership, power, influence, authority and
delegations. -John 1993
Decision making process is a conscious, intellectual activity involving judgment, evaluation
and selection from among several alternatives. -According to Claude
Types of decision making
There are 4 managerial decisions
a. Mechanistic decision b. Analytical decision
c. Judgmental decision d. Adoptive decision
Mechanistic decision
Routine and repetitive in nature
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
This decision helps to solve the complex problems.
It involves a problem with a large number of decision variables where the outcome of
each decision alternatives can be computed.
Computational techniques involve linear programming and statistical analysis.
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.
1. Nursing Administration decision making
According to Ann Bill Taylor
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.
Generally decisions are broadly divided into two categories:
1. Typical, routine, unimportant decisions
2. Important, vital or strategic decisions
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;
1. Optimizing: It is an approach in which an individual analyze a problem, determines desired
out comes, identifies possible solutions, predict the consequences of each actions, and select
the courses that yields the greatest amount of preferred outcomes.
2. Satisfying: It is an approach, where by an individual chooses a problem solutions, and then
select best of remaining options.
3. Mixed scanning: making a decision that satisfies to remove least promising solutions, and
then select best of remaining options.
4. Opportunistic: making a decision for the solution chosen by problem identifier.
5. Do nothing: taking decision after waiting for the storm to pass.
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.
Time and basis for decision making
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.
6. Experimentation: This provides another means by which various alternatives can be
evaluated. Since experimentation becomes and expensive basis for decision making in many
cases, it is used sparingly for indicating the best course of actions in problems like policy
formation, product development, introduction of new organizational technique etc.
Factor affecting decision making
Internal factors
Decision makers physical and emotional status
Personal characteristics and values
Past experience and interest
Knowledge and Attitude
Self awareness and courage
Energy and creativity
Resistance to change
Sensitivity and flexibility
External factors
Cultural environment
Philosophical environment
Social back ground
Time
Poor communication
Cooperation
Coordination
Steps in decision making
1. Making the diagnosis
2. Analysing the problem
3. Searching alternative solutions
4. Selecting best possible solution
5. Putting the decision into effect
6. Following up the decision
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.
2. Analyzing the problem
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.
3. Searching alternative solution
After anodizing the problem attempts are made to find alternative solutions to the
problem. In the absence of alternatives decision making process will become.
4. Selecting best possible solution
Selection of one best course of action among the several alternatives developed; require
an ability to draw distinctions between tangible and intangible factors as well as facts and
guesses. The four criteria have been suggested by Dracker in selecting the best solution.
1. Proportion of risk to the expected gain.
2. Relevance between the economy of effort and the possibility of results.
3. The time considerations that meet the needs of the situation.
4. The limitation of recourses.
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.
5. Putting the decision in to effort
The decisions can be made effective through the action of other people. In order to
overcome the opposing on the part of employees managers can make three important
preparations.
a. Communication of decisions
b. Securing employee acceptance
c. The timing of decisions
6. Follow up the decision
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.
Decision making authorities
1. Individual
2. Group
3. Committees

Individuals as decision makers
The autocratic managers 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 factors in decision making
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.
Advantages of group participation
Increasing self expression, innovation and development.
Increases the commitment.
Disadvantages of group participation
Change in the participants may create problems.
Few people may dominate in the group.
Members may become more interested in arguments and winning than finding a solution.
The decisions can be most acceptable but not optional.
Committee Aspects in Decision Making
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
Indecisiveness can be result in the adjournment of the committee.
Pressure for unanimity discourages creativity from the members.
Models of decision making
1. The Normative Model
2. The Decision Tree Model
3. The Descriptive Model
4. The Strategic Model
5. Optimizing Model
6. Satisfying Model
1. The Normative 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:
a. Define and analyze the problem.
b. Identify all available alternatives.
c. Evaluate the pros and cons of each alternative.
d. Rank the alternatives.
e. Select the alternative that maximizes satisfaction.
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.
Vroan and Yeltons Normative M odel
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
AI making decision by yourself using information available to you at that time.
AII obtain necessary information from your subordinates then decide on a solution to your
problem. But subordinates will be unaware about the problem.
CI - shares the problem with subordinates individually, and gets their ideas and suggestions.
Then you make a decision that may or may not reflect your subordinates influence.
CII- you share the problem with subordinates as a group, together you generate and evaluate
alternatives and attempt to reach agreement on a solution. You do not try to influence the group
to adopt your solutions but are willing to accept and to implement any solution that has the
support of the entire topic.
GI is applicable only in more comprehensive models.
Vroan identified 7 rules that do most of the work of the model. Three rules protect the decision
and quality and four rules protect the acceptance.
The information rule: If the quality of decision is important and the leader doesnt poses
adequate information to solve the problem then AI is eliminated from the feasible set.
The goal congruence rule: if the quality of decision is important and the subordinates do
not share the organizational goals to be obtained in solving the problem then GII is
eliminated.
The unstructured problem rule: If the quality of decision is important and the leader
doesnt 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.
The acceptance priority rule: if acceptance is critical, not assured by an autocratic
decision and if subordinates can be trusted then AI, AII, CI, and CII are eliminate.
2. The Decision Tree Model
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

A3

Alternatives A4

Chance events Probable consequences
3. The Descriptive Model
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:
a. Establish acceptable goal.
b. Define subjective perceptions of the problem.
c. Identify acceptable alternatives.
d. Evaluate each alternative.
e. Select alternative.
f. Implement decision.
g. Follow up.
Decision point 1
The descriptive model may lend itself well to nurses faced with daily decision making
that must be completed rapidly and with significant consequences. Steps in the model are not
unlike those in the familiar nursing process, although the sequencing is different. Readers may
readily identify conditions in their own environments similar to those described by Simon and
see immediate application of this model. Lancaster and Lancaster illustrated the use of this
model for nursing administrators.
4. The Strategic Model
Strategic decision making usually relates to long-range planning. As an example,
hospitals are beginning to merge, and certainly nursing departments will be affected. Among the
decisions that will be made are the need for one top manager or department head versus two or
more, whether to decentralize and eliminate middle managers, and what maximize the use of
scarce resources and provide for their efficient use.
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
In decision making

Identifying
the Problem
Selecting
the Single
Best Choice
Developing
Potential
Solutions
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
Screening solutions using predetermined criteria
Identifying the costs and benefits as nearly as possible, and
Selecting the single best solution.
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.
Tool of decision making
1. Judgemental technique
2. Operational research technique
3. Delphi technique
4. Decision tree
1. Judgmental technique
a) This is the oldest technique and subjective in decision making.
b) Based on past experience and intuition about future.
c) Useful in making routine decision.
d) Cheap and not time consuming.
e) Hazardous due to a chance for taking wrong decision.
f) Rarely used in large capital commitments.
2. Operational Research Technique (OR)
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
Construction of mathematical model that pinpoints the important factor in the
situation.
Definition of criteria to be used for comparing the relative merits of various
possible courses of action.
Procuring empirical estimates of the numerical parameters in the model that
specify that particular situation to which it is applied.
Carrying out through the mathematical process of finding and series of action
which will give optimal solution.
Types of Operational Research Technique
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 opponents 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.
b. Helps to predict time.
c. Helps to determine priorities.
d. Use of recourses can be considered when setting priorities.
e. Assignment can be changes temporarily.
f. Overtime or temporary help can be given to facilitate the activity flow.
g. Can manipulate the time required to move from one event to another.
5. Critical path method (CPM):
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.
The Delphi technique is free from others influence.
Doesnt require physical presence.
Appropriate for scattered group.
But it is true consuming.
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.
Advantages of decision making
1. It is characterized by order and direction that enables managers to determine where they
are.
2. Provide a frame work data gathering which is relevant to the decision.
3. Allows application of previous knowledge and experience that minimize errors and
improve quality of patient care and work of an organization.
4. Increase managers confidence and ability in making decision.
DECENTRALIZATION
Introduction
Decentralization is the division of activities by forming departments. In nursing service,
departmentalization aims on attaining a better quality of patient care through benefits derived
from specialist nurses. Departmentalization aims to provide better arrangements, control of
facilities, equipments and materials required to perform the necessary service.
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.
Decentralization versus Centralization
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.
Complete centralization complete decentralization

Authority decentralization

Authority not delegated
Definition of decentralization
Decentralization is the dispersion or delegation of responsibilities and the authority to
lower levels of an organization. Institution makes use of both centralization & decentralization.
Top management needs a positive attitude towards decentralization and they need competent
personal to whom they can delegate authority.
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.

Dec
Decentralization (Flat, Horizontal, Participatory) Structure
Flat organizational structures are characteristic of decentralized management.
Decentralization refers to the degree of which authority is shifted downward within an
organization to its divisions, services, and units. Decentralization is delegating decision making
In nursing, as in other organizations, delegation fosters participation, teamwork, and
accountability. A first line manger with delegated authority will contact another department to
solve a problem in providing a service. The first line manager does not need to go to his or her
department head of the other service, creating a communication bottleneck. The people closest to
the problem solve it, resulting in efficient and cost effective management.
Nursing Administrator
Maternity
supervisor
Pediatric
supervisor
Surgery
supervisor
s
Nurse Nurse Nurse Nurse Nurse Nurse
Research conducted on Magnet hospitals found the most of the hospitals has a
decentralized structure in which nurses had a feeling of control over their unit work environment.
Porter OGrady identified the following conditions as essential for effective decentralization:
Freedom to function effectively
Support from Peers and leaders
Concise and clear expectations of the work environment
Appropriate resources
Advantages and limitations of decentralization
Advantages
The advantages of decentralization are as follows:
1. Relieves top manager from burden of managing.
2. Encourages subordinates to undertake responsibility.
3. More freedom to managers.
4. Increases motivation of subordinates.
5. Enhances competition among various departments/units.
6. Helps setting up of profit centres.
7. Promotes development of general managers.
8. Prepares mangers for rapid change in the organization.
Limitations
The limitations of decentralization are as follows:
1. Maintenance of uniform policy throughout organization becomes difficult.
2. Increases complexity of coordination.
3. May lead to loss of control by superior level managers.
4. May be limited by inadequate control techniques.
5. May be constrained by inadequate planning.
6. Limited by inadequate training.
7. Limited by inadequate number of qualified personnel at lower level.
8. It may be limited by external factors like; government regulations, taxation policy of
government, etc.
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.
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:
I. Louis Allen, "Management is what a manager does."
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."
III. George R. Terry, "Management is a distinct process consisting of planning, organizing,
activating and controlling performed to determine and accomplish the objective by the use of
human beings and other resources."
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."
Leadership and Decision-making Concept:
According to this concept, "management is an art and science of decision-making and
leadership." Most of the time of managers is consumed in taking decisions. Achievement of
objects depends on the quality of decisions. Similarly, production and productivity both can be
increased by efficient leadership only. Leadership provides efficiency, coordination and
continuity in an organization. Leadership and decision-making concept as given by some authors
is given below:
I. Donald J. Clough, "Management is the art and science of decision-making and leadership".
II. Ralph, C. Davix, "Management is the function of executive leadership anywhere."
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:
According to this concept, "management is an art of increasing productivity."
Economists treat management as an important factor of production. According to them,
"Management is also a factor of production like land, labor, capital and enterprise." The main
followers of this concept of management are John F. Mee, Marry Cushing Niles, F.W. Taylor
etc. The productivity concept, as given by the authors is given below:
I. Jon, F. Mee, "Management may be defined as the art of securing maximum prosperity 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."
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".
II. Megginson, "Management is management, whether it is in Lisbon, or in London or in Los
Angeles."
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

Management is the creation and control of technological and human environment of an
organization in which human skill and capacities of individuals and groups find full scope for
their effective use in order to accomplish the objective for which an enterprise has been set up. It
is involved in the relationship of the individual, group, the organization and the environment.
-A dasgupta 1969
Management is a good planning, organizing directing, co ordinating and controlling to eliminate
chaos, errors and waste and get better utilization of manpower and materials.
-George A Melresh
Management is the process and agency which directs and guides the operations of an
organization on the realizing established aims.
NURSING MANAGEMENT
MISSION STATEMENTS
A Mission Statement defines the organization's purpose and primary objectives. Its prime
function is internal to define the key measure or measures of the organizations success and
its prime audience is the leadership team and stockholders. Mission statements are the starting
points of an organisations strategic planning and goal setting process. They focus attention and
assure that internal and external stakeholders understand what the organization is attempting to
accomplish.
Dimensions of Mission statements:
According to Bart, the strongest organizational impact occurs when mission statements contain 7
essential dimensions.
Key values and beliefs
Distinctive competence
Desired competitive position
Competitive strategy
Compelling goal/vision
Specific customers served and products or services offered
Concern for satisfying multiple stakeholders

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.
Execution and control of work plan:
One of the greatest possible contributors to wastage of our precious recourses, whether at
the local or national level, is the failure of those at any level of administration, and at all
stages in the management of the activity, to base all decision on verifiable facts.
Delegation of responsibility and authority:
The delegation of responsibility and authority is an important aspect of successful
administration, to place the responsibility for decision at the lowest possible
organizational level in order to attain decision as speedily as possible.
Human relation and good morale:
Since the function of administration is to attain an established objective through the
management of people, administration if deeply concerned with human relation. Good
morale of the staff is essential to the success of any organization.
Effective communication:
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:
Administrators must be completely flexible to meet the changing needs of the
situation.
TRENDS IN NURSING ADMINISTRATION
I. Historical and
II. Educational trends
I. HISTORICAL
Late nineteenth century.
Beginning of twentieth century
Early twentieth century to 1946
The post independence period
LATE NINETEENTH CENTUR. The states of nursing that today had its beginning in
madras around the 17s in the 19
TH
century. This started with training for women for
improving nursing in military hospitals.
BEGINNING OF TWENTIETH CENTURY: The trend set in the late 19
th
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.
1905: The association of nursing superintend was formed .
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.
The early 20
th
century to 1946
1926: The first nurses registration at was enacted in madras presidency.
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 15
th
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.
1949: The first meeting of India nursing council was held
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
1. The health service development committee
2. The health serving planning committee
3. The committee to review conditions of service.
4. Chads committee
5. Mukerjee committee.
6. Mukerjee committee.committe
7. Jungalwala karthar singh committee.
8. Srivasthav committee.
Educational trends
FMHW Programme :
1. Meant to work at sub centers.
2. Main thrust: MCH service, implementing intervention of national health
programme.
3. Including IMR, MMR child mortality rates.
Old ANM programme
1. Meant to meet the demands generalized service
GNM programme
Bachelors degree programme .
Post certificate diploma programme in
1. Public health nursing
2. Psychiatric nursing
3. Pediatric nursing
4. Cancer nursing
5. Nursing education and administration
6. Other nursing specialities
M.Sc.
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.
1. AIIMS ,New Delhi
2. All India institute of hygiene and public health, Calcutta
3. PGI, Chandigarh
4. IPGMER, Pondicherry
5. MAHE, maniple
6. NIMHANS, Bangalore.
7. NIHFW, New Delhi.
ISSUES IN NURSING ADMINISTRATION
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 :
Taken in to consideration the national health policy goals and
programmes
Shifted its emphasis from traditional to community health oriented
approach and re-oriented nursing circular accordingly.
Be making sincere efforts to prepare nurses for the job they are
accepted to perform in their work field in terms of appropriate skills,
knowledge and right attitude and the desired behaviour patterns
reflecting the values for caring and at the level of .
Been preparing nurses keeping in the status and countries health
needs in minds.
Made studies on our west countries nursing training needs and
training load.
C. Nursing practice :
In the community setting and
In the institutional setting at the level of primary, secondary, and
tertiary levels of care.
Are nurses as matter of policy conceited in all matters related
decisions area for nursing practice?
Can it be said that nursing service rendered reflect quality of nursing
care do there have the necessary back up support from the system for
performing the way they are required to perform.
Are the nurses aware of the shift of emphasis on the primary health
care approach.
D. Nurse themselves:
Long hours of duties with very little time for recreation.
Non availability of health care programme of nurses.
Pressure from influence people
Non involvement of nurses in nursing matters.
Poor pay structures.
Lack of security and safety.
Non availability of basic communities like toilet facility, in
residential accommodation of community nurses.

Nursing in different prospective
Traditional nurse role
The traditional roles of nursing revolve round sick individual who are hospitalized.
Here the nurses work by large in the shadow of the physician and very few
independent decision making area left to them.
Community nurse role
Doctor halfdal mehalar former director general of the world health organization
1. Health maintenance and promotion.
2. Specific protection.
3. Disease prevention.
4. Rehabilitation.
5. Treatment of minor ailments.
6. Referral appropriate contumely.
7. Community mobilization.
8. MCH and family welfare services covering
9. child survival and safe mother hood program me.
10. School health services
Expanded nurse role
1. Performs not only the basic nursing care activities.
2. To have sound knowledge of operating the equipment to adopt appropriate
emergency measures
3. To the patterns and co-coordinators giving patients care services in the
hospitals.
4. To act managers teachers and supervisors while rendering patient care services.
Role of nurse administration
Provide visibility for organization goal
Provide recourses and define constraints
Mediate conflict
Serve as a coach
Monitor result

THEORIES AND MODELS
A. SCIENTIFIC MANAGEMENT THEORY:
Principles: the scientific management focuses on
Observation
The measurement of outcome
The pioneers of scientific management are:
1. Frederick W. Taylor (1856-1915)
2. Gantt Henry I. Gantt (1861-1910)
3. Emerson (1853-1936)
1) Frederick W. Taylor (1856-1915):
Taylor is recognized as father of scientific management. He conducted Time-And-
Motion studies to time the workers, Analyze their movements and set their standards. He
used stop watches. He applied the principles of observation, measurement and scientific
comparison to determine the most effective way to accomplish a task.
Achievements of Taylor:
1. He trained his workers to follow the time to complete the task given. The most
productive workers were hired even when they were paid an incentive or wage.
2. Labour costs per unit were reduced as a result.
3. Responsibilities of management were separated from the functions of the workers.
4. Developed systematic approach to determine the most efficient means of
production.
5. He considered management function is to plan.
6. Working conditions and methods to be standardized to maximize the production.
7. It was the managements responsibility to select and train the workers rather than
allow them to choose their own jobs and train by themselves.
8. He introduced an incentive plan to pay the workers according to the rate of
production to minimize workers dissent and reduce resistance to improved
methods.
9. Increased production and produce higher profits.
The effect of time- motion study of Taylor:
1. Reduced wasted efforts
2. Set standards of performance
3. Encouraged specialization and stressed on the selection of qualified workers who
could be developed for a particular job.

2) Gantt Henry I. Gantt (1861-1910):
Gantt was concerned with problems related to efficiency. He contributed to scientific
management by refining the previous work of Taylor than introducing new concepts.
1. He studied the amount of work planned or completed on one axis to the time
needed or taken to complete a task on the other axis.
2. Gantt also developed a task and bonus remuneration plan whereby workers
received a guaranteed days wages plus a bonus for production above the standard
to stimulate higher performance.
3. Gantt recommended to select workers scientifically and provided with detailed
instructions for their tasks.
4. He argued for a more Humanitarian approach by management, placing emphasis
on service rather than profit objectives.
5. He recognized useful non monetary incentives such as job security and
encouraging staff development.
3) Emerson (1853-1936):
His emphasis was on conservation and organizational goals and objectives.
He defined principles of efficiency related to:
1. Interpersonal relations and to system in management.
2. Goals and ideas should be clear and well-defined as the primary objective is to
produce the best product as quickly as possible at minimal expense.
3. Changes should be evaluated-management should not ignore commonsense by
assuming that big is necessarily better.
4. Competent counsel is essential.
His theory explains about
1. Management can strengthen discipline or adherence to the rules by justice, or
equal enforcement on all records, including adequate, reliable and immediate
information about the expenses of equipment and personnel should be available as
a basis for decisions.
2. Dispatching or production scheduling is recommended.
3. Standardized schedules, conditions and written instructions should be there to
facilitate performance.
4. Efficiency rewards should be given for successful completion of tasks.
5. Emerson moved further beyond scientific management to classic organizational
theory.
4. Charles Babbage (1792-1871): Charles Babbage ,a scientist mainly interested in
mathematics, contributed to the management theory by developing the principles of cost
accounting and the nature of relationship between various disciplines. Charles
Babbage laid the foundation for much of the work that later come to be known as
scientific management. He concentrated on production problems and stressed the
importance.
1) Division and assignment of work on the basis of skill and
2) The means of determining the feasibility of replacing manual operations with
automatic machinery.
B. CLASSIC ORGANIZATIONAL THEORY:
Importance of classic organization theory:
The classic administration-organization thinking began to receive attention in
1930.
Organization is viewed as whole rather than focusing solely in production.
The concepts of scalar levels, span of control, authority, responsibility,
accountability, line staff relationships, decentralization, and
departmentalization become prevalent.
Three pioneers of Classic organizational theory:
1) Henry Fayol (1841-1925):
Fayal was a French industrialist known as father of the management process
school concerned with management of production shops. He studied the functions of
managers and concluded that management is universal.
Functions of management:
1. Planning policies, programs and procedures.
2. Organization based on hierarchy of authority
3. Directing the business in order to gain optimum return from all workers.
4. Coordination, signifying harmony in activities of the organization and to
facilitate its working
5. Control, the errors of the functionaries of organization and ensure that such
errors do not occurs.
Fayol divided all the work carried out in a business enterprise into the following
categories.
1. Technical activities (production, manufacture, etc)
2. Commercial activities (buying, selling, personnel, and industrial relations)
3. Financial activities( to have optimum use of capitals)
4. Security activities(production of property and persons)
5. Managerial activities(planning organizing, commanding, directing, coordination
control, communication, motivation .leadership)
Principles by which good organization can be recognized. They are as follows:
1. The number of organization units should be the minimum needed to cover the
major enterprise functions.
2. All related functions should be combined within one unit.
3. The number of levels of authority should be kept to a minimum.
4. There should be room for initiative with the limit of his assigned authority.
5. Functions should be assigned so as to minimize cross relations between
organizational units.
6. No more employees should report to a superior than he can effectively direct and
coordinate.
2) Max Webber theory (1864-1920):
He is German psychologist. He earned the title of father of organizational theory.
His emphasis was on rules instead of individuals and on competencies over favoritism.
His conceptualization was on bureaucracy, structure of authority that would facilitate the
accomplishment of organizational objectives:
The three basis for authority:
1. Traditional authority, which is accepted because it seems things have always been
that way such as the rule of a king in a monarchy.
2. Charisma, having a strong influential personality.
3. Rational legal authority which is considered rational in formal organizations
because the person has demonstrated the knowledge, skills and ability to fulfill the
position.
3) James Mooney Theory (1884-1957):
Moony believed that management to be the technique of directing people and
organization the technique of relating functions. Organization is managements
responsibility.
Four universal principles:
1. Coordination and synchronization of activities for the accomplishment of goal.
2. Functional affects the performance of ones job description.
3. Scalar process organizes level of commands.
4. Arrange authority in to a higher Archie.
Consequently people get their right to command from their position in the
organization.

C. HUMAN RELATION THEORY:
The human relations movement began in 1940s.
Focused on the effect that the individuals have on the success or failure of an
organization.
Classic organization and management theory concentrated on the physical
environment fail to analyze the human element.
Instead of concentrating on the organizations structure, managers encourage workers to
develop their potentials and help them meet their needs for
Recognition
Accomplishment
Sense of belonging
1). Follett theory (1868-1933):
1. Follett stressed the importance of coordinating the psychological and sociological
aspects of management in 1920s.
2. She perceived the organization s a social system and management as a social
process.
3. Indicated that legitimate power is produced by a circular behaviour where by
superiors and subordinates mutually influence one another.
4. The law of the situation dictates that a person does not take orders from another
person but from the situation.
2). Lewin theory (1890-1947):
1. Lewin focused on the Group dynamics.
2. He maintained that groups have personalities of their own: composites of the
members personalities.
3. He showed that group forces can overcome individual interests.
D. BEHAVIORAL SCIENCE THEORY:
Emphasis is on:
1. Use of scientific procedures to study the psychological,
2. Sociological,
3. Anthropological aspects of human behaviour in organization.
Behavioural Science Indicated:
1. The importance of maintaining a positive attitude toward people,
2. Training managers,
3. Fitting supervisory actions to the situation,
4. Meeting employees needs.
5. Promoting employees sense of achievement,
6. Obtaining commitment through participation in planning and decision making.
1) Douglas McGregors Theory (1932):
McGregors is the father of the classical theory of management which termed
theory. He developed the managerial implications of Maslows theory. He noted that
ones style of management is dependent on ones philosophy of humans and categorized
those assumptions as theory X and theory Y.
Theory X
1. The managers emphasis is on the goal of organization.
2. The theory assumes that people dislike work and avoid it.
Consequence of theory X
Workers must be directed
Controlled
Coerced
Threatened
So that organizational goals can be met.
According to theory X
1. Most people want to be directed and to avoid responsibility because they have
little ambition.
2. They desire security.
Managers who accept the assumption of theory X
1. Will do the thinking and planning with little input from staff associates.
2. They will delegate little, supervise closely.
3. Motivate workers through fear ad threats
4. Failing to make use of the workers potentials.
Theory Y
It is focuses on goal.
1. People do not inherently dislike the work and that work can be a source of
satisfaction.
2. Workers have the self direction and self control necessary for meeting their
objectives.
3. Will respond to the rewards for the accomplishment of those goals.
Managers who believe in this Y theory:
1. Will allow participation
2. They will delegate
3. Give general supervision than close supervision
4. Support job enlargement
5. Use positive incentives such as praise and recognition.
They believe that under favourable conditions: people seek responsibility and display
imagination, unity and creativity. According to theory Y human potentials are only
partially used.
2).Rensis Likerts theory:
Dr Rensis Likert has studied human behaviour within many organisations. After
extensive research, Dr. Rensis Likert concluded that there are four systems of
management. According to Likert, the efficiency of an organisation or its departments is
influenced by their system of management. His theory of management is based on his
work at the University of Michigans institute for social research.Likert categorised his
four management systems as follows;
He identified three variables in organizations.
1. The casual variable includes leadership behaviour.
2. The intervening variables are perceptions, attitudes and motivations.
3. The end results variables are measures of profits, costs and productivity.
Factors measured by likert scale
The scale measures several factors related to leadership behaviour process:
Motivation
Managerial
Communication
Decision making process
Goal setting
Staff development
Four types of management system according to likert, effcets on the management
systems:
a). Exploitive-authoritative:
1. He associates the first system with the least effective in performance.
2. Managers show less confidence in staff associates and ignore their ideas.
3. Consequently staff associates do not feel free to discuss their jobs with their
managers
b). Benevolent- authoritative:
1. Staff associates ideas are sometimes sought, but they do not feel free to discuss
their jobs with the manager.
2. Top and middle management are responsible for setting goals.
3. There is minimal communication. Mostly downward and received with suspicion.
4. Decisions are made at the top with some delegation.
c). Consultative system:
1. The manager has substantial confidence in staff associates.
2. Their ideas are usually sought.
3. They fell free to discuss their job with the manager.
4. Goal setting is fairly general.
5. It has limited accuracy and accepted with some caution.
6. Broad policy is set at the top level.
7. There are decisions making throughout organization.
8. Control functions are delegated to lower level where.
9. Reward and self guidance are used.
10. There is some resistance from informal groups in the organization.
d) Participative group:
Group Participative is the most effective performance. Managers have complete
confidence in their staff associates. Their ideas are always sought, and they feel
completely free to discuss their jobs with the manager. Goals are set at all levels. There is
a great deal communication- upward, downward, and later that is accurate and received
with open mind.
E. MODERN MANAGEMENT THEORIES:
The modern era is characterized by trends in the management through viz:-
1. Microanalysis of human behaviour, motivation, group dynamics leadership
leading to many theories of organization.
2. The macro search for fusion of the many systems in business organization-
economic social technical political and quantitative methods in decision- making.
Modern management theories era can be father classified as the three streams viz:
1. Quantitative approach
2. System approach
3. Contingency approach
Indicating further refinement, extension and synthesis of all the classical and neo-
classical approaches to management.
1. Quantitative approach: Management science refers to the application of Quantitative
methods to management. Management science has an interdisciplinary basis in other
words management science is a combination and interaction of different scientists.
2. System approach:-according to system approach the organization is the unified,
purposeful systems composed of interrelated parts and also interrelated with its
environment. Each unit must mesh/ interact with the organization as a whole, each
manager most interact/ communicate and deal with executives of other unites and the
organization itself must also interact with other organizations and society as whole.

An open system model
Ludwing Von Bertanffy:
Bertanffy, a biology is credited with coining the general system theory. His contention
were that it was possible to develop a theoretical framework for describing relationship in
the real world and different disciplines with similarities could be developed into a general
systems model. The similarities were:
1. Study of organization
2. State of equilibrium
3. Openness of all systems and their influence o the environment and environment
influence on the system.

3. Contingency approach:

The contingency approach can be described as the behavioural approach.
Contingency theory does not prescribe the application of certain management
principles to any situation.
Contingency theory is recognition of the extreme importance of individual
manager performance in any given situation.
It rests on the extent of manager power and control over a situation and the degree
of uncertainty in any given situation.
The role of management in the contingency approach is to develop an appropriate
management solution for any given organizational environment.
It is principally directed at the management practitioner seeking to control a
distinct Organizational environment.

Luther Gulick:
He was influenced by Taylor and Fayol. He used Fayals 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 acronymPOSDCORB.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 Fayals 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)

Abraham H. Maslow (1908-1970)
Receiving his doctorate in psychology, Abraham Maslow was the first psychologist to
develop a theory of motivation based upon a consideration of human needs.

Maslows theory of human needs has three assumptions

Factor within Person
Maslows need hierarchy
Physiological. The need for food, drink, shelter and relief from pain
Safety and Security. The need for freedom from threat, that is, the security from
threatening events or surroundings.
Belongingness, Social and love. The need for friendship affiliation interaction
and love
Esteem. The need for self-esteem and for esteem from others
Self- Actualization. The need for fulfill oneself by making maximum use of
abilities skills and potential.

Human needs are never
completely satisfied
Human behaviour is
purposeful and is motivated
by need satisfaction.
Hierarchical structure of
importance from the lowest to
highest
Douglas McGregor (1906-1964)
McGregor is the other major theorist associated with the Human Relations School of
management.
McGregor believes there are two basic kinds of managers. One type of manager, Theory
X, has a negative view of employees assuming they are lazy, untrustworthy and incapable
of assuming responsibility while the other type of Manager,
Theory Y, assumes employees are trustworthy and capable of assuming responsibility
having high levels of motivation.
Herzbergs two factor theory:
This theory was developed in 1959.It is based on realisation that work motivation and
job-satisfaction are two dimensions that influence the productivity of an employee.
Herzbergs finding that good working conditions, adequate salary, good physical
facilities, good human relation, quality of supervision might contribute to job satisfaction,
of employees, which are hygiene factors. Whereas factors like recognition of work
done, status, opportunities for growth, challenging task, play an important role in creating
work motivation for employees, which are the motivation factors.ltter, many authors
interpreted that all the motivation factors described by Herzberg do not give equal
amount of satisfaction to all employees.
Implications of management theories in nursing:
1. Taylors theory can be implemented in nursing to study complexity of care and
determine staffing needs and observe efficiency and nursing care.
2. Nurses can utilize Emersons theory of early notion of the importance of
objectives setting in an organization.
3. Nurses should be aware of the managerial tasks as defined by Fayol: Planning,
Organizing, Directing, Coordinating and Controlling.
4. The theory of human relations of Follett and Lewin emphasise the importance for
nurse managers to develop staff to their full potential and meeting their needs for
recognition, accomplishment and sense of belonging.
5. Mc Gregon and Likert support the benefits of positive attitudes towards people,
development of workers, satisfaction of their needs and commitment through
participation.


Unit III

PLANNING
Planning process: Concept, Principles, Institutional
policies
Mission, philosophy, objectives,
Strategic planning
Operational plans
Management plans
Programme evaluation and review technique(PERT),
Gantt chart,
Management by objectives(MBO)
Planning new venture
Planning for change
Innovations in nursing

Application to nursing service and education

PLANNING
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 clients assessment data and
diagnostic statements for direction and formulating client goals and designing the nursing
strategies required to prevent, reduce or eliminate the clients health problems.

ROGRAM EVALUATION AND REVIEW TECHNIQUE (PERT)
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.
PERT uses a network of activities. Each activity is represented as a step on chart. It is an
important tool in the timing of decisions. In simplest form of PERT, a project is viewed as a total
system and consisting of setting up of a schedule of dates for various stages and exercise of
management control, mainly through project status reports on this progress.
Program Evaluation & Review Technique includes:
1. The finished product or service desired
2. The total time & budget needed to complete the project or program.
3. The starting date & completion date.
4. The sequence of steps or activities that will be required to accomplish the project or program.
5. The estimated time & cost of each step or activity.
Steps for accomplishing the project are:
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.
c. The pessimistic time: This is estimated on maximum potential difficulties.
Calculation of the critical path , the sequence of the events that would take the greatest
amount of time to complete the project or program by the planned completion date. The reason
this is the critical path because it will leave the least slack time.
USES
Why should nurse managers use the PERT system for controlling?
1. It forces planning and shows how pieces fit together.
2. It does this for all nursing line managers involved.
3. It establishes a system for periodic evaluation & control at critical points in the program.
4. It reveals problems & is forward- looking.
5. PERT is generally used for complicated & extensive projects or programs.
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.
Modern and Philips enlist the advantages of PERT:
1. It encourages logical discipline in planning, scheduling and control of project.
2. It encourages more long range & detailed project planning
3. It provides a standard method of documenting and communicating project plans, schedules,
and time and cost- performance.
4. It identifies the most critical elements in the plan, thus focusing management attention .i.e.
most constraining on the schedule.
5. It illustrates the effects technical procedural changes on overall schedules.
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.
These are possible nursing actions for a project:
1. Gather data
2. Analyze data
3. Develop a plan
4. Implement the plan.
5. Evaluation, feedback, and modification

Figure is an only an example .Application of these controlling process by nurse managers
would be specific to the project or program, and the time elements for the various activities
would vary with each. Also these 5 major activities with estimated completion times. The nurse
managers goal is to complete each activity or phase on or before the projected date.

MBO (Management by Objectives)

Management by objectives (MBO) is a process whereby superiors &
subordinates jointly identify the common objectives ,set the results that should be achieved by
subordinates, asses the contribution of each individual, and integrate individuals with the
organization so as to make best use of organizational resources.

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.

MBO is a result centered, non-specialist, operational managerial process for the
effective utilization of material, physical & human resources of the organization by integrating
the individual with the organization & organization with the environment.

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

1. MBO is an approach & philosophy to management & not merely a technique.

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.

4. The basic emphasis of MBO is an objectives.MBO is also concerned with
determining what these results & resources should be. This MBO tries to match
objectives & resources.

5. The MBO is characterized by the participation concerned managers in objective
setting, the performance reviews, and his performance.

6. Periodic review of performance is an important feature of MBO.

7. Objectives in MBO provide guidelines for appropriate systems procedures.
Steps in process of MBO
1. Setting of Organizational Purpose & Objectives

2. Identify the Key Result Areas(KRAs)

3. Establishment of the objectives of the supervision

4. Recommending objectives for the subordinates by the superiors.

5. Setting subordinates objectives

6. Periodic review of the performance of the subordinates.

7. Review of the performance by the superiors.

8. Final review of performance by the superiors.

9. Performance appraisal by superiors.

10. Providing feedback to the top level.

Steps of MBO
1. Setting Goals
1. Top managers formulate the overall organizational goals
2. Middle managers work with first line managers to set goals
3. This strengths organizations overall goals and commitment.
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
Managers review the performance of the people by supervisor
Evaluate the plans to achieve individual & group goals
Discuss how can these obstacles be removed.
MBO Process Cycle

Benefits of MBO
1. Better management of organization
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
1. Time and cost
2. Failure to teach MBO philosophy
3. Problems in objective setting
4. Emphasis on short- term objectives
5. Inflexibility
6. Frustration
Pre requisites for installing MBO program
1. Purpose of MBO
2. Top management support

3. Training for MBO

4. Participation

5. Feedback for self direction & self control

6. Other factors:-
i. Implementing MBO at lower levels
ii.MBO & Salary Decision
iii. Conflicting objectives.
VENTURE PLANNING
Venture Planning is a personal assessment of your feelings and the feasibility of a
venture. Venture Planning answers the question, should I be doing this and why? The Venture
Feasibility process examines seven key factors in any venture.
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 model.
Venture Formation involves all of the following stages:
Idea - Concept Development - Venture Development - Monitoring Progress - Initiating
New Changes - Venture Feasibility Analysis - Business or Operational Plan - Budget vs.
Actual - New Plans.
There are four keys to good venture planning:
Focus on one venture at a time in one business area at a time.
Discover the opportunity first, and then evaluate how to exploit it.
Develop three cases good, bad & likely for each scenario of a venture concept.
Identify what type of venture you want. Each type has an entirely different model,
implementation and end result. Each demands a different entrepreneurial approach and
each requires different management and style.
There Are 11 Keys to a Good First Venture
1) Founder's alignment with the mission.
2) Guaranteed or qualified customers.
3) Lifestyle of High Profit smaller business.
4) Routine concept.
5) Available product.
6) Advantageous Cash Flow.
7) Supportive local environment.
8) Neutral State and Federal Environment.
9) Equity Control.
10) Relevant Experience.
11) Low Overhead.
Emerging venture areas in nursing that needs planning
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;
Institution based care
Process oriented
Procedure driven
Based on mechanical and manual intervention
Provider driven
Treatment based
Reflective of late stage intervention
Based on vertical clinical relationships
According to Porter-O Grady (2003), the emerging realities for nursing practice for this century
will be;
o Mobility based on multiple settings
o Outcome driven
o Best- practice oriented
o Emphasized by technology and minimally invasive intervention
o User driven
o Health based
o Geared for early intervention
o Based on horizontal clinical relationships

Functions of good nurse manager
A nurse managers functions include the following;
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.
PLANNING FOR CHANGE
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
Planning: Planning refers to thinking ahead of time and formulation of preliminary
thoughts.
Planned change: Planned change entails planning and application of strategic actions
designed to promote movement towards a desired goal.
o Planned change is a change that results from a well thought out and deliberates
effort to make something happen. It is the deliberate application of knowledge
and skills by a leader to bring about a change.
Tappen, 1995
Change agent: A change agent is one who generates ides, introduces the innovation,
and works to bring about the desired change.

Change agent
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;
The ability to combine ideas
The ability to energize others
Skills in human relations
Integrative thinking
Flexibility modify ideas
Persistent, confident and has realistic thinking
Trustworthy
Ability to articulate a vision, and
Ability to handle resistance.
Assumptions regarding change
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 individuals personal values and beliefs,
the more likely the change is to be accepted. Likewise the more difficult the goal is from
the individuals 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,
individuals 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:
1. Targeted Commitment Levels
2. Executive Ownership
3. Visible, sustained sponsorship
4. Deployment/Implementation Support and Monitoring
5. Employee Support
6. Post Deployment Preparation
Strategies for planned change
In general, three categories of change models exist: empirical-rationale, power-coercive, and
normative-educative model. (Bennis, Benne and Chin [1969], The planning of change)
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 agents 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 followers 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.
Barriers to change and strategies to overcome
It is important to identify all potential barriers to change, to examine them contextually
with those affected by proposed change, and to develop strategies collectively to reduce or
remove the barriers.
Change requires movement, which as physics indicates, is a kinetic activity that that
requires energy to overcome resistance.

Barrier Discussion Strategy
Desire to remain in
our comfort zone
Those who become increasingly attached to a
familiar way of doing things (comfort zone)
often view change as an unwelcome disruption.
Rational- empirical
strategies
Inadequate access to
information
Lack of information, inability to read and
understand the available resources.
Rational- empirical
strategy
Lack of shared vision Lack of widespread involvement, input, and
ownership of change will cripple a change
effort.
Normative- re-
educative strategy
Lack of adequate
planning
Involving individuals in planning gives a sense
of control and decreases their resistance to
change.
Rational- empirical
and normative- re-
educative strategies
Lack of trust Trust in the change agent and ability of self to
bring about change is necessary.
Rational- empirical
and normative- re-
educative strategies
Resistance to change Co-operation and involvement of the whole
team will only bring effective and lasting
changes.
Normative- re-
educative strategy
Poor timing or
inadequate time
planned
Poor timing and lack of planning can fail to
bring desired change.
Introducing change
at a time when
people are ready to
change guarantees
success
Fear that power,
relationships, or
control will be lost
Every change represents potential for loss to
someone.
Normative- re-
educative strategy
Amount of personal
energy needed for
change may be great
Sometimes change is desired, but people are not
willing to do what is necessary to effect the
change.
Slow the change
process and give
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 by Exception: This occurs when someone makes an exception to an existing
belief system. For instance, if a client believes that all nurses are bossy, but then
experiences nursing care from a much modulated nurse, they may change their belief
about that particular nurse, but not all nurses in general.
Incremental Change: A change that happens so gradually, that an individual is not aware
of it.
Pendulum Changes: Are changes that result in extreme exchanges of points of view.
Paradigm Change: Involves a fundamental rethinking of premises and assumptions, and
involve a changing of beliefs, values and assumptions about how the world works.
Change Theories in Nursing
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 Lewins, Lippitts, and Havelocks theories of change. The characteristics of change
theories are;
Problem identification
Plan for innovation
Strategies to reduce innovation
Evaluation plan
Kurt Lewins change theory:
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 Lewins 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.
Equilibrium - This equilibrium, or present level of productivity, can be raised or lowered by
changes in the relationship between the driving and the restraining forces. Equilibrium is reached
when the sum of the driving forces equals the sum of the restraining forces.
Lippitts phases of change theory:
Lippitts 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
agents stamina, commitment to change and power to make change happen. The fifth stage
describes what the change agents 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 1:Diagnose the problem
Phase 2:Assess the motivation and capacity for change
Phase 3:Assess the resources and motivation of the change agent(commitment the
change, power, and stamina)
Phase 4:Define progressive stages of change
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 model:
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 P Kotter's 'eight steps to successful change'
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.
General considerations for planning change
Secure and maintain commitment to change
Define and communicate desired end state
Identify critical success factors
Establish targets and prioritize activities
Develop a theme
Understand why the change is desired/ required
General considerations for planning change
Secure and maintain commitment to change
Define and communicate desired end state
Identify critical success factors
Establish targets and prioritize activities
Develop a theme
Understand why the change is desired/ required
Nurse Leader (manager) as role model for Planned Change
Implement a comprehensive and coordinated change management program: Discover,
develop, detect.
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.
Make change visible with new tools and/or environment.
Ensure clear, concise, and compelling communication.
Integrate change goals with day-to-day activities, e.g., recruiting, performance
management, and budgeting.
Address short-term performance while setting high expectations about long-term
performance.
Help management avoid attempts to short circuit the change management process.
Foster change in peoples 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.
Acknowledge and celebrate successes regularly and publicly!
Mistakes by a leader manager
+ 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.

Creativity and innovation

Creativity is defined as artistic or intellectual inventiveness.
Innovation is defines as introduction of something new. These definitions suggest that the
terms are interchangeable. A person could say that creativity is the mental work or action
involved in bringing something new into existence, while innovation is the result of that effort.

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).

Systemic innovations according to (Drucker 1992) require willingness to look on changes
as an opportunity. Innovations do not create change. Successful innovations are accomplished by
exploiting the change not forcing it.

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. Its important to take time to develop a support for
the strategy. In more complex strategies it may be important to bring other
administrators.

Gaining support for the innovation
Some strategies require little or resources to implement where as others require
significant physical and financial resources. If resources are needed then gaining support
for the accusation of those resources are essential. Grants can provide good funding
sources but require time and effort to secure and may be for a limited time.
Administrative support may be required but administrators may also be an excellent
resource to tap to discuss the potential funding or acquisitions of the physical resource.

Preparing faculty members for the innovation
Rehearsal time may be required or additional education may be required. Planning
sufficient for those activities will increase everyones comfort level with this process.
This is the time where everyone agrees how the strategy will be in run. Use of perception,
validate and clarification can be a valuable tool.

Implementing the evaluation
In this step it is hope that the things will be going well, but flexibility may be
required if problems arise. Sometimes unintended consequences, such as surfacing of
emotional issues can occur. Administrator should be alert to the need for the follow up or
referral if problem arise.

Evaluating the outcome
It is the final step of the process. It may be possible to measure short term
attainment goals. A strong evaluation process provides an opportunity to evaluate the
outcome of the change.
Sources of innovation
Seven sources for innovative ideas have been identified by (Drucker 1992)

Four sources are found internally within the institutions are:
Unexpected outcomes: Situation presents themselves that require different methods to
be adopted. Knowing what is happening in an institution allows an individual to prepare
for the impending changes.
Incongruous circumstances: Disruptions occur that require change to be made
discrepancies exists between the reality as it is and reality as it is assumed to be.
Innovations made on the process needs: Procedures and policies need to be altered to
respond to the new regulations, policies or law.
Changes in structure: Organizational changes require changes in method of the
operations.

Three sources are outside the institutions:
Change in the demographics: Alteration in the community statistics such as age and
income levels affect the organizational operations.
New information or knowledge: New technological knowledge requires change in
practice.
Change in perception, taste and meaning: Shifts in demographics, technologies and
social needs create different ways of looking at the situation.

Steps in Innovation adoption
Knowledge: Aware of new information and possible significance to practice.
Persuasion: Positive attitudes about importance and utility of new knowledge.
Decision: Trial use of new information to test relevance to practice.
Implementation: Change of care setting to facilitate use of the innovations.
Confirmation: Gathering of evidence to confirm appropriateness of using the
innovations.

Theories
Planned change using linear approaches
Theories for planned change

Six phases of planned change

Havelock (1973) is credited with this planned change model

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

Application to practice: Useful for low level, low complexity change.

Seven phases of planned change

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

Application to practice: Useful for low level, low complexity change.

Innovation decision process

Rogers (1995) is credited with formulating this process.

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.

Response to change / Human side of change

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 agents recognition of the ideal and common patterns of the individuals
behaviour responses to change can facilitate an effective change process (Rogers 1983).

The responses and brief descriptions are as follows:
Innovators thrive on change, which may be disruptive to the unit stability.
Early adopters are respected by their peers and thus are sought out for advice and
information about innovations/changes.
Early majority prefer doing what has been done in the past but eventually will accept the
new ideas.
Late majority are openly negative and agree to change only after most others have
accepted the change.
Laggards prefer keeping tradition and openly express their resistance to new ideas.
Rejecters oppose change actively.

General characteristics of effective change agents

Is a respected member of the organization (insider) or community (outsider).
Possesses excellent communication skills.
Understands change process.
Knows how group functions.
Is trusted by others.
Participates actively in change processes.
Processes expert and legitimate power.

Principles characterizing effective change implementation
- The recipients of change feel they own the change.
- Administrators and other key personnel support the proposed change.
- The recipients of change anticipate benefit from the change.
- The recipient of change participates in identifying the problem warranting a
change.
- The change holds interest for the change recipients and other participants.
- Agreements exist within the work group about the benefit of the change.
- The change agents and recipients of change perceive a compatibility of values.
- Trust and empathy exist among the participants of the change process .
- Revision of the change goal and process is negotiable.
- The change process is designed to provide regular feedback to its participants.

Challenges met by the change leaders
Mc Daniels (1996) advocates that change leaders in healthcare organizations meet
the challenges of managing by applying 12 recomendations:
1. Dispense with controlling and planning.
2. Operate on the margin between order and disorder.
3. Develop new organizations with the help of everyone.
4. Allow individual autonomy.
5. Encourage information sharing among staffs.
6. Promote staffs knowledge of others work.
7. Stimulate open learning through discussion generating creative tension.
8. Considering the organization structure as dynamic.
9. Help staffs discover their goals.
10. Encourage cooperation not competition.
11. Approach work from smarter view, not harder.
12. Uncover values continuously to form organization wide visions.

*****


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

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.
Organization is a form of every human association for the attainment of common
purpose and the process of relating specific duties or function in a whole
-J D Mooney
Organization consists of the relationship of individual to individuals and groups to groups
which are related as to bring about an orderly division of labor.
- Pfiffiner.
Organization is a formal structure of authority through which work subdivisions are
arranged, defined and coordinated for the defined objective.
- Luther Gullick
Organization is a system of co-operative activities of two or more persons.
-Chester I Bernard.
An organization is defined as a designed and structured process in which individuals
interact for objectives
-Hicks and Gullet, 1975.
Nature of organization
Four Ps are required to form the bases for organization,
P- Purposes
P- Process
P- Person target group
P- Place setting

Importance of organization
- It increases managerial efficiency .
- 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.
- It places a proportionate and balanced emphasis on various activities.
- It facilitates coordination in the enterprises.
- It provides scope for training and developing managers.
- It helps to consolidate growth and expansion of the institution/enterprise.
- It invites creative and innovative ideas.
- It prevents the growth of laggards, wire pullers or other forms of corrupters
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 chain of command
+ Principle of unity of command
+ Principle of span of control
+ 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
Types of organizational theories
1)Classical
organization
theory
2)Neoclassical
theory
3)Modern theories 4)Individual
processes
a)Taylors
scientific
management
approach
a)The systems
approach
a)Motiv
ational
theory
b)Webers
bureaucratic
approach
b)Socio-technical
approach
b) Role theory
c)Administrative
theory
c)The contingency or
Situational approach
c)Personality
theory

TYPES OF ORGANIZATIONAL THEORIES
1) Classical organization theory
a) Taylors scientific management approach
b) Webers bureaucratic approach
c) Administrative theory
2) Neoclassical theory
3) Modern theories
a) The systems approach
b) Socio-technical approach
c) The contingency or situational approach
4) Individual processes:
a) Motivational theory
b) Role theory
c) Personality theory
1) Classical organization theories (Taylor, 1947; Weber, 1947; Fayol, 1949) deal
with the formal organization and concepts to increase management efficiency.
Taylor presented scientific management concepts,
Weber gave the bureaucratic approach, and
Fayol developed the administrative theory of the organization.

A) Taylor's scientific management approach
Is based on the concept of planning of work to achieve efficiency, standardization,
specialization and simplification.
Taylor suggested that, to increase productivity was through mutual trust between
management and workers,
Taylor developed the following four principles of scientific management for improving
productivity:
1. Science, not rule-of-thumb Old rules-of-thumb should be supplanted by a scientific
approach to each element of a person's work.
2. Scientific selection of the worker Organizational members should be selected based on
some analysis, and then trained, taught and developed.
3. Management and labor cooperation rather than conflict Management should
collaborate with all organizational members so that all work can be done in conformity
with the scientific principles developed.
4. Scientific training of the worker Workers should be trained by experts, using scientific
methods.

B) Weber's bureaucratic approach
Weber (1947) based the concept of the formal organization on the following principles:
1. Structure: In the organization, positions should be arranged in a hierarchy, each with a
particular, established amount of responsibility and authority.
2. Specialization: Tasks should be distinguished on a functional basis, and then separated
according to specialization, each having a separate chain of command.
3. Predictability and stability The organization should operate according to a system of
procedures consisting of formal rules and regulations.
4. Rationality: Recruitment and selection of personnel should be impartial.
5. Democracy: Responsibility and authority should be recognized by designations and not
by persons.
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

b) The concept of line and staff :
The concept of line and staff is relevant in organizations which are large and require
specialization of skill to achieve organizational goals.
Line personnel are those who work directly to achieve organizational goals.
Staff personnel include those whose basic function is to support and help line personnel.

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 ,
-Planning, Organizing, Training, Commanding and Coordinating functions.
Gulick and Urwick (1937) also considered organization in terms of management
functions such as,
- Planning, Organizing, Staffing, Directing, Coordinating, Reporting and Budgeting.

2) Neoclassical theory
Classical theorists recognized the importance of individual or group behavior and
emphasized human relations.
Based on the Hawthorne experiments, the neoclassical approach emphasized social or
human relationships among the operators, researchers and supervisors
Productivity increases as a result of high morale, which was influenced by the amount of
individual, personal and intimate attention workers received.
Principles of the neoclassical approach
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.
Participative management :Participative management or decision making permits
workers to participate in the decision making process. This was a new form of
management to ensure increases in productivity.
3) Modern theories
It is based on the concept that the organization is a system which has to adapt to changes
in its environment.
Notable characteristics of the modern approaches to the organization are:
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 systems approach views organization as a system composed of
interconnected - and thus mutually dependent - sub-systems
Sub-systems can have their own sub-sub-systems.
A system can be perceived as composed of some components, functions and
processes (Albrecht, 1983).
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.
(ii) Linking processes-
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:
Decisions may be to produce or participate in the system.
Decision to produce depends upon the attitude of the individual and the demands of the
organization.
Decision to participate refers to the individual's decisions to engross themselves in the
organization process. That depends on what they get and what they are expected to do in
participative decision making.
(iii) Goals of organization:
The goals of an organization may be growth, stability and interaction.
Interaction implies how best the members of an organization can interact with one another to
their mutual advantage.
b) Socio-technical approach
The socio-technical systems approach is based on the premise that every organization
consists of the people, the technical system and the environment (Pasmore, 1988).
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.
c) The contingency or situational approach
The situational approach is based on the belief that there cannot be universal guidelines
which are suitable for all situations.
Organizational systems are inter-related with the environment.
The contingency approach suggests that different environments require different
organizational relationships for optimum effectiveness, taking into consideration various
social, legal, political, technical and economic factors
4) Individual Processes
a) Motivational Theory
Motivation drives behavior; it is the force behind an individuals decision to commit or
not commit to certain acts or behaviors.
An individual calculates an E (energy, enthusiasm, effort) the product of need, and
prediction for likelihood of achieving the desired results.

When a person enters into a contract with an organization some calculation will be made
in regards to the individuals 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
- In an organization roles can help to clearly define boundaries between individuals .
- 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 employees 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.
Personality can either aid or hinder meeting work goals dependent on fit.
For e.g. Personality types are Type a vs. Type B
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 As 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 Bs 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:
Nurses need to know
-Where they belong,
-Where they stand in relation to the quality and quantity of their performances
-Where to go for assistance.
Economy:
Nurses need as much self-control of their work as they can possibly be given.
They need to be self motivating .
There should be the smallest possible number of overhead personnel necessary to keep
the division and units operating and well maintained.
Direction of vision-
Nurse managers must direct their vision and that of their employees
-toward performance,
-toward the future and
- 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.
Stability and Accountability-
Nurses should be organized to feel community belongingness .
They can adapt to show objectives requiring changes in their functions and productivity.
Perception and Self renewal-
Nursing services should be organized to produce future leaders.
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.
2) Flat or Decentralized Structure.
3) Matrix Structure.
4) Adhocracy Structure.
5) Shared Governance.

Tall or Centralized Structure
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
Enables an individual to
be an expert in the
narrow area over which
he or she is responsible.
Because the supervisor
has fewer people to
supervise, close
supervision is possible.
The top level authority
are the primary decision
makers and have a great
deal of control over
actions of others.
The most skilled
individuals may end
up doing nothing but
supervising, whereas
those less capable do
the actual tasks.
Those who are
closely supervised
may feel stifled and
even mistrusted
sometimes.
Communication is
difficult because it
may pass through
many layers.
Implementation of
decisions may
excessively delay.

Flat or Decentralized Structure
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.


Matrix Structure
These structures are most often found in very large, multifaceted organizations.
Many organizations try to apply principles of business to health care.
There is simplification of
communication patterns,
flowing easily from lower
levels to higher levels in a
direct manner.
Greater speed with which
the organization can
respond to problems or new
opportunities, as decisions
can be made by those in the
situation.
Less chance of
communication becoming
lost or distorted as it moves
within an organization
Managers may lack
expertise in wide variety of
operations for which they
are responsible and thus
make inappropriate
decisions.
If individuals within the
organization are not
competent, their
inappropriate decisions
and actions may do great
harm .
This resulted in the organization of areas around product lines (which focuses on end
product of health care) and service line (represents the tasks required to accomplish the
delivery of the product)

A team approach to projects or
problems brings together wide
expertise and often generates
more creative solutions
Leadership conflict
There is flexible use of human
resources
Lack of understanding of
roles and expectations
The team members learn more
about one anothers concerns and
thus improves working
relationships, functional
integration
Confusion, Conflict and
Ambiguity
Communication is also improved
by close contact with all
organizational groups.
Time allocation between
working for team and
working for department
may become an issue.


Adhocracy Structure
- This type of structure uses teams of specialists who are organized to complete a
particular project or task.
- These groups are referred to as project team or task force.
- It is composed of highly specialized professionals, the work is delegated by a director
to members of the project team who provide particular expertise.
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.
Implementations Of Shared Governance:
President
It requires the staff nurses participate in professional development designed to increase
the nurses understanding of decision making, team building, group dynamics, leadership
and budgeting.
Disadvantages:
Time involved in shared governance is costly to organizations.
Its cost effectiveness in terms of patient outcomes is questioned sometimes.

ORGANIZATIONAL EFFECTIVENESS
The product or output of an organization is termed organizational effectiveness (O.E).
There should be a relationship between organizational effectiveness and performance
(O.P).
Nurse Managers define the goals and provide the resources for both the organizational
effectiveness and organizational performance.
For e.g-
The dimensions include:
Patient satisfaction with care
Family satisfaction with care
Staff satisfaction with work
Staff satisfaction with rewards , intrinsic and extrinsic
Staff satisfaction with professional development career, personal and educational
Staff satisfaction with organization
Management satisfaction with staff.
Community relationships.
Organizational
Nurse administrators control these dimensions of organizational effectiveness.
The organization is effective or productive when the people are performing care that
meets clients needs and for which employees have a sense of accomplishment.
An organization can be shaped through:
- Job enlargement that is qualitative- meaningful, interesting, and intellectually rewarding.
- Making the structure more manageable. Increasing clinical nurses autonomy reduces the
organization's size.
- Increasing the span of control of the manager.
- Shortening the hierarchy.
- Involving the employees in participation.
- Decentralization.
- Increasing the employees stake in his or her own performance.
- Increasing creativity while maintaining fiscal responsibility.
- Replacing direction and control with advice.
- Meeting employees need.
ORGANIZATIONAL CLIMATE
It is the emotional state and the perceptions and feelings shared by members of the
system.
It can be formal, relaxed, defensive, cautions, accepting, trusting etc.
It is the employees subjective impression or perception of their organization.
It relates to the personality of an organization and can be changed.
Organizational climate, defined differently by many researchers and scholars, generally refers to
the degree to which an organization focuses on and emphasizes:
Innovation
Flexibility
Appreciation and recognition
Concern for employee well-being
Learning and development
Citizenship and ethics
Quality performance
Involvement and empowerment
Leadership
Sociological dimensions of organizational climate:
Clarity in specifying certification of the organizational goals and policies. This is
facilitated by smooth flow of information and management support of employees.
Commitment to goal achievement through employee involvement.
Standards of performance that challenge promote pride and improve individual
performance.
Responsibility for one's own work fostered and supported by managers.
Teamwork- a sense of belonging, mutual trust and respect.
Environmental dimensions of climate:
It includes
-Room attractiveness
-Illumine
-Shape of the furniture
Practicing nurses wants a climate that will give them
-Job satisfaction
-Good working conditions
-High salaries
-Opportunities for professional growth
-Career development experiences that will help them to determine and direct their
professional futures.
-Administrative support that includes adequate staffing and shift options
-To develop their self esteem through self actualization.
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
Expectations Types of expectations regarding how managers behave and make
decisions
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
Programs Programming and formal initiatives help support and emphasize a
workplace climate
Leadership Leaders that consistently support the climate desired

Role of Nurse Managers In Organizational Climate
Nurse Managers should emphasize management tasks or activities that stimulate
motivation in nursing employees.
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.
Nurse manager will work to establish an organizational climate that provides
-Incentives for clinical nurses,
-Places them on committees,
-Is creative and equitable in all staffing matters;
-Emphasizes pride,
-Promotes participation,
-Rewards seniority and achievements,
-Reduces boredom and frustrations.
Nurse Managers need management education and training.
(Nurse managers and practicing nurses can work together to manage the work and the work
environment so that energy channeled into accomplishing personal and organizational goals.)
Activities to promote positive organizational climate
Developing the organization's mission, philosophy, vision , goals and objectives
statements with input from practicing nurses , including their personal goals.
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.
Promoting team work.
Asking practicing nurses to state their satisfactions and dissatisfactions during meetings
and conferences and through surveys.
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.
Emphasizing programs to recognize practicing nurses contributions to the organization.
Assessing needed threats and punishments and eliminating them.
Providing job security with an environment that enables free expression of ideas and
exchange of opinions.
Being inclusive in all relationships with practicing nurses.
Helping practicing nurses to overcome their short comings and to develop their strengths.
Encouraging and supporting loyalty, friendliness, and civic consciousness.
Developing strategic plans that include decentralization of decision making and
participation by practicing nurses.
Being a role model of performance desired of practicing nurses.

ORGANIZING NURSING SERVICES AND PATIENT CARE
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.
DEFINITION OF NURSING SERVICE
WHO expert committee on nursing defines the nursing services as the part of the total
health organization which aims to satisfy major objective of the nursing services is to provide
prevention of disease and promotion of health.
OBJECTIVES OF NURSING SERVICE
The first component of nursing service administration is the planning and it should be
based on clearly defined objectives. The objectives of nursing service department are as follows:

Objectives in relation to Patient care
The primary emphasis is on total patient care that is:
To give highest possible quality care in terms of total patients need which include
physical, psychological, social, educational and spiritual needs by collaborating with
other health tem members.
To assist the physician in providing medical care to the patients.
To provide preventive and rehabilitative services.
To provide round the clock nursing care to all the patients.
To render timely and appropriate nursing service to emergency patients.
To provide cost effective quality care as per the needs of patients.
Confidentiality and privacy of each patient should be maintained.
Constant monitoring and evaluating is of utmost importance to improve patient care
continuously.

Objectives in relation to Education
Planning of education and training programme for nurses are must for professional
growth and development needs through in-service education and research support.
To provide regular staff development, in-service education and guidance services for all
members of nursing staff.
To conduct regular orientation programme for new entrants and for those have been on
the job for a long time.
To conduct training for operating procedure of latest gadgets and on handling
sophisticated bio-medical equipment.

Objectives in relation to Administration and Organization
To make regular supervision through rounds.
To ensure that the essential equipment is provided in functional status for nursing care
services.
To provide regular flow of essential supplies to render quality nursingcare.
To have a proper system of rotation of staff, provision for annual leave and days off for
the nursing staff without hampering patient care.
Establish a communication system for nursing personnel, other health worker, patients,
health authorities, government authorities and public.
Ensure that each nurse identifies her job responsibilities and accountability.
Counseling for health personnel, patients and the public.
The formulation of policies, standards, goals of nursing service, education and practice.
Maintaining proper documentation of the personnel employed in nursing service.

Objectives in relation to Research
Establish a system for collection of essential information, research and studies concerning
all aspects of nursing.
To contribute in research programme conducted by hospitals and by other health
personnel.
To encourage and support the nurse to conduct research projects/ activities.

Objectives in relation to Performance appraisal
Appraise the performance of nursing service personnel regularly against set standards and
performance indicators objectively with a view to maintain quality-nursing services.

PRINCIPLES OF NURSING SERVICE
Initiate a set of human relationships at all levels of nursing personnel to accomplish their
job and responsibilities through systematic management process by establishing flexible
organizational design
Establish adequate staffing pattern for rendering efficient nursing service to clients and its
management
Develop and implement proper communication system for communicating policies,
procedures and updating advance knowledge.
Develop and initiate proper evaluation and periodic monitoring system for proper
utilization of personnel
Develop or revise proper job description for nursing personnel at all the levels and all
units for proper delivery of nursing care.
Share nursing information system with other discipline functionaries in the hospital.
Assist the hospital authorities for preparation of budget by involvement.
Participate in interdepartmental programs and other programs conducted by other
disciplinaries for improvement of hospital services.
Develop and initiate orientation and training programs for new employees in cooperative
with authorities and other health disciplines
Create an atmosphere that conductive to give proper required learning experience for the
students
Assist in the development of a sound, constructive program of leadership in nursing to
assure intellectual administration and management to safeguard, conserve and preserve
nursing resources of the hospitals.
Participate in the application of data and research
Participate in community health programs, associated with hospital.
FUNCTIONS OF NURSING SERVICE
To assist the individual patient in performance of those activities contributing to his
health or recovery that he would otherwise perform unaided has had the strength, will or
knowledge.
To help and encourage the patient to carry out the therapeutic plan initiated by the
physician.
To assist other members of the team to plan and carry out the total programme of care.
The organization of nursing care constitutes a subsystem for achieving the hospitals overall
objective. Nursing care of patients generally takes forms:
Technical
Educational
Trusting relationship
The director of nursing service is delegated the authority and responsibilities for
organizing and administrating the nursing services in hospital. It is her duty to institute the
essential characteristics of good nursing services in her institute such as:

Purposes and objectives of the nursing service:
The purposes should be in accordance with the hospital philosophy regarding patient
care and approved by administration. It must characterize the principles of excellence in
service, in practice and leadership. Objectives are specific, practical, attainable,
measurable and understandable to all the nursing staff.

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.
Written statement of purposes and objectives of nursing
services
Plan of organization
Policy and administrative manuals
Nursing practice manual
Nursing service budget
Master staffing pattern
Nursing care appraisal plan
Nursing service administrative meetings
Adequate infrastructure facilities, supplies and equipment
Written job description & job specifications
Personnel records
Personnel policies
Health services
Inservice education
Co-ordination
Advisory committee

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.

Nursing practice manual:
This the written procedure available as evidence of the standards of performance
established by nursing service organization for safe and effective practice after taking
into consideration the best use of available resources. Liberal use of diagram and
precautions in nursing manual helps to keep instruction direct and exact. The advantages
are ensure economy of time effort & material and provides basis for training for new
personnel to acquire knowledge and current skill.

Nursing service budget:
It is required for personnel budget, nurses welfare activities, staff development
programme, equipment and capital expenditure, supplies and expenses. Budget
preparation should includes analysis of past operation and anticipating the future revenue
and expenses.

Master staffing pattern:
It is the number and composition of nursing personnel assigned to work in a hospital
in different department / wards at a given time. This helps the director to visualize the
equitable distribution of nursing personnel among various nursing unit. It serves as a
guide for planning daily, weekly and monthly schedules.

Nursing care appraisal plan:
Employing various techniques such as supervision, ward rounds, conference,
anecdotal record, rating scale, checklist, suggestion box and peer review can do
performance appraisal of nurses. This is done to improve the quality of service provided,
determine the job competence and to enhance staff development.
Nursing service administrative meetings:
This meeting gives opportunity for free communication, planning and evaluation of
the nursing service through regular meeting of the director of nursing with total nursing
staff. The purposes are regular exchange of view between management and nursing
service for improving working condition, welfare of patient and improvement in methods
and organization of work.

Adequate infrastructure facilities, supplies and equipments:
The director of nursing evaluates periodically the adequate resources and arranges
new facilities needed for patient care in discussion with the hospital administrator.

Written job descriptions and job specifications:
In job description the responsibility are clearly spelt out as precisely including the job
content, activities to be performed, responsibility and result expected from various role
required by the organization. It is useful for reducing conflict, frustration, overlapping
duties and acts as a guide to direct and evaluate person.

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 nurses 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.

ORGANISATION OF NURSING SERVICES:

DIRECTOR (hospital) DIRECTOR OF HEALTH
SERVICE
Chief Nursing Officer Asst. Director of Health Service
Nursing Superintendent Nursing Superintendent Grade-I
Deputy Nursing Superintendent Nursing Superintendent Grade-II
Assistant Nursing Superintendent Head Nurse
Ward Sister - Clinical Supervisor Staff Nurse
Staff nurse Student nurse

ORGANIZING NURSING SERVICE AT VARIOUS LEVELS
The organization of nursing service varies from institution to institution.
Organizational set-up at Directorate General of Health Services

DGHS

Addl.DG (PH) Addl.DG (N) Addl.DG (M)

ADG ADG ADG
(Community Nsg service) (Nsg-education & research) (Hospital Nsg service)

DADG DADG DADG
Community & Nsg officer Principal Nsg.Supdt
PHN Supervisor Senior Tutor Dy.Nsg.Supt
PHN Tutor Asst.Nsg.Supt
LHV Clinical Instructor Ward sister
ANM Staff Nurse

Organizational set-up of Nursing Service at Central Level
Secretary, Health
Director Nursing Service
Joint/Deputy Director Nursing services

ADNS ADNS ADNS

DADNS DADNS DADNS

DADNS DADNS DADNS
Dist. Nsg officer DADNS Nsg.Supdt
PH. Nsg officer Principal Dy.Nsg.Supt
PHN at PHC Senior Tutor Asst.Nsg.Supt
LHV Tutor Ward sister
ANM Clinical Instructor Staff Nurse

Organizational set-up of Nursing Service at State Level
Director Nursing Services
Deputy Director Nursing Services
Assistant Director Nursing Services
Deputy Assistant Director Nursing Services

DMO DNO DHO

ADNO (Hosp&Nsg.Edu) ADNO (Community)

Nsg Supt/Dy.Nsg.Supt Principal tutor Dist.PNO
Asst.Nsg.Supt Tutor PHN Supervisor (CHC)
Ward Sister Clinical Instructor PHN (PHC)
Staff Nurse LHV
ANM
KEYS:
- DGHS - Director General of Health Services
- Addl. DG (PH) - Additional Director General (Primary Health)
- Addl. DG (M) - Additional Director General (Medical)
- Addl. DG (N) - Additional Director General (Nursing )
- ADG - Assistant Director General
- DADG - Deputy Assistant Director General
- PHN - Primary Health Nurse
- LHV - Lady Health Visitor
- ANM - Auxiliary Nurse Midwives
- ADNS - Assistant Director Nursing Service
- DADNS - Deputy Assistant Director Nursing Service
- DMO - Director of Medical Office
- DNO - Director of Nursing Office
- DHO - Director of Health Office
ROLE AND FUNCTION OF NURSE ADMINISTRATOR
The Principal Matron of the hospital will be responsible to the Commandant of the
hospital for the following duties:
Administration
Organizes, directs and supervises the nursing services both day and night.
Coordinates assignments of staff.
Establishes the general pattern of delegation of responsibilities and authority.
Formulates standing orders for the nursing care.
Ensures appropriate allocation of duties and responsibilities to all nursing staff
working under her.
Formulates nursing policies to ensure quality patient care and adequate attention
at all times.
Responsible for efficient functioning of the nursing staff.
Evaluates the personal performance of the nursing staff.
Discipline
Ensure that a standard of discipline of nursing staff is high at all times.
Maintain good order and discipline in wards/departments.
Makes daily rounds of the hospital wards/departments and also seriously ill
patients. In addition she will make unscheduled rounds in the hospital in the
evenings.
Brings immediately to the notice of the medical superintendent all matters
concerning neglect of duty, insubordination either by nursing staff, patients or
visitors or any un-towards incident, which comes to her notice for taking suitable
action as required as per the orders on the subject.
Public Relations
Promotes and maintains harmonious and effective relationship with the various
administrative departments of the hospital and related community agencies.
Maintain cordial relationships with the patients and their families.
Office Routine
Scrutinizes the reports and returns and submits in accordance with existing orders.
Confidential Reports
Initiates the confidential reports of nursing staff on due dates.
Responsible for the nursing budget.
Education
Carries out in-service training for all categories of nursing staff and paramedical
personnel and keeps the records of such trainings.
Conduct various update courses based on the needs.
Encourages the personnel to participate in the continuing education programme.

Welfare
Responsible for health and welfare of nursing staff.
Ensures annual and periodical health examination and maintenance of health
records.
Conferences
Responsible for organizing and conducting staff meeting of the nursing staff once
in three months.
Holds conference in nursing care problems and discuss policies as regards to
working conditions, working hrs and other facilities.
Supervision
Supervises nursing care given to the patients and all nursing activities within the
nursing unit.
Supervises the work of all paramedical staff of the hospital.
Records and Reports
Maintains various records such as duty roster nursing staff, day off book, personal
bio-data, leave plan, staff conference book, courses file etc.
PROBLEMS AND CHALLENGES FACED BY THE NURSE ADMINISTRATOR
Lack of adequate training.
Problem of personnel management.
Inadequate number of nursing staff.
Shortage of trained manpower.
Lack of motivation.
No involvement in planning.
No career mobility.
Poor role model.
No research scope.
Professional risk/hazards.
No autonomy in nursing activities.
Day to day problem in nursing services
Shortage of nurses.
Lack of motivation.
Negative attitude.
Lack of training.
Lack of team approach.
Inactive participation of program
Lack of interpersonal relationship
Less involvement in patients care by the nursing supervisors.
Lack of supervision.
ORGANIZING PATIENT CARE
The overall goal of nursing is to meet the patient nursing needs with the available
resources for providing smooth day and night 24 hrs quality care to patients and to honor his
rights. To ensure that nursing care is provided to patients, the work must be organized. A
Nursing Care Delivery Model organizes the work of caring for patients. The decision of which
nursing care delivery model is used is based on the needs of the patients and the availability of
competent staff in the different skill levels. For organizing function to be productive and
facilitate meeting the organizations needs, the leader must know the organization and its
members well.
The top level manager who influence the philosophy and resources necessary for any
selected care delivery system to be effective
The first and middle level managers generally have their greatest influence on the
organizing phase of the management process at the unit or departmental level. The
managers organize how work is to be done, shape the organizational climate, and
determine how patient care delivery is organized.
The unit leader-manager determines how best to plan work activities so organizational
goals are met effectively and efficiently, involves using resources wisely and
coordinating activities with other departments.
DEFINITION OF PATIENT CARE
The services rendered by members of the health profession and non-professionals under
their supervision for the benefit of the patient.
OR
The prevention, treatment and management of illness and the preservation of mental and
physical well-being through the services offered by the medical and allied health
professions.
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. 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 patients 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.
Johnson describes prototype evaluation with four basic categories for a typical patient
requiring one on- one care. Each category addresses activities of daily living, general
health, teaching and emotional support, treatment and medications. Data are collected on
average time spent on direct and indirect care.
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
Area of care Category I Category II Category III Category IV
Eating Feeds self Needs some help in
preparing
Cannot feed self but is
able to chew and
swallowing
Cannot feed self
any may have
difficulty
swallowing
Grooming Almost
entirely self
sufficient
Need some help in
bathing, oral hygiene
Unable to do much for
self
Completely
dependent
Excretion Up and to
bathroom
alone
Needs some help in
getting up to bathroom
/urinal
In bed, needs bedpan /
urinal placed;
Completely
dependent
Comfort Self
sufficient
Needs some help with
adjusting position/ bed..
Cannot turn without
help, get drink, adjust
position of extremities

Completely
dependent
General
health
Good Mild symptoms Acute symptoms Critically ill
Treatment Simple
supervised,
simple
dressing
Any Treatment more
than once per shift,
foley catheter care,
I&O.
Any treatment more
than twice /shift
Any elaborate/
delicate procedure
requiring two
nurses, vital signs
more often than
every two hours..
Health
education &
teaching
Routine
follow up
teaching
Initial teaching of care
of ostomies; new
diabetics; patients with
mild adverse reactions
to their illness
More intensive items;
teaching of
apprehensive/ mildly
resistive patients.
Teaching of
resistive patients,

MODES OF ORGANIZING PATIENT CARE / METHODS OF PATIENT
ASSIGNMENT
The most well known means of organizing nursing care for patient care delivery are,
Case method or Total patient care
Functional nursing
Team nursing
Modular or district nursing
Progressive patient care
Primary nursing
Case management
Each of these basic types has undergone many modifications, often resulting in new
terminology. For example, primary nursing has been called case method nursing in the past and
is now frequently referred to as a professional practice model. Team nursing is sometimes called
partners in care or patient service partners and case managers assume different titles, depending
on the setting in which they provide care. When closely examined most of the newer models are
merely recycled, modified or retitled versions of older models. Choosing the most appropriate
organizational mode to deliver patient care for each unit depends on the skill and expertise of the
staff, the availability of registered professional nurse, the economic resources of the organization
and the complexity of the task to be completely.

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.
Nurses 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 patients 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.
Nurses 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.

RN
Medication Nurse

RN
Treatment Nurse

LPN
Vital signs Nurse

UAP
Hygiene
Nurse

Patients assigned to the team

Charge Nurse
Merits:
Each person become very efficient at specific tasks and a great amount of work can be
done in a short time (time saving).
It is easy to organize the work of the unit and staff.
The best utilization can be made of a persons aptitudes, experience and desires.
The organization benefits financially from this strategy because patient care can be
delivered to a large number of patients by mixing staff with a large number of unlicensed
assistive personnel.
Nurses become highly competent with tasks that are repeatedly assigned to them.
Less equipment is needed and what is available is usually better cared for when used only
by a few personnel.

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.


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.
Charge Nurse RN
Team Leader RN Team Leader RN
RN NA LPN NA LPN RN
Group of Patients Group of Patients
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 patients
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.

PRIMARY CARE NURSING
Features:
It was developed in the 1960s with the aim of placing RNs at the bedside and improving
the professional relationships among staff members. The model became more popular in the
1970s and early 1980s as hospitals began to employ more RNs. It supports a philosophy
regarding nurse and patient relationship.
It is a system in which one nurse is caring for all the needs of a patient or more within a
24 hour from admission to discharge. He or she is responsible for coordinating and implementing
all the necessary nursing care that must be given to the patient during the shift. If the nurse is not
available, the associate nurse responsible for filling in for the nurses absence will provide
hospital care to the patient based on the original plan of care made by the nurse. In acute care the
primary care nurse may be responsible for only one patient; in intermediate care the primary care
nurse may be responsible for three or more patients This type of nursing care can also be used in
hospice nursing, or home care nursing.


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 patients 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 nurses talent to his/her own patients.
Patients
Total patient care 24 hrs/day
Communicates with
supervisors

Consults with physician
or other healthcare
providers

Associate (days)
when primary nurse is
not available

Associate (afternoon)
When primary nurse is
not available

Associate (evenings)
when primary nurse is
not available

PRIMARY
NURSE
CASE MANAGEMENT
Features:
The case manager (RN or social worker with managerial qualification) is assigned
responsibility of following a patients 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 clients
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 clients 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.

FACTORS INFLUENCING THE QUALITY PATIENT CARE
Many variable factors influence the number of nurses needed on a ward in order to render a
high quality of patient care.
The total number of patient to be nursed
The degree of illness of patients (physical dependency)
Type of service: medical, surgical, maternity, pediatrics and psychiatric
The total needs of the patients
Methods of nursing care
Number of nursing aids and other non professional available, the amount and quality of
supervision available
The amount, type and location of equipment and supplies
The acuteness of the service and the rate of turnover in patients according to the degree or
period of illness.
The experience of the nurses who are to give the patient care.
The number of non-nurses who involve in the patient care, the quality of their work, their
stability in service.
The physical facilities
The number of hours in the working week of nurses and other ward personnel and the
flexibility in hours
Methods of performing nursing procedures
Affiliation of the hospital with the medical school
Methods of assignment-individual, team or functional method
The standards of nursing care.

PLANNING AND ORGANIZING HOSPITAL UNITS AND ANCILLARY SERVICES
(SPECIFICALLY CSSD, LAUNDRY, KITCHEN, LABORATORY SERVICES,
EMERGENCY DEPARTMENT)
Planning and organization of hospital units:
A hospital is responsible to render an essential service. In fulfilling this responsibility, hospital
planning should be guided by certain universally acknowledged principles. The principles are
usually irrespective of the level of planning, i.e. whether at national level, state level or
individual hospital level.
Aims of hospital planning:
To enlarge the existing hospital by introducing new facilities.
To increase utilization of hospital facilities.
To increase population coverage
To increase productivity of hospital
Modernization of the already existing facilities
To reduce the cost of operations and maximize efficiency of services.
Guiding principles in planning:
Patient care of high quality: it can be achieved by the hospital through adopting following
measures:
a. Provision of appropriate technical equipments and supplies.
b. An organizational structure that assigns responsibility and requires accountability
for various functions within the organization.
c. A continuous review of adequacy of care provided by physicians, nursing staffs
and paramedical personnel.
Effective community orientation: this should be achieved by the hospital by adopting
following measures:-
a. A governing board made up of persons who have demonstrated concerns for
community and leadership ability.
b. Policies that assure availability of services to all people.
c. Participation of the hospital in community programmes to provide preventive
care.
Economic viability: this is achieved by adopting measures like:-
a. A corporate organization that accepts responsibility for sound financial
management in keeping with desirable quality of care.
b. A planned programme of expansion based solely on demonstrated community
need.
c. An annual budget plan that will permit the hospital to keep pace with times.
Orderly planning: orderly planning should be achieved by the hospital by following:-
a. Acceptance by the hospital administrator of primary responsibility for short and
long-range planning with support and assistance from competent financial,
organizational and functional advisors.
b. Preparation of a functional programme that describes the short range objectives
and facilities, equipments and staffing necessary to achieve them.
Sound architectural plan: it is achieved by the following:-
a. Selection of a site large enough to provide for future expansion and accessibility
of population.
b. Recognition of the need of uncluttered traffic patterns within for movement of
staff, patients and visitors and efficient transportation of supplies.
Medical technology and planning: development in medical technology is taking place so
rapidly that now the use of sophisticated technology determines the professional status.
Classification of hospitals:
Hospitals in general are classified into two categories depending upon the agencies which
finance them:
1. Government or public hospitals: they are managed by government services, either central
or state or public, municipal or departmental bodies that are financed from the overall
budget for public services.
2. Non-government hospitals: they are managed by individuals, charitable organizations,
religious groups, industrial undertakings etc.
On the basis of ownership patterns, non-governmental hospitals are classified as:
- Private (personal)
- Partnership
- Private (family) trust
- Public charitable trust
- Cooperative society
- Private limited company
- Public limited company
Hospital planning process:
i. Conceptualization of hospital: here the imagination or idea of the originator takes into a
practical shape, and compares his dreams with the existing hospitals of country or outside
world, tries to fit dreams into any such project.

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 societys 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.

iv. Geographical, environmental and miscellaneous factors:
Meteorological information: temperature, rainfall, humidity
Geographical information: existing road and rail communications, susceptibility to
quakes/floods, building height restrictions due to proximity of airports.
Miscellaneous availability: trained manpower, water, sewage disposal.

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.

No. of beds Land in acres Storey of building
50 beds 10 acres Single storey
100 beds 15-20 acres -do-
200 beds 20-25 acres Double storey
500 beds 55-70 acres 3-5 storey
700 beds 80-90 acres 4-6 storey
1000 beds 90-100 acres 6-9 storeys

- 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 nurses 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 day
2
.

- 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
OPDs. 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
buildings 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 dont 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
patients 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
3
1/2
to 4 ft.
- Clearance between wall and side of bed is 2ft.
- Length of bed is 66, 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
ICU 120-150 sq ft/bed
Obstetrics and orthopedics 120 sq ft/bed

support service area: this section of ward includes:
Nursing station/duty room: it should be located at such a place that the
time taken by a nurse for moving from one place to another is limited.
Centralize location is desirable.
Treatment room: the room is meant for examination of patients and should
be equipped with examination table, spotlight, dressing material, hand
washing facility etc.
Clean work room: it is a working room for staff nurses in nursing unit,
contains work benches for preparation of trays, care of materials,
equipments and supplies etc.
Pantry: it is a place where the dishes are cleaned, washed and stored.
Unit store: it is meant for storing the supplies and linens.
Sanitary area: it includes baths and toilets, dirty utility room, store for
sweepers etc.
+ Ward design: the primary objective of a ward design is to facilitate the nurse to hear and
see everything in the ward and to enable the patients to easily call the nurse when need
help.
I. open ward: in an open hall, beds are placed in rows facing each other and nursing
station in the center of the hall.
II. Riggs ward: in this design, 3-4 beds are placed parallel to the windows in open
bays separated from each other by low partition.
III. Unilateral riggs ward: side beds are placed in each bay separated from nurses
station with its standby services by a common corridor.
IV. Bilateral ward: it has been accepted as most suitable and workable conditions, two
unilateral riggs wards are on either side of a central nursing station.
V. T-shaped ward: bed bays are placed in front of the nursing station and critical
patients bays are in front of nursing station. Isolation bays are at both sides and
ancillary and other service areas are behind the nursing station.

Open ward

Open ward

Rigg,s ward


Riggs unilateral ward

Riggs bilateral 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.
Bed size of the hospital Location of CSSD
Up to 100 beds In operation theatre
100-500 beds CSSD centrally located in service area
Above 500 beds CSSD in service area and a separate unit for
OT to be called theatre sterile supply unit (
TSSU).

The following areas are to be provided in CSSD:
i. Equipment storage room
ii. Receiving counter and clean up room
iii. Needles and syringes processing room
iv. Gloves assembling room with rubber goods processing room
v. Clean work area including sterilizers
vi. Sterile storage area and issue counter
vii. gauze and dressing assembly area
Percentage distribution of the space is as follows:
Clean area including sterilization- 40%
Sterile storage area-15%
Equipment storage-14%
Fluids, needles and syringes- 14%
Receiving and clean up area-12%
Glove processing area-5 to 7%
Additional 25% space located for future expansion

Layout:
+ Location should be where the most rapid means of transportation of supplies and
equipment is possible.
+ There should be avoidance of back tracking of sterile goods.
+ There should be a continuous flow of equipment from the receiving counter to the
dispensing counter.
+ The contamination of sterile goods should be avoided.
+ Sterilizing area should be the last area before the sterile storage and dispensing counter.
+ The receipt and issue counters are separated by a corridor to avoid contamination.

Separation of sterilized items by a partition or corridor

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
entrance
10.50
lockers
7.00
Staff change room
7.00
Dirty receipt and disassembly
7.00
Washing, disinfection and decontamination
17.50
assembly
10.50
Linen processing
10.50
sterilization
14.00
Sterile storage
21.00
distribution
10.50
Counter of receipt of
used items
Decontamination and
cleaning area
Processing
Packing of items

Sterilization Sterilized items store Distribution point
Trolley wash
7.00
Trolley bay
10.50
Bulk store
17.50
Duty room
3.50
toilet
3.50
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 160-180
0
c 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 90
0
c 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.

iv. Quality control methods:
- Routine temperature/pressure and holding time testing of each autoclave.
- Steam clox is also very handy and reliable. Changes color from brown to green
- Heat/time, moisture sensitive tapes may be used in same way as that of steam
clox
- Random samplings of sterilized items are also tested in laboratory
- Culture of wall/floor and scrapings.

Laundry services:
Functions of laundry:
+ Control of cross infection: it reduces the chances of cross infection.
+ Patient satisfaction: the patient likes to have clean linen which is changed and washed
frequently and has a psychological effect on patient.
+ Public relation: the image of hospital also depends on clean look of linen as it instills
confidence in patients and relatives.
Types of laundry:
a. In-plant or in-house laundry: in this system, the hospital has its own linen and laundry
and all activities of the hospital laundry services are done in hospital premises. A hospital
with more than 100 beds can run this type of laundry services.
b. Rental system: this system is used in advanced western countries. The owner of the linen
is also the supplier of linens to the hospitals and is also responsible for the replacement as
well as the laundering of patients and staff linen.
c. Contract system: in India, all hospitals have their own linen, majority of the hospitals get
the laundering done by contract dhobis. In some cases, a subsidized contract type is
prevalent and in some cases, the hospitals provide water and washing area within the
hospital premises.
d. Co-operative system: it is most beneficial to the smaller hospitals than the large hospitals
as they share the service of highly qualified laundry services.
Planning and organization of laundry services:
Location: if possible, the laundry should be in the same building as the hospital, and should have
separate entrance and exit areas. It is recommended to have a mechanized laundry in the
basement, with proper drainage arrangements.
Space requirements:
The requirement for any laundry services has been worked out to be approx. 10-15 sq.ft./bed.
No.of beds Space
200-300 beds 3750 sq.ft.
300-500 beds 5670 sq.ft.
500-600 beds 6460 sq.ft.
>650 beds 8210 sq.ft.

Floor area/space requirement:
According to Dr. Mc Gibony, the area for a laundry for a teaching hospital in India should be at
least 5800 sq.ft.
Physical layout:
1. Straight through flow: the planning of the building and installation of equipment in a
straight flow from the dirty end to the clean end.
2. U-flow: where the dirty and clean ends are in the same direction.
3. Gravity flow: this takes advantage of the underground, with dirty end at the top and clean
end at the bottom.
Laundry is divided into two distinct areas:
Dirty area: it comprises of
Reception of solid linen
Sorting of soiled linen into suitable quantities for processing
Clean area: it comprises of
drying
finishing
discharge
a barrier wall between the clean and dirty area is desirable

Schematic design of functional areas:

Reception of dirty
linen and storage
room
Decontamination and sluice
room
Boiler room
Toilet Washer
Laundry
manager
Staff room
Store of
detergent
Store of spare
linen
Linen mending Hydro extractor
Issue area Storage of
clean linen
Pressing and
laundering
Drier
Ancillaries:
Laundry managers office
Stores
Tailoring bay
Workers rest room
Toilet
Boiler room
Material and decor:
The route of soiled linen from the using points to the laundry and the flow of clean linen
from laundry to the using points should be planned as to minimize the possibility of
contamination of clean linen.
The laundry should be grouped into specific separate areas.
Laundry managers office should be located as centrally as possible to properly supervise
the entire laundry operations.
The walls should have large vision panels to allow full view of each area.
A toilet, locker and shower facilities should be provided in the soiled linen receiving,
sorting and washer loading room and clean linen processing room.
Supply storage room should be adjacent and connected to the soiled linen receiving,
sorting and washer loading room.
Sufficient space should be provided for the storage of one weeks supply of detergents,
bleaches and others.
The floor for the laundry should have smooth, slip resistant and water proof surface, the
walls should have a smooth washable surface free from all corners, edges or projections
which create maintenance problems.
Utility services like piping, electrical wiring should be designed and sized with
appropriate consideration for future expansion.
The steam supply system should be designed to deliver steam to the equipment in right
quantity at a desired temperature.
Hot water should be available at 180
0
F by the pipeline to the laundry at the required
temperature from the boiler room.
The power supply to the laundry is usually 220 or 440 volts in three phases , four wire
alternative system and must be accessible
Lighting should be free of glare and shadows.
Fire extinguishers should be located in the laundry near the clean linen and the processing
areas.
There is a need for flow of drains in the sorting and washing areas.
Ventilation system must be able to provide a comfortable environment for the workers.
Sewing and mending room should be located near to the clean linen and pack preparation
room.

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:
Category of employees Beds
100 200 300 500 750
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
Fig. 1 shows staff requirement
Location and space requirement:
Location: the dietary department should be located on the ground floor near wards where the
diets need to be taken and also accessible to road as supplies are to be carried to storage area.

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.
Office store
keeper
They are further divided based on temperature requirements:
+ items to be stored at room temperature like onion, potato etc
+ Items require cool temperature (8-10
0
c is maintained) for which walk-in cooler
can be provided to store milk, eggs, butter etc.
+ Deep fridge where temperature is below 0
0
c 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.

Fig 2. - The figure explains the layout of kitchen

Walk-in cold
store
Dry store Fresh store Recipient area of
provisioning
Preparation area Dry store
Cooking area
Trolley+ pot wash
area
Distribution area and service
Wards
Dietician
Supervisor
Staff room
Staff toilet
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
0
c, 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.

Planning and organizational considerations:
1. Location: there are two essential location requirements:
- It must be on ground floor and easily accessible to both ambulatory and ambulance
patients, and there should be minimal separation between it and radiology department.
- Secondly, the emergency department should have ready access to the acute patient care
areas, eg. Operation theatre, ICU, blood bank etc.
Emergency department must be designed; usually 1000 sq.ft is required for daily patient load of
100 patients.
2. Stretcher, trolley, wheelchair store: a store for stretcher, trolley and wheelchairs should
be located adjacent to the entrance.
3. Ambulance attendants, police, mass media room: an equipped room of about 10 m
2
near
the entrance hall with attached toilet serves the needs of above personnel.
4. Work area: it should be spacious with enough room for personnel and patients.
5. Waiting area for emergency department patients: the main function of this is to be the
passageway to patient examination and treatment area.
6. Waiting area for relatives: patient relatives should not be allowed in the work areas of
emergency department. Waiting room with recreational facilities may be provided.
7. Visitors toilet: it should be provide near the main waiting space.
8. Nurses station and administrative office: this should be next to the entrance and manned
on 24 hr. basis. It should be provided with multiple telephones, bulletin board with duty
roster of doctors on call and directive pertaining to the emergency department should be
displayed. Nurses work room should be well stocked with drugs, IV fluids.
9. Examination and treatment area: this area should always be in readiness to receive
patients at all times, and should consist of a large room and number of separate smaller
rooms for examination and treatment. It should be well illuminated space with oxygen
supply, resuscitation equipment, suction, portable X-ray, electrocardiographs, and
Boyles apparatus.
10. Equipment:
+ Stretchers
+ On-the wall oxygen unit
+ On-the wall suction unit
+ BP apparatus, otoscope, stethoscope, opthalmoscope etc.
+ Spot lights
+ Utility table
+ Airways and resuscitation bags
11. Resuscitation room: the patient is to be stabilized in this room before shifting to treatment
or recovery room, or to ICU or nursing unit. It should be well equipped with resuscitation
equipment, ECG machine and X-ray viewing screening with facility for performing
minor operative procedures.
12. Operation room: a self sufficient operation room to serve patients who need minor
surgery and no admission or who are critically ill etc. in emergency department.
13. Fracture room: a separate fracture room equipped similar to OT and additional facilities
for reduction of closed fractures under local anesthesia can be planned with hospitals
with turnover of emergency patients in excess of 15,000 per annum.
14. Plaster room: it is needed for treatment of fractures and application plasters.
15. Care of burns: a separate room with 20 m
2
area should be reserved for immediate care of
burn patients. An observation ward of about 6-8 beds for patients to be kept under
observation overnight or 24 hrs.
16. Isolation room: for obstetric patients, pediatric patients.
17. Other rooms: these should be planned based on the local needs:
+ Room for dead bodies
+ Pantry-7 m
2

+ Storage space
+ Utility and soiled linen room-7 m
2

+ Cleaners room-house keepers room 4m
2

+ Change room duty rooms 9m
2

+ Conference room and reference library 8m
2

Staffing pattern:
- Full time emergency physicians, especially trained in emergency medicine
- A well staffed emergency department needs 8 nurse shifts of 8 hours each per 100
daily patients visits. Additional staff nurses is required if there is observation
ward attached.
- For registration and records, usually 3 clerks work in day and afternoon shift,
and one during night.
- Security should be available round the clock
- Public relations and social worker should be available to take care of the anxious
and disturbed patients and their relatives.
Medico-legal aspects of emergency department:
a. Negligence: it is the breach of duty owed by a doctor to his patients to exercise
reasonable care/skills resulting in some bodily, mental or financial disability.
b. Duty to treat all: according to the recent supreme court decision, no doctor can refuse
giving first aid treatment to accident victims or any other patients.
c. Problem areas in emergency department:
Consent to treatment: a written consent must be obtained from the patient to treat
him, with the patients knowledge regarding procedures.
Medical records: medical records and proper record keeping are high priority in
any hospital. Proper documentation of patients case history with informed
consent is necessary.
Reporting to authorities: all medico-legal cases e.g. Assault and battery, child
abuse, accidents etc. Should be reported to proper authorities e.g. Police. The
cases of AIDS and venereal diseases should be reported to health authorities.

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 hospitals 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.

ORDERLY FLOW OF CASUALITY: It is important to minimize confusion in receiving
causalities. A team of well qualified physician and nurses at the reception itself sorts out
causalities and make quick decisions of the treatment.
i. Additional nursing staff volunteers may be called and posted.
ii. Services of all departments of the hospital should be well integrated in the disaster plan
viz. dietary department, laundry, public works department (PWD), engineering unit, etc.
iii. The planning should also take into consideration other aspects like traffic control, types of
medical records to be maintained, standardization of emergency medical tags, public
information centers, controlled dissemination of information without or with minimum
distortion, preparation of emergency supplies kept ready, all ambulance kept ready,
arrangement of additional vehicles.

COMMUNICATION SYSTEM: Additional communication system should be planned. It is
also important to keep the hospital informed about the inflow of the casualties from the scene.
THE DISASTER MANAGEMENT CYCLE
1. DISASTER EVENT: This refers to the REAL TIME event of the hazard occurring and
affecting elements of risk.
2. RESPONSE AND RELIEF: This refers to the first stage response to any calamity, which
include setting up control rooms, putting the contingency plan in action, issue warnings,
evacuating people to safe areas, rendering medical aid to the needy, etc.
3. RECOVERY: It has three overlapping phases of emergency relief rehabilitation and
reconstructing.
4. DEVELOPMENT: Evolving economy and long-term prevention/disaster reduction
measures like construction of houses capable of withstanding the onslought of heavy rains,
wind speeds and shocks of earthquakes.
5. REDUCTION AND MITIGATION: Protective or preventive actions that lessons the scale
of impact. Minimizing the effects of disaster. Eg. building codes and zoning, vulnerability
analyses, public education.
6. PREPAREDNESS: Includes the formulation and development of viable emergency plans,
of the warning system, the maintenance of inventories and the training of personnel.
DISASTER
IMPACT
RESPONSE
RECOVERY
DEVELOPMENT PREVENTION
MITIGATION
PREPAREDNESS

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 whos 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

3. DELAYED OR MEDIUM PRIORITY:
- Delayed patients may have injuries that span a wide range
- They may have severe internal injuries, but are still compensating

Delayed patients have:
- Respirations under 30/minutes
- Capillary refill under 2 seconds
- Can do-follow simple commands

4. MINOR OR MINIMAL OR AMBULATORY PATIENTS
Patients with minor lacerations, contusions, sprains, superficial burns are identified as
minor/minimal
5. EXPECTANT OR LEAST PRIORITY
Morbid patients who require a great deal of attention with questionable benefit have the
lowest priority.
Patients with whom there are signs of impending death or massive injuries with poor
likelihood of survival are labeled as expectant

Color code
Red indicate high priority treatment or transfer
Yellow signals medium priority
Green indicate ambulatory patients
Black indicates dead or moribund patients

HOSPITAL DISASTER PLAN
The hospital is an integral part of the society and it has great role to play in the disaster
management. Every hospital big or small, public or private has to prepare a disaster plan, and
must learn to activate the disaster plan at the hour of need. Disasters in the hospital perspective
can be grouped into two categories:
1. Internal Hospital disasters like fire, building collapse, terrorism, etc
2. External disasters like earthquakes, floods, etc
OBJECTIVES OF HOSPITAL DISASTER PLAN
1. Preparedness of staff, optimising of resources and mobilisation of the logistics and
supplies within short notice
2. To make community aware about the hospital disaster plan and benefits of plan
3. Training and motivation of the staff
4. To carry out mock drills
5. Documentation of the plan and making hospital staff aware about the various steps of the
plan
DESIGNING OF HOSPITAL DISASTER PLAN
1. Disaster management committee:
The hospital disaster management committee is the decision making body for formulation of
the policy and plan for disaster management. It constitutes the following members.
a. Director of the hospital
b. HOD of accidents and emergency services
c. All heads of the departments
d. Nursing superintendent
e. Hospital administrator
f. Representatives of the staff

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 victims
potential for survival.
o Higher priority is always given to victims 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
for health
Staffing
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
Organization is the formal structure of authority calculated to define, distribute and
provide for the co-ordination of the tasks as contribution to the whole. When the aims of the
organization properly design the planning of its institutions and its functional standard, it will
have identified the kind and numbers of personnel it needs.
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).
NMIS includes these five elements;
1. Quality of patient care to be delivered and its measurement.
2. Characteristics and care requirements of patients.
3. Prediction of the supply of nurse power required for components 1 &2.
4. Logistics of the staffing program pattern and its control.
5. Evaluation of the quality of care desired, thereby measuring the success of the staffing
itself.
Philosophy of staffing in nursing
Nurse administrators of a hospital nursing department might adopt the following philosophy.
1. Nurse administrators believe that it is possible to match employees knowledge and
skills to patient care needs in a manner that optimizes job satisfaction and care
quality.
2. Nurse administrators believe that the technical and humanistic care needs of critically
ill patients are complex that all aspects of that care should be provided by
professional nurses.
3. Nurse administrative believe that the health teaching and rehabilitation needs of
chronically ill patients are so complex that direct care for chronically ill patients
should be provided by professional and technical nurses.
4. Should believe that believe that patient assessment, work quantification and job
analysis should be used to determine the number of personnel in each category to be
assigned to care for patients of each type (such as coronary care, renal failure, etc.,).
5. Should believe that a master staffing plan and policies to implement the plan in all
units should be developed centrally by the nursing heads and staff of the hospital.
6. Should the staffing plan should be administrated at the unit level by the head nurse, so
that can change based on unit workload and workflow.
Objectives of staffing in nursing
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.
NORMS OF STAFFING(S I U- staff inspection unit)
Norms
Norms are standards that guide, control, and regulate individuals and communities. For
planning nursing manpower we have to follow some norms. The nursing norms are
recommended by various committees, such as; the Nursing Man Power Committee, the High-
power Committee, Dr. Bajaj Committee, and the staff inspection committee, TNAI and INC. The
norms has been recommended taking into account the workload projected in the wards and the
other areas of the hospital.
All the above committees and the staff inspection unit recommended the norms for
optimum nurse-patient ratio. Such as 1:3 for Non Teaching Hospital and 1:5 for the Teaching
Hospital. The Staff Inspection Unit (S.I.U.) is the unit which has recommended the nursing
norms in the year 1991-92. As per this S.I.U. norm the present nurse-patient ratio is based and
practiced in all central government hospitals.
Recommendations of S.I.U:
1. The norms for providing staff nurses and nursing sisters in Government hospital is given
in annexure to this report. The norm has been recommended taking into account the
workload projected in the wards and the other areas of the hospital.
2. The posts of nursing sisters and staff nurses have been clubbed together for calculating
the staff entitlement for performing nursing care work which the staff nurse will continue
to perform even after she is promoted to the existing scale of nursing sister.
3. Out of the entitlement worked out on the basis of the norms, 30%posts may be sanctioned
as nursing sister. This would further improve the existing ratio of 1 nursing sister to 3.6.
staff nurses fixed by the government in settlement with the Delhi nurse union in may
1990.
4. The assistant nursing superintendent are recommended in the ratio of 1 ANS to every 4.5
nursing sisters. The ANS will perform the duty presently performed by nursing sisters
and perform duty in shift also.
5. The posts of Deputy Nursing Superintendent may continue at the level of 1 DNS per
every 7.5 ANS
6. There will be a post of Nursing Superintendent for every hospital having 250 or beds.
7. There will be a post of 1 Chief Nursing Officer for every hospital having 500 or more
beds.
8. It is recommended that 45% posts added for the area of 365 days working including 10%
leave reserve (maternity leave, earned leave, and days off as nurses are entitled for 8 days
off per month and 3 National Holidays per year when doing 3 shift duties).
Most of the hospital today is following the S.I.U.norms. In this the post of the Nursing Sisters
and the Staff Nurses has been clubbed together and the work of the ward sister is remained same
as staff nurse even after promotion. The Assistant Nursing Superintendent and the Deputy
Nursing Superintendent have to do the duty of one category below of their rank.

BAJAJ COMMITTEE, 1986
An "Expert Committee for Health Manpower Planning, Production and Management"
was constituted in 1985 under Dr. J.S. Bajaj, the then professor at AIIMS.
Manpower is one of the most vital resources for the labour intensive health services industry.
Health for all (HFA) can be achieved only by improving the utilization of these resources.
Major recommendations are:-
1. Formulation of National Medical & Health Education Policy.
2. Formulate on of National Health Manpower Policy.
3. Establishment of an Educational Commission for Health Sciences (ECHS) on the lines of
UGC.
4. Establishment of Health Science Universities in various states and union territories.
5. Establishment of health manpower cells at centre and in the states.
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.
7. Carrying out a realistic health manpower survey.
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

7. For intensive units 1:8 (1:3 for each shift)
(8 beds ICU/200 beds) + 30% leave reserve

8. For specialized deptts and
clinics, OT, Labour room 8:200 + 30% leave reserve

Community Nursing Service
Projected population - 991,479,200 (medium assumption) by 2000 AD
1 Community Health Centre - 1,000,00 population
1 Primary Health Services - 30,000 population in plain area
1 Primary Health Services - 20,000 population in difficult areas
1 Sub-centre - 5000 population in plain area
1 Sub-centre - 3000 population for difficult area

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.

HIGH POWER COMMITTEE ON NURSING AND NURSING PROFESSION (1987-
1989)
High power committee on nursing and nursing profession was set up by the Government
of India in July 1987, under the chairmanship of Dr. Jyothi former vice-chancellor of SNDT
Women University, Mrs. Rajkumari Sood, Nursing Advisor to Union Government as the
member-secretary and CPB Kurup, Principal, Government College of Nursing, Bangalore and
the then President. TNAI is also one among the prominent members of this committee. Later on
the committee was headed by Smt. Sarojini Varadappan, former Chairman of Central Social
Welfare Board.
The terms of reference of the Committee are:
To look into the existing working conditions of nurses with particular reference to the
status of the nursing care services both in the rural and urban areas.
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.
To look into the training of all categories and levels of nursing, midwifery personnel to
meet the nursing manpower needs at all levels o health services and education.
To study and clarify the role of nursing personnel in the health care delivery system
including their interaction with other members of the health team at every level of health
service management.
To examine the need for organised nursing services at the national, state, district and
local levels with particular reference to the need for planning service with the overall
health care system of the country at the respective levels.
To look into all other aspects, the Committee will hold consultations with the State
Governments.
ECOMMENDATIONS OF HIGH POWER COMMITTEE ON NURSING AND
NURSING PROFESSION
Working conditions of nursing personnel
1. Employment
Uniformity in employment procedures to be made. Recruitment rules are made for all categories
of nursing posts. The qualifications and experience required or these be made thought the
country.
2. Job description
Job description of all categories of nursing personnel is prepared by the central government
to provide guidelines.
3. Working hours
The weekly working hours should be reduced to 40 hrs per week. Straight shift should be
implemented in all states. extra working hours to be compensated either by leave or by extra
emoluments depending on the state policy .nurses to be given weekly day off and all the gazetted
holidays as per the government rules.
4. Work load/ working facilities
Nursing norms for patient care and community care to be adopted as recommended by the
committee.
Hospitals to develop central sterile supply departments, central linen services, and central
drug supply system. Group D employees are responsible for housekeeping department.
Policies for breakage and losses to be developed and nurses not are made responsible for
breakage and losses.
5. Pay and allowances
Uniformity of pay scales of all categories of nursing personnel is not feasible. However special
allowance for nursing personnel, i.e.; uniform allowance, washing, mess allowance etc should be
uniform throughout the country.
6. Promotional opportunities
The committee recommends that along with education and experience, there is a need to
increase the number of posts in the supervisory cadre, and for making provision of guidance and
supervision during evening and night shifts in the hospital.
-Each nurse must have 3 promotions during the service period.
-Promotion is based on merit cum seniority.
-Promotion to the senior most administrative teaching posts is made only by open selection.
-In cases of stagnation, selection grade and running scales to be given.
7. Career development
Provision of deputation for higher studies after 5 yrs of regular services be made by all
states. The policy of giving deputation to 5 -10 % of each category be worked out by each state.
8. Accommodation
As far as possible, the nursing staff should be considered for priority allotment of
accommodation near to work place. Apartment type of accommodation is built where
married/unmarried nurses can be allowed to live. Housing colonies for hospital s must be
considered in long run.
9. Transport
During odd hours, calamities etc arrangements for transport must be made for safety and security
of nursing personnel.
10. Special incentives
Scheme of special incentives in terms of awards, special increment for meritorious work for
nurses working in each state/district/PHC to be worked out.
11. Occupational hazards
Medical facilities as provided by the central govt. by extended by the state govt to nursing
personnel till such times medical services are provided free to all the nursing personnel. Risk
allowance to be paid to nursing personnel working in the rural $ urban area.
12. Other welfare services
Hospitals should provide welfare measures like crche facilities for children of working staff,
children education allowance, as granted to other employees, be paid to nursing personnel.
Additional Facilities for Nurses Working In the Rural Areas
Family accommodation at sub centre is a must for safety and security of ANM's /LHV.
Women attendant, selected from the village must accompany the ANM for visits to other
villages.
The district public health nurse is provided with a vehicle for field supervision.
Fixed travel allowance with provision of enhancement from time to time.
Rural allowance as granted to other employees is paid to nursing personnel.
NURSING EDUCATION
Nursing education to be fitted into national stream of education to bring about uniformity,
recognition and standards of nursing education. The committee recommends that;
1. There should be 2 levels of nursing personnel - professional nurse (degree level) and
auxiliary nurse (vocational nurse). Admission to professional nursing should be with 12 yrs
of schooling with science. The duration of course should be 4 yrs at the university level.
admission to vocational /auxiliary nursing should be with 10 yrs of schooling .The duration
of course should be 2 yrs in health related vocational stream.
2. All school of nursing attached to medical college hospitals is upgraded to degree level in a
phased manner.
3. All ANM schools and school of nursing attached to district hospitals be affiliated with
senior secondary boards.
4. Post certificate B.Sc. Nursing degree to be continued to give opportunities to the existing
diploma nurses to continue higher education.
5. Master in nursing programme to be increased and strengthened.
6. Doctoral programme in nursing have to be started in selected universities.
7. Central assistance be provided for all levels of nursing education institutions in terms of
budget( capital and recurring)
8. Up gradation of degree level institutions be made in a phased manner as suggested in report.
9. Each school should have separate budget till such time is phased to degree/vocational
programme. The principal of the school should be the drawing and the disbursing officer.
10. Nursing personnel should have a complete say in matters of selection of students. Selection
is based completely on merit. Aptitude test is introduced for selection of candidates.
11. All schools to have adequate budget for libraries and teaching equipments.
12. All schools to have independent teaching block called as School Of Nursing with adequate
class room facilities, library room, common room etc as per the requirements of INC.

Continuing Education and Staff Development
Definite policies of deputing 5-10% of staff for higher studies are made by each state.
Provision for training reserve is made in each institution.
Deputation for higher study is made compulsory after 5 yrs.
Each nursing personnel must attend 1 or 2 refresher course every year.
Necessary budgetary provision be made.
A National Institute for Nursing Education Research and Training needs to be established
like NCERT, for development of educational technology, preparation of textbooks, media, /
manuals for nursing.

NURSING SERVICES: HOSPITALS/INSTITUTIONS (URBAN AREAS)
Definite nursing policies regarding nursing practice are available in each institution.
These policies include:
a) Qualification/recruitment rules
b) Job description/job specifications
c) Organizational chart of the institutions
d) Nursing care standards for different categories of patients.
1. Staffing of the hospitals should be as per norms recommended.
2. District hospitals /non teaching hospitals may appoint professional teaching nurses in the
ratio of 1; 3 as soon as nurses start qualifying from these institutions.
3. Students not to be counted for staffing in the hospitals
4. Adequate supplies and equipments, drugs etc be made available for practice of nursing. The
committee strongly recommends that minimum standards of basic equipment needed for
each patient be studied , norms laid down and provided to enable nurses to perform some
of the basic nursing functions . Also there should be a separate budget head for nursing
equipment and supplies in each hospitals/ PHC. The NS and PHN should be a member of
the purchase and condemnation committee.
5. Nurses to be relieved from non -nursing duties.
6. Duty station for nurses is provided in each ward.
7. Necessary facilities like central sterile supplies, linen, drugs are considered for all major
hospitals to improve patient care. Also nurses should not be made to pay for breakage and
losses. All hospitals should have some systems for regular assessment of losses.
8. Provision of part time jobs for married nurses to be considered. (min 16-20hrs/week)
9. Re-entry by married nurses at the age of 35 or above may also be considered and such
nurse be given induction courses for updating their knowledge and skills before
employment.
10. Nurses in senior positions like ward sisters, Asst. nursing superintendents, Deputy NS;
N.S must have courses in management and administration before promotions.
11. Nurses working in speciality areas must have courses in specialities. Promotion
opportunities for clinical specialities like administrative posts are considered for
improving quality nursing services.
The committee recommends that Gazetted ranks be allowed for nurses working as ward sister
and above (minimum class II gazetted). Similarly the post of Health Supervisor (female) is
allowed gazetted rank and district public health nurse be given the status equal to district
medical/ health officers.
Community Nursing Services
Appointment of ANM/LHV to be recommended.
- 1 ANM for 2500 population (2 per sub centre)
- 1 ANM for 1500 population for hilly areas
- 1 health supervisor for 7500 population (for supervision of 3 ANM's)
- 1 public health nurse for 1 PHC (30000 population to supervise 4 Health
Supervisors)
- 1 Public Health Nursing Officer for 100000 population (community health centre)
- 2 district public health nursing for each district.
ANM/LHV promoted to supervisory posts must undergo courses in administration and
management.
Specific standing orders are made available for each ANM/LHV to function effectively in
the field.
Adequate provision of supplies, drugs etc are made.
Norms recommended for nursing service and education in hospital setting.
1. Nursing Superintendent -1: 200 beds (hospitals with 200 or more beds).
2. Deputy Nursing Superintendent. - 1: 300 beds ( wherever beds are over 200)
3. Assistant Nursing Superintendent - 1: 100
4. Ward sister/ward supervisor - 1:25 beds 30% leave reserve
5. Staff nurse for wards -1:3 ( or 1:9 for each shift ) 30% leave reserve
6. For nurses OPD and emergency etc - 1: 100 patients ( 1 bed : 5 out patients) 30% leave
reserve
7. For ICU -1:1(or 1:3 for each shift) 30% leave reserve
For specialized departments such as operation theatre, labour room etc- 1: 25 30% leave reserve.

INDIAN NURSING COUNCIL (INC)
The Indian Nursing Council is an Autonomous Body under the Government of India and
was constituted by the Central Government under the Indian Nursing Council Act, 1947 of
parliament. It was established in 1949 for the purpose of providing uniform standards in nursing
education and reciprocity in nursing registration throughout the country. Nurses registered in one
state were not registered in another state before this time. The condition of mutual recognition by
the state nurses registration councils, called reciprocity was possibly only if uniform standards of
nursing education were maintained.
Functions of Indian Nursing Council.

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:
Staff nurse Sister(each
shift)
Departmental sister/ assistant nursing
superintendent
Medical ward 1:3 1:25 1 for 3-4 weeks
Surgical ward 1:3 1:25 1 for 3-4 weeks
Orthopedic ward 1:3 1:25 1 for 3-4 weeks
Pediatric ward 1:3 1:25 1 for 3-4 weeks
Gynecology ward 1:3 1:25 1 for 3-4 weeks
Maternity ward
including newborns
1:3 1:25 1 for 3-4 weeks
ICU 1:1(24 hours) 1
CCU 1:1(24 hours) 1
Nephrology 1:1(24 hours) 1 1 department sister/assistant nursing
superintendent for 3-4 units clubbed
together
Neurology & and
neurosurgery
1:1(24 hours) 1
Special wards- eye,
ENT etc.
1:1(24 hours) 1
Operation theatre 3 for 24 hours
per table
1 1 department sister/asst nursing
superintendent for 4-5 operating
rooms
Casuality and
emergency unit
2-3 staff nurses
depending on the
number of beds
1 1 department sister/assistant nursing
superintendent

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

For B.Sc. and M.Sc. nursing:
Annual intake of 60 students for B.Sc. (N) and 25 for M.Sc. (N) programme

B.Sc. (N) M.Sc. (N)
Professor cum principal
1
Professor cum vice
principal
1
Reader/Associate
professor
1 2
Lecturer
2 3
Tutor/clinical instructor
19
Total
24 5
One in each specialty and all the M.Sc. (N) qualified teaching faculty will participate in both
programmes.
Teacher-student ratio = 1:10
GNM and B.Sc. (N) with 60 annual intake in each programme
1
Professor cum vice
principal
1
Reader/Associate
professor
1
Lecturer
4
35
Total
42
Basic B.Sc. (N)

Admission capacity
Annual intake
40-60 61-100
1 1
Professor cum vice
principal
1 1
Reader/Associate
professor
1 1
Lecturer
2 4
19 33
Total
24 40

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:
1.
Microbiology
2.
Bio-chemistry
3.
Sociology.
4.
Bio-physic
5.
Psychology
6.
Nutrition
7.
English
8.
Computer
9.
Hindi/Any other language
10.
Any other- clinical discipliners
11.
Physical education

The above teachers should have post graduate qualification with teaching experience in
respective area
School of nursing-B
Qualification of teaching staff-
1.
M.Sc. (N) with 3 years of teaching experience or B.Sc.(N)
basic or post basic with 5 years of teaching experience.
2.
Professor cum vice
principal
M.Sc. (N) or B.Sc. (N) (Basic)/Post basic with 3 years of
teaching experience.
3.
M.Sc. (N) or B.Sc. (N) (Basic) / Post basic or diploma in
nursing education and Administration with two years of
professional experience.

For School of nursing with 60 students i.e. an annual intake of 20 students:
Teaching faculty
No. required
Principal
1
Vice-principal
1
Tutor
4
Additional tutor for interns
1
Total
7
Teacher student ratio should be 1:10 for student sanctioned strength

ESTIMATION OF NURSING STAFF REQUIRMENTS- ACTIVE ANALYSIS AND
RESEARCH STUDIES

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 patients 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
Area of care Category I Category II Category III Category IV
Eating Feeds self Needs some help in
preparing
Cannot feed self
but is able to
chew and
swallowing
Cannot feed self
any may have
difficulty
swallowing
Grooming Almost entirely self
sufficient
Need some help in
bathing, oral
hygiene
Unable to do
much for self
Completely
dependent
Excretion Up and to bathroom
alone
Needs some help in
getting up to
bathroom /urinal
In bed, needs
bedpan / urinal
placed;
Completely
dependent
Comfort Self sufficient Needs some help
with adjusting
position/ bed..
Cannot turn
without help, get
drink, adjust
position of
extremities
Completely
dependent
General
health
Good Mild symptoms Acute symptoms Critically ill
Treatment Simple
supervised, simple
dressing
Any Treatment
more than once per
shift, foley catheter
care, I&O.
Any treatment
more than twice
/shift
Any elaborate/
delicate procedure
requiring two
nurses, vital signs
more often than
every two hours..
Health
education
and teaching
Routine follow up
teaching
Initial teaching of
care of ostomies;
new diabetics;
patients with mild
adverse reactions to
their illness
More intensive
items; teaching of
apprehensive/
mildly resistive
patients.
Teaching of
resistive patients,

Calculating Staffing Needs
The following are the hours of nursing care needed for each level patient per shift:
Category I Category II Category III Category IV
NCHPPD for
Day shift
2.3 2.9 3.4 4.6
NCHPPD for
P.M (Evening)
shift
2.0 2.3 2.8 3.4
NCHPPD for
night shift
0.5 1.0 2.0 2.8

A guide to staffing nursing services
1. Projecting Staffing Needs
Some steps to be taken in projecting staffing needs include:
1. Identify the components of nursing care and nursing service.
2. Define the standards of patient care to be maintained.
3. Estimate the average number of nursing hours needed for the required hours.
4. Determine the proportion of nursing hours to be provided by registered nurses and
other nursing service personnel
5. Determine polices regarding these positions and for rotation of personnel.
2. Computing number of nurses required on a Yearly Basis
1. Find the total number of general nursing hours needed in one year. Average patient
census X average nursing hours per patient for 24 hours X days in week X weeks in
year.
2. Find the number of general nursing hours needed in one year which should be given
by registered nurses and the number which should be given by ancillary nursing
personnel.
a. Number of general nursing hours per year X percent to be given by registered
nurses.
b. Number of general nursing hours per year X percent to be given be ancillary
nursing personnel.

Computing number of nurses assigned on weekly basis
1. Find the total number of general nursing hours needed in one week. Average patient
censes X average nursing hours per patient in 24 hours X days in week.
2. Find the number of general nursing hours needed in the week which should be given by
registered nurses and the number which could be given by ancillary nursing personnel.
a. Number of general nursing hours per week X percent to be given by registered
nurses.
b. Number of general nursing hours per week X percent to be given by ancillary nurses.

One method for determining the nursing staff of a hospital
1. To determine the number of nursing staff for staffing a hospital involves establishing the
number of work days available for service per nurse per year.
Example: Analysis of how the days are used;
Days in the year 365
Days off 1 day/week 52
Casual leave 12
Privilege leave 30
1 Saturday /month 12
Public Holidays 18
Sick Leave 8
Total non-working days 132
Total working days /nurse/year 233
So 1 nurse = 233 working days /year
Example, 20 nurse means 20X233= 4660 hours
4660/365= 12.8 (13).
2. Work load measurement tools
Requirement for staffing are based on whatever standard unit of measurement for
productivity is used in a given unit. A formula for calculating nursing care hours per
patient day (NCH/PPD) is reviewed.

NCH/PPD = Nursing hours worked in 24 hours

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, nurses 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 systems 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

16/18.03= 88.74% budget adequacy.

Nurse Staffing, Models of Care Delivery, and Interventions
Nurse Staffing
Measure
Definition
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
hours per patient day
All staff or all hours of care including RN, LVN, aides counted per
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
patient day
RN or LVN full time equivalents per patient day (an FTE is 2080 hours
per year and can be composed of multiple part-time or one full-time
individual)
Nursing skill (or
staff) mix
The proportion or percentage of hours of care provided by one category
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)
Nursing Care
Delivery Models
Definition
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
Nursing Care
A model that generally uses an all-RN staff to provide all direct 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
Nursing Care
A model using the RN as a team leader and LVNs/UAPs to perform
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
Environment/Shared
governance
Characterized as "good places for nurses to work" and includes a high
degree of RN autonomy, MD-RN collaboration, and RN control of
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, Hpital Ambroise Par, 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-Hpitaux 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.

2. THE IMPACT OF NURSING GRADE ON THE QUALITY AND OUTCOME OF
NURSING CARE.
Carr-Hill RA, Dixon P, Griffiths M, Higgins M, McCaughan D, Rice N, Wright K.
Centre for Health Economics, University of York, UK.
Abstract
The large industry which has grown up around the estimation of nursing requirements for a ward
or for a hospital takes little account of variations in nursing skill; meanwhile nursing researchers
tend to concentrate on the appropriate organisation of the nursing process to deliver best quality
care. This paper, drawing on a Department of Health funded study, analyses the relation between
skill mix of a group of nurses and the quality of care provided. Detailed data was collected on 15
wards at 7 sites on both the quality and outcome of care delivered by nurses of different grades,
which allowed for analysis at several levels from a specific nurse-patient interaction to the shift
sessions. The analysis shows a strong grade effect at the lowest level which is 'diluted' at each
succeeding level of aggregation; there is also a strong ward effect at each of the lower levels of
aggregation. The conclusion is simple; you pay for quality care.
PMID: 7780528 [PubMed - indexed for MEDLINE]

3. IMPACT OF SHIFT WORK ON THE HEALTH AND SAFETY OF NURSES AND
PATIENTS.
Berger AM, Hobbs BB.
College of Nursing, University of Nebraska Medical Center, Omaha, USA. aberger@unmc.edu
Abstract
Shift work generally is defined as work hours that are scheduled outside of daylight. Shift work
disrupts the synchronous relationship between the body's internal clock and the environment.
The disruption often results in problems such as sleep disturbances, increased accidents and
injuries, and social isolation. Physiologic effects include changes in rhythms of core temperature,
various hormonal levels, immune functioning, and activity-rest cycles. Adaptation to shift work
is promoted by reentrainment of the internally regulated functions and adjustment of activity-rest
and social patterns. Nurses working various shifts can improve shift-work tolerance when they
understand and adopt counter measures to reduce the feelings of jet lag. By learning how to
adjust internal rhythms to the same phase as working time, nurses can improve daytime sleep and
family functioning and reduce sleepiness and work-related errors. Modifying external factors
such as the direction of the rotation pattern, the number of consecutive night shifts worked, and
food and beverage intake patterns can help to reduce the negative health effects of shift work.
Nurses can adopt counter measures such as power napping, eliminating overtime on 12-hour
shifts, and completing challenging tasks before 4 am to reduce patient care errors.

4. NURSE STAFFING AND PATIENT, NURSE, AND FINANCIAL OUTCOMES.
Unruh L.
Department of Health Professions, University of Central Florida, Orlando, FL, USA.
lunruh@mail.ucf.edu
Abstract
Because there's no scientific evidence to support specific nurse-patient ratios, and in order to
assess the impact of hospital nurse staffing levels on given patient, nurse, and financial
outcomes, the author conducted a literature review. The evidence shows that adequate staffing
and balanced workloads are central to achieving good outcomes, and the author offers
recommendations for ensuring appropriate nurse staffing and for further research.
Policy Polit Nurs Pract. 2009 Nov;10(4):240-51.

5. AN APPLIED SIMULATION MODEL FOR ESTIMATING THE SUPPLY OF AND
REQUIREMENTS FOR REGISTERED NURSES BASED ON POPULATION HEALTH
NEEDS.
Tomblin Murphy G, MacKenzie A, Alder R, Birch S, Kephart G, O'Brien-Pallas L.
Dalhousie University, Halifax, Nova Scotia, Canada, University of Toronto, Toronto, Ontario,
Canada. gail.tomblin.murphy@dal.ca
Abstract
Aging populations, limited budgets, changing public expectations, new technologies, and the
emergence of new diseases create challenges for health care systems as ways to meet needs and
protect, promote, and restore health are considered. Traditional planning methods for the
professionals required to provide these services have given little consideration to changes in the
needs of the populations they serve or to changes in the amount/types of services offered and the
way they are delivered. In the absence of dynamic planning models that simulate alternative
policies and test policy mixes for their relative effectiveness, planners have tended to rely on
projecting prevailing or arbitrarily determined target provider-population ratios. A simulation
model has been developed that addresses each of these shortcomings by simultaneously
estimating the supply of and requirements for registered nurses based on the identification and
interaction of the determinants. The model's use is illustrated using data for Nova Scotia,
Canada.
J Public Health Manag Pract. 2009 Nov;15(6 Suppl):S56-61.

6. HEALTH HUMAN RESOURCES PLANNING AND THE PRODUCTION OF
HEALTH: DEVELOPMENT OF AN EXTENDED ANALYTICAL FRAMEWORK FOR
NEEDS-BASED HEALTH HUMAN RESOURCES PLANNING.
Birch S, Kephart G, Murphy GT, O'Brien-Pallas L, Alder R, MacKenzie A.
Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario,
Canada. birch@mcmaster
Comment in:
J Public Health Manag Pract. 2009 Nov;15(6 Suppl):S62-3.

Abstract
Health human resources planning is generally based on estimating the effects of demographic
change on the supply of and requirements for healthcare services. In this article, we develop and
apply an extended analytical framework that incorporates explicitly population health needs,
levels of service to respond to health needs, and provider productivity as additional variables in
determining the future requirements for the levels and mix of healthcare providers. Because the
model derives requirements for providers directly from the requirements for services, it can be
applied to a wide range of different provider types and practice structures including the public
health workforce. By identifying the separate determinants of provider requirements, the
analytical framework avoids the "illusions of necessity" that have generated continuous increases
in provider requirements. Moreover, the framework enables policy makers to evaluate the basis
of, and justification for, increases in the numbers of provider and increases in education and
training programs as a method of increasing supply. A broad range of policy instruments is
identified for responding to gaps between estimated future requirements for care and the
estimated future capacity of the healthcare workforce.

RECRUITMENT CREDENTIALING, SELECTION, LACEMENT& RETENTION
RECRUITMENT
INTRODUCTION:
Recruitment is an important function of health manpower management, which
determines, whether the required will be available at the work spot, when a job is actually to be
undertaken. Recruitment procedures include the process and the methods by which vaccines are
notified, post are advertised, applications are handled and screened, interviews are conducted and
appointments are made.
MEANING:
In a simple term, recruitment is understood as the process of searching for and obtaining
applicants for job, from among whom the right people can be selected.
DEFINITION:
1. According to B Flippo: Recruitment is defined as the process of searching for prospective
employees and stimulating them to apply foe job in the organization.
2. According to IGNOU Module: It is a process in which the right person for the right post is
procured.
3. According to Yoder: Recruitment is a process to discover the sources of manpower to
meet the requirements of the staffing schedule and to employ effective measures for
attracting that manpower in adequate numbers to facilitate effective selection of an efficient
working force.

TYPES OF RECRUITMENT:
There are three types of recruitment:
1. Planned: arise from changes in organization and recruitment policy
2. Anticipated: by studying trends in the internal and external organization.
3. Unexpected: arise due to accidents, transfer and illness.

LIKAGES OF REQUIREMENT TO HUMAN RESOURCE ACQUISITION
The requirement process is concerned with the identification of possible sources of
human resources supply and tapping those resources, the total process acquiring and placing
human resources in the organization. Requirement fails in between different sub process like:

BASIC ELEMENTS OF SOUND RECRUITMENT POLICY:
+ Discovery and cultivation of the employment market for post in the public service
+ Use of the attractive recruitment literature and publicity
+ Use of the scientific tests for determining abilities of the candidate
+ Tapping capable candidates from within the services
+ Placement program which assigns the right man to the right job.
+ A follow up probationally program as an integral process.
PURPOSES AND IMPORTANCE:
- Determine the present and future requirements of the organization in conjunction with the
personnel planning and job analysis activities
- Increase the pool of job candidates with minimum cost
Manpower
planning
Job analysis
Selection

Recruitment
Placement
- Help increase the success rate of the selection process reducing the number of obviously
under qualified or over qualified job applicants.
- Help reduce the probability tat the job applicants, once recruited and selected will leave
the organization only after short period of time.
- Meet the organizations legal and social obligations regarding the composition of its work
force
- Start identifying and preparing potential job applicants who will be appropriate
candidates
- Increase organizational and individual effectiveness in the short and long term.
- Evaluate the effectiveness of various recruiting techniques and sources for all types of job
applicants.
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 companys 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:

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.
SOURCES OF
RECRUITMENT

DIRECT
SOURCES

INDIRECT
SOURCES
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:

FACTORS EFFCTING RECRUITMENT:
All organization, whether large or small, do engage in recruiting activity, though not to
the same extent. This differs with:
1) The size of the organization
2) The employment conditions in the community where the organization is located
3) The effects of past recruiting efforts which show the organizations ability to locate and
keep good performing people
4) Working conditions an salary and benefit packages offered by the organization- which
may influence turnover and necessitate future recruiting
5) The rate of growth of organization
6) The level of seasonality of operations and future expansion and production programs.
7) Culture, economical and legal factors etc.

STEPS
Planning
Strategy
development
Searching
Screening
Evaluation &
Control
CREDENTIALING
INTRODUCTION
Credentialing is the process of establishing the qualification of licensed professionals,
organizational members or organizations, and assessing their background and legitimacy. Many
health care institutions and provider networks conduct their own credentialing, generally through
a credentialing specialist or electronic service, with review by a medical staff or credentialing
committee. It may include granting and reviewing specific clinical privileges and medical or
allied health staff membership.

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 Swans 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, lets 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.
HEALTH CARE CREDENTIALING
DEFINITION:
Health care credentialing is a system used by various organizations and agencies to
ensure that their health care practitioners meet all the necessary requirements and are
appropriately qualified. The credentials may vary depending on the specified area of the
practitioner. For example: An X-ray technician may have different credentialing forms than an
osteopathic physician.
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 employers 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 employers 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 candidates character and personality, and the information to be given
by the head teacher should include candidates attendance at school, studies completed, grades,
rank in class and his or her own evaluation of the candidates 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 applicants 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:

Interviewing functions of the personnel manager:
The responsibilities of the personnel manager are:
A) To screen the application of the candidate
B) To give information about
a) general nature of work
b) hours of work
c) pay-scale, allowances and starting total salary
d) fringe benefits
e) leave policy
f) brief information about the background of the hospital
g) To discover any differences in the expectations of the hospital and those of the
candidate.

Name and Address of the hospital
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 )

Encl: 1

The responsibilities of the department head are:
A) To review the job-application form to check pertinent data on experience;
B) To assess the professional competence of the candidate
C) To give detailed picture of the job requirement to the applicant;
D) To advise the personnel manager if he thinks that the previous training or experience or
both of the applicant justifies a higher starting salary.
II. Pre-employment tests:
To ensure selection of the most suitable candidates for various posts, interviews should
be conducted carefully & pre-employment tests should be held in a systematic manner wherever
necessary & possible.
For certain Categories of post, there is a need for testing the professional competence of the
candidates. These tests can broadly be divided in to four types:
1) Tests of general ability- intelligence
2) Tests of specific abilities- aptitude tests
3) Tests of achievement-trade tests
4) Personality tests- Tests of emotional stability, interest, values, traits etc.

1) Tests of general ability: These tests can give a useful indication of candidates 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.

IMPORTANCE OF SELECTION AND PLACEMENT:
+ To fairly and without any element of discrimination evaluate job applicants in view of
individual differences and capabilities
+ To employee qualified and competent hands tat can meet the job requirement of the
organization
+ To place job applicants in the best interests of the organization and the individual
+ To help in human resources man power planning purposes in organization
+ To reduce recruitment cost that may arise as a result of poor selection & placement
exercises.
PLACEMENT TEAM:
Our current placement team consists of a placement coordinator & four academic tutors,
each with specialist knowledge relevant to the degree courses you under the supervision are
studying. These tutors advice and support you throughout your preparation for placement.
+ PROMOTION
INTRODUCTION:
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 oppose
it by saying that managements resort to favoritism. The unions generally favor promotions on the
basis of seniority. It is hence essential to examine this issue and arrive at an amicable solution.
DEFINITION:
A change for better prospects from one job to another job is deemed by the employee as a
promotion.
FACTORS IMPLYING PROMOTION:
The factors which are considered by employees as implying promotion are:

FACTORS
IMPLYING
PROMOTION
An increase in salary
An increase in
prestige
An upward movement in
the hierarchy of jobs
Additional supervisory
responsibility
A better future
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.

ADVANTAGES OF A SOUND PROMOTION POLICY:
From a scientific management view point, a sound promotion policy has many advantages.
+ It provides an incentive to employee to work more and show interest in their work. They
put in their best in their best and aim for promotion within the organization.
+ It develops loyalty amongst the employees, because a sound promotion policy assures
them of their promotions if they are found fit.
+ It increases satisfaction among the employees.
+ It generates greater motivation as they do not have to depend on mere seniority for that
advancement.
+ A sound promotion policy retains competent employees, and provides them ample
opportunities to rise further
+ It generally results in increased productivity as promotion will be based on an evaluation
of the employees performance.
+ Finally, increases the effectiveness of an organization

SOLUTION TO PROMOTION PROBLEMS:
Difficult human relations problem can arise in promotion cases. These problems may be reduced
to the minimum if extra and following principles are observed.
In promoting an employee to a better job, his salary should be at least one step above his
present salary.
Specific job specifications will enable an employee to realize whether or not his
qualifications are equal to those called for.
There should be a well-defined plan for informing prospective employees may know the
various avenues for their promotion.
The organization chart and promotion charts should be made so that employees may know
the various avenues for their promotion.
The promotion policy should be made known to each and every organization.
Management should prepare and practice promotion policy sincerely.

+ RETENTION
NURSE RETENTION
By Lee Ann Runy
An Executives Guide to Keeping One of Your Hospitals Most Valuable Resources
With no end in sight for the nations nursing shortage, hospitals are placing greater
emphasis on retaining their current RN staff. Its 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 whats 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.

PRINCIPLES ANE ELEMNTS OF A HELPFUL PRACTICE AND WORK
ENVIRONMENT:
To foster staff retention, organizations need to develop environments in which nurses
want to work. Among other things, nurses want safe workplaces that promote quality health care.
Its the role of the nurse executive and nurse manager to establish a work environment that
supports professional practice, says Pamela Thompson, CEO of the American Organization of
Nurse Executives. Thats one key piece to retention. Its also important that nurses play an
active role in shaping their environment. Nurses want to work in a place that brings high quality
to patients and know they have a role in the process, says Susan Shelander, director of
recruitment and retention for Memorial Hermann, Houston. Creating such an environment is not
easy.
The Nursing Organizations Alliance developed a set of principles to help hospitals and other
health care entities create positive work environments. More than 40 nurse organizations,
including AONE, have endorsed the principles.
NINE PRINCIPLES TO HELP FOSTER STAFF RETENTION:
1.Respectful collegial
communication and behavior
Team orientation
Presence of trust
Respect for diversity
2. Communication-rich culture Clear and respectful
Open and trusting
3. A culture of accountability Role expectations are clearly defined
Everyone is accountable
4. The presence of adequate
numbers of qualified nurses
Ability to provide quality care to meet
client/patient needs
Work and home life balance
5. The presence of expert,
competent, credible, visible
leadership
Serve as an advocate for nursing practice
Support shared decision-making
Allocate resources to support nursing.
6.Shared decision-making at all
levels
Nurses participate in system, organizational and
process decisions
Formal structure exists to support shared
decision-making
Nurses have control over their practice.
7.The encouragement of
professional practice and continued
growth/ development
Continuing education/certification is
supported/encouraged
Participation in professional association
encouraged
An information-rich environment is supported.
8. Recognition of the value of
nursings contribution
Reward and pay for performance.

9. Recognition of nurses for their
meaningful contribution to the
practice
Career mobility and expansion
FIVE CHARACTERISTICS OF SUCCESSFUL RECRUITMENT AND RETENTION
PROGRAMS:
1. Sustained leadership commitment to workforce as a strategic imperative.
2. A culture centred around employees and patients.
3. Work with other organizations to address workforce needs
4. Systematic and structured approach
5. Excellence in human resource practice
PERSONNEL POLICIES
DEFINITION OF PERSONNEL POLICIES
Policy: 1. Statement of predetermined guidelines
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 organizations 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:
1) To the employee it represents a guarantee of fair and equitable treatment.
The establishment of good personnel policies helps to give the employee a sense
of security and individual worth.
It gives employee pride and loyalty to the organization for which he/she works.
Policies that are planned in advance are likely to meet the needs of the
organization better.
2) To the supervisor it is a safeguard in that it relieves her of the responsibility of making a
personal decision which may conflict with decisions given by other supervisors.
Established personnel policies serve as guides to action so that a great deal of time
is saved by administrational personnel in handling individual cases.
A well understood clearly written policy saves the time of an employee as well as
the employer.
PHILOSOPHY:
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.

FUNCTIONS AND TECHNIQUES OF ADMINISTRATION TO MEET THE
OBJECTIVES SPECIFIED BY THE STATEMENT OF POLICY.
SL NO. FUNCTIONS TECHNIQUES
1. Employment
Job analysis, job specifications, time schedules, works
Schedules, manuals, agreed code of regulations, assessment of
personnel
2. Remuneration Job evaluation
3. Health and safety
Physical examination, safety training, accident analysis,
sickness statistics
4. Welfare
Social and recreational programs, rest rooms, canteen, pension
schemes, employers counseling
5. Training On the training, training for leadership

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 dont 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
ELEMENTS OF PERSONNEL POLICIES STATEMENT
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.
Equipment Use Regulations
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.
PROCESS OF DEVELOPMENT OF PERSONNEL POLICIES
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:
1) Clarification by top management of philosophy and the objectives of the organization.
2) Analysis of personnel policy requires assessment of relevant facts. Job is delegated to the
committee who through interviews and conferences collect data from inside and outside
the organization.
3) Consultation with staff representatives.
4) Writing the first draft of the policy statement.
5) Further discussion to get the final approval of policies from top management and staff
representatives.
6) Communication of policy statements by means of training session, discussion groups and
staff hand books.
7) Periodic re evaluation and follow up

POLICIES RELATED TO NURSING PRACTICE:
SERVICE STAFFING POLICIES (HOSPITAL)
Employment- recruitment rules,
qualification
Job description
Working hours
Work load, working facilities
Vacations
Holidays
Sick Leave
Weekend Off
PROCESS
Communicating the Policy
Discussing the Proposed Policy
Appraising the Policy
Adopting and Launching Policy
Writing the Personnel Policy
Fact Finding
Reporting Of Personnel Policy
Policies for breakage and losses
Special allowances- special duty/
hard duty allowance, medical
allowance. The nursing
personnel have demanded a
uniform allowance of Rs 3,000
per month and a nursing
allowance of Rs 1,600 per
month.
Promotional opportunities
Career development
Accommodation
Transport
Special incentives
Occupational hazards
Rotation To Different Shifts
Overtime
Part Time Personnel
Exchanging Hours

POLICIES RELATED TO NURSING EDUCATION
Policies For College Of Nursing
STUDENTS STAFFS HOSTEL POLICIES
Admission Policies
Working Hours
Attendance
Uniform
Medical Facilities
Internship
Holidays
Special Leave
Withdrawal From
Course
Discipline
Recruitment Policies
Policy On
Termination
Staff Benefits
Uniform
Duty Hours
Retirement Age

Permission to meet
only authorized
visitors
Permission for a
dayout
Visiting hours
Permission letter for
outing
Signing the register
Disciplinary action
on violation of rules

FACTORS INFLUENCING PERSONNEL POLICY
The following factors will influence determining of personnel policies of an organization:
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
organizations 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.

CHARACTERISTICS OF PERSONNEL POLICIES
Specific Consistency, Permanency, Flexible with Purpose Recognize individual
differences.
Be formulated with regards for the interest of all parties, i.e. employer, employee
(individual/ groups) public and clients.
Confirm to the government regulations be written and formulated as a result of careful
analysis of all facts available.
Be forward looking and forward planning for continuing development
Recognize individual difference
ADVANTAGES
Helps to give employees a sense of security and individual worth.
Gives the employees pride and loyalty to the organization for which they work.
Employees tend to give good service and identify themselves with the goals of the
organization and they want to remain in the organization.
Are planned in advance and with due consideration on how policy will apply in various
situations to meet the needs of the organization
As guides to action, save a great deal of time of the administrator.
A clearly written policy saves the time of the employee as well.
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:
Staff development refers to all training and education provided by an employee to
improve the occupational and personal knowledge, skills and attitude of vested employees.
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.
NEED FOR STAFF DEVELOPMENT:
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.

PRINCIPLES INVOLVED STAFF DEVELOPMENT:
Activities must base of needs and interest of employees and organization.
Learning is combination of theory and experience.
Learning is internal, personal and emotional process.
Learning involves changes in behavior.
Learner should be encouraged to contribute in learning process.
Problem solving approach is well suited because; effective learning takes place when
there is need/problem.
Positive reward is effective.
Teaching learning should be based on educational psychology.
Learning can be maximized by providing favorable condition.
Learning is active process i.e., teacher and learner should be active in learning.
Teaching must satisfy learning needs of an individual.
Use variety of sources for learning as adult learners have wide range of previous
experience.

STAFF DEVELOPMENT MODEL FOR GOAL ACHIVEMENT OF THE HEALTH
CARE AGENCY, THE NURSE AND THE NURSING PROFESSION
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.
This model has three main components.
Education
Experience
Socio-economics

Educational component includes:
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.
In-service education is referred to an agency based educational activity. It begins with
orientation to the health care agency and to a particular position and continues in the
form of specific skill training related to nursing or more generalized skill training related
to patient care within the context of the health care team.
Extramural education includes short courses, conferences, seminars and like, which are
planned for group learning, as well as programmed learning and correspondence courses.
Post basic education refers to formal study at degree-granting institution. It involves full
time commitment to an academic programme leading to university diploma, certificate,
baccalaureate degree, masters degree or doctorate degree etc.
Experience:
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.
TYPES OF STAFF DEVELOPMENT:
Staff development includes formal and informal group and individual training and
education. Staff development activities include the following:

Staff
development
Induction
training
Job
orientation
In service
education
Continuing
education
Induction training (3 days): Is a brief standardized introduction to an agencys 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 agencys philosophy, goals and
norms.
Job orientation (2- 24weeks): Is an individualized training programme intended to acquaint a
newly hired employee with job responsibilities work place, clients and co-workers.
In-service education(2- 8hours): It is a planned educational experience provided in the job
setting and closely identified with service in order to help the person to perform more effectively
as a person and as a worker.
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.
FACTORS INFLUENCING STAFF DEVELOPMENT PROGRAMME
The major factors that determine the administrative structure of an agency-wide staff
development programme are:-
+ Administrative philosophy, policies and practices of health care agency
+ Policies, practices and standards of nursing and other health professionals
+ Human and material resources within the health care agency and community
+ Physical facilities within a health care agency and community
+ Financial resources within a health care agency and community
FUNCTIONS OF STAFF DEVELOPMENT PERSONNEL:
Personnel assigned to staff development should provide the following consultative
functions for health care agency.
Determination of the administrative structure of the staff development programme.
Determination and establishment of organizational methods, policies and procedures for
a staff development programme.
Determination and establishment of lines of communication for the utilization of
facilities and resources personnel for the staff development programme.
Determination of organizational and individual staff development needs and priority.
Development of measurable short and long term objectives for staff development
programmes.
Promotion, development, implementation and evaluation of programmes to meet these
objectives.
Planning, co-ordination and utilization of community resources to assist in meeting these
objectives.
Provision of a consultative service and a resource for information relative to staff
development.
PROGRAMMES FOR STAFF DEVELOPMENT
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
Make rounds with the physicians
Attend medical round in a teaching centre
Visit another hospital to observe their method of patient care
Attend professional meetings, conferences, etc. and present papers
Read articles of special interest and report them to staff
BENEFITS OF STAFF DEVELOPMENT:
For the employees:
+ Leads to improved professional practice
+ Aids in updating knowledge and skills at all levels of organization
+ Keep the nurses abreast of the latest trends and developments in techniques
+ Equips the nurses with knowledge of current research and developments
+ Helps the nurses to learn new and to maintain old competencies
For the organizations/employer:
Keeps the nursing staff enthusiastic in their learning
Develop interest and job satisfaction amongst the staff
Develops the sense of responsibilities for being competent and knowledgeable
Creates an appropriate environment and sound decisions as well as using effective
problem solving techniques
Helps the nurse to adjust to change
Aids in developing leadership skills, motivation and better attitudes
Aids in encouraging and achieving self development and self confidence
Makes the organization a better place to worker
ROLE OF ADMINISTRATOR IN S.D.P
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:
1. In service education is defined as a continued programme of education provided by
the employing authority, with the purpose of developing the competences of
personnel in their functions appropriate to the position they hold, or to which they
will be appointed in the service.
2. In-service education is a planned instructional or training programme provided by an
employing agency in the employment setting and designed to increase competence in
a specific area.
3. In-service education is an ongoing on-the-job instruction that is given to enhance, the
workers performance in their present job.
AIM OF IN-SERVICE EDUCATION:
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.

CONCEPTS OF IN-SERVICE EDUCATION:

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.

Concept
Planned education activities
Provided in a job setting
Help a persons
performance effectively
as a personal work
Closely identified with
service
CHARACTERISTICS
It should be given in job setting
Every programme should be planned and ongoing
It should be closely related and identified with service components
It should help the employees learning and improve her/his knowledge, skills and
attitude.

FACTORS INFLUENCING IN-SERVICE EDUCATION:
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:-
1. Cost of healthcare In-service education programme may increase the efficiency of
nursing services, but it adds additional expenditure on health care delivery system.
2. Manpower In-service education requires need qualified human resources, leads to
increase human resources.
3. Changes in nursing practices it leads to frequent changes in the programme and in-
service education.
4. Standards of nursing practice
5. Organization of nursing departmental planned approaches is regular.
APPROACHES TO IN-SERVICE EDUCATION:
The pattern of in-service education desired to be:
+ Centralized Approach
+ Decentralized Approach
+ Co-ordinated Approach

1. Centralized Approach: - The in-service curriculum ought to emanate from and be
conducted by nursing personnel in the central administration of the agency. None of the
learners are consulted or participate in planning learning experiences and yet are expected
to attend an in-service offering.
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:
It may lead to in reducing spontaneous, interested participation and enthusiasm of
learners.
2. Decentralized Approach: - It is planned by and conducted for the employees of one or
more units. The employees are expected to keep administration informed of their
activities and possibly consult with administration when help is wanted, but the
employees are expected to develop and direct their own learning experiences.
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

3. Co-ordinated Approach: - It is a compromise between the centralized and decentralized
patterns in that, while the practicing nurse does indeed carry a large measure of
responsibility for the in-service curriculum, the central administration of nursing
personnel of the agency is responsible for a broad programme which is of importance to
all nursing personnel. This approach involves both nursing administrators and
practitioners in complementary way.
Advantages:
Mutual co-ordination and assistance to central administration is improved
Duplication is avoided
Unity of efforts is maintained
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.
NEED FOR CONTINUING EDUCATION:
Respond effectively to the challenge of current social changes.
To improve the health care, economic and educational opportunities.
To improve the new health patterns of health care.
Due to increasing trend towards specialization.
Due to legislation and its impact on the education of health personnel.
PHILOSOPHY OF CONTINUING EDUCATION:
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 FOR CONTINUING EDUCATION:
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.
THE PLANNING FORMULA:
1. What is to be done?
Get a clear understanding of what your unit is expected to do in relation to the work
assigned to it. Break the units 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.

STEPS IN THE PLANNING PROCESS:
1. Establishing goals compatible with the purpose or mission of the organization.
2. Deciding upon specific objectives consistent with these goals.
3. Determining the course of action required to meet the specific objectives.
4. Assessing the available resources for establishing the programme.
5. Establishing a workable budget, appropriate for the programme.
6. Evaluating the results at stated intervals.
7. Reassessing he goals and updating the plan periodically.
ROLES AND FUNCTIONS OF ADMINISTRATOR/MANAGER IN STAFF
DEVELOPMENT:
ROLES: He/ she:
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:
Works with reduction department to delineate shared individual responsibility
Ensures that all staff are competent for roles assigned
Ensure that there are adequate resources for staff development
Assumes responsibly for quality and fiscal control of staff development.
Provides input in formulating staff development policies

EVALUATION OF STAFF DEVELOPMENT PROGRAM
Staff development is an important part of assisting performance improvement at
organiational, faculty/central department, unit and individual levels. It is therefore important that
the transfer of learning into the workplace is assessed through a process of review and evaluation
so that its success or otherwise can be established and so that we can demonstrate the
contribution learning makes towards overall organisational success.
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
Formative evaluation: Evaluation that is used to modify or improve a professional development
program is called formative evaluation. Formative evaluation is done at intervals during a
professional development program. Participants are asked for feedback and comments, which
enable the staff developers to make mid-course corrections and do fine-tuning to improve the
quality of the program.
Summative evaluation: Evaluation to determine the overall effectiveness of a professional
development program is called summative evaluation. Summative evaluation is done at the
conclusion of the program. It is collected at three levels: educator practices, organizational
changes, and student outcomes.
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.
Reaction: Measures how those who participate in professional development activities
react to what has been presented. Although typically characterized as the happiness
quotient, participants need to have a positive reaction to a professional development
activity if information is to be learned and behavior is to be changed.
Learning: Measures the extent that professional development activities have improved
participants' knowledge, increased their skills, and changed their attitudes. Changes in
instructional behavior and actions cannot take place without these learning objectives
being accomplished.
Behavior: Measures what takes place when the participant completes a professional
development activity. It is important to understand, however, that instructors cannot
change their behavior unless they have an opportunity to do so.
Results: Measures the final results that occurred because an instructor participated in
professional development activities. Evaluating results represents the greatest challenge
in evaluating professional development approaches

DUTIES OF NURSING AND NON NURSING PERSONALS IN HOSPITAL
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.
GENERAL ROLE OF REGISTERED NURSES IN HOSPITAL
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.
Counseling helps in reviewing training needs, improving better communication between
employees and employers and helps in solving personal and official problems of employees.
External and internal stress, lack of training, difficulties in job, emotional deprivation etc can be
tackled under employee counseling. Use of counseling methods and skills of the counselor can
be utilized effectively, to create a better harmonious hospital staff environment
Problems to be handled by the Counselor
The problems coming under employee counseling in a hospital setting are

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
Common personal problems include, housing, transportation, admission of children in
schools etc.
3. Behavioural and Organisational 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 clients 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 peoples 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 clients 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.

2. Contribute to the development of provincial hospital planning and facilitating the
implementation of Standard Based Management in the Provincial Hospitals.

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.

6. Act as a resource to provide models of best practice for hospital management through
research, training, document translation, and any other means as needed.

7. Participate in and sometimes leading quality assurance and performance improvement
activities as required by the hospitals.

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.
Some duties of advocator:
Clarifying treatment and medical options.
Gathering information.
Asking specific questions.
Note taking, to make sure all the appropriate information received from caregivers is
captured and retained.
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:
DUTIES OF NURSING SUPERINTENDENT:
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.
Supervise nursing staff
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.
Oversee hiring and training
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.
Create work schedules
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.
Manage other departments
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.
Negotiate with vendors
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.
DUTIES OF ASSISTANT NURSING 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.
2. Assist in planning work schedule, determining manpower levels, materials quantities,
equipment, requirements, etc. are maintained, including field engineering and construction
activities.
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.
6. Perform additional assignments per supervisors direction.
DUTIES OF WARD SISTER:
Functions:
A. Clinical Activities:
1. Assesses the situation of given unit in relation to different types of patients care,
facilities provided by the nursing personnel.
2. Identifies the patients need/problem in the unit.
3. Assigns the patients care and others activities to nursing personnel.
4. Evaluates the patients care given by nurses.
5. Attends Doctors round and Matron and Assistant Matrons Clinical rounds.
6. Checks and caries out and delegates Doctors 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 patients 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
1. Makes duty roaster for 24 hrs coverage in unit of the Hospital.
2. Conducts nursing conference, meeting and individual conference when necessary.
3. Investigates complaints promptly and takes action according to rules and policy of the
hospital.
4. Reports and records absence and sickness of staff including leaves.
5. Maintains cleanliness of the ward and its environment, furniture, equipment, e.g.
ventilation, lighting, heating, noise, odors.
6. Maintains adequate linen, other supplies, requisition for ward stores and repairs, replaces
supplies as necessary.
7. Keeps up-to-date record of drugs and maintains records of its administration.
8. Checks and manages all equipment periodically, to see that it is in good order.
9. Checks daily availability and conditions of emergency equipment and supplies.
10. Maintains inventories, reports, breakages and losses.
11. Helps in Controlling the visitor of patients as needed.
12. Ensures that relatives of very ill patient are allowed to stay with patients when necessary.
13. Accompanies, the Matron on the round and reports to her any important incidents.
14. Informs Matron immediately of any special emergencies or accidents in the ward, and
keeps a written record of nay incidents.
15. Coordinates between Matron and staff in her unit and also with other departments.
16. Takes active part in condemnation of useless materials.
17. Helps Matron for annual plans and budgets in her ward.
18. Delegates responsibilities to the responsible person in her absence.
19. Assist the Matron and Assistant Matron for disaster plan and organization.

D. Educative Activities
1. Identifies the learning need of staff in ward.
2. Plans, conducts and recommends the in-service education and training programme for her
staff.
3. Manages and facilitates the clinical teaching activities for the students and staffs.
DUTIES OF OTHER NURSING PERSONALS:
Duties and responsibilities of Perioperative nurses:
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 patients 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.
RN First Assistant after completing extensive additional education and training to
deliver direct surgical care, the RN First Assistant may directly assist the surgeon by
controlling bleeding and by providing wound exposure and suturing during the actual
procedure
Diabetes management nurses:
Diabetes Management Nurses are registered nurses who assist patients to
manage diabetes. Their main duty is to educate patients and their families about diabetes and
the self-management skills required. They provide advice on exercise, diet and medication and
monitoring insulin levels. These nurses often work in outpatient clinics and often travel to
hold clinics in regional areas.
The main duties of a Diabetes Management Nurse include:

-Dealing with complications of patients diagnosed with diabetes mellitus
-Working closely with physicians, pharmacists and other healthcare professionals
-Educating patients of the best practices in improving their health
-Informing patients families on living with diabetes
-Providing advice on diet and exercise
-Advising on injecting medications
-Administering tablets or insulin if the patient is unable
- Monitoring blood glucose levels
Duties and responsibilities of Dermatology nurses:
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.
Duties and responsibilities of geriatric nurses:
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.
Duties and responsibilities of Pediatric oncology nurses:
A pediatric nurse works in the pediatric department of a hospital, children's clinics or at
their homes. The basic duties of a pediatric nurse involve performing physical examinations and
giving medicines administrated by the doctor to hospitalized patients. As little children are
usually afraid of medical settings, it is the duty of the pediatric nurse to make them comfortable
with encouraging words, so that they can conduct the necessary tests and treatment procedures
smoothly.

Responsibilities of a pediatric nurse involves taking temperature, blood pressure,
respiratory rate and heart rate of the patient. He/she also has the duty of starting intravenous
medications, performing head to toe examinations and also collecting samples of patient's urine
and stools for laboratory tests.

Ambulatory care nurses:
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:
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.
Emergency or trauma nurses:
Emergency or trauma nurses will work in hospital or stand-alone emergency departments,
providing initial assessments and care for patients with life-threatening conditions.
The main duties of an Emergency / Trauma Nurse include:
- Providing care to patients in an emergency situation
- Administering emergency procedures e.g. code blue and CPR
- Acting fast and thinking on their feet
- Handling complex and difficult situations
- Operating healthcare machines

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:
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:
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.
Medical surgical nurses:
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
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.
Occupational health nurses:
The occupational health nurse role includes:
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:
Perianaesthesia nurses provide preoperative and postoperative care to patients undergoing
anesthesia during surgery or other procedure.
Mental health 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.
Some of the principal duties are:
Oversee detoxification and substitute prescribing programmes;

Provide support to clients on an individual and group basis;

Liaise with mental health team, addictions team, psychology dept, social workers, medical staff
and general health team;

Delivering drug/alcohol education and awareness packages to clients and staff;

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 clients 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 disability nurses:
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.
The main duties of an Intellectual and Developmental Disabilities Nurse include:

- Providing care for patients with physical, mental or behavioral disabilities
- Caring for patients of all ages
- Assisting with feeding and controlling bodily functions
- Supporting patients and encouraging them to be independently mobile
- Educating patients and their families of Intellectual and Developmental Disabilities
- Assisting patients with language skills and other forms of 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:
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 specialist:
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.
Infection control nurses:
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.
A. Principal (school of nursing, College of Nursing)
Job Summary
Principal, College of Nursing is the administrative head of the College of Nursing, will be
directly responsible to the Director of the Medical Education/Director of Health and Family
Welfare services and responsible for implementation and revision of curriculum for various
courses, and research activities of the college of Nursing.
Duties and Responsibilities
Administration
Planning
Develops philosophy and objectives for educational program.
Identifies the present needs related to educational program.
Investigates, evaluates and secures resources.
Formulates the plan of action.
Selects and organizes learning experience.
Organizing
Determines the number of position and scope and responsibility of each faculty and staff.
Analyses the job to be done in terms of needs of education program.
Prepares the job description, indicate line of authority, responsibility in the relationship and
channels of communication by means of organizational chart and other methods.
Considers preparation, ability and interest personally in equating responsibility.
Delegates authority commensurate with responsibility.
Maintains a plan of work load among staff members.
Provides an organizational framework for effective staff functioning such as meeting of the
staff, etc.
Directing
Recommends appointment and promotion based on qualification and experience of the
Individual staff, scope of job and total staff composition.
Subscribes and encourages developmental aspects with reference to welfare of staff and
students.
Provides adequate orientation of staff members.
Guides and encourages staff members in their job activities.
Consistently makes administrative decision based on established policies.
Facilitates participation in community, professional and institutional activities by providing
time, opportunity for support for such participation.
Creates involvement in designing educationally sound program.
Maintenance of attitude rightly acceptable to staff and learners.
Provides for utilization in the development of total program and encourages their
contribution.
Provides freedom for staff to develop active training course within the framework for
curriculum.
Promotes staff participation in research.
Procures and maintains physical facilities which are of a standard.
Coordinating
Coordinates activities relating to the programs such as regular meetings, time schedule,
maintaining effective communication, etc.
Initiates ways of cooperation.
Interpretes nursing education to other related disciplines and to the public.
Controlling
Provides for continuous follow up and revision of education program.
Maintains recognition of the educational program by accrediting bodies. University, etc,
KNC, INC, etc.
Maintains a comprehensive system of records.
Prepares periodic report which revives the progress and problems of the entire program and
presents plans for its continuous development.
Prepares, secures approval and administrates the budget.
Instruction (Teaching)
Plans for participating in educational programs for further development.
Recognizes the needs for continuing education for self and staff provides stimulation of
opportunities for such development.
Participate as a teacher in the educational program.
Guiding
Provides for systematic guidance program for staff members and students.
Encourages studies, research and writing for publication.
Provides and maintains a program for recruitment, selection and promotion of students.
B.VICE- PRINCIPAL
Financial:
Assists Principal in carrying out financial activities:
Planning and revising budget
Monitoring College expenditure
In the absence of Principal, performs all the functions
Educational:
Assists Principal in planning, implementation and evaluation of the programmes.
Assists Principal in identifying needs for professional development of faculty and
conducting staff development programme.
Supervises postgraduate students in conducting research.
Participates in teaching of various educational programmes.
In the absence of Principal, chairs the assigned committee meetings.
Supervises all educational programmes in coordination with the coordinators.
Guides faculty in day-to-day academic activities
Supervisory:
Shares responsibility with Principal and Professor in supervision of teaching and
nonteaching staff.
Plans academic staff assignments in consultation with Principal.
Participates in conduct of orientation programme
Supervises and guides staff in conducting their activities.
Writes staff performance report and reviews evaluation report of assigned staff.
Assists Principal in monitoring students welfare activities e.g. Mess, hostel, Health,
Sports , S.N.A. etc.
Assists Principal in administration and supervision of library.
Establishment:
Assists Principal in maintaining rules and regulations in college campus
Supervises overall functioning of staff and students' hostel.
Assists Principal in maintaining discipline in the college.
Assists Principal in reviewing recruitment and promotion policies of teaching and
non-teaching staff.
Interpersonal:
Assists Principal in maintaining human relation and communication
Identifies conflict among staff members, initiates solution and reports to Principal
when necessary.
Communicates with staff in explaining administrative constraints.
Facilitates guidance and counselling students and staff as per need.
Any other responsibility assigned by the Principal.

C. PROFESSOR, COLLEGE OF NURSING AND ASSISTANT PROFESSOR
COLLEGE OF NURSING
1. Title: Professor, College of Nursing
Job Summary
The Professor is overall in charge of the department and thereby responsible for administration
teaching activity and guidance of that particular department.
Administration
Participating in determination of educational purposes and policies.
Contributes to the development and implementation of the philosophy and purposes of the
educational program.
Utilizes opportunities through group action to initiate improvement of the educational
program.
Interprets educational philosophy and policy to others.
Directs the activities of staff working in the department.
Instruction
Identifying needs of learners.
Identifies the needs of the learners in terms of objectives of the program and utilizing records
of previous experience, personal interviews, tests and observations.
Assists learners and identifying their needs.
Develops plan for learning experience.
Participates in the formulation and implementation of the philosophy and objectives program.
Selects and organizes learning experiences which are in accordance with their objectives.
Participates in the continuous development and the evaluation of the curriculum.
Plans within the educational unit, with the nursing services and allied groups.
Ascertains, selects and organizes facilities, equipment and materials necessary for learning.
Helping the Learners to Acquire
Desirable Attitudes, Knowledge and Skill
Seeks to create a climate conducive to learning.
Assists learners in using problem solving techniques.
Uses varied and appropriate teaching methods effectively.
Uses incidental and planned opportunities for teaching.
Encourages learners to assume increasing responsibility for own development.
Evaluating Learners Progress
Recognizes individual differences in apprasing the learners progress.
Uses appropriate devices for evaluation.
Measures and describes quality of performance objectively.
Helps learners for self evaluation.
Participates in staff evaluation of learners progress.
Recording and Reporting
Maintains and uses adequate and accurate records.
Prepares and channels clear and concise reports.
Shares information about learners needs and achievements with other concerned with
instruction and guidance.
Participates in the formulation and maintenance of comprehensive record system.

Investigative Way to improving Teaching
Measures effectiveness of instruction by use of the
Increases knowledge and skill in own curriculum area.
Analyzes and evaluates resources material.
Devices teaching methods appropriate to objectives and content.
Guidance
Cooperating in guidance program.
Shares in planning, developing and using guidance programme.
Gives guidance within own field of competence.
Helps the learner with special problems to seek and use additional helps as indicated.
Counseling
Helps the learner to grow in self understanding.
Promotes continuous growth and development towards maturity.
Continues to develop competence in problem solving process.
Cooperates in and/or initiates group activities in development and evaluation of studies.
Utilizes findings of research.
Makes data available concerning learners and concerning methods of teaching and
evaluation.

1. Assistant Professor, College of Nursing, Title: Assistant Professor, College of
Nursing
Job Summary
The assistant professor usually works under professor and/HOD of the particular department of
specialty and assists him/her in administration, teaching and guidance and counseling and
research activities.
Administration
Participates in determination of educational purposes and policies.
Contributes to the development and implementation of the philosophy and purposes of the
total education program.
Utilizes opportunities through group action to initiate improvement of the total educational
program.
Interprets educational philosophy and policy to others.
Directs the activities of staff working in the department.
Instruction
Identifying the needs of learners.
Identifies the needs of the learners in terms of the objectives of the program by utilizing
records of previous experience, personal records of previous experience, personal interviews,
tests and observations.
Assists learners in identifying their needs.
Develops plan for learning experience.
Participates in the formulation and implementation of the philosophy and objectives of the
program.
Selects and organizes learning experience which are in accordance with their objectives.
Participates in the continue development and evaluation of the curriculum.
Plans within the educational, with the nursing services and allied groups.
Ascertains, selects and organizes facilities, equipment and materials necessary for learning.
Helping the Learners to Acquire Desirable Attitudes, Knowledge and skill.
Seeks to create a climate conductive to learning.
Assists learners using problem solving techniques.
Uses varied and appropriate teaching methods effectively.
Uses incidental and planned opportunities for teaching.
Encourages learners to assume increasing responsibility for own development.
Evaluative Learning Progress
Recognize individual differences in appraising the learners progress.
Uses appropriate devices for evaluation.
Helps learners for self evaluation.
Participates in staff evaluation of learners progress.
Recording and Reporting
Achievement with others concerned with co
Maintains and uses adequate and accurate records.
Prepares and channels clear and concise reports.
Shares information about learners needs and achievement with others concerned with
instruction and guidance.
Participates in the formulation and maintenance of comprehensive record system.
Investigating Ways Improving Teaching
Measures effectiveness of instruction by use of appropriate devices.
Analyzes and evaluates resource material.
Devices teaching methods appropriate to objectives and content.
Guidance
Cooperating in guidance program.
Shares in planning, developing and using guidance program.
Gives guidance within own field of competence.
Helps the learners with special problems to seek and use additional help as indicated.
Counseling
Helps the learner to grow in self understanding.
Promotes continuous growth and development towards maturity.
Assisting in selection and Promotion of Learners
Participates in development of criteria for selection and promotion of learners.
Research
Imitates and participates in studies for the improvement of educational programs.
Identifies problems in which research is indicated or potentially desirable.
Cooperates in and/ or initiates group activity in development and evaluation of studies.
Utilizes findings of research.
Makes data available concerning learners and concerning methods of teaching and
evaluation.
D. LECTURER, COLLEGE OF NURSING, TITLE: LECTURER, COLLEGE OF
NURSING
Job Summary
He/She works under the direction of the department head and assists him in administration,
instruction and guidance activities.
Instruction
Identifies the needs of the learners in terms of the program by utilizing the records of
previous experience, personal interviews, tests and observation.
Assists the learners in identifying their needs.
Participates in formulation and implementation of the philosophies and objectives of the post.
Selects and organizes learning experiences which are in accordance with these objectives.
Plans with the educational unit with nursing service and allied groups.
Ascertains, selects and organizes facilities equipment and materials necessary for learning.
Assists the learners in using problem solving process.
Prepares clear and concise reports.
Share information about learners needs and achievements with others concerned.
Measures effectiveness of instruction by use of appropriate devices.
Devices leaching methods appropriate to objectives and content.
Guidance and Counseling
1. Gives guidance with own field of competence.
2. Helps the learner to grow in self understanding.
Research
Assist in initiating and participating in studies for the improvement of educational program.
Identifies the problems in which research is indicated or potentially desirable.
Make data available concerning learners and concerning methods of teaching and evaluation.
Cooperate in and/ or initiates group activity in development and evaluation of studies.
Utilizes the findings of research.
E. SENIOR TUTOR
Participates in teaching and supervising the courses of undergraduate students.
Participates in curriculum development , evaluation and revision.
Guide in research projects for undergraduate students.
Acts as a Counsellor for staff and students.
Maintains various records.
Conducting and participating in department meetings and attending various meetings.
Participating in Administration activities of department.
F. TUTOR
Participates in teaching and supervising the courses of undergraduate students.
Coordinates with the external lecturer for various courses as assigned.
Participate in the evaluation of students.
Guide the students in conducting seminars, discussions and presentations etc.
Maintain students' records.
Participate in student counselling programmes.
G. CLINICAL INSTRUCTOR
Demonstrate standards for nursing practice.
Supervise and teach the students in the clinical fields.
Participate in evaluation of students.
Assist the students in conducting health education programme.
Maintain students' records.
Participate in the student counselling programmes.
Participate and promote student welfare activities.

Unit VI
DIRECTING Motivation: Intrinsic, extrinsic, Creating motivating
climate,
Motivational theories
Communication : process, types, strategies,
Interpersonal
communication, channels, barriers, problems,
Confidentiality,
Public relations
Delegation; common delegation errors
Managing conflict: process, management,
negotiation, consensus
Collective bargaining: health care labour laws,
unions, professional
associations, role of nurse manager
Occupational health and safety

DIRECTING
MOTIVATION
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 defined as
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 Maslows 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,
NEED FOR MOTIVATION:
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 Performance = Ability + 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 persons 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 cant be observed directly; we can
observe an individuals action and interpret his behavior in terms of underlying motives.
This leaves a wide margin of error. Our interpretation may not reveal the individuals 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
Motivation comprises of three main components:
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
1) Internal or push forces:
Needs
For security
For self-esteem
For achievement
For power
Attitudes
About self
About job
About supervisor
About organization
Goals
Task completion
Performance level
Career advancement

2) External or pull forces:
a. Characteristics of the job
Feedback
Amount
Timing
Work load
Tasks
Variety
Scope
Discretion
How job is performed
b. Characteristics of the work situation
Immediate Social Environment
Supervisor(s)
Workgroup members
Subordinates
Organizational actions
Rewards & compensation
Availability of training
Pressure for high levels of output

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.

CREATING A MOTIVATING CLIMATE
As the organization has an impact on intrinsic and extrinsic motivation, it is
important to examine organizational climates or attitudes that influence workers morale and
motivation. Employees want achievement, recognition and feedback, the opportunity to
assume responsibility, a chance for advancement, fairness, good leadership, job security and
acceptance and adequate monetary compensation. All these create a motivating climate and
lead to satisfaction in the work place.
e.g. nurses who experience satisfaction stay where they are, contributing to organizations
retention.

STRATEGIES TO CREATE A MOTIVATING CLIMATE
1. Have a clear expectation for workers and communicate effectively.
2. Be fair and consistent when dealing with all employees.
3. Be a firm decision maker.
4. Develop a team work/team spirit.
5. Integrate the staffs needs and wants with the organizations interest and purpose.
6. Know the uniqueness of each employee.
7. Remove traditional blocks between the employee and the work to be done.
8. Provide opportunities for growth.
9. Encourage participation in decision-making.
10. Give recognition and credit.
11. Be certain that employees understand the reason behind decisions and actions.
12. Reward desirable behaviour.
13. Allow employees exercise individual judgement as much as possible.
14. Create a trustful and helping relation with employees.
15. Let employees exercise as much control as possible over their work environment.

Leadership Roles and Management Function Associated With Creating A Motivating
Work Climate:-
Leadership Roles:
1. Recognize each worker as unique individual who is motivated by different things.
2. Identifies the individuals and collective value system of the unit and implements a reward
system that is consistent with those values.
3. Listen attentively to individual and collective work values and attitudes to identify unmet
collective needs that can cause dissatisfaction
4. Encourage workers to stretch themselves in an effort to promote self growth and self
actualization.
5. Maintains a positive and enthusiastic image as a role model to subordinates in the clinical
setting
6. Encourage mentoring, sponsorship and coaching with subordinates.
7. Develop time and energy to create an environment that is supportive and encouraging to the
discouraging individual.
8. Develop a unit philosophy that recognizes the unique worth of each employee and promote
reward systems that make each employee feel like a winner.
9. Demonstrates through actions and words a belief in subordinates that they desire to meet
organizational goals.
10. Is self- aware regarding own enthusiasm for work and takes steps to motivate self as
necessary.

MEASURES TAKEN BY THE NURSE MANAGER TO FACILITATE NURSES
MOTIVATION: -
The nurse manager while managing the nursing unit will have to choose a combination of the
following measures to facilitate nurses motivation.
1) Act as a Role model (Set a good example):-
a) Set high standards in the units.
b) Maintain a positive attitude towards the work and staff.
c) Be optimistic; in other words, be aware of how difficult the job is and how it can be done.
d) Ask for help when in need.
e) Admit mistakes.

2) Develop and maintain Good Personal Relations:-
a) Use two-way communication.
b) Be friendly, not to criticize staff in front of others and be fair.
c) Keep a sense of humor and avoid getting angry.
d) Try to understand nurses attitudes, likes, dislike their experience, previous training,
problems in their work and needs.
These measures will help in understanding nurses behavior. Understanding is the first step
toward motivating nurses. Trust comes with understanding and it develops slowly based on the
respect and acceptance of the manager. Motivation is based on understanding and trust.
Some guidelines for developing trust:-
a) Apply rules equally and consistently.
b) Avoid favoring some nurses over others, be fair.
c) Share information show respect for ideas and opinions and confidentiality.
d) Be supportive at all times.

3) Post Each Nurse where she can work best:-
The nurse is more likely to succeed and be motivated if her/his interests and skills are
considered in the assignment. Success is the best motivator.

4) Use a participative style:-
Participation and sharing information will motivate nurses since they feel they are taking part
in decisions. Motivation requires more than physical involvement in a job. It also demands
mental and emotional involvement.
5) Guide, encourage and support continuously:-
Guidance means helping nurses in planning, evaluating their work and in solving work and
personal problems..
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.
Reward Good work:-
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.

6) Build team work (Team spirit)
a) Schedule regular meetings.
b) Make nurses feel that their job is important to the success of the team.
c) Integrate the needs and wants of the staff nurses with those of the nursing unit.
d) Think of nurses in the unit as a group and do what is best for them.
7) Provide continuing education:-
Nurses enjoy learning new knowledge and skills or updating the existing knowledge and
skills or taking new responsibilities through continuing education.
SYMPTOMS OF MOTIVATED NURSES:-
1. Show interest, enthusiasm and have a positive attitude.
2. Believe their work is important and work hard.
3. Work well with their supervisors and others.
4. Take part willingly in planning, implementing and evaluating their work.
5. Show responsible behavior.
Strive to find the best way to produce optimal job performance.

THEORIES OF MOTIVATION
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.
A) Content theories of motivation
This is also called as the Need theory. It mainly focuses on the internal factors that
energize and direct human behaviour. Some of the need theories are-

1) Abraham Maslow (1943)
Maslows theory included 5 basic needs in his theory, namely the- The physiological
needs, Safety and security needs, Love needs, self-esteem needs and self-actualization
needs. Maslow suggested that human needs are ordered in a hierarchy from simplex to
complex. Higher level needs do not emerge as motivators until lower needs are satisfied
and a satisfied need no longer motivates behaviour.
Physiological needs: Food, water, warmth, shelter, sleep, medicine and education, etc.
Once the physiological needs are met, the next level becomes predominant.
Safety and security needs: These are the needs to be free of physical danger and of the
fear of losing a job, property, food or shelter. It also includes protection against any
emotional harm.
Social needs: Since people are social beings, they need to belong and be accepted by
others. People try to satisfy their need for affection, acceptance and friendship. After the
lower needs are well satisfied, affiliation or acceptance will emerge as dominant and the
person strives for meaningful social relationship.
Esteem needs: According to Maslow, once people begin to satisfy their need to belong,
they tend to want to be held in esteem both by themselves and by others. This kind of need
produces such satisfaction as power, prestige status and self-confidence.
Need for self-actualization: Maslow regards this as the highest need in his hierarchy. It is
the drive to become what one is capable of becoming; it includes growth, achieving ones
potential and self-fulfilment. It is to maximize ones potential and to accomplish
something.
2) Alderfer ERG theory
ERG theory is similar to Maslows hierarchy of needs. The existence (E) needs are
equivalent to physiological and safety needs; relatedness (R) needs to belongingness,
social and love needs. The growth (G) needs to self-esteem and self actualization- personal
achievement and self-actualization. The major conclusions of this theory are:
w In an individual, more than one need may be operative at the same time.
w If a higher need goes unsatisfied than the desire to satisfy a lower need intensifies.
w 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

3) Frederick Herzberg Two Factor need theory (1966)
Herzberg felt that job satisfaction and dissatisfaction exists on dual scales. Workers are
motivated by two types of needs/factors-
Needs relating to the work itself called intrinsic/motivation factors (satisfiers):
challenging aspects of the work, achievement, added responsibility, opportunities for
growth and opportunities for advancement
Needs relating to working conditions called extrinsic/hygiene factors (dissatisfiers):
salary, status, working conditions, quality of supervision, job security and agency policies.
According to Herzberg, the hygiene factors must be maintained in quantity and quality to
prevent dissatisfaction. They become dissatisfiers when not equitably administered,
causing low performance and negative attitudes.
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) McGregors 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

B) Process theories of motivation
Process theories of motivation provide an opportunity to understand thought processes
that influence behaviour. The major process theories are- Vrooms expectancy theory, goal-
setting theory and reinforcement theory.
1) Reinforcement theory
B.F. Skinners theory (1969) suggests that an employees work motivation is controlled
by conditions in the external environment, that is, by designing the environment properly,
individuals can be motivated. Instead of considering internal factors like impressions,
feelings, attitudes and other cognitive behaviour, individuals are directed by what happens in
the environment external to them. Skinner states that work environment should be made
suitable to the individuals and that punishment actually leads to frustration and de-
motivation. Hence, the only way to motivate is to keep on making positive changes in the
external environment of the organization.
Positive behaviour should be reinforced or rewarded as this increase the strength of a
response or induces its repetition. Reinforcers tend to weaken over time and new ones have
to be developed.
Negative reinforcement occurs when desired behaviour occurs to avoid negative
consequences of punishment. Punishment creates negative attitude and can increase costs.

2) Expectancy theory of Vroom
This theory postulates that most behaviours are voluntarily controlled by a person and are
therefore motivated. It focuses on peoples effort-performance expectancy, or a persons
belief that a chance exists for a certain effort to lead to a particular level of performance. This
theory states that motivation depends on three variables-
Attractiveness: the person sees the outcome as desirable.
Performance-reward linkage: the person perceives that a desired outcome will result
from a certain degree of performance.
Effort-performance: the person believes that a certain amount of effort will lead to
performance.

3) J. Stacy Adams Equity theory
Third process theory and focuses on fair treatment. Persons believe that they are being
treated with equity when the ratio of their efforts to rewards equals those of others. Equity
can be achieved or restored by changing outputs, attitudes, the reference person, inputs or
outputs of the reference person or the situation. People have a tendency to use subjective
judgment to balance the outcomes and inputs in the relationship for comparisons between
different individuals. Accordingly,

4) Jeremy Benthams The Carrot and the Stick Approach
English philosopher, Jeremy Bentham ideas developed his ideas in the early years of
the Industrial Revolution, around 1800. Benthams view was that all people are self-
interested and are motivated by the desire to avoid pain and find pleasure. Any worker will
work only if the reward is big enough, or the punishment sufficiently unpleasant. With this
view, the carrot and stick approach was built into the philosophies of the age.
This metaphor relates to the use of rewards and penalties in order to induce desired
behaviour. It came from the old story that to make a donkey move, one must put a carrot in
front of him or dab him with a stick from behind. Despite all the research on the theories of
motivation, reward and punishment are still considered strong motivators.
In almost all theories of motivation, the inducements of some kind of carrot are
recognized. Often this is money in the form of pay or bonuses. Even though money is not the
only motivating force, it has been and will continue to be an important one. The trouble with
the money carrot approach is that too often everyone gets a carrot, regardless of
performance through such practices as salary increase and promotion by seniority, automatic
merit increases, and executive bonuses not based on individual manager performance.
The stick, in the form of fearfear of loss of job, loss of income, reduction of bonus,
demotion, or some other penalty has been and continues to be a strong motivator. It often
gives rise to defensive or retaliatory behaviour, such as union organization, poor-quality
work, executive indifferences, and failure of a manager to take any risks in decision-making
or even dishonesty. However, fear of penalty cannot be overlooked. Whether managers are
first-level supervisors or chief executives, the power of their position to give or with hold
rewards or impose penalties of various kinds gives them an ability to control, to a very great
extent, the economic and social well-being of their subordinates

5) Goal-setting theory of Edwin Locke
This theory is based on goals as determinants of behaviour. The theory states that when
the goals to be achieved are set at a higher standard than, employees are motivated to
perform better and put in maximum effort. The more specific the goals, the better the results
produced. The goals must be achievable, and their difficulty level must be increased only to
the ceiling to which the person will commit. Goal clarity and accurate feedback increases
security. It revolves around the concept of Self-efficacy i.e. individuals belief that he or
she is capable of performing a hard task.
6) Arousal/ Cognitive Evaluation theory
Focuses on internal processes that mediate the effects of conditions of work on performance.
This theory states, a shift from external rewards to internal rewards results into motivation. It
believes that even after the stoppage of external stimulus, internal stimulus survives. It relates
to the pay structure in the organization. Instead of treating external factors like pay,
incentives, promotion etc and internal factors like interests, drives, responsibility etc,
separately, they should be treated as contemporary to each other. The cognition is to be such
that even when external motivators are not there the internal motivation continues.

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.
Motivational theories for Better Nursing Management
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.
* Punishment: Nursing Superintendent, for example, can withhold reward or promotion so as to
change the behaviour of staff. Scolding in front of others or humiliating should be avoided.
* 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.
* Giving feeling of personal responsibility or keeping interactions. The newly appointed staff
should be left independent but be observed closely.
* 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.
PROBLEMS IN APPLYING MOTIVATION THEORIES
This article presents a non-exhaustive account of some problems in applying motivational
theories to the actual conditions of the workplace. It should give readers a general idea of some
of the less effective and more effective methods for motivating employees.

Reward vs. Punishment
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.
Persuasion vs. Coersion
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.
Knowing Your Workers
Understanding what is important to an individual is endemic for understanding how to motivate
that person effectively. Is an individual motivated by the opportunity to develop professionally or
by the possibility of making more money? Does he or she want more responsibility or more
clearly defined responsibilities? Is it important that he or she see the end-product of their work or
not? Usually, employees are not motivated by just one thing, which can make it difficult to
determine the best strategy for motivation.
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.
METHODS FOR MOTIVATING EMPLOYEES
1. Job rotation: This is also known as cross training. It can be effective for employees that
perform repetitive tasks in the job. This allows the employees to learn new skills by
shifting them from one task to another.

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.

COMMUNICATION MEANING, PROCESS, PRINCIPLES AND
TECHNIQUES, TYPES, ADVANTAGES, DISADVANTAGES,

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:
Communication is a process of change. In order to achieve the desired result, the
communication necessarily is effective and purposive.
DEFINITION OF COMMUNICATION:
Communication is a process in which a message is transferred from one person to other
person through a suitable media and the intended message is received and understood by the
receiver.
IMPORTANCE OF COMMUNICATION:
Promotes motivation:
Communication promotes motivation by informing and clarifying the employees about the
task to be done, the manner they are performing the task, and how to improve their performance
if it is not up to the mark.

Source of information:
Communication is a source of information to the organizational members for decision-
making process as it helps identifying and assessing alternative course of actions.
Altering individuals attitudes:
Communication also plays a crucial role in altering individuals 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 employees attitudes.
Helps in socializing:
Communication also helps in socializing. In todays life the only presence of another
individual fosters communication. It is also said that one cannot survive without communication.
Controlling process:
Communication also assists in controlling process. It helps controlling organizational
members behavior in various ways. There are various levels of hierarchy and certain principles
and guidelines that employees must follow in an organization. They must comply with
organizational policies, perform their job role efficiently and communicate any work problem
and grievance to their superiors. Thus, communication helps in controlling function of
management.
ELEMENTS:
There are seven elements of communication:

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:

* One of the most essential characteristics of an impressive communication is "Clarity".
* Use Simple and Sound words, so that listeners can grab it easily.
* Be clear in your thoughts, jumbled and confused mind cannot deliver a good and clear saying.
* Avoid using any technical terms, try to explain in laymen language.
* Use Examples to explain & support complex scenarios.
* Work a little bit on your accent and pronunciation.

2. Aim or Goal:

* At every stage of your talk/communication, don't forget your "Aim or Goal".
* Try to deduce an acceptable stuff by judging Pros & Cons impartially.
* Communicate with a broad and practical mind.

3. Precision:

* Be precise & exact in your approach. Neither be too deep nor be too short.
* Include some good facts acknowledging your topic.

4. Avoid Repeatability, unless required so.

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.

6. Globalization and Localization:

* 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.

8. Know and Analyze the audiences.

9. Do a good Homework.

10. Dress properly:

* 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:
All of the managers functions involve communication. The communication process
involves six steps.
Ideation encoding transmission receiving decoding response

Response decoding receiving transmission encoding
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. Ones 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 receivers 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
receivers 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:
Communication should be conviction.
Communication should be appropriate to situation.
Communication should have objective and purposes.
Communication should promote total achievement of purposes.
Communication should represent the personality and individuality of the communication.
Communication involves special preparation.
Communication should be oriented to the interest and needs of the receiver.
Communication through personal contact.
Communication should seek attention.
Communication should be familiar.

TECHNIQUES TO IMPROVE THE 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 persons 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 patients 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
patients 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 patients feeling and thoughts to respond to
and pursue.
Silence:
This is lack of verbal communication for a therapeutic reason. Then the nurses 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 patients
choices.
TYPES OF COMMUNICATION:

Communication

On the basis of relationship on the basis of flow on the basis of
expression

Formal informal vertical horizontal verbal non verbal

Downward upward oral written.

ONE-WAY V/S TWO WAY 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.
Two way communication:
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:
It is officially organized channels of communication and it is delayed communication. It is
generally used for all practices purposes. This authoritative, specific, accurate and reaches
everybody. The medium of formal communication may be department meeting, conferences,
telephone calls, interviews, circular etc.
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:
Good communication requires awareness of symbolic communication, the verbal and
nonverbal symbolism used by others to convey meaning.
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.
Denotative and connotative meaning:
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.
The connotative meaning is the shade or interpretation of a words meaning influences
by the thoughts, feelings or ideas people have about the word.
Pacing:
Conversation is more successful at an appropriate speed or pace nurse should speak
slowly enough to enunciate clearly. Pacing is improved by thinking before.
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.
Clarity and brevity:
Effective communication is simple, brief and direct. Clarity is achieved by speaking
slowly, enunciating clearly and using, repeating important parts of a message also clarifies
communication.
Brevity is achieved by using short sentences and words that expresses an idea simply
and directly.

Credibility:
Credibility means worthiness of belief, trustworthiness and reliability.
Time and relevance:
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:
It is transmitting message in writing. Written communication can be followed when a
record of communication is necessary.
NON VERBAL COMMUNICATION:
Communication can occur even without word. Non-verbal communication is message
transmission through body language without using words. It includes bodily movements,
positive, facial expression. Silence is non verbal communication. It can speak louder than words.
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 nurses 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:
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.
Hand movements and gestures:
Hands also communicate by touch, slapping or caring anothers head communicates
obvious feelings.
MECHANICAL COMMUNICATION:
By using mechanical devices the communication will be sent. For e.g. internet, radio,
T.V. etc.
ADVANTAGES OF COMMUNICATION:
Oral communication:
+ It is face to face system and hence can be clarified.
+ There is an opportunity to ask questions, exchange ideas and clarify meaning.
+ It can develop a friendly and co-operative spirit.
+ It is easy and quick.
+ It is flexible and hence effective.
+ It has permanent record for future reference.
+ It is less likely to be misunderstood.
+ It will have adequate coverage and accuracy.
+ Suitable for communicating lengthy messages.
+ It is an authoritative communication.
DISADVANTAGES OF COMMUNICATION:
Oral communication:
+ The spoken words may be misunderstood.
+ The facial expression and tone of voice of the communicator may misled the receiver.
+ Not suitable for lengthy communication.
+ It requires the art of effective specificity
+ It has no record for future reference.

+ It requires skill and education for understanding.
+ It is also one way communication and hence may not be effective.
+ There is no opportunity for the subordinates to ask questions and exchange ideas.
+ It may not communicate all aspects.
STRATEGIES OF COMMUNICATION:
Think before you speak:
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 is having a direct conflict with another employee.
* An employee is concerned about another employee's conduct.
* An employee's performance has dropped substantially.
* An employee has a health issue or personal problem.
* 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:
There are four levels 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.

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
Management
Subordinates Subordinates
Lateral communication:
Lateral or horizontal communication is referred to the communication which takes place
between the departments or personnel on the same level of the hierarchy.

Diagonal communication:
Diagonal communication occurs between two individuals or departments that are not on
the same level of the hierarchy.

Laboratory x-ray laundry
CSSD
Common means are: unit in-charge ordering diet for the patient, X-ray department informs
appointments given to patients in a particular unit, etc.

Management
Subordinates
Subordinates
Management
Nursing department
Medical department
departm departmen
Pediatrics Surgical Medical Pathology Surgical unit Medical unit
BARRIERS OF COMMUNICATION:
Communication barriers create problem of misunderstanding and conflict between men who
live together in the same community, who work together on the same job and even between men
living in the distinct parts of the world who have never seen one another.
Following are the main barriers to overcome:
1. Due to organization structure:
The breakdown or distribution in communication sometimes arises due to:
1. Several layers of management;
2. Long lines of communication;
3. Special distance of subordinates from top management;
4. Lack of instructions for passing information to the subordinates;
5. Heavy pressures of work at certain levels of authority.
2. Due to status and position:
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:
a. consideration of prestige, ego and strategy.
b. underrating the understanding and intelligence of subordinates.
2. Prejudice among the supervisors and subordinates may stand in the way of a free flow of
information and understanding.
3. The supervisors particularly at the middle level may sometimes like to be in good books of
top management by:
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.
Lack of ability to communicate:
All persons do not have the skill to communicate. Skill in communication may come
naturally to some, but an average man may need some sort of training and practice by way of
interviewing and public speaking, etc.
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
vendors 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:
+ The decibal theory
+ The sell theory
+ The minimet theory
The decibal theory:
It argues that the best way to get the message across is to state ones 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.
The sell theory:
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.
The minimet theory:
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.

DEFINITION OF PUBLIC RELATION:
Public relation are knowing what the public expects and explaining how administration is
meeting these desires.. - John Millet

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 hospitals entire range of programs and services.
Enhance the hospitals 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.

ELEMENTS OF PUBLIC RELATIONS:
A planned effort or management function.
The relationship between an organization and its publics.
Evaluation of public attitudes and opinions.
An organizations policies, procedures and actions as they relate to said organizations
publics.
Steps taken to ensure that said policies, procedures and actions are in the public interest
and socially responsible.
Execution of an action and or communication programme.
Development of rapport, goodwill, understanding and acceptance as the chief end result
sought by public relations activities.

FORMS OF PUBLIC RELATION:
Public relation is a general term that may include many other relations with different audiences,
strategies and tactics. For example:
Employee relations:
It is a function of public relations that includes responding to employee concerns and informing and
motivating staff. Some tactics used for employee relations may include new employee education,
employee award programs and recognitions, new-hire press releases and newsletters to name a few.

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.

PUBLIC RELATION PLAN FOR A HOSPITAL:
Every hospital should have a current public relations plan that outlines goals and desired
outcomes for a period of three to five years. Once a general PR plan is in place, periodic planning and
updating is critical. The plan and its updates will not only help guide employees responsible for public
relations work, but will result in an effective tool to communicate with the board and other staff.
Following are the key elements of an effective PR plan:

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 hospitals target audiences.
Other audiences to consider may include employees, board members, community leaders, local
government officials, state legislators, vendors and suppliers.

Tactics:
Its 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 its mailed with at a minimum.
Dont underestimate time investments-------- Every public relations activity has time investments
and opportunity costs and dont 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 didnt anticipate.

METHOD OF IMPROVING PUBLIC RELATION IN HOSPITAL:
There are certain other aspects which need careful consideration which are described in brief as under.

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.

Name Labels and Uniform:
All functionaries should wear uniforms and name labels. This creates initial good impression on
patients and reflects good administration. It also infuses among the employees a pride and sense of
belonging to the institutions. These also help in identifying the staff by name and their status. These are
particularly useful in OPD and ancillary departments.

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 employees 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.

The speciality clinics:
The speciality clinics if located proximally are one of the concentrated areas of the OPD services. It
will facilitate mutual interaction of the functionaries and effective protocol among the various specialities
and will in turn save great deal of effort for the patient to move around for multiple consultations, as and
when necessary.

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.

Complaints and Suggestions:
The best way to deal with complaints is to do everything possible to avoid getting them by
anticipating the problems. In spite of the best intentions of everyone and as it happens everywhere else,
sometimes things go wrong. Any complaint and suggestions should receive prompt attention and wherever
possible remedial actions be taken. Equally important is that whatever action is taken, the same is
communicated to the complaint.

Mortuary and Chaplain Facility:
The disposal of the dead is influenced by religion, social and cultural beliefs and practices. It is
necessary to provide within the hospital or its premises a place to which a dead body can be moved quietly
so that other patients do not get upset. Disposal of dead has a great bearing on public relations of the
hospital. This is a sensitive area for the relatives and friends. Even unintentional neglect or delay may
carry unpleasant impression about the hospital. Utmost care is needed by all members of the staff to
ensure that prompt and proper disposal of the dead is arranged.

NEED FOR PUBLIC RELATION IN THE COMMUNITY:
+ The main goal is to raise the standard of care to the highest level.
+ To improve the existing channels of communication and to establish new ways of setting-up of
two-way communication.
+ To provide the community with the concept of what a hospital and a health centre are.
+ To ensure financial support.
+ To create mutual understanding and goodwill through proper communication.
+ To provide extra services of volunteers.
+ To keep in touch with the community to assess their needs.
+ To interpret the expectation of the community, their opinion and impression of the hospital to the
top level management.
+ In large hospitals relationships can become very impersonal. Project a good image of the hospital
through effective staff performance.
+ Public relationship is all about relationships efforts, commitment and activities, which go into
building. The right sort of relationships where there is good public relations, the hospital and
health care are functioning at its best and contribute maximum to which it serves.

METHODS OF MAINTAINING PUBLIC RELATION IN THE COMMUNITY:
There are mainly two methods:
Operative methods
Communicative methods

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 womens 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.

Qualities of public relation staff:

Warm and friendly with good common sense.
Good organizing ability.
Good judgement, creativity and then critical ability.
Imagination and appreciate others.
Calm and not excitable person.
Ability to take pains.
Lively and inquisitive minds.
Willingness to work long and in constraint atmosphere, whenever necessary especially in
pulse polio campaigns.
Resilient and a sense of humour.
Flexibility and ability to deal with many problems.
Ability to communicate in any languages.
Capable of correcting and subediting others communication.
Loyalty to the organization.

Indicators for assessing public relation in the community:
Patient-satisfaction surveys.
General opinion pool.
Quality of care using checklist.
Number of complain received.
Extent of voluntary efforts by the community.
Turnover of the health staffs.
Consistency of the attendance of the patients in clinics and health centers.
Donations.
Inpatients leaving against medical advice.
Good recovery: achievement of the health activities.
Poor recovery and high death rate.
Vital rates such as IMR, MMR, BR and DR in the area.
Incidence and prevalence rate of the communicable diseases in the community.

PUBLIC RELATION IN AN EDUCATIONAL INSTITUTION

PUBLIC IMAGE:
An idea or mental picture about the organization by the public.

STEPS FOLLOWED IN PUBLIC RELATION IN EDUCATIONAL INSTITUTION:
The followings are the steps followed in public relation campaign in an educational institution.

i. Listing and prioritizing of information is to be disseminated:
May wish to inform the public:
a) The new policy of the Government or organization.
b) The change in the existing policy.
c) The new scheme promoted.
d) The change in the existing scheme.
Public Relations activity starts with identifying the message to be disseminated and prioritized.

ii. Ascertaining the existing knowledge level or understanding the perceptions of the public:
The organization can check a quick survey among the target group of the public to ascertain the
knowledge level of the issue for which the organization is planning to initiate Public Relations process and
in case of the image it is essential to know whether the image is positive, neutral or negative in terms of
the assessment or in terms of the organization or both.

iii. Communication objectives and prioritize:
Based on the knowledge level or image factor, a communication objective is to be established
which is possible to evaluate and the top management approval is required. For example, communication
objective instead of using the term increasing awareness level about the scheme, it should be specific "By
2005, in the number of families where of the scheme be at least one lakh" so that we can evaluate the
impact.

iv. Message and Media:
After choosing the objective, the content of the message need to be developed. While developing the
message we should keep in mind the media in which we are going to use for disseminating that message.
TV/Visual media may be effective for showing the demonstrating awareness. Training media may be
effective whether the recipient may wish to keep the gap or further reference.

v. Implementation of message and media:
Based on the expected reaching level and target group, the budget is to be prepared and message is
transmitted. through the appropriate media.

vi. Impact assessment:
After release of the message, it is essential to study the impact at interval by interacting with the
target group.

vii. Message redesigned:
In case, the interaction of the target group reveals the message did not reach as expected the
modification in message or media need to be done and the revised message should be disseminated.

TYPES OF PUBLIC RELATION:

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.

Collaboration or strategic restructuring:
If you're organization is undertaking these activities, celebrate it publicly.
Presentations:
Find ways to give even short presentations, for example, at local seminars, conventions, seminars,
etc. It's amazing that one can send out 500 brochures and be lucky to get 5 people who respond. Yet,
you can give a presentation to 30 people and 15 of them will be very interested in staying in touch with
you.

QUALITIES OF A PUBLIC RELATION OFFICER IN THE EDUCATIONAL INSTITUTION:
Abundant common sense.
First class organizing capacity.
Good judgment and objectivity.
Imagination ability and ability to appreciate.
Infinite capacity for taking pain.
Willingness to work long.
Be realistic and sense of humor.
Ability to write and speak English correctly.
Pleasant voice and ability to speak in public.
Innovative in ideas.
Basic understanding about the profession.
Image building abilities.
Intelligence, foresight, result oriented approach.
Media specialization.
Editorial expertise.
Insight in research.

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.
Course Scheduling and Public Relations:
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.
Campus Upkeep and Student Affairs:
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.
Public relation with parents:
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.
Monitor the healthcare of students enrolled in the campuses of your zone.
Ensure that hygiene and sanitation is maintained in the sick room so that the recovery is faster.
Keep in touch with the Campus Doctor in order to take precautionary measures against
common ailments.
Ascertain that the parents of students who are sick are informed about the health status of their
wards.

DELEGATION
Introduction
Delegating is a major element of the directing function of nursing management. It
is an effective nurse management competency by which nurse managers get the work
done through their employees. Delegation is part of management; it requires professional
training and development to accept the hierarchical responsibilities of delegation.
Definition
Delegation can be defined as getting work done through others, or as directing the
performance of one or more people to accomplish organizational goals.
Delegation is the process of assigning responsibility and authority to co- worker and
ensuring his accountability.
DELEGATION HAS THREE ESSENTIAL ASPECTS OR DIMENSIONS
1. Assignment of duties and task
2. Grant of authority, power, right or permission
3. Creation of accountability
Assignment of duties:
As one person cannot perform all the tasks, he must allocate a part of his to subordinates
for the purposes of accomplishment by them
Grant of authority:
Delegation of authority means division of authority and powers downwards to the
subordinates. If the delegated duty is to be discharged by subordinates, they must be
entrusted with requisite authority for enabling them to make such work performance.
Creation of accountability
Delegation of duties implies accountability from side of subordinates. Because of this
accountability, the manager must keep for himself some reserved authority and duties for
directing, regulating and controlling the course of work undertaken by his subordinates.
PRINCIPLES OF DELEGATION
There are four fundamental principles which serve as guides for effective delegation:
1. Assignment of duties in terms of expected results.
2. Parity of authority and responsibility. While assigning duties to subordinates, there
should be equality of authority and responsibility.
3. Clarification of limits of authority: It is the clear limit of authority that permits
subordinates to exercise initiative to develop their personal capacity through
freedom of action and to know their area of operation.
4. Unity of command: As employee should receive orders from one superior only. So
subordinates should always be placed under the guidance, control and supervision
of one supervisor who will set up work priorities and will arrange for co-
operation.
List of ways or steps for nurse managers to successfully delegate:
1. Train and develop subordinates:
It is an investment .Give them reasons for the task, authority, details, opportunity
for growth, and written instructions if needed.
2. Plan ahead. It prevents problems.
3. Control and coordinate the work of subordinates.
Develop ways of measuring the accomplishment of objectives with
communication, standards, measurements, and feedback to prevent errors. Nursing
employees want to know the nurse managers expectations of them. They
understand expectations from clearly defined jobs, work relationships, and
expected results.
4. Visit subordinates frequently. Spot potential problems of morale, disagreement
and grievance.
5. Coordination to prevent duplication of effort.
6. Solve problems and think about new ideas. Emphasize employees solving their
own problems.
7. Accept delegation as desirable.
8. Specify goals and objectives.
9. Know subordinates capabilities and match task or duty to the employee. Be sure
the employee considers it important.
10. Agree on performance standards. Relate managerial
11. References to employee performance.
12. Take an interest
13. Assess results. The nurse manager should accept the fact that employees will
perform delegated tasks in their own style.
14. Give appropriate tasks.
15. Do not take back delegated tasks.

REASONS FOR DELEGATING
Assigning routine tasks
Assigning tasks for which the nurse manager does not have time.
Problem solving
Changes in the nurse managers own job emphasis.
Capability building.
The nurse manager should be careful not to misuse the clinical nurse by
delegating tasks that can be done by non- nurses or non-licensed personnel.
BARRIERS TO DELEGATING
Barriers in the delegator
1. Preference for operating by oneself
2. Demand that everyone know all the details.
3. I can do it better myself fallacy.
4. Lack of experience in the job or in delegating.
5. Insecurity
6. Fear of being disliked
7. Refusal to allow mistakes
8. Lack of confidence in subordinates.
9. Perfectionism, leading to excessive control.
10. Lack of organizational skill in balancing work loads.
Barriers in the delegate
1. Lack of experience
2. Lack of competence
3. Avoidance of responsibility
4. Overdependence on the boss
5. Disorganization
6. Overload of work
Barriers in the Situation
1. One- person show policy
2. No toleration of mistakes
3. Criticality of decisions
4. Urgency, leaving no time to explain
5. Confusion in responsibilities and authority.
6. Understaffing.
ADVANTAGES OF DELEGATION
Delegation serves as a vehicle of co-ordination. The various levels of the
organization are used appropriately
A sound system of delegation tends to develop an increased sense of responsibility
and enhanced potential work capacity of individual employee.
It reduces the executive burden- It relieves the superior of time- consuming, minor
duties and allows him to concentrate more effectively on major responsibilities of
his own position.
Delegation minimizes delay when decision have no longer to be referred up the
line.
As delegation provides the means of multiplying the limited personal capacity of
the superior it is instrumental for encouraging of business.
Delegation permits the subordinates to enlarge their jobs, to broaden their
understanding and develop their capacity.
Delegation raises subordinates position in stature and importance and increase
their job satisfaction.
DISADVANTAGES OF DELEGATION
+ Frailty of human life
+ Eye wash delegation
+ Unfamiliarity with art of delegation
+ Incapacity of subordinates.
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.
THE HISTORY OF CONFLICT MANAGEMENT
Early in the 20
th
century, conflict was considered to be an indication of poor
organizational management, was deemed destructive, and was avoided at all costs. When conflict
occurred, it was ignored, denied, or dealt with immediately and harshly. The theorists of this era
believed that conflict could be avoided if employees were taught the one right way to do things
and if expressed employee classification was met swiftly with disapproval.
In the mid 20
th
century, when organizations recognized that worker satisfaction and
feedback were important, conflict was accepted passively and perceived as normal and expected.
Attention cantered on teaching managers how to resolve conflict rather than how to prevent it.
Although conflict considered to be primarily dysfunctional, it was believed that conflict and
cooperation could happen simultaneously.
Conflict also has a qualitative nature. A person may be totally overwhelmed in one
conflict situation, yet be able to handle several simultaneous conflicts at a later time. The
difference is in the quality or significance of that conflict to the person experiencing it.
MEANING & DEFINITION OF CONFLICT
Conflict can be defined as an expressed struggle between at least two interdependent
parties, who perceive that incompatible goals, scarce resources, or interference from
others are preventing them from achieving their goals (Wilmot & Hocker, 2001).
Conflict is related to feelings, including feelings of neglect, of being viewed as taken for
granted, of being treated like a servant, of not being appreciated, of being ignored, of
being overloaded, and other instances of perceived unfairness.
Conflict management is the process of planning to avoid conflict where possible and
organizing to resolve conflict where it does happen, as rapidly and smoothly as possible.
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.

COMMON CAUSES OF CONFLICT
1. Vertical conflict: Occurs between hierarchical levels
2. Horizontal conflict: Occurs between persons or groups at the same hierarchical level.
3. Line-staff conflict: Involves disagreements over who has authority and control over
specific matters
4. Role conflict: Occurs when the communication of task expectations proves inadequate or
upsetting
5. Work-flow interdependencies: Occur when people or units are required to cooperate to
meet challenging goals.
6. Domain ambiguities: Occurs when individuals or groups are placed in ambiguous
situations where it difficult to determine who is responsible for what.
7. Recourse scarcity: When resources are scarce, working relationships are likely to suffer.
8. Power or value asymmetries: Occurs when interdependent people or groups differ
substantially from one another in status and influence or in values.
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.

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.

Felt conflict
Perceived conflict
Conflict resolution or conflict
management
Manifest conflict
Conflict aftermath
Latent conflict (also
called 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 managers 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 organizations 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
members 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 supervisors
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 employees 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.
Greenhalghs 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
others 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 somebodys
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.

Dimension
Viewpoint Continuum
Difficult to Resolve Easy to Resolve
Issue in question
Size of stakes
Interdependence of the
parties
Continuity of interaction
Structure of the parties

Involvement of third parties
Perceived progress of the
conflict
Matter of principle
large
Zero sum

Single transaction
Amorphous or fractionalized,
with weak leadership
No neutral third party
available
Unbalanced: One party
feeling the more harmed
Divisible issue
Small
Positive sum

Long-term relationship
Cohesive, with strong
leadership

Trusted, powerful,
prestigious, and neutral
Parties having done equal
harm to each other
TECHNIQUES OR SKILLS FOR MANAGING CONFLICT
Aims: The manager should work on a compromise to stimulate the interaction and involvement
of the parties, another aim of conflict management. Other aims include better decisions and
commitment to decisions that have been made.
Strategies:
There are 5 strategies from conflict management theory for managing stressful situation.
1. Avoidance
2. Accommodation
3. Competition
4. Compromise
5. Collaboration
Avoidance/Avoiding (no winners/no losers):
This isn't the right time or place to address this issue. In the avoiding approach, the
parties involved are aware of a conflict but choose not to acknowledge it or attempt to resolve it.
Avoidance may be indicated in trivial disagreements, when the cost of dealing with the conflict
exceeds the benefits of solving it, when the problem should be solved by people other than you,
when one party is more powerful than the other, or when the problem will solve itself. The great
problem in using avoidance is that the conflict remains, often only to re-emerge at a later time in
an even more exaggerated fashion.

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.

Collaboration/Collaborating (win/win): Teamwork and cooperation help everyone achieve
their goals while also maintaining relationships.
Collaborating is an assertive and cooperative means of conflict resolution that results
in a win-win solution. In collaboration, all parties set aside their original goals and work together
to establish a supraordinate or priority common goal. In doing so, all parties accept mutual
responsibility for reaching the supraordinate goal. Although it is very difficult for people truly to
set aside original goals, collaborating cannot occur if this doesnt happen.
For example, a nurse who is unhappy that she did not receive requested days off might
meet with her superior and jointly establish the supraordinate goal that staffing will be adequate
to meet the patient safety criteria. If the new goal is truly a jointly set goal, each party will
perceive that an important goal has been achieved and that the supraordinate goal is most
important. In doing so, the focus remains on problem solving and not on defeating the other
party.

MANAGE AND RESOLVE CONFLICT SITUATIONS

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
Collective bargaining is a process between employers and employees to reach an agreement
regarding the rights and duties of people at work. Collective bargaining aims to reach a collective
agreement which usually sets out issues such as employees pay, working hours, training, health
and safety, and rights to participate in workplace or company affairs.
DEFINITION:
Collective bargaining is an agreement between a single employer or an
association of employers on the one hand and a labour union on the other, which regulates the
terms and conditions of employment
(Tudwig Teller)
Collective bargaining is a process of discussion and negotiation between two
parties, one or both of whom is a group of persons acting in concest. More specifically it is the
procedure by which an employer or employers and a group of employees agree upon the
conditions of work
(The encyclopaedia of social science)
Collective bargaining takes place when a number of work people enter into a
negotiation as a bargaining unit an employer or group of employer with the object of reaching
an agreement on conditions of the employment of the work people
(According to J.H. Rishardwon)
OBJECTIVES OF COLLECTIVE BARGAINING
Collective bargaining has benefits not only for the present, but also for the future. The objectives
of collective bargaining are:
1. To provide an opportunity to the workers, to voice their problems on issues related to
employment.
2. To facilitate reaching a solution that is acceptable to all the parties involves.
3. To resolve all conflicts and disputes in a mutually agreeable manner.
4. To prevent any conflict/disputes in the future through mutually signed contracts.
5. To develop a conductive atmosphere to foster good organizations relations.
6. To provide stable and peaceful organization (hospital) relations.
7. To enhance the productivity of the organization by preventing strikes lock out ect.
CHARACTERSTICS OF COLLECTIVE BARGAINING
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.
10.

UNION/LABOUR ORGANIZATION:
An organization in which employees participate for the purpose of
negotiating with the employer about grievances, labour disagreement, wages, hours of work
and conditions of employment.
PREPARATION FOR COLLECTIVE BARGAINING:
Preparation should begin months before the contract talks.
Chairperson should be establish and maintain pleasant relationship with union
representatives by treating them courteously in social situations, grievance
hearing.
Obtain information from other nurse executives about union activities in
neighbouring health agencies.
Review other labour contracts negotiating in other agencies to determine what
type of demands were made by various worker categories.
Keep ongoing recording agencys employees grievances and analyse these before
negotiation begins.
Research the wage salary structures of other health agencies in the community
and compare against agencies current wage package.
Should read the act to identify limitations.
COLLECTIVE BARGAINING PROCESS

Collective bargaining generally includes negotiations between the two parties (employees
representatives and employers representatives). Collective bargaining consists of
negotiations between an employer and a group of employees that determine the conditions
of employment. Often employees are represented in the bargaining by a union or other labor
organization. The result of collective bargaining procedure is called the collective
bargaining agreement (CBA). Collective agreements may be in the form of procedural
agreements or substantive agreements. Procedural agreements deal with the relationship
between workers and management and the procedures to be adopted for resolving individual
or group disputes.
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.

The collective bargaining process comprises of five core steps:
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 employers 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.

STEPS
Selection of a bargaining agent.
Certification to contract.
Contract administration.
The nurse managers role.
Decertification.
Selection of bargaining agent:
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:
- American federation of, county and municipal employees (AFSCME).
- Service employees international union (SEIU).
The election outcome is determined by the group receiving a simple majority of the votes
cast. The union winning this election certified to enter into contract negotiations with the
employer.
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:
Certification by the National Labour Relations Board (NLRB) of a union to be the
bargaining agent does mean that a group of people have the right to enter into a contract with an
employer, a concept known as certification 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:
A union among security clause.
A management rights clause.
Seniority.
Fringe benefits.
Layoff and reduction in work language.
Floating procedure.
Insurance.
Retirement issues.
Professional issues.
The contract is considered to be in effect when both management of the
organization and employees agree on its content. The final agreement is subject to a ratification
vote by the affected employees. Passage of the contract, or ratification, is obtained by a simple
majority of eligible members who vote.
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 managers role:
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:
Grievance can usually be classified as
o Those caused by misunderstanding.
o Those caused by intentional contract violations.
o Those caused by symptomatic problems outside the scope of the labour agreement.
Grievance caused by a misunderstanding usually stem from circumstances surrounding the
grievance, a lack of familiarity with the contract or an inadequate labour agreement.
Intentional violation of a contract is usually an effort to capitalize on ambiguous contract
language or past practices.
Symptomatic grievances are simply a means for the employee to show dissatisfaction or
frustration and stem from the human element in management / labour relationship.
THE GRIEVANCE PROCESS: an example;
The following steps comprise the typical grievance process:
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.
SUGGESTIONS HELPFUL IN HANDLING GRIEVANCE:
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 informations, evaluated and anticipates the other partys 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; dont become overconfident.
THE GRIEVANCE HEARING
In the grievance hearing, remember this key behaviour:
Put the grievant at ease. Do not interrupt or disagree.
Listen openly and carefully.
Discuss the problem calmly and with an open mind.
Get the story straight. Get all the facts ask logical questions.
Consider the grievant view points
Avoid snap judgements. Do not jump to conclusions
Make an equitable decision, and then give it to the grievant promptly.
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

Economic TYPES OF Sympathy
Strikes STRIKES strikes

Illegal Unfair
Strikes labor strikes
Economic strikes:
Employees 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.
Unfair labour strikes:
Result from an unfair labour practice by an employer or a union.
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:
It is a work stoppage to force an employer to bargain with a particular organisation.
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
A collective bargaining process generally consists of four types of activities- distributive
bargaining, integrative bargaining, attitudinal restructuring and intra-organizational bargaining.
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 partys gain is another
partys 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.
LEVELS OF COLLECTIVE BARGAINING
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.

Sectoral bargaining, which aims at the standardization of the terms of
employment in one industry, includes a range of bargaining patterns. Bargaining
may be either broadly or narrowly defined in terms of the industrial activities
covered and may be either split up according to territorial subunits or conducted
nationally
.

The third bargaining level involves the company and/or establishment. As a
supplementary type of bargaining, it emphasizes the point that bargaining levels need
not be mutually exclusive.

IMPORTANCE OF COLLECTIVE BARGAINING
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
o It increases the strength of the workforce, thereby, increasing their bargaining
capacity as a group.
o Collective bargaining increases the morale and productivity of employees.
o It restricts managements freedom for arbitrary action against the employees.
Moreover, unilateral actions by the employer are also discouraged.
o Effective collective bargaining machinery strengthens the trade unions
movement.
o The workers feel motivated as they can approach the management on various
matters and bargain for higher benefits.
o It helps in securing a prompt and fair settlement of grievances. It provides a
flexible means for the adjustment of wages and employment conditions to
economic and technological changes in the industry, as a result of which the
chances for conflicts are reduced.
o Collective bargaining develops a sense of self respect and responsibility
among the 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.
3. Collective bargaining opens up the channel of communication between the workers
and the management and increases worker participation in decision making.
4. Collective bargaining plays a vital role in settling and preventing industrial disputes.
Importance to society
1. Collective bargaining leads to industrial peace in the country
2. It results in establishment of a harmonious industrial climate which supports which
helps the pace of a nations efforts towards economic and social development since
the obstacles to such a development can be reduced considerably.
3. The discrimination and exploitation of workers is constantly being checked.
It provides a method or the regulation of the conditions of employment of those who are
directly concerned about them.
ADVANTAGES AND DISADVANTAGES OF COLLECTIVE BARGAINING:
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

NURSES UNIONS AND ASSOCIATIONS
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.

OCCUPATIONAL HEALTH AND SAFETY

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.

Man and physical, chemical and biological agents:

Physical agent- the physical factors in the working environment which may be adverse to
health are heat, cold, humidity, air movement, heat radiation, light, noise, vibrations and ionizing
radiation. The factors act in different ways on the health and efficiency of the workers, singly or
in different combinations. The amount of work and the breathing place, toilet, washing and
bathing facilities are also important factor in occupational environment.

Chemical agents- these 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.

Man and machine:

An industry or factory implies the use of machines driven by power with emphasis on
mass production. The unguarded machines, protruding and moving parts, poor installation of the
plant, lack of safety measures are the cause of accidents which is the major problem in industries.

Man and man:
There are numerous psychological factors that operates in the place of work. These are
human relationships amongst workers themselves on the one hand, and those in authority over
them on the other hand. Examples of psychosocial factors include the type and rhythm of work,
work stability, service conditions, job satisfaction, leadership style, security, workers
participation, communication, system of payment, welfare conditions, degree of responsibility,
trade union activities, incentives and a host of similar other factors, all entering the field of
human relationships. In modern occupational health, the emphasis is upon the people, the
conditions in which they live and work, their hopes and fears and their attitudes towards their
job, their fellow-workers and employers.

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 miners 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.

Ultraviolet radiation: occupational exposure to ultraviolet radiation occurs mainly in arc
welding. Such radiation mainly affects the eyes, causing intense conjunctivitis and
keratitis (Welders flash). Symptoms are redness of the eyes pain, these usually disappear
in a few days with no permanent effect on vision or on the deeper structures of the eyes.

Ionizing radiation: ionizing radiation is finding increasing application in medicine and
industry, eg: X- ray and radioactive isotopes. Important radio-isotopes are cobalt 60 and
phosphorus 32. Certain tissues such as bone marrow are more sensitive than others and
from genetic standpoint, there are special hazards when the gonads are exposed. The
radiation hazard comprises genetic changes, malformation, cancer leukaemia, depilation,
ulceration, sterility and in extreme cases death. The international commission of
radiological protection has set the maximum permissible level of occupational exposure
at 5 rem per year to the whole body.

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.

Mechanical hazards: the mechanical hazards in industry centre round machinery,
protruding and moving parts and the like. About 10% of accidents in industry are said to be
due to mechanical causes.

Psychosocial hazards: the psychosocial hazards arises from the workers 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.

Disease due to physical agent:
1. Heat- heat hyperpyrexia, heat exhaustion, heat syncope, heat cramps, bruns and
local effects such as prickly heat.
2. Cold- trench foot, frost bite, chilblains
3. Light- occupational cataract, miners nystagmus
4. Pressure- caisson disease, air embolism, blast(explosion)
5. Noise- occupational deafness
6. Radiation- cancer, leukaemia, aplastic anemia, pancytopenia
7. Mechanical factors- injuries, accidents
8. Electricity- burns

Disease due to chemical agents:
1. Gases: Co
2,
Co, HCN, CS, NH
3
, N
2
, H
2
S, HCL, SO
2
-
these causes gas poisoning.
2. Dusts (pneumoconiosis)
Inorganic gases: coal dust-anthracosis; silica-silicosis; asbestos-asbestosis, cancer;
iron-siderosis.
Organic(vegetable) dusts: cane fibre-bagassossis; cotton dust-byssinosis; tobacco-
tobacossis; hay or grain dust-framers lung.
3. Metals and their compounds: toxic hazards from lead, mercury, cadmium, manganese,
beryllium, arsenic, chromium etc.
4. Chemicals: acids, alkalies, pesticides
5. Solvents: carbon bisulphide, benzene, trichloroethylene, chloroform, etc.

Disease due to biological agents:
Brucellosis, leptospirosis, anthrax, actinomycosis, hydatidosis, psittacosis, tetanus,
encephalitis, fungal infections, etc.

Occupational cancer:
Cancer of the skin, lungs, bladder.

Occupational dermatosis:
Dermatitis, eczema

Disease of psychological origin:
Industrial neurosis, hypertension, peptic ulcer, etc.

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.

FARMERS LUNG:
It is due to the inhalation of mouldy hay or grain dust which contains micropolyspora
faeni , the main cause of farmers 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

The characteristics of occupational cancer are:
They appear after prolonged exposure
The period between exposure and development of disease may be 10 to 25 years.
The disease may develop even after cessation of exposure.
The localization of tumors is remarkably constant in any one occupation.

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.

CONTROL OF INDUSTRIAL CANCER:
Elimination or control of industrial carcinogens well-designed building or machinery,
closed system of production.
Medical examinations and Inspection of factories.
Notification and licensing of establishments
Personal hygiene measures
Education of workers and management and research.

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.

The dermatitis producing agents are further classified into:
Primary irritants acids, alkalies, dyes
Sensitizing substances allergic dermatitis.

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.
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
0.3 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.

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.

HEALTH PROBLEMS DUE TO INDUSTRIALIZATION:
Environmental sanitation problems housing, water pollution, air pollution, sewage
disposal.
Communicable diseases
Food sanitation
Mental health.
Accidents and Social problems.
Morbidity and mortality.

MEASURES FOR HEALTH PROMOTION OF WORKERS:
The aim of occupational health is the promotion and maintenance of the highest
degree of physical, mental and social well-being of workers in all occupations. The measure for
the general health protection of workers was the subject of discussion by an ILO/WHO
Committee on Occupational Health in 1953. The committee recommended the following:

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

5. MEASURES FOR WOMEN AND CHILDREN:

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 crches 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:

It is an important health promotional measure. It should be given in all levels
management, supervisory staff, workers, trade union leaders and community.

7. FAMILY PLANNING:
Family planning is now become a decisive factor for the quality of life, and this applies to
industrial workers also. The workers must adopt the small family norm.
PREVENTION OF OCCUPATIONAL DISEASES:

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:

> Design of building > Dust enclosure and isolation
> Good housekeeping > Local exhaust ventilation
> General ventilation > Protective devices
> Mechanization > Environmental monitoring
> Substitution > Statistical monitoring and research

3. LEGISLATION:

The most important factory laws in India today are ;
The Factory Act , 1948
The Employees State Insurance Act , 1948
Some of other specialized acts adapted to the particular circumstances of the industry are
The Mines Act, The Plantation Act, The Minimum Wages Act, The Maternity Benefit Act, etc.
OHSMS:
In the changed industrial scenario, an emphatic world wide Endeavour is visible in improving
quality in all functions of an organization. Recognizing that the workplace safety and health is a
decisive factor in an organizational effectiveness, several management frameworks have been
proposed to implement cost-effective occupational health safety(OHS) in preventing work place
aliments and promoting health and welfare of workers resolving around the international
standards organization families of management standards(eg:ISO 9000 and 14000).
Broadly, an ideal OHS management system (OHSMS) should provide a structured process to
minimize potentials of work-related injuries and illness, increase productivity by reducing the
direct and indirect cost associated with accidents, and increase the quality of manufactured
products for rendered services. It must provide a direction to OHS activities, in accordance with
organizational policies, regulatory requirements, industry practices and standards, including
negotiated labour arguments. Therefore, conforming to an OHSMS may be significant value to
an organization. This approach has drawn significant attention among the standard organizations,
the accreditation and certification bodies and the national agencies in formalizing, implementing
and evaluating OHSMS.
The framework for certification of OHSMS, namely occupational health and safety assessment
series (OHSAS) specification (OHSAS 18001;1999) has been developed by an association of
national standards and certification bodies, and specialist consultants. It has been developed to be
compatible with the ISO 9000 (quality) and ISO 14000 (environment) standards in order to align
and integrate quality, environment and OHS, management systems in organizations.
The organization which has established, implemented and maintained OHSMS meeting the
specification, is eligible to apply for certification. The scheme is established with the aim that
upon receiving the certification, the organization will become more aware and self regulating in
promoting health and safety at their work places. The certification offers independent
verification and auditing that an organization has taken reasonable measures to minimize
workplace risks and injuries.
In order to implement OHSMS, 18001 specification, an organization, requires to establish OHS
policy.
Management review

Audit Feedbackfrom measuring performance

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

Audit feed back from measuring

Implementation and operation
Plan and integration concepts of hazards prevention, meet statutory, regulatory and policy
requirements, develop OHS goals and objectives, and establish OHS management program.
Planning

Feedback from measuring performance
Audit

Checking and corrective action
Implement the OHSMS, prioritizing the OHS resources, defining the structure and responsibility
of personnel, establishing documentation of the care system elements and interaction, including
procedure for controlling documents and data.
Implementation and operation

Policy
Planning
Implementation
and operation
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

Internal factors external factors

OHS policy
Undertake management review to monitor progress of OHSMS implementation.

IMPORTANCE OF OCCUPATIONAL HEALTH IN HOSPITALS

Hospitals are large, organizationally complex, system driven institutions employing large
numbers of workers from different professional streams. They are also potentially hazardous
workplaces and expose their workers to a wide range of physical, chemical, biological,
ergonomical and psychological hazards. Thus Occupational Health and Safety issues relating to
the personal safety and protection of its workers is a very important Environmental Health
concern for hospitals.

Personal (Staff) Protection Physical Hazards

Radiation Exposure

There is a wide range of radiation hazards related to medical imaging (x rays, nuclear
scans utilizing radioactive isotopes) and radiation oncology which utilizes ionizing radiation
from a variety of sources to treat a range of malignant tumors. These sources include (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
.

Checking and
corrective action
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.

Personal (Staff) Protection Chemical Hazards
Toxic chemicals in use in hospitals include:-
Industrial cleaners used by contracted cleaning staff.
Chemical sterilizers, in particular gluteraldehyde used for the sterilization of endoscopes
and other equipment that cannot be steam sterilized.
Tissue preservatives such as formaldehyde used to store and preserve body tissue prior to
histopathology.
Chemical reagents used in the hospital Pathology Laboratory.
Cytotoxic drugs requiring preparation prior to parenteral administration to cancer
patients.
Processing chemicals for X-ray film development.
Anesthetic gases in the Operating Theatre.
The hierarchy of principles for controlling chemical hazards are well documented and utilized
within hospitals:-
Elimination (use an alternative process or strategy eg. disposables).
Substitution (use the least toxic chemical that will do the job).
Isolation (keep the relevant chemical in one isolated area if possible).
Enclosure (e.g. gluteraldehyde fume cupboard, preparation enclosure for cytotoxics,
closed circuit anesthetic machines with scavenging of exhaust gases).
Ventilation (X-ray processors).
Personal protection (gloves, goggles, plastic gowns etc. where appropriate).
Personal hygiene (hand washing after use).
General cleanliness (clean up spills, appropriate storage, etc.).
Again, relevant staff must have appropriate training and education in the use of any of these
chemicals, and must be informed of any dangers including those of low risk.

Personal (Staff) Protection Biological Hazards

Management of biological hazards should be comprehensively covered in the hospitals
Infection Control Manual, with the policies and procedures developed and monitored by an
Infection Control Committee chaired by an Infection Control Nurse. There are 3 important
modes of disease transmission from patients to staff:
1. Airborne and droplet aerosol exposure - includes viral upper respiratory tract infections,
measles and TB. Preventative measures include (i) keeping distance (>1m) from frontal
coughing as much as possible (ii) wash hands after every patient contact and especially
avoid rubbing eyes before washing (iii) high filtration face masks (where applicable -
generally not practical in the outpatient setting) (iv) isolate inpatients in a negative air
pressure room.
2. Skin contact exposure - includes Staphylococcus aureus and Varicella. Prevention
requires protective gown and gloves.
3. Exposure to infectious fluids via broken skin, eyes, mucous membranes, and parenteral
exposure - includes hepatitis B, hepatitis C, and HIV from all body fluids except sweat,
as well as gastroenteritis and hepatitis A from fecal fluid. Preventative measures include
universal precautions (gloves, gown, goggles and mask), and appropriate management of
sharps, spills, and contaminated waste.
If acute exposure to a biological hazard does occur, staff members need to be aware of relevant
policies and procedures for appropriate management of the exposure. This will include:
Appropriate washing for mouth, eyes or skin exposure
First aid for penetrating sharps injury
Prophylaxis for high risk exposure
Testing of the source if possible
Testing and follow up of exposed staff
Incident reporting.

Personal (Staff) Protection Psychological Hazards
Hospitals are stressful places for sick and injured patients and their families. However they
can also be stressful for staff due to such factors as:
Shift work, on call duty, fatigue and burn out.
High workload and demand.
High or unrealistic patient expectations.
Verbal abuse or threats from disgruntled or intoxicated patients.
High or unrealistic expectations from supervisors and management.
Problematic interpersonal work relationships.
Frustrations due to limited resources, especially staffing levels.
Poor organizational climate with low staff morale.
Hospitals are part of a high demand, high expectation service industry and are heavily reliant on
staff for the friendly, safe, effective and efficient delivery of services. To optimize productivity
and attitude of staff, senior management must be committed to ensuring a conducive
organizational climate with high staff morale. Clear priorities and direction, realistic
performance goals and workloads, commitment to continuing education and quality assurance,
reception to staff feedback, and support with counseling services for stressed staff are all
important components.

Patient Protection
Nosocomial Infection Control

Minimizing adverse outcomes of health care for inpatients is of prime importance to
hospitals and a major focus of Quality Assurance activities. A very significant indicator of
quality care is the nosocomial infection rate.
The hospitals Infection Control Nurse and Infection Control Committee are concerned with the
prevention, surveillance and control of nosocomial infections. The Infection Control Program
should be documented in the hospitals Infection Control Manual, which outlines the principles,
strategies, policy and procedures for infection control in the hospital. All staff need to be familiar
with its contents. Regular feedback on surveillance of nosocomial infection rates will help
motivate staff to remain vigilant.

Patient Safety
Injury prevention for patients may require some of the following interventions when
appropriate:-
Diligence in keeping bed rails up particularly for those patients with an altered conscious
state from medication or illness.
Bathroom / toilet aids particularly for the elderly or disabled.
Nurse and physiotherapy assisted mobilization during recovery.
Walking aids for the disabled, and during recovery.
Occupational therapy home assessment for home aids.
Community nurse visits for bathing etc. following discharge.

Evacuation Plans for Internal Emergencies

Various internal emergencies including fire, explosion and bomb threat may require
evacuation of all or parts of the hospital. Well-documented and rehearsed evacuation plans are
required to ensure the safe evacuation of disabled, immobilized or otherwise helpless patients. In
critical care areas this will include manual back up for life support systems.
Food Safety
Hospital kitchens prepare meals for inpatients and in many cases prepare meals for the
staff canteen. It is obviously imperative that food storage, handling and preparation is done to the
highest standards and poses no risk to already sick or compromised patients.

ROLE OF OCCUPATION HEALTH NURSE:
Occupational health nurses, as the largest single group of health care
professionals involved in delivering health care at the workplace, have responded to these new
challenges. They have raised the standards of their professional education and training,
modernized and expanded their role at the workplace, and in many situations have emerged as
the central key figure involved in delivering high quality occupational health services to the
working populations. Occupational health nurses, working independently or as part of a larger
multi professional team, are at the frontline in helping to protect and promote the health of
working populations.

DEFINITION:- OCCUPATIONAL HEALTH NURSE

Occupational Health Nurses (OHN)s are registered nurses who independently
observe and assess the worker's health status and to respect them from job tasks and hazards.
Using their specialized experience and education, these registered nurses recognize and prevent
health effects from hazards exposure.
SCOPE
Educationally prepared to recognize adverse health effects of occupational exposure and
address methods for hazard abatement and control, OHNs bring their nursing expertise to all
industries such as meat packing, manufacturing, construction as well as the health care industry.
OHNs:
o Have special knowledge of workplace hazards and the relationship to the
employee health status.
o Understand industrial hygiene principles of engineering controls, administrative
controls, and personal protective equipment.
o Have knowledge of toxicology and epidemiology as related to the employee and
the work site.
Typical OHN Activities:
Observation and assessment of both the worker and the work environment.
Interpretation and evaluation of the worker's medical and occupational history, subjective
complaints, and physical examination, along with any laboratory values or other
diagnostic screening tests, industrial hygiene and personal exposure monitoring values.
Interpretation of medical diagnosis to workers and their employers.
Appraisal of the work environment for potential exposures.
Identification of abnormalities.
Description of the worker's response to the exposures.
Management of occupational and non-occupational illness and injury.
Documentation of the injury or illness.

Role of the Occupational Health Nurse in Workplace Health Management
The occupational health nurse may fulfill several, often inter related and complimentary,
roles in workplace health management, including:
+ __Clinician
+ __Specialist
+ __Manager
+ __Co-ordinator
+ __Adviser
+ __Health educator
+ __Counsellor
+ __Researcher

1. CLINICIAN:
Primary prevention - The occupational health nurse is skilled in primary prevention of
injury or disease. The nurse may identify the need for, assess and plan interventions to,
for example modify working environments, systems of work or change working practices
in order to reduce the risk of hazardous exposure.
Emergency care - The occupational health nurse is a Registered Nurse with a great deal
of clinical experience and expertise in dealing with sick or injured people. The nurse
should provide initial emergency care of workers injured at work, transfer of the injured
worker to hospital and emergency services. Occupational health nurses employed in
mines, on oil rigs, in the desert regions are more responsible for this work.
Treatment services - In some countries occupational health services provide curative
and treatment services to the working population, in other countries such activities are
restricted.
Nursing diagnosis - Occupational health nurses are skilled in assessing clients health
care needs, establish a nursing diagnosis and formulating appropriate nursing care plans,
in conjunction with the patient or client groups, to meet those needs. Nurses can then
implement and evaluate nursing interventions designed to achieve the care objectives.
The nurse has a prominent role in assessing the needs of individuals and groups, and has
the ability to analyse, interpret, plan and implement strategies to achieve specific goals.
Individual and group care plan - The nurse can act on the individual, group, enterprise
or community level.
General Health advice and health assessment - The occupational health nurse will be
able to give advice on a wide range of health issues, and particularly on their relationship
to working ability, health and safety at work or where modifications to the job or working
environment can be made to take account of the changing health status of employees.

2. SPECIALIST:

Occupational health policy, and practice development, implementation and
evaluation- The specialist occupational health nurse may be involved, with senior
management in the enterprise, in developing the workplace health policy and strategy
including aspects of occupational health, workplace health promotion and environmental
health management.
Occupational health assessment - Occupational health nurses can play an essential role
in health assessment for fitness to work, pre employment or pre placement examinations,
periodic health examinations and individual health assessments for lifestyle risk factors.
Health surveillance - Where workers are exposed to a degree of residual risk of
exposure and health surveillance is required by law the occupational health nurse will be
involved in undertaking routine health surveillance procedures, periodic health
assessment and in evaluating the results from such screening processes. The nurse will
need a high degree of clinical skill when undertaking health surveillance and maintain a
high degree of alertness to any abnormal findings.
Sickness absence management - Occupational health nurses can contribute by helping
managers to manage sickness absence more effectively. The nurse may be involved in
helping to train line managers and supervisors in how to best use the occupational health
services.
Rehabilitation - Planned rehabilitation strategies, can help to ensure safe return to work
for employees who have been absent from work due to ill health or injury. The
occupational health nurse is often the key person in the rehabilitation programme who
will, with the manager and individual employee, complete a risk assessment, devise the
rehabilitation programme, monitor progress and communicate with the individual, the
occupational health physician and the line manager.
Maintenance of work ability - The occupational health nurse may develop pro-active
strategies to help the workforce maintain or restore their work ability.
Health and safety
Hazard identification - The occupational health nurse often has close contact with the
workers and is aware of changes to the working environment. Because of the nurses
expertise in health and in the effects of work on health they are in a good position to be
involved in hazard identification.
Risk assessment - Legislation is increasingly being driven by a risk management
approach. Occupational health nurses are trained in risk assessment and risk management
strategies depending upon their level of expertise.

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:

To management and staff on issues related to workplace health management -
Occupational health nurses act as advisers to management and staff on the development
of workplace health policies and practices, and can fulfil an advisory role by participating
in, for example, health and safety committee meetings, health promotion meetings, and
may be called upon to provide independent advice to managers or workers who have
specific concerns over health related risks.
As a conduit to other external health or social agencies - Occupational health nurses
act in an advisory role when seeing individuals who may have problems that, whilst not
directly related to work may affect future work attendance or performance.

6. HEALTH EDUCATOR:

Workplace Health promotion - Health education as one of the key prerequisites of
workplace health promotion is integral aspect of the occupational health nurses role. In
some countries the nurse is required to support activities aimed at adoption of healthy
lifestyles within on-going health promotion process, as well as participate in health and
safety activities. Occupational health nurses can carry out a needs assessment for health
promotion.

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.

ETHICS IN OCCUPATIONAL NURSING

The International Commission on Occupational Health (ICOH) has published
useful guidance on ethics for occupational health professionals. This guidance is
summarized in the following three paragraphs;
1. Occupational Health Practice must be performed according to the highest professional
standards and ethical principles. Occupational health professionals must serve the health
and social wellbeing of the workers, individually and collectively. They also contribute to
environmental and community health.
2. The obligations of occupational health professionals include protecting the life and the
health of the worker, respecting human dignity and promoting the highest ethical
principles in occupational health polices and programs. Integrity in professional conduct,
impartiality and the protection of confidentiality of health data and the privacy of workers
are part of these obligations.
3. Occupational health professionals are experts who must enjoy full professional
independence in the execution of their functions. They must acquire and maintain the
competence necessary for their duties and require conditions which allow them to carry
out their tasks according to good practice and professional ethics.

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
MANAGEMENT
Concepts, principles and procedures
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


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.
Objectives of material management
+ To reduce cost of material
+ Ensure a good support with suppliers(vendors)
+ Effective and efficient handling of materials at all stages and in all sections.
In other hand objectives of material management
Low purchase price
Maintaining continuous supply
Maintaining quality
Cordial relationship with supplier
Low pay roll cost
Development of vendose
Good record
Low storage cost
Favourable reciprocal relation
New material & products
Standardization
Product improvement
Interdepartmental harmony
Economic forecasting.
Aim of Material Management
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.
Purpose of Material Management
To gain economy in purchasing
To satisfy the demand during period of replenishment
To carry reserve stock to avoid stock out.
To stabilize fluctuations in consumption
To provide reasonable level of client services
Increase efficiency of health care systems.
Develop knowledge and skills of health care
Provide materials in required quantity and quality as when required.
Basic Principles of material Management
Effective management and supervision; it deals on material functions of; planning,
organizing, staffing, controlling, report and budgeting.
Sound purchasing method
Skillful and hard poised negotiation
Effective purchase system
Should be simple
Simple inventory control program.
Functions of Material Management
+ Material planning & budgeting
+ Purchasing
+ Inventor control
+ Cost reduction
+ Value analysis
+ Receiving & inspection
+ Stocking & distribution
+ Disposal.
Elements of Material Management
Material planning
Purchasing
Receiving & warehousing
Store keeping
Inventory control
Value analysis
Standardization
Production control
Transportation
Material handling
Disposal scarp
PROCEDURE
Good material managers adopt the following procedures:
Taking inventory regularly and systematically
Requisitioning at indenting according to actual needs
Receiving and inspecting incoming items
Storing and protecting items
Issuing items for use
Proper use of items.

Some more procedures
+ 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.
PLANNING AND PROCUREMENT PROCEDURES IN MATERIAL
MANAGEMENT
Material management is a scientific technique, concerned with planning, organizing and
controlling the flow of materials from their initial purchase through internal operations to the
service point through distribution. The material management in the health care system is
concerned with providing the drugs, supplies and equipment needed by health personnel to
deliver health services. About 40 percent of the funds in the health care system are used up for
providing materials. It is of great importance that materials of right quality are supplied to the
consumers. Material management integrates all material functions;
Planning for materials
Demand estimation
Purchasing
Inventory management
Inbound traffic
Warehousing and stores
Incoming quality control

MATERIAL PLANNING
"Material planning is the scientific way of determining the requirements that goes into
meeting production needs within the economic investment policies.
- Gopalakrishnan & Sunderasan
It is done at all stages and all levels of management. Material planning is based on certain
feedback information and reviews.
Aim of material management planning
To get:
The Right quality
Right quantity of supplies
At the Right time
At the Right place
For the Right cost
Purpose of material management planning
To gain economy in purchasing
To satisfy the demand during period of replenishment
To carry reserve stock to avoid stock out
To stabilize fluctuations in consumption
To provide reasonable level of client services
Objectives of material management planning
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
Basic principles of material management Planning
Effective management and supervision depends on managerial functions of:
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
Techniques of Material Planning
Bill of Material technique:
BOM is the simplest technique of materials planning.
Explosion of bill of materials refers to splitting the requirements for the product to
be manufactures in to its basic components. E.g. in health care is drugs
manufactured in the pharmacy
This technique is ideally suited to engineering industries.
The technique is based on demand forecasts.
Requirement for various materials are listed with their complete specifications

Past Consumption Analysis Technique
In this technique future projection is made on the basis of the past consumption
data, which is analyzed taken in to consideration the past and future plans.
Statistical tools like mean, median, mode and standard deviation are used in
analyzing the past consumption.
Elements of Material Management Planning
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.
Identify the needed items
Need for variety reduction-less number of materials, less will be the problems of
planning
Lying down proper specification based on ISI or other standards

Calculate from the trends in Consumption
Review past the consumption in the past

Review with resource constraints
Availability of funds

Procurement process planning
Problems affecting material planning
Corporate/ Government objectives and plans
Technology available
Market demand
Lead time and rejection rates
Working capital available
Nature of inventory required
Capacity and its utilization of the organization
Seasonal variations
Information and data available
Overall material policy

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.
Objectives of procurement system
Acquire needed supplies as inexpensively as possible
Obtain high quality supplies
Assure prompt and dependable delivery
Distribute the procurement workload to avoid period of idleness and overwork
Optimize inventory management through scientific procurement procedures

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
Methods in Procurement Process and Negotiation Strategies
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

Restricted or limited tender
From limited suppliers (about 10)
Lead-time is reduced
Better quality

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

Many Suppliers Strategy
Many sources per item
Adversarial relationship
Short-term
Little openness
Negotiated, sporadic POs
High prices
Infrequent, large lots
Delivery to receiving dock

Few Suppliers Strategy
1 or few sources per item
Partnership (JIT)
Long-term, stable
On-site audits and visits
Exclusive contracts
Low prices (large orders)
Frequent, small lots
Delivery to point of use

Contractual services by Directorate General of Supplies and Disposals for Government
Institutions
Fixed quantity contract: supply firms are called upon to offer to supply a definite
quantity of stores by a specified date. Such contracts are binding both parties
Running Contract: these contacts are for supply of an approximate quantity of stores
at a specified price during a certain period of time.
Rate contract: most common contracts in health care institutions, in which firms are
asked to supply stores at specific rates during the period covered by the contract. No
fixed quantity is mentioned. This system of offers maximum flexibility in ordering
specified quantity of materials at frequent intervals.
Points to remember while purchasing
Proper specification; Seek order acknowledgement
Invite quotations from reputed firms
Comparison of offers based on basic price, freight and insurance, taxes and levies
Quantity & payment discounts and Payment terms
Delivery period, guarantee
Vendor reputation (reliability, technical capabilities, Convenience, Availability, after-
sales service, sales assistance)
Short listing for better negotiation terms
Procurement of equipments- Points to be noted before purchase of equipment:
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
Store must be of adequate space
Materials must be stored in an appropriate place in a correct way
Group wise and alphabetical arrangement helps in identification and retrieval
First-in, first-out principle to be followed
Monitor expiry date
Follow two bin or double shelf system, to avoid stock outs
Reserve bin should contain stock that will cover lead time and a small safety stock
Issue and use
Can be centralized or decentralized
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

Functions of inventory control
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.
- A items- Represents high cost centre
- B items- intermediate cost centre
- C items- low cost centre.
It is the process of classifying items by using values as measure.
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
THE ABC METHOD OF INVENTORY CONTROL
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:
1. Rigorous value analysis
2. Rigid estimates
3. Strict and close watch
4. Management of items should be done at top management level
5. Centralized purchasing and storage
+ 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
2.Purchase based on rigid requirement
3.Reasonably strict watch and control
4. Management be done at middle level
+ Class C: Low values items, but are required in large quantities and consists of various
types and varieties like clips, washers. It needs only a simple and inexpensive system of
control in which some of the routine may be relaxed.
C items
1. Ordinarily control measures
2. Purchased based on usage estimates
3. Controls exercises by store keeper
4. Management be done at lower levels.
5.Decentralized (delegated) purchasing
Another recommended breakdown of ABC classes:
1. "A" approximately 10% of items or 66.6% of value
2. "B" approximately 20% of items or 23.3% of value
3. "C" approximately 70% of items or 10.1% of value
ABC CLASSIFICATION LEVELS
Items Class A Class B Class C
Number of items as a % of total number 10 20 70
Annual usage value as a % on total usage
value
70 20 10

Annual value (a) is defined as: A= VQ,
where, Q= annual consumption on quantity terms
V= value (cost) per item
ABC analysis tells us that 5-10 percent of all items(called A category) accounts for 70% of
annual consumption costs, another 10-20% of items (B category) account for 20-30% of the
costs, while the balance 70% of items(C category) account for about 5-10% of costs.
PROCEDURE OF ABC CLASSIFICATION
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.
Class B items come in between A and C on degree of control.
ADVANTAGES
Provides a mechanism for identifying items that will have a significant impact on overall
inventory cost
It helps in economizing ones effort to achieve greater results.
It helps to segregating those items which ought to be given priority to maximize results.
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.
Proper use of valuable time of store personnel.
Simple no confusing formulas are involved
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.
+ Loose control on C may result in shortages.
+ 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.
+ ABC ignores market conditions, market availability, competitions, seasonal variations
etc.

VED ANALYSIS
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.
THE VED METHOD OF INVENTORY CONTROL
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.
Essential items follow vital items in their hierarchy of importance.
Desirable items are least importance in terms of functional considerations, which are
loosely controlled at the lower level.
MATRIX OF ABC/ VED ANALYSIS
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.
PLANNING EQUIPMENTS AND SUPPLIES FOR NURSING CARE: UNIT AND
HOSPITAL
Material Management Cycle
Demand estimation
Receiving & inspection
Stocking
Inventory control
Distribution
Hospital Supplies and Equipments
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.
Materials used in hospitals
Hospital material medical side
Perfusion material
Surgical disposables
Instruments
Drugs, medicine, oxygen, linen
Biomedical equipment
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
Hospital material management side
Computer, fax, telephone, stationery
items
Public address items overhead
projector
Audiovisual systems

Purchase of supplies and equipment
The purchase of equipments and supplies in a hospital is carried out through:
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 :
Transport charges (local delivery reduce the transport charge)
Incidental costs
Cost of chemicals and other consuable to be used with the equipment(eg; ECG paper for
an ECG machine)
Operating costs(hiring a technician)
Cost of maintenance service; 10-20% of hospital equipment may remain idle if serving is
not done periodically.
Cost of technology obsolesces: When a better quality appears in market there is tendency
to discard the old model.
Replacement cost of equipment
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:
Methods of handling linen supply include:
a) Departmentalised system
b) Centralised linen supply
General utility services in the hospital
1. Electric supply and installations
2. Water supply
3. Disposal of waste liquids and solids
4. Refrigeration , air conditioning, ventilation and environment control
5. Trasport
6. Supply of medical gases, compressed air, hot water, vacuum suction and gas plants
7. Laundry
8. Fire hazard
9. Communication
10. Repairs workshop.
Essential equipments for a 50 bedded district hospital(WHO)
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.
PLANNING SUPPLIES AND EQUIPMENTS DURING EMERGENCIES AND
DISASTER
Introduction
Emergency preparedness planning requires a wide variety of supplies, equipment and
resources, including personal protective equipment (PPE), decontamination equipment, and
training. Planning should include collaborating with local emergency planning committees,
local/state public health departments, and area hospitals to determine the supplies, equipment,
and resources each healthcare facility needs to handle a disaster.
Products and contracted suppliers
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.
Products and equipment for emergency preparedness
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.
Safety catalog search terms by categories and subcategories
Category Subcategories
Apparel Personal or
protective clothing
Eye, face, head, foot, hearing protection;
respiratory protection
Personal protective
equipment (PPE)

PPE response kits
(A, B, C, D)
Example: first responder level C kit
Clinical diagnostics Clinical diagnostics; sample collection/transportation; swabs, wipes
Decontamination Spill control
Detection; monitoring Detection instruments; personal alarm kits; gas detection instruments
Fire equipment Extinguishers
First aid Blankets, kits
Mail handling products Powder-free gloves, bags
Monitoring
Operations; traffic
safety
Crowd control, flashlights, signs, barricades
Safety First aid, personal protection
Surge capacity Temporary negative pressure units
Training resources Health & training services; respiratory protection training, hearing and
biological screening
General Considerations in material management during disaster:
a. Supplies and Equipment:
1. Extra supplies will be obtained from purchasing personnel through runners.
2. Outside supplies will be ordered by the Purchasing Director and brought into the hospital
via the loading dock.
3. Be responsible for setting up extra beds in hospital if needed, as well as transporting
storeroom supplies and bringing in extra supplies from other areas.
4. Be willing to help with movement of victims from ambulance to Triage.
b. Materials Management - Purchasing
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.
c. Valuables and Clothing:
1. Large paper or plastic bags are available in the treatment Areas and the storeroom for
patient's clothing and valuables.
d. Housekeeping and Laundry
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
1. Check area for supplies and equipment.
2. Keep minimum list of supplies on hand and be prepared to process additional sterile
supplies quickly.
3. Notify anesthetists who will maintain adequate anesthesia and drug supplies.
f. Hospital Unit - Supervisor will:
1. Prepare for expansion by notifying maintenance of number of extra beds needed and
where to set them up.
2. Send for extra supplies needed from Purchasing, CSR, Laundry, and Dietary.
3. Will make wheelchairs available.
g. Laboratory
1. Have arrangements made to obtain additional blood, equipment and supplies from area
agencies.
i. Pharmacy
1. Report to Command Center, and then remain in department.
2. Have list of drug suppliers that can provide emergency supplies quickly
3. Keep minimum supply of emergency drugs on hand at all times.
4. Pharmacy should remain open and have a runner to deliver needed meds to areas.
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.
INVENTORY CONTROL, CONDEMNATION AND DISPOSAL.
Definition Of inventory control:
Inventory: inventory is the list of moveable items which are required to manufacture a product
or to maintain equipment. Inventory is a unique item having identification number, nomenclature
and specification.
Following are the types of inventory:
Raw materials
Components
Work in progress
Finished goods
The inventory is basically of two types:
Official inventory: the materials lying in the main store s and being accounted for but have not
been issued to the user units.
a. Medical and surgical items
b. Dressings
c. Linens
d. X-ray supplies
e. Laboratory supplies
f. Housekeeping items
g. All processed sterile items
Unofficial inventory: the materials have been issued to the user units like the dispensary, CSSD,
laundry, wards, OPD, cast rooms etc. In case of forecasting or demand estimation, these items
are not taken into consideration by the hospital administration, so it is called as un-official
inventory for hospitals.
Functions of inventory control:
- To carry adequate stock to avoid stock-outs
- To order sufficient quantity per order to reduce order cost
- To stock just sufficient quantity to minimize inventory carrying cost
- To make judicial selection of limiting the quantity of perishable items and costly
materials
- To take advantage of seasonal cyclic variation on availability of materials to order the
right quantity at the right time.
- To provide safety stock to take care of fluctuation in demand/ consumption during lead
time.
- To ensure optimum level of inventory holding to minimize the total inventory cost.
Concepts relevant in controlling inventory costs:
The following concepts are relevant in controlling the inventory costs:
Periodic/ cyclic system: this system involves review of stock status at periodic/ fixed
intervals and placement of orders depending on the stock on hand and rate of
consumption. The ordering interval is thus fixed but the quantity to be ordered varies
each time.
Two bin system: it is a system where the stock of each item is held in two bins, one
large bin containing sufficient stock to meet the demands during interval between
arrival of an order quantity and placing of next order, and the other bin containing
stocks large enough to satisfy probable demands during the period of replenishment.
When the first bin is empty, an order for replenishment is placed, and the stock in the
second bin is utilized until the ordered material is received.
Lead time: this is the period required to obtain the supply once the need is
determined. It is therefore the average number of days between placing an indent and
receiving the material. Lead time is composed of two elements: administrative or
buyers lead time (i.e. Time required for raising purchase requisitions, obtaining
quotations, raising purchase order, order to reach supplier etc) and delivery or
suppliers leading time ( i.e. Time required for manufacture, packing and forwarding,
shipment, delays in transit)
Minimum/safety/ buffer stock: this is the amount of stock that should be kept in
reserve to avoid a stock-out in case consumption increases unexpectedly or in case
the lead time turns out to be longer than normal. It is also the level at which fresh
supply should normally arrive, failing which action should be taken on an emergency
basis to expedite supply and replenish the stock.
Safety stock = maximum daily consumption-average daily consumption x total lead
time
Maximum order level: this is the maximum quantity of the materials to be stocked,
beyond which the item must not be in the inventory. If the inventory is maintained
beyond this point, there would be loss to the hospital by way of expiry of life items
beyond the shelf life of items, loss incurred on the capital locked up in the inventory,
unnecessary use of items just to exhaust the inventory.
Re-order level: this is the value which is very important from the point of view of the
inventory control. This is the point at which we have to place an order for
procurement for replenishing the stock. It is derived by the formula (minimum order
level + buffer stock )
Costs:
a. Ordering costs: this is the cost of getting an item into the store. The process of ordering
starts with raising requisition, placing an order, follow up, transportation receipt and
inspection, acceptance and placing in stores.
b. Carrying costs: this is the cost of holding an item in the store till it is issued out or sold.
Following are the elements:-
+ Interest on capital cost incurred.
+ Cost of obsolescence, wastages, damages.
+ Rent, insurance, depreciation and taxes
+ Maintenance costs of inventory like special treatment, stock taking etc.
+ Operating costs of store like direct labor and overheads like electricity, dust
proofing etc.
c. Shortage costs: these are the costs incurred both directly and indirectly due to shortages
like intangible costs due to loss of goodwill, opportunity loss or production hold costs.
d. Total inventory cost: A total inventory cost consists of carrying costs and ordering costs.
e. Lead time: this is the time which has elapsed between placing an order till the same items
are received, stocked and ready to use.

Average inventory:
Average inventory is defined in two cases:
Average inventory at constant usage rate:
Average inventory = opening stock+ closing stock
2
Average inventory at variable usage rate:
Simple average method:
Average inventory = opening stock+ closing stock
2
Six monthly average method:
Average inventory= opening stock+ stock after 6 months+ closing stock
2

Quarterly average method:
Average inventory = sum of 4_- quarterly stock + closing stock
5
Monthly average method:
Average inventory = sum of 12_- quarterly stock + closing stock
13
Selective inventory control:
Definition: selective inventory control means grouping the inventory and classifying for the
purpose of applying the right type of control based on their costs and functional importance.
Objective: the primary objective of inventory control is to minimize total cost of inventory. It
requires the following
- Supervision on planning and control of inventory functions like forecast of requirements
- Purchase quantity fixation
- Storage and supply

Need for selective inventory control:
Inventory consists of many items, in which some are costly whereas some may be not.
Some inventories are required in large quantities whereas some are required in limited
quantities, thus each item require different type of control, some tight and some loose.
Methods of selective inventory control:
Following are the popular methods of selective inventory control:
a. ABC analysis
b. VED analysis
CONDEMNATION & DISPOSAL
The materials which could not be used within its shelf life, deteriorated and declared unfit for
use, became obsolete or banned due to legal provisions are considered for condemnation or
disposal.
Criteria for condemnation:
The equipment has become:
1. Non-functional & beyond economical repair
2. Non-functional & obsolete
3. Functional, but obsolete
4. Functional, but hazardous
5. Functional, but no longer required

PROCEDURE FOR CONDEMNATION
Following procedure is generally carried out in case of the materials particularly drugs and non-
drug items:
A condemnation committee comprising of three or more members is constituted by the
competent authority, the terms of reference of the committee are:
i. To go in details of the reasons as to why this situation has occurred.
ii. The people who are responsible for the lapses on the aspects from acquisition to
storage and distribution of materials.
iii. To suggest measures to be taken for disposal of the items.
The committee members go into details through inventory records right from the point of
demand estimation to the distribution level of materials, and will find out reasons for
being an item surplus and remained unused.
The committee will declare the items condemned and make recommendation for further
disposal of items.
The condemned items are to be destroyed, so it is to be taken out from the inventory
registers, a write off sanction of the competent authority is obtained before final disposal.
The items particularly medicines which are toxic and cannot be disposed of by burial or
as per the relevant laid down rules under the subject of waste disposal.
The effective measures are taken for disposal of surplus items before it becomes unfit for use is:
A list of surplus material is circulated among the hospital staff/user units requesting them
to pay special attention for mobilizing such items and giving priority to this category of
items.
The surplus materials are transferred to other hospitals where these may be required.
The surplus materials are offered to the manufacturer/ suppliers for buy back.
In case of materials other than drugs like equipments, instruments any such articles are
treated as salvage or scrap, whatever the case may be, action is taken accordingly:
The materials may be sold by inviting tender.
Open auctions of items through authorized auctioneers.

Unit VIII
CONTROLLING
Quality assurance Continuous Quality Improvement
Standards
Models
Nursing audit
Performance appraisal: Tools, confidential reports,
formats,
Management, interviews
Supervision and management: concepts and principles
Discipline: service rules, self discipline, constructive
versus
destructive discipline, problem employees, disciplinary
proceedings enquiry etc
Self evaluation or peer evaluation, patient satisfaction,
utilization review

QUALITY ASSURANCE- CONTINUOUS QUALITY IMPROVEMENT

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 assurance is the measurement of provision against expectations with declared
intention and ability to correct any demonstrated weakness. -Shaw
Quality assurance is a management system designed to give maximum guarantee and
ensure confidence that the service provided is up to the given accepted level of quality, the
standards prescribed for that service which is being achieved with a minimum of total
expenditure. -British Standards Institute
CQI is an ongoing quality improvement measure using management and scientific
methods of quality assurance involving data collection, its analysis, and formulating ways to
improve performance outcome according to proposed standards.
Quality assurance vs. Continuous quality improvement (Koch, 1993)
Quality improvement is not necessarily a replacement for existing quality assurance activities,
but rather an approach that broadens the perspectives on quality.
Quality assurance (QA) Quality Improvement (QI)
Inspection oriented (detection)
Reaction
Correction of special causes
Responsibility of few people

Narrow focus
Leadership may not be vested
Problem solving by authority
Planning oriented (prevention)
Proactive
Correction of common causes
Responsibility of all people involved
with the work
Cross- functional
Leadership actively leading
Problem solving by employees at all
levels
Objectives
To successfully achieve sustained improvement in health care, clinics need to design
processes to meet the needs of patients.
To design processes well and systematically monitor, analyze, and improve their
performance to improve patient outcomes.
A designed system should include standardized, predictable processes based on best
practices.
Set Incremental goals as needed.
NASA Ames Research Center Health Unit

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.

Management improvement- This is to provide quality assurance programme as a tool
for managerial problem solving. It includes identification of the problem in areas of
technical quality, efficiency, risk and patient satisfaction to assess its nature, causes and
taking effective actions to reduce or eliminate the identified problems.

Facilitation of adoption of innovations- It includes evaluation of performance of
individuals professionals, preparation of appropriate criteria for assessment of processes
and outcome, exchange of information within and outside the organization, and
introduction of innovations with assessment of their impact on patient care outcome, risk
and satisfaction by using the patient as a unit for analysis.
Quality assurance whether in health or education had two main objectives:

To provide technical assistance in designing and implementing effective strategies for
monitoring quality and correcting systemic deficiencies and

To refine existing methods for ensuring optimal quality health care through an applied
research programme
(Decker, 1985 and Schroeder, 1984).

Purposes/ Need
Rising expectations of consumer of services.
Increasing pressure from national, international, government and other professional
bodies to demonstrate that the allocation of funds produces satisfactory results in terms of
patient care.
The increasing complexity of health care organizations.
Improvement of job satisfaction.
Highly informed consumer
To prevent rising medical errors
Rise in health insurance industry
Accreditation bodies
Reducing global boundaries.
Principles
QM operates most effectively within a flat, democratic and organizational structure.
Managers and workers must be committed to quality improvement.
The goal of QM is to improve systems and processes and not to assign blame.
Customers define quality.
Quality improvement focuses on outcome.
Decisions must be based on data.
According to W Edward Deming; (Demings 14 points)
Crete consistency of purpose for improvement of product and service.
Adopt the new philosophy
Cease dependence on inspection to achieve quality.
End the practice of awarding business on the basis of price tag.
Improve constantly and forever the systems of production and service.
Institute training on the job.
Institute leadership.
Drive out fear.
Break down barriers between departments.
Eliminate slogans, exhortations, and target for the workforce.
Eliminate numerous quotas for the workforce and numerical goals of management.
Remove barriers that rob people of pride and workmanship.
Institute a vigorous programme of education and self-improvement for everyone.
Put everyone in the company to work to accomplish the transformation.
Approaches
General approach
Specific approach
General approach: - It involves large governing or official bodies evaluating a person or
agencies ability to meet established criteria or standard during a given time.
a) Credentialing- It is the formal recognition of professional or technical competence
and attainment of minimum standards by a person and agency. Credentialing
process has 4 functional components
- To produce a quality product
- To confirm a unique identity
- To protect the provider and public
- To control the profession
b) Licensure- It is a contract between the profession and the state in which the
profession is granted control over entry into an exit from the profession and over
quality of professional practice.
c) Accreditation- It is a process in which certification of competency, authority, or
credibility is presented to an organization with necessary standards.
d) Certification
e) Charter- It is a mechanism by which a state government agency under state law
grants corporate state to institutions with or without right to award degrees.
f) Recognition- It is defined as a process whereby one agency accepts the
credentialing states of and the credential confined by another.
g) Academic degree
Specific approach: - These are methods used to evaluate identified instances of provider and
client interactions.
a) Audit- It is an independent review conducted to compare some aspect of quality
performance, with a standard for that performance.
b) Direct observation- Structured or unstructured based on presence of set criteria.
c) Appropriateness evaluation- The extent to which the managed care organization provides
timely, necessary care at right levels of service.
d) Peer review- Comparison of individual providers practice either with practice by the
providers peer or with an acceptable standard of care.
e) Bench marking- A process used in performance improvement to compare oneself with
best practice.
f) Supervisory evaluation
g) Self-evaluation
h) Client satisfaction
i) Control committees
j) Services- Evaluates care delivered by an institution rather than by an individual provider.
k) Trajectory- It begins with the cohort of a person who shares distinguishing
characteristics and then follows the group going through the healthcare system noting
what outcomes are achieved by the end of a particular period
l) Staging- It is the measurement of adverse outcomes and the investigation of its
antecedence.
m) Sentinel- It involves maintaining of factors that may result in disease, disability or
complications such as;
- Review of accident reports
- Risk management
- Utilization review
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 patients current or future health that results
from nursing interventions.
According to Manwell, Shaw, and Beurri, there are 3As and 3Es;
- 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;
AHRQ Agency for Healthcare Research and Quality
IHI Institute for Healthcare Improvement
JCAHO Joint Commission on Accreditation of Healthcare Organizations
NAHQ National Association for Healthcare Quality
IOM Institute of Medicine
NCQA National Committee for Quality Assurance

Areas of QA
The assurance in various key areas are;
Outpatient department- The points to be remembered are;
- Courteous behavior must be extended by all, trained or untrained personnel.
- Reduction of waiting time in the OPD and for lab investigations by creating more
service outlets.
- Provide basic amenities like toilets, telephone, and drinking water etc.
- Provision of polyclinic concept to give all specialty services under one roof.
- Providing ambulatory services or running day care centers.
Emergency medical services
Services must be provided by well trained and dedicated staff, and they should
have access to the most sophisticated lifesaving equipment and materials, and
also have the facility of rendering pre- hospital emergency medical aid through a
quick reaction trauma care team provided with a trauma care emergency van.
In- patient services
Provide a pleasant hospital stay to the patient through provision of a safe, homely
atmosphere, a listening ear, humane approach and well behaved, courteous staff.
Specialty services
A high tech hospital with all types of specialty and super- specialty services will
increase the image of the hospital.
Training
A continuous training programme should be present consisting of on the job
training, skill training workshops, seminars, conferences, and case presentations.

MODELS
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, patients right to quality care and nursing contributions.

Identify
structure ,
standard and
criteria
Apply the process,
standards and
criteria
Evaluate
outcome of
standards
and criteria
3. Quality Health Outcome Model: The uniqueness of this model proposed by Mitchell & Co is
the point that there are dynamic relationships with indicators that not only act upon, but also
reciprocally affect the various components.
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.
It consists of 5 steps: define, measure, analyze, improve and control (DMAIC).
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.
Indicators of quality assurance
Waiting time for different services in the hospital
Medical errors in judgment, diagnosis, laboratory reporting, medical treatment or surgical
procedures, etc.
Hospital infections including hospital- acquired infections, cross infections.
Quality of services in key areas like blood bank, laboratories, X- ray department, central
sterilization services, pharmacy and nursing.
Quality improvement process- Steps

QI process steps include;

Identify needs most important to the consumer of health care services.
Assemble a multidisciplinary team to review the identified consumer needs and services.
Collect data to measure the current status of these services.
Establish measurable outcomes and quality indicators.
Select and implement a plan to meet the outcomes.
Collect data to evaluate the implementation of the plan and achievement of outcomes.

Quality assurance cycle:

In practice, QA is a cyclical, iterative process that must be applied flexibly to meet the needs of a
specific program. The process may begin with a comprehensive effort to define standards and
norms as described in 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.

1. Planning for Quality Assurance
This first step prepares an organization to carry out QA activities. Planning begins with a review
of the organizations scope of care to determine which services should be addressed.

2. Setting Standards and Specifications
To provide consistently high-quality services, an organization must translate its programmatic
goals and objectives into operational procedures. In its widest sense, a standard is a statement of
the quality that is expected. Under the broad rubric of standards there are practice guidelines or
clinical protocols, administrative procedures or standard operating procedures, product
specifications, and performance standards.
3. Communicating Guidelines and Standards
Once practice guidelines, standard operating procedures, and performance standards have been
defined, it is essential that staff members communicate and promote their use. This will ensure
that each health worker, supervisor, manager, and support person understands what is expected
of him or her. This is particularly important if ongoing training and supervision have been weak
or if guidelines and procedures have recently changed. Assessing quality before communicating
expectations can lead to erroneously blaming individuals for poor performance when fault
actually lies with systemic deficiencies.

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.

5. Identifying Problems and Selecting Opportunities for Improvement
Program managers can identify quality improvement opportunities by monitoring and evaluating
activities. Other means include soliciting suggestions from health workers, performing system
process analyses, reviewing patient feedback or complaints, and generating ideas through
brainstorming or other group techniques. Once a health facility team has identified several
problems, it should set quality improvement priorities by choosing one or two problem areas on
which to focus. Selection criteria will vary from program to program.

6. Defining the Problem
Having selected a problem, the team must define it operationally-as a gap between actual
performance and performance as prescribed by guidelines and standards. The problem statement
should identify the problem and how it manifests itself. It should clearly state where the problem
begins and ends, and how to recognize when the problem is solved.

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.

8. Analyzing and Studying the Problem to Identify the Root Cause
Achieving a meaningful and sustainable quality improvement effort depends on understanding
the problem and its root causes. Given the complexity of health service delivery, clearly
identifying root causes requires systematic, in-depth analysis. Analytical tools such as system
modeling, flow charting, and cause-and-effect diagrams can be used to analyze a process or
problem. Such studies can be based on clinical record reviews, health center register data, staff or
patient interviews, service delivery observations.

9. Developing Solutions and Actions for Quality Improvement
The problem-solving team should now be ready to develop and evaluate potential solutions.
Unless the procedure in question is the sole responsibility of an individual, developing solutions
should be a team effort. It may be necessary to involve personnel responsible for processes
related to the root cause.

10. Implementing and Evaluating Quality Improvement Efforts
The team must determine the necessary resources and time frame and decide who will be
responsible for implementation. It must also decide whether implementation should begin with a
pilot test in a limited area or should be launched on a larger scale. The team should select
indicators to evaluate whether the solution was implemented correctly and whether it resolved
the problem it was designed to address. In-depth monitoring should begin when the quality
improvement plan is implemented. It should continue until either the solution is proven effective
and sustainable, or the solution is proven ineffective and is abandoned or modified. When a
solution is effective, the teams should continue limited monitoring.

JCAHO quality assurance guidelines/steps:

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 Commissions
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.

2. Delineate scope of care and services:
Scope of care refers to the range of services provided to patients by a unit or department. To
delineate the scope of care for a given department personnel should ask themselves, what is
done in the department?

3. Identify important aspects of care and services:
Important aspects of nursing care can best be described as some of the fundamental contribution
made by nurses while caring for patients. They are the most significant or essential categories of
care practiced in a given setting. There is no prescribed list of important aspects of care that
every organization must monitor.

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).

5. Establish thresholds for evaluation:
Thresholds are accepted levels of compliance with any indicators being measured. Thresholds
for evaluation are the level of or point at which intensive evaluation is triggered. A threshold can
be viewed as a stimulus for action.

6. Collect data:
Once indicators have been identified, a method of collecting data about the indicators must be
selected. Among the many methods of data collection is interviewing patient/family, distributing
questionnaires, reviewing charts, making direct observation etc.

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 patients 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.

9. Assess action taken:
Continuous and sustained improvement in care requires constant surveillance by nurses of the
intervention initiated to improve care.

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 bedside in relation to
predetermined criteria like errors, omissions, deficiencies, as well as efficiencies and also
excess in the care of patients under them. It involves direct and indirect observation,
interviewing the staff responsible for care, and reviewing the patients records and care
plan.
It can be also done to identify the job satisfaction of staff nurses in accordance with their
work performance.
Audit cycle
According to Payne, the steps in audit or utilization review include;
Criteria development
Selection of cases
Work sheet preparation
Case evaluation
Tabulation of evaluation
Presentation of reports
The basic audit cycle can be depicted as;

In general, the stages of audit cycle are;
Identify the need for change
Setting criteria and standards
Collecting data on performance
Assess criteria against criteria and standards
Identify need for change (re- evaluation)
Advantages
Patient is assured of good service.
Better planning of quality improvement can be done.
It develops openness to change.
It provides assurance, by meeting evidence based practice.
It increases understanding of clients expectations.
It minimizes error or harm to patients.
It reduces complaints or claims.
Disadvantages
It may be considered as a punishment to professional group.
Medico- legal importance- They feel that they will be used in court of law as any
document can be called for in a court law.
Many components may make analysis difficult.
It is time consuming
It requires a team of trained auditors.

1. set
standards
2. observe
practice
changes
3. compare
with standards
4. implement
change
PERFORMANCE APPRAISAL
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.
Performance appraisal is a method of evaluating the behavior of employees in the work
spot, normally including both the quantitative and qualitative aspects of job performance.
Performance here refers to the degree of accomplishment of the tasks that make up an
individual's job. It indicates how well an individual is fulfilling the job demands. Often the term
is confused with effort, but performance is always measured in terms of results and not efforts.

The performance appraisal process includes day-to-day manager-employee interactions
(coaching, counseling, dealing with policy/procedure violations, and disciplining); written
documentation (making notes about an employee's behavior, completing the performance
appraisal form); the formal appraisal interview; and follow-up sessions that may involve coach-
ing and/or discipline when needed.

DEFINITION
Edwin b flippo, performance appraisal is a systematic, periodic and so far as humanly possible,
an impartial rating of an employees 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.
According to scott, clothier and spriegal, performance appraisal is a record of progress for
apprentices and regular employees, as a guide in making promotions, transfer or demotions, as a
guide in making lists for bonus distribution, for seniority consideration and for rates of pay, as an
instrument for discovering hidden genius, and as a source of information that makes conferences
with employees helpful.
OBJECTIVES OF APPRAISAL.
1. To determine the effectiveness of employees on their present jobs so as to decide their
benefits.
2. To identify the shortcomings of employees so as to overcome them through systematic
guidance and training.
3. To find out their potential for promotion and advancement.
PURPOSES AND BENIFITS
Performance appraisal can serve many purposes and has several benefits. Among them are:
1. To provide backup data for management decisions concerning salary standards, merit
increases, selection of qualified individuals for hiring, promotion or transfer, and
demotion or termination of unsatisfactory employees.
2. To serve as a check on hiring and recruiting practices and as validation of employment
tests.
3. To motivate employees by providing feedback about their work.
4. To discover the aspirations of employees and to reconcile them with the goals of the
organisation,
5. To provide employees with recognition for accomplishments,
6. To improve communication between supervisor and employee, and to reach an
understanding on the objectives of the job,
7. To help supervisors observe their subordinates more closely, to so a better coaching job,
and to give supervisors a stronger part to play in personnel management and employee
development,
8. To establish standards of job performance.
9. To improve organisational development by identifying training and development needs to
employees and designing objectives for training programmes based on those needs,
10. To earmark candidates for supervisory and management developments and
11. To help the organisation determine if it is meeting its goals.
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.
CONCEPT OF PERFORMANCE APPRAISAL
1. The appraisal should be in writing and carried at least once a year.
2. The performance appraisal information should be shared with the employee.
3. The employee should have the opportunity to respond in writing to the appraisal.
4. Employees should have a mechanism to appeal the results of the performance
appraisal.
5. The manager should have adequate opportunity to observe the employees job
performance during the course of the evaluation period.
6. Anecdotal notes on the employees performance should be kept during the entire
evaluation period.
7. Evaluator should be trained to carry out the performance appraisal process.
8. As for as possible, the performance appraisal should focus on employee behaviour
and results rather than on personal traits or characteristics.

CHARECTERISTICS AND OBSTACLES
The following characteristics are essential elements of effective performance appraisal:
1. The philosophy, purpose, and objectives of the organisation are clearly stated so that
performance appraisal tools can be designed to reflect these.
2. The purposes of performance appraisal are identified, communicated, and understood.
3. Job descriptions are written in such a manner that standards of job performance can be
identified for each job.
4. The appraisal tool used is suited to the purposes for which it will be utilised and is
accompanied by clear instructions for its use.
5. Evaluators are trained in the use of the tool.
6. The performance appraisal procedure is delineated, communicated, and understood.
7. Plans for policing the appraisal procedure and evaluation appraisal tools are developed
and implemented.
8. Performance appraisal has the full support of top management.
9. Performance appraisal is considered to be fair and productive by all who participate in it.
The principal obstacles to effective performance appraisal are:
1. Lack of support from top management.
2. Resistance on the part of evaluators because:
a. Performance appraisal demands too much of supervisors efforts in terms of time,
paperwork, and periodic observation of subordinates performance.
b. Supervisors are reluctant to play god by judging others.
c. Supervisors do not fully understood the purpose and procedures of performance
appraisal.
d. Supervisors lack skills in appraisal techniques.
e. Performance appraisal is not perceived as being productive.
3. Evaluation biases and rating errors, which result in unreliable and invalid ratings.
4. Lack of clear, objective standards of performance.
5. Failure to communicate purposes and results of performance appraisal to employees.
6. Lack of a suitable appraisal tool.
7. Failure to police the appraisal procedure effectively.

PRINCIPLES OF PERFORMANCE APPRAISAL
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.
KINDS OF PERFORMANCE APPRAISAL
There are many kinds of performance appraisal available. But the management wants to
adopt only one of the types of performance appraisal. The appraisal is done adopting any one
of the two approaches. These two approaches are traits and results. The traits approach refers
to appraising the employee on the basis of 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
a. Each employee or worker can be compared with the other person.
b. A small organization can get maximum benefits through the ranking method.
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.

2. Paired Comparison Method
This method is a part of ranking method. Paired comparison method has been developed
to be used in a big organization. Each employee is compared with other employees taking
only one at a time. The evaluator compares two employees and puts a tick mark against
an employee whom he considers a better employee. In the same way, an individual is
compared with all other existing employees. Finally an employee who gets maximum
ticks for being a better employee is consider the best employee.
Advantages
a. This method is suitable for big organizations.
b. Individual traits are evaluated under this method.
Disadvantages
a. The understanding of this method is difficult one.
b. It involves considerable time.

3. Forced distribution method
A method which forces the rater to distribute the ratings of the overall performance of an
employee is known as forced distribution method. Group wise rating is done under this
method. This method is suitable to large organisations, but the individual traits could not
be appraised under this method.
Example: a group of workers doing the same job would fall into the same group as
superior, at and above average, below average and poor. The rator rates 15% of the
workers as superior, 35% of the workers as at and above average, 35% of workers as
below average and 15% of workers as poor.
4. Grading
Certain categories of abilities or performance of employees are defined well in advance
to fall in certain grades under this method. Such grades are very good, good, average,
poor and very poor. Here the individual traits and characteristics are identified.
5. Checklist
The appraisal of the ability of an employee through getting answers for a number of
questions is called the method of check list. These questions are related to the behaviour
of an employee. The evaluation is done by a separate department, but the duty of
collection of checklist answers is given to a person who is designated as a rator. The rator
indicates the answers of an employee against each question by putting a tick mark. There
are two columns provided to each question as yes or no.

A model check list is given below.
A. Is the employee satisfied with the job? Yes No
B. Does he finish the job accurately? Yes No
C. Does he respect the superiors? Yes No
D. Is he ready to accept responsibilities? Yes No
E. Does he obey the orders? Yes No
6. Forced choice method
A series of groups of statements are prepared positively or negatively under this method,
both these statements describe the characteristics of an employee, but the rator is forced
to tick any one of the statements either out of positive statements or out of negative
statements. The degree of description of the characteristics of an employee varies from
one statement to another.
The following are the positive statements;
a. The employee completes the job in time usually.
b. The employee has the ability to complete the job and complete the job as and when
there is a need.
The negative statements are also prepared. The final rating is done on the basis of all such
statements. But the ratter does not know the statements which are for final rating.
7. Critical Incident method
The performance appraisal of an employee is done on the basis of the incidents occurred
really to the concerned employee. Some incidents occurred due to the inability of the
employee, but the rating is done on all the events occurred in a particular period.
Some of the events or incidents are given below.
a. Refused to co-operate with other employees
b. Unwilling to attend further training
c. Got angry over work or with subordinates
d. Suggested a change in the method of production
e. Suggested a procedure to improve the quality of goods
f. Suggestion of a method to avoid or minimize wastage, spoilage and scrap.
g. Refused to obey orders
h. Refused to follow clear cut instructions

8. Field review method
An employees performance is appraised through an interview between the rator and the
immediate superior or superior of a concerned employee. The rator asks the superiors
questions about the performance of an employee, the personnel department prepares a
detail report on the basis of this collected information. A copy of this report is placed in
the personnel file of the concerned employee after getting approval from the superior.
The success of this type of appraisal method is based on the competence of the
interviewer.

9. Essay evaluation
With easy evaluation technique the nurse manager is required to describe the employees
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.
The components are
a. Use of nursing process
b. Professionalism
c. Maintaining safety
d. Continuing education
e. Initiative character.
STEPS FOR PEER REVIEW
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 managers 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.

Types of appraisal interview
1. Tell and sell interview
It is based on the assumption that employees have some deficiencies but they need to
be convinced about these deficiencies. The purpose of this interview is
a. To let the employee to know how well he is doing.
b. To draw up a plan of improvement for him.
c. To gain the employees acceptance of the evaluation.
2. Tell and listen interview.
The objective of this interview is to communicate the evaluation to the employee and
then listen sympathetically to his reactions. It consists of two parts
The first part covers the strong and week points of the employees performance.
The second part is used to explore thoroughly the employees feelings about the
evaluation.

3. Problem solving interview.
In this interview the aim is not appraisal but development of an employee. Therefore,
the interviewer takes himself out of his usual role as a judge and puts himself in the
role of a helper. He does not communicate the evaluation to the employee. He does
not communicate the evaluation to the employee. He does not point out the areas of
improvement; rather he stimulates the employee into thinking about improving his
own performance. He does not supply remedies or solutions but considers all ideas on
job improvement suggested by the employee. This he does by skilful questions

Example. Can you plan to deal with emergencies?

Key behaviours for an appraisal interview
1. Put the employee at ease
2. Clearly state the purpose of the appraisal interview
3. Go through the ratings one by one with the employee.
4. Draw out the employee reactions to the ratings.
5. Decide on specific ways in which performance areas can be strengthened.
6. Set a follow up date.
7. Express confidence in the employee.
METHODS OF APPRAISIGN PERFORMANCE
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
employees strengths and potential. Essay content should reflect the employees 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.
1. The disadvantages of essays are
2. They are time consuming
3. They tend to vary greatly in length and content
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.
LIMITATIONS OF PERFORMANCE APPRAISAL
The following are the limitations of performance appraisal:
1. The performance appraisal methods are unreliable.
2. If an employee is well known to an employer, the performance appraisal may not be
correct.
3. The inability of supervision to appraise an employee does not bring out the accurate
performance appraisal.
4. Some qualities of an employee can not be easily appraised through any performance
appraisal method.
5. A supervisor may appraise an employee to be good to avoid incurring his displeasure.
6. Uniform standards are not followed by the supervisors in the performance appraisal.

POTENTIAL APPRAISAL PROBLEMS.
1. Leniency error: the tendency of a manager to over rate staff performance.
2. Recency error: the tendency of a manager to rate an employee based on recent events
rather than over the entire evaluation period.
3. Halo error: the failure to differentiate among various performance dimensions when
evaluating.
4. Ambiguous evaluation standards problem: the tendency of evaluators to place differing
connotations on rating scale words
SUPERVISION AND MANAGEMENT
Supervision is defined as An art or a process by which designated individual or group of
individuals oversee the work of others and establish controls to improve the work as well as the
worker.
Supervision is generally termed as an educational process in which a person with better
training or more experience takes the responsibility of training a person with less training or less
experience, and in this educational process the leadership of the supervisor and the growth of the
supervised combine to achieve and maintain progressively the highest level of performance of
which the worker is capable.
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
1. To help subordinate to do their job skilfully and efficiently.
2. To develop subordinates capacity to the fullest extent.
3. To promote team work
4. To promote moral and motivation among workers.
5. To bridge the gap between personal goal and organizational goal.

To improve the
quality of work /
performance
Helping the person
doing the work and
develop the highest
possible standard
PURPOSE OF SUPERVISION:

PRINCIPLES OF SUPERVISION
1. Supervision should aim at growth in knowledge and improvement of skill of the person.
2. Supervision should improve the ability in thinking and adjusting to the new situation.
3. It should help to formulate objects.
4. Good supervision stimulates their interest and effectors.
5. No undue pressure for achievement
6. Autonomy to subordinate preferred
7. Supervision should have competence
8. Supervision should have receive training
9. Decision making is encouraged
10. Free communication to required
11. No over burdening to staff
12. Good leadership by supervisor
13. Suitable climate for work
14. Give guidance
15. Supervision should encourage innovation allowing free flow of ideas and share positive
experiences of personnel.

1.Individual conference
2.Group conference
3.Training sessions
4.Review of records
5.Evaluation sessions
6.Direct observation
COMMON SUPERVISORY METHODS

PRINCIPLES APPLIED TO NURSING:
Supervision should be focused on the attainment of one goal, the giving of a high quality
of nursing care.
Strives to make the ward a good learning situation.
Supervision is well planned.
It should posters the ability to think and act herself.
Helps her to attain objectives stimulates interest and effort.
Encourages and challenges her to greater endeavour through adequate approval
commendation and by recognition of work well done.
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
Understand the training background and ability of the supervised.
Good knowledge, the local practice
Good in health, skills in T.G & PR/t have pleasing manner.
Good listener.
Supervisor should have leads examplenory life
Creative enthusiasm
Just impartial human, tolerant and tactful
Helpful
Good power of judgment.
SUPERVISION CONSIST OF

FUNCTIONS OF SUPERVISION:

Leadership

Motivation

Communication

Evaluation

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.
Identify the problem and helps to solve.
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:
(1) Direct supervision Face to face talk with worker
+ Points to be considered:
- Do not loose temper
- Use democratic approach and avoid autographic
- Give workers chance to reply
- Do not talk too much and too fast
- Be human in behavior
- Do not give instructions haphazard way.
(2) Indirect supervision: With the help of record and reports of the worker and through
written instructions.
This includes:
- Ensuring carrying out allotted work
- Analysis of monthly progress input efforts and achievement
- Analyzing amount of work allotted
- Support and guidance.
Methods of supervision:
(1) Technical vs. creative supervision
(2) Co-operative vs. authoritarian
(3) Scientific vs. institutive
(4) Task oriented vs. employee oriented
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.
Creative provides maximum adaptation to the situ
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.
Both are needed all to situation.
III. Scientific supervision Relies on objective study and measurement than personal
judgment / opinion.
Intitutive supervision :It needs to maintain IPR
IV. Task oriented supervision emphasize the task more than performer.
Employee oriented: Supervisors are more concerned about worker staff their needs and
welfare than assigned tasks.
TOOLS FOR SUPERVISION
- Checklist
- Rating scales
- Nurses reports
- Nursing rounds
- Job descriptions
- Personnel policies
- Staff educations
- Problem solving approach
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 nurses individuality.
THE PROCESS OF SUPERVISION:
Stage 1: Preparation for supervision
1. A supervisor should focus on specific issue.
- Efficacy of service provided to the
- Relevant problems
- Efficacy problem utilization management of limited resources.
2. Study of document
3. Identification of priorities
4. Preparation of a supervision schedule
Stage 2: supervision
Use tools: - Job description
- Task description
- Weekly time table
- Check list / rating for each work
As a supervisor the following duties has to be performed.
Establish contact
Review the objectives, targets and norms
Review job descriptions
Note actual / potential conflict
Observe the actual performance.
Observe the individual nursing staff carries out his/her tasks.
Identify the gaps & needs for follow up action based on feed back data attained through
the observation.
Stage 3: Follow up of supervision
Unless actions to follow-up the gaps and needs identified during stage are taken, supervision
remains incomplete. Each supervisor must prepare a report on the observations made during
supervision. The follow-up action may include:
Organizing in-service training programmes/continuing education programmes for the
nursing personnel.
Reorganization of time table / work plan/ duty roaster.
Initiating changes in logistic support or supply system.
Initiating actions for organizing staff welfare activities.
Counseling and guidance regarding career development and professional growth.
THE EFFECTIVENESS OF SUPERVISION DEPENDS ON:
1. Human relations skill
2. Technical and Managerial knowledge
3. Leadership position
4. Improved upward relations
5. Relief from non-supervisory duties
6. General and lose supervision

1. Human relations skill:
Supervision is mainly concerned with instructing, guiding and inspiring human
beings towards greater performance. For purpose of direction, the supervisor has to
rely on leadership, counseling, communication and other determinants of human
relations
2. Technical and Managerial knowledge:
Guidance implies a complete understanding of all work problems, for which
supervisor should have good knowledge about technical aspect of job and also the
managerial aspect
3. Leadership position
The authority of supervisor must be made commensurate with their duty so as to
make the job of supervision a satisfying, rewarding and challenging one
4. Improved upward relations
To ensure god quality of supervisors, the supervisors should be regularly allowed to
present their views and suggestions to top executive in regard to the personnel and
their works performance.
5. Relief from non-supervisory duties
To make the supervisory duties purposeful, the supervisors are to be relieved of many
routine activities that divert their attention from the real job.
6. General and lose supervision
According to some experience, the general and loose supervision is more productive
than close supervision. Here the leader must allow freedom and initiative to his
followers for pursuing a common course of action.
PROBLEMS OF SUPERVISION
PROBLEMS IN NURSING SERVICE:
There are no perfect nursing service programs/situations without any problems
1. Shortage of nursing personnel.
2. Individual differences among personnel in interests, capacities and abilities.
3. Lack of information, insight and understanding of changes and developments in the
interest of the continuance and improvement of nursing.
4. Lack of clearly defined assignments, multiple responsibility and lack of planning on the
part of those to whom personnel is responsible
5. Outdated policies, procedures and guides to workmanship which cause them to be
disregarded and unused.
6. Inadequate, unsafe, and defective equipment.
7. . Ill health in the part of personnel
8. Undesirable personnel characteristics with special attention to attitudes.
COMMON PROBLEMS IN COMMUNITY HEALTH NURSING SUPERVISION:
1. Problems inherent to budgeting, planning and timing.
2. Personnel problems including problems of poor performance.
3. Grievances
4. Lack of financial resources.
5. Lack administrative support
6. Staff members who are inflexible and resist any type of change
7. Assignment to projects other than those committed to perform
8. Lack of political support
9. . Staff members who do not accept or support the program goals.
10. Conflict within the nursing unit itself.
11. Inability to proceed (for many reasons) because the timing is wrong
12. Inability to hire qualified personnel.
13. .Changes in program priorities.
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 agencys 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 aims and objectives of discipline are:
1. To obtain a willing acceptance of the rules, regulations and procedures of an organization
so that organizational goals can be achieved.
2. To impart an element of certainty despite several differences in informal behavior
patterns and other related changes in an organization
3. To develop among the employees a spirit of tolerance and a desire to make adjustments
4. To give and seek direction and responsibility
5. To create an atmosphere of respect for the human personality and human relations
6. To increase the working efficiency and morale of the employees so that their productivity
is stepped up, the cost of production brought down and the quality of production
improved.

PRINCIPLES OF DISCIPLINARY ACTION
1. Have a positive attitude:
The managers attitude is very important in preventing or correcting undesirable behavior.
People tend to do what is expected of them. Therefore the manager must maintain a positive
attitude by expecting the best from the staff.
2. Investigate carefully:
The ramifications of a disciplinary action are serious. If a staff nurse is disciplined unfairly or
unnecessarily, the effects on the entire staff nurse may be severe. Therefore managers must
proceed with caution. They should collect facts, check allegations, and even ask the accused
employees for their side of the story.
3. Be prompt:
If the disciplinary action is delayed, the relationship between the punishment and the offense
becomes less clear.
4. Protect privacy:
Disciplinary actions affect the ego of the staff nurse. Discussing the situation in private,
causes less resentment and greater chance for future co-operation. However, a public
reprimand may be necessary for the nurse who does not take private criticism seriously.
5. Focus on the act:
When disciplining a staff nurse, the manager should emphasize that it was the act that was
unacceptable, not the employee.
6. Enforce rules consistently:
Consistency reduces the possibility of favoritism, promotes predictability, and fosters
acceptance of penalties.
7. Be flexible:
Individuals and circumstances are never the same. A penalty should be determined only after
the entire record is reviewed.
8. Advise the employee:
The employees must be informed that their conduct is not acceptable. Anecdoctal notes can be
of little value if the staff nurse is not informed of the contents promptly.
9. Take corrective, consistent action:
The manager should be sure that the staff nurse understands that the behavior was contrary to
the organizations requirements.
10. Follow up:
The manager should quietly investigate to determine whether the staff nurse behavior has
changed. If not, the manager should determine the reason for the nurses attitude.
COMPONENTS OF A DISCIPLINARY ACTION PROGRAM
1. CODES OF CONDUCT: The employees must be informed of codes of conduct. Agency
handbooks, policy manuals, and orientation programs may be used. Eg. Employee code of
conduct.
2. AUTHORISED PENALTIES: The agencys disciplinary action program should indicate that
the current action is being administered without bias and is directly related to the offense.
3. RECORDS OF OFFENCES AND CORRECTIVE MEASURES: The personnel record
should clearly indicate the offense, managements efforts to correct the problem and the
resulting penalties.
4. RIGHT OF APPEAL: Formal provision for right of employee appeal is a part of each
disciplinary action program.
EMPLOYEE CODE OF CONDUCT
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.

3. POSITIVE DISCIPLINE APPROACH
It is based on the assumption that an employee with self-respect, respect for authority, and
interest in the job will adhere to high quality work standards; and when an interested,
respectful and self-respecting worker temporarily strays from his/ her usually highs standards,
a friendly reminder is enough to redirect their efforts in the desired direction
Organisations that have employed a positive discipline have noted a subsequent decrease in
absences, dissmisals, disciplinary actions, grievances and arbitration, along with improvement
of employee morale.

4. SELF CONTROLLED DISCIPLINE APPROACH
The employees bring his or her behaviour into agreement with the organisations
behavioural official code i.e. the employees regulate their own activities for the common good
of the organisation. As a result human beings are reduced to work for a peak performance
under self controlled discipline.

5. ENFORCED DISCIPLINE APPROACH
A managerial action enforces compliance with organisations rules and regulations ie. It is
a common discipline imposed from the top. Here the manager exercises his authority to
compel the employees to behave in a particular way.
SELF DISCIPLINE
It refers to ones 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 VS DESTRUCTIVE DISCIPLINE
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
DEALING WITH DISCIPLINARY PROBLEMS
Disciplinary action may be ineffective because of methodological weakness or of procedural
omissions by the manager. Methodological problems result from improper documentation of
disciplinary interview and procedural problems from failure to apply discipline in a timely
fashion and to follow due process.
1. DISCIPLINARY CONFERENCE
It is a group discussion using both directive and non-directive interview techniques. It is
damaging to employees self-esteem to receive criticism from an authoritative figure. Thus a
disciplinary conference is anxiety provoking situation for both employee and the manager.
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 employees anxiety
may block perception of the painful feedback offered by the manager.
3. MODEL STANDING ORDERS
It specifies the terms and conditions which govern day to day employer-employee relationship,
infringement of which could result in a charge of misconduct
4. ERRORS IN DISCIPLINIG EMPLOYEES
The frequent errors encountered while disciplining the employees are:
Delay in administering discipline
Ignoring rule violation in hope that it is an isolated event
Accumulations of rule violations, causing irritated manager to blow up
Administering sweetened discipline
Failure to administer progressively severe sanctions
Failure to document disciplinary actions accurately
Imposing discipline disproportionate to the seriousness of the offense
Disciplining inconsistently
DISCIPLINARY PROCEEDINGS ENQUIRY IN MANAGEMENT
CCSR(CENTRAL CIVIL SERVICES RULES) AND KCSR(KARNATAKA CIVIL SERVICES
RULES)
General Civil Services Rules
The essence of Government service is the sense of discipline to which all Government
employees are subject and it is related to the employees code of conduct and discipline.
Article 311 of the constitution enumerates two fundamental principles upon which the whole
procedural law concerning departmental punishments on civil servants rests.
The first clause of the article contains the guarantee that no civil servant shall be dismissed
or removed by an authority surbordinate to that by which he was appointed.
The second clause guarantees to him a reasonable opportunity of defence on the charges
against him, supplemented by a second opportunity of showing cause why such a punishment
should not be imposed on him, if after enquiry it is proposed to dismiss or to remove or to
reduce him in rank.
Only the appointing authority can impose major punishment (dismissal, removal or reduction
in rank). The power of punishment can never be delegated.
Enquiry officer is a officer subordinate to the appointing authority; who conducts formal
enquiry about the charges on the charged official. The enquiry report contains findings of the
charges, but there should be no recommendations about the punishment.
CAUSES OF DISCIPLINARY PROCEEDINGS
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.
STAGES OF DISCIPLINARY PROCEEDING ENQUIRY
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 ones work, based on evidence and explicit
criteria, for the purpose of doing better work in the future.
PURPOSES OF SELF EVALUATION
1. To encourage continuing self-evaluation and reflection and to promote an ongoing, innovative
approach.
2. To encourage individual professional growth in areas of interest to the employee
3. To improve morale and motivation by treating the employee as a professional in charge of his
or her own professional growth.
4. To encourage collegiality and discussion about practices among peers in an organisation
5. To support employees as they experiment with approaches that will move them to higher
levels of performance
BENEFITS OF SELF EVALUATION
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.
TOOLS FOR SELF EVALUATION
Staff annual professional review procedures
Peer support
o Coaching
o Joint preparation of materials
o Planning
o Team building
Observation can involve experts, can be informal or formal procedures. Feedback from such
observation is very valuable, but must be handled sensitively
Audit checklist
PEER EVALUATION
INTRODUCTION
In response to the publics clamor for improved care quality, some nursing organizations
instituted peer review as one method for increasing nurses accountability for effective decision-
making and interventions. It is a mechanism for developing faculty leaders who can meet the
challenges posed by public demands for accountability in healthcare management.
DEFINITION
Peer review is a process by which employees of the same rank, profession, and setting evaluate
one anothers job performance against accepted standards.
- O Loughlin and Kaulbach
THE SUCCESS OF PEER EVALUATION DEPENDS ON
Short but objective method
Trained observers
Constructive feedback for faulty development
Open communication and trust

METHODS OF PEER EVALUATION
Direct observation
Videotaping
Evaluation of course materials
Analysis of portfolios
PROCESS OF PEER REVIEW
I. Establish a policy requiring peer reviews
II. Establish criteria for peer evaluations
III. Procedure for conducting peer evaluations
a. Faculty chosen to conduct peer evaluations shall be tenured and hold on academic
rank higher than that of the faculty member being evaluated
b. A written report, addressing the criteria, shall be prepared and signed by the
evaluator
c. The department shall archive the written evaluations for use in future evaluations
d. One copy of the peer evaluation shall be placed in the permanent personnel file of the
person being evaluated
e. All reports of peer evaluations shall be included in the tenure file, and are to be
carefully reviewed at the department.
PATIENT SATISFACTION
INTRODUCTION
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 a health care recipients reaction to salient aspects of the
context, process, and result of their service experience. -
Pascoe (1983)
Patient satisfaction is dened as the extent of the resemblance between the expected quality
of care and the actual received care.
- Scarding (1994)
NEED FOR EVALUATING PATIENT SATISFACTION
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. Satised 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.
METHODS OF MONITORING PATIENT SATISFACTION
Medical audit
Quality assurance committee reviews
Indices of nursing performances
Judgemental method
COMPONENTS OF EVALUATION OF PATIENT SATISFACTION
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.
AIMS AND OBJECTIVES:
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
organisations employees at discounted rates.
3. Cost containment to limit each patients 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.
UTILISATION REVIEW NURSE
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

FISCAL PLANNING (BUDGETING)
Introduction
Budgeting is the heart of administrative management. It serves as a powerful tool of co-
ordination and negatively an effective device of eliminating duplication and the wastage. These
are served by devices such as justification of estimates, supervision of the use of appropriate
funds, timing of the rate of expenditure and the like.
Definition:
A budget may be a simple plan of ones personal finances, or it may be a complex
document used by large organization.
According to TN Chhabra a budget is an estimation of future needs arranged
according to orderly basis covering some or all activities of an enterprise for a definite period of
time
According to Dimock Budget is a balance estimated expenditure and receipts for a
given period of time. In the hands of the administrator the budget is the record of the past
performance, a method of current control and projection of future pans.
Feature of budget
Budget should be simple in design and oriented to those who use it
It should be flexible. It should be adjust various needs and conditions of the institution
It should be synthesis of past, present and future
It should be product of joint venture and co-operation of executives/ department heads at
different levels of management.
Budget is composed of two segment; that are income and expenditure. Income limits
expenditure; hence income should be estimated prior to the estimation expenditure.
A budget reflects the goals and aspirations of the faculty
Budget making involves the whole situation
Budget is forward planning. Planned activities are vital for efficient and successful
functioning
A budget gives direction- it is more than the list of the desired and approved expenditure.
It is also the instrument of administration and management.
It should have support of top management throughout the period of its planning and
supplementation.
Budget has a time period usually annual. It is important to secure the maximum
participation of organization in preparation on of budget.

Purposes of budget
1. To provide definite targets for income and expenditure of the department
2. To co-ordinate the activities of the different functional heads in the working of these
departmental budget
3. To enable a cash flow statement prepared month by month
4. To aid management in formulating future policy decision to promote the growth and
welfare of the organizations
5. To provide useful tool for the control of costs
6. To provide a tool for communication and co ordination within the organization.
7. To improve financial planning and decision making.
8. To identify controllable and uncontrollable cost area.

Importance of budget
Budget is a numerical description of expected income and planned expenditure for an
organization for a specified period of time. It is a concrete, picture of the total operation of an
enterprise/ organization/ institution in monetary term, i.e., finance
The following point serves the 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.
1. Budget should provide sound financial management by focusing on requirement of the
organization
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.
4. Budget requires that programme activities planned in advance
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
COLLECTION OF PAST DATA

ASSESS SUCCESS AND FAILURES OF PAST

SETTING OBJECTIVES FOR FORECAST YEAR

OBJECTIVES ARRANGED IN TERMS OF INDICATED UNITS

PREPARATION OF REPORTS ON EXPENSES

PREPARATION OF BUDGET REPORT

REVIEW OF BUDGET REPORT

EVALUATION FOR MODIFICATION OR CHANGRS

FINAL PRESENATION BEFORE BOARD OF TRUSTEES FOR DECISION

GENRAL BUDGET: How to make your self
Step 1 : Determine your monthly income
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.
Step 2: List your fixed and variable monthly expenses
Such as housing, utilities, food and transportation. Remember to allocate funds for
clothing, medical care, child care, personal expenses, recreation and emergencies/repairs.
Add all of your expensesthis is VALUE B.
Step 3: Find your discretionary income
By subtracting your total expenses (B) from your total net income (A).
Write this number down on a piece of paper as VALUE C.
Step 4: List all unsecured debts
The monthly payments and the balances. If you dont know your exact debt amount, now
is the time to determine it.
Write this number down on a piece of paper as VALUE C.
Step 5: Determine if you have any remaining discretionary income
After making these installment payments by subtracting your total monthly
payments to creditors (D) from your discretionary income (C).
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
Step 6 to establish short- and long-term goals
Make a list of these goals
Long-Term Real Estate Purchases, Future Education, Retirement
Short-Term Home Improvements, New Car, Travel
Other Desired Investments Stocks, Bonds, CDs, Mutual Funds
Determine how much you need to save monthly
Steps in effective budgeting process
Determine the requirements: inputs from all levels of hierarchy must be obtained
Develop plan: Budget for 12months is set. Zero-Based budget
Analyze and control the operation: continuous monitoring is essential
Review the plan: Periodic revision and modification
Steps in budgeting for college of nursing
Request for the needs of various departments
Review the budget appropriation and actual expenditure for the current year
Contemplated changes
Salary fixation
Requirement estimation
Summary of new needs
The steps of planning budget for nursing unit
Assistance of his/her subordinates
Review of budget
Ascertain changes
Preparing requirements
Summary of new needs
Submitting to institutional administrator
Roles and Responsibilities of the Nurse Administrator/Principal in Budgeting
Participation in planning budget
Consult an take assistance of his/her subordinates
Request sufficient finds
Submit budget request
Support the budget when it is allotted.
Cover the routine budget control

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 bedside in relation to
predetermined criteria like errors, omissions, deficiencies, as well as efficiencies and also
excess in the care of patients under them. It involves direct and indirect observation,
interviewing the staff responsible for care, and reviewing the patients records and care
plan.
It can be also done to identify the job satisfaction of staff nurses in accordance with their
work performance.
Audit cycle
According to Payne, the steps in audit or utilization review include;
Criteria development
Selection of cases
Work sheet preparation
Case evaluation
Tabulation of evaluation
Presentation of reports
The basic audit cycle can be depicted as;

In general, the stages of audit cycle are;
Identify the need for change
Setting criteria and standards
Collecting data on performance
Assess criteria against criteria and standards
Identify need for change (re- evaluation)
Advantages
Patient is assured of good service.
Better planning of quality improvement can be done.
It develops openness to change.
It provides assurance, by meeting evidence based practice.
It increases understanding of clients expectations.
It minimizes error or harm to patients.
It reduces complaints or claims.
1. set
standards
2. observe
practice
changes
3. compare
with standards
4. implement
change
Disadvantages
It may be considered as a punishment to professional group.
Medico- legal importance- They feel that they will be used in court of law as any
document can be called for in a court law.
Many components may make analysis difficult.
It is time consuming
It requires a team of trained auditors.

COST ACCOUNTING AND COST ANALYSIS
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.
Origin of cost accounting
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.
Classical cost elements are:
1. Raw materials
2. Labor
3. Indirect expenses/overhead
Elements of cost
1. Material (Material is a very important part of business)
A. Direct material
2. Labor
A. Direct labor
3. Overhead
A. Indirect material
B. Indirect labor
Standard cost accounting
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:
By nature or element: materials, labor, expenses
By functions: production, selling, distribution, administration, R&D, development,
As direct and indirect
By variability: fixed, variable, semi-variable
By controllability: controllable, uncontrollable
By normality: normal, abnormal
There are various managerial accounting approaches:
Standardized or standard cost accounting
Lean accounting
Activity-based costing
Resource consumption accounting
Throughput accounting
Marginal costing/cost-volume-profit analysis

Activity-based costing
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:
lean-focused performance measurements
simple summary direct costing of the value streams
decision-making and reporting using a box score
financial reports that are timely and presented in "plain English" that everyone can
understand
radical simplification and elimination of transactional control systems by eliminating the
need for them
driving lean changes from a deep understanding of the value created for the customers
eliminating traditional budgeting through monthly sales, operations, and financial
planning processes (SOFP)
value-based pricing
correct understanding of the financial impact of lean change
As an organization becomes more mature with lean thinking and methods, they recognize that
the combined methods of lean accounting in fact creates a lean management system (LMS)
designed to provide the planning, the operational and financial reporting, and the motivation for
change required to prosper the company's on-going lean transformation.
Marginal costing
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
Throughput Accounting (TA) is a dynamic, integrated, principle-based, and
comprehensive management accounting approach that provides managers with decision support
information for enterprise optimization.
Advantages
The accumulated data enable a head nurse to assess the cost
It enables a nurse manager to identify the interaction between different expenditure.
It enables a manager to identify popular services.
Disadvantages
It is difficult to associate some costs with particular programme
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.
[

Cost benefit analysis
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.
Z= Present value of economic benefits/ present value of economic costs
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
2. The categories of care or activities and their interventions
3. Inter-mediate and long term outcome criteria
4. The variance record (to allow deviations to be documented and analysed).
Critical Pathway Development
Select a Topic .
Topic selection in general should concentrate on high-volume, high-cost diagnoses and
procedures. Critical pathway development has focused on several cardiovascular diseases and
procedures because of volume and costs. These include bypass surgery, diagnostic
catheterization, coronary angioplasty, acute myocardial infarction, and unstable angina. These
diagnoses and procedures tend to be more suitable for critical pathway development because of
the predictable course of events that occur during the hospitalization. In addition, marked
variation in care has been observed in these conditions, which makes the goal of decreased
variation and reduction in resource utilization possible. Furthermore, there has been evidence of
noncompliance with guideline recommendations. In this case, the pathways might improve
guideline compliance and potentially improve quality of care.
Select a Team .
It is important to develop a multidisciplinary team for critical pathway development.
Historically, critical pathway development has been a nursing initiative. Although this has been a
successful model in some institutions, one fault of this process is lack of physician commitment
to the pathway. Active physician participation and leadership is crucial to the development and
implementation of the pathway. In addition, it is important to include representatives from all
groups that would be affected by the pathway, for example, house staff, physical therapy
personnel, and dietary personnel. The lack of involvement of physicians has been cited as a
reason for failure of a pathway.
Evaluate the Current Process of Care .
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.
Determine the Critical Pathway Format .
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.
Document and Analyze Variance .
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.
Critical Path Analysis and PERT Charts
Critical Path Analysis and PERT are powerful tools that help you to schedule and manage
complex projects. They were developed in the 1950s to control large defense projects, and have
been used routinely since then.
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 (Program Evaluation and Review Technique)
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:
Shortest time + 4 x likely time + longest time
-----------------------------------------------------------
6

Importance
Critical Path Analysis is an effective and powerful method of assessing:
What tasks must be carried out.
Where parallel activity can be performed.
The shortest time in which you can complete a project.
Resources needed to execute a project.
The sequence of activities, scheduling and timings involved.
Task priorities.
The most efficient way of shortening time on urgent projects.
CPM - Critical Path Method
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 provides the following benefits:
Provides a graphical view of the project.
Predicts the time required to complete the project.
Shows which activities are critical to maintaining the schedule and which are not.
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

Steps in CPM Project Planning
1. Specify the individual activities.
2. Determine the sequence of those activities.
3. Draw a network diagram.
4. Estimate the completion time for each activity.
5. Identify the critical path (longest path through the network)
6. Update the CPM diagram as the project progresses.
1. Specify the Individual Activities
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.
2. Determine the Sequence of the Activities
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.
3. Draw the 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.
4. Estimate Activity Completion Time
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.
5. Identify the Critical Path
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.
6. Update CPM Diagram
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
- Support the introduction of evidence-based medicine and use of clinical guidelines
- Support clinical effectiveness, risk management and clinical audit
- Improve multidisciplinary communication, teamwork and care planning
- Can support continuity and co-ordination of care across different clinical disciplines and
sectors;
- Provide explicit and well-defined standards for care;
- Help reduce variations in patient care (by promoting standardisation);
- Help improve clinical outcomes;
- Help improve and even reduce patient documentation
- Support training;
- Optimise the management of resources;
- Can help ensure quality of care and provide a means of continuous quality improvement;
- Support the implementation of continuous clinical audit in clinical practice
- Support the use of guidelines in clinical practice;
- Help empower patients;
- Help manage clinical risk;
- Help improve communications between different care sectors;
- Disseminate accepted standards of care;
- Provide a baseline for future initiatives;
- Not prescriptive: don't override clinical judgement;
- Expected to help reduce risk;
- Expected to help reduce costs by shortening hospital stays
Issues with Critical Pathways
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.
Issues - potential problems and barriers to the introduction of CPs
May appear to discourage personalised care
Risk increasing litigation
Don't respond well to unexpected changes in a patient's condition
Suit standard conditions better than unusual or unpredictable ones
Require commitment from staff and establishement of an adequate organisational
structure
Problems of introduction of new technology
May take time to be accepted in the workplace
Need to ensure variance and outcomes are properly recorded.
HEALTH CARE REFORM
Health care reform is a general rubric used for discussing major health policy creation or
changesfor 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 primary objectives of health care reform include:
Provide healthcare coverage for all.
Decrease the costs of health care services and coverage
Health care reforms in India
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.
The ministry is composed of three departments:
1 Department of Health
2 Department of Family Welfare
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:
1) National AIDS Control Programme (AIDS)
2) National Cancer Control Programme (cancer)
3) National Filaria Control Programme (filariasis)
4) National Iodine Deficiency Disorders Control Programme (iodine deficiency)
5) National Leprosy Eradication Programme (leprosy)
6) National Mental Health Programme (mental health)
7) National Programme for Control of Blindness (blindness)
8) National Programme for Prevention and Control of Deafness (deafness)
9) National Tobacco Control Programme (tobacco control)
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)
12) Revised National TB Control Programme (tuberculosis)
13) Universal Immunization Programme
14) Medical Council of India
15) Dental Council of India
16) Pharmacy Council of India
17) Indian Nursing Council
18) All India Institute of Speech and Hearing (AIISH), Mysore
19) All India Institute of Physical Medicine and Rehabilitation (AIIPMR), Mumbai
20) Hospital Services Consultancy Corporation Limited (HSCC)
2. Department of Family Welfare
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
National Institute of Health and Family Welfare (NIHFW), South Delhi
International Institute for Population Sciences (IIPS), Mumbai
Central Drug Research Institute (CDRI), Lucknow
Indian Council of Medical Research (ICMR), New Delhi - founded in 1991, it is one of
the oldest medical research bodies in the world
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:
Various research councils
1) Central Council for Research in Ayurveda and Siddha (CCRAS)
2) Central Council for Research in Unani Medicine (CCRUM)
3) Central Council for Research in Homoeopathy (CCRH)
4) Central Council for Research in Yoga and Naturopathy (CCRYN)
5) Several educational institutions:
6) National Institute of Ayurveda, Jaipur (NIA)
7) National Institute of Siddha, Chennai (NIS)
8) National Institute of Homoeopathy, Kolkata (NIH)
9) National Institute of Naturopathy, Pune (NIN)
10) National Institute of Unani Medicine, Bangalore (NIUM)
11) Institute of Post Graduate Teaching and Research in Ayurveda, Jamnagar,Gujarat
(IPGTR)
12) Rashtriya Ayurveda Vidyapeeth, New Delhi (RAV)
13) Morarji Desai National Institute of Yoga, New Delhi (MDNIY)
14) Indian Medicine Pharmaceutical Corporation Limited (IMPCL), Mohan, Uttaranchal (a
public sector undertaking)
15) Professional councils
16) Central Council of Homoeopathy (CCH)
17) Central Council of Indian Medicine (CCIM)
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.
Indian healthcare reforms
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.
37 percent of Indian population is undernourished. They have difficulty in meeting even
basic needs. 55 percent of the population have a diet which is calorie sufficient but
nutrient deficient whereas eight percent of the population is over-nourished. Hence, there
is a total imbalance of nutrition which leads to anaemia, TB and many other diseases
which increases the disease burden of India.
Statistics tells us that arthritis, hypertension, diabetes, CVD, cancer patients and elderly
patients are major part of our disease burden. Besides acute diseases, almost all of them
trace their origin to (a lack of) nutrition.
As Indian population is getting increasingly health conscious, almost 64 percent of out-
of-pocket expenditure in India constitutes healthcare expenditure as compared to 18
percent globally. This population can be called as 'Healthy Boomers'. They need to be
properly directed towards maintaining their health, in the same way as they have career
and financial plans.
All nations have a significant role of Health Insurance in healthcare. In India, both the
patient and the payer is almost same. Here, a sharing model between Health Insurance
and patient can be adopted. 70 to 75 percent of the burden can be still borne by patient or
medical consumer, depending on the nature of disease. Therefore, I am of the opinion
that this sharing ratio should even be reversed as the severity of the disease increases, for
example in the case of cancer, where the institution should bear 70 percent of the
expenses otherwise the patient will die of the cost before the disease kills him.
65 percent of Indian population lives in rural areas while only two percent qualified
medical doctors are available in these areas. Indian healthcare today is urban centric. It
needs to be reformed through medical infrastructure inclusive of doctors, nurses,
paramedicos, etc.
Indian healthcare system should start from preventive care through nutrition. Reforms
must provide impetus to lift the population which is at the bottom of the pyramid.
'Health is Wealth' is an old paradigm of India, as people were in 'scarcity thinking' mode,
as they were completely dependent on their livelihood to provide for their family's health
and well being. Resources were earlier scarce and people were driven to planning. This
mentality has given way to the 'abundant mentality' as today's generation has not seen
these scaricity of resources. Demographics are changing as well, and today 60 percent of
population does not have the responsibilities of a family to look after. For them this
paradigm needs to be inculcated through education. This new paradigm should originate
from nutrition to exercises to preventive healthcare to healthcare. It should be proactive
rather than reactive in terms of its reforms.
As quickly as possible, health must become a priority issue for the Government of India.
Though the Department of Pharmaceuticals today comes under the Ministry of Chemicals
and Fertilizers Food, it deals with issues concerning our health like Food Safety &
Standards (FSS), Ayush and related bodies. Therefore, it should be appropriately part of
Ministry of Health and Family Welfare or in any other suitable ministry. Government has
taken up health issues like HIV, TB and tobacco through massive government programs.
Overall, India needs to reform its healthcare system through policies, medical
infrastructure, education and realization of right nutrition to lifestyle management. Acute
diseases over time will be at reactive end of the reforms
HEALTH CARE ECONOMICS
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.

History and evolution
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
A health insurance policy is a contract between an insurance company and an individual
or his sponsor (e.g. an employer). The contract can be renewable annually, monthly or be
lifelong. The type and amount of health care costs that will be covered by the health insurance
company are specified in advance, in a member contract or "Evidence of Coverage" booklet. The
individual insured person's obligations may take several forms:
[8]

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.
BUDGETING FOR VARIOUS UNITS.
How to Make a Hospital Budget
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
1. Determine hospital revenue.

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.

2. Figure out expenses.

+ Start with the physical facility.
+ How much does it cost to keep up the building or buildings.
+ What is the maintenance cost of each department, engineering, air-conditioning,
heat, water, other utilities.
+ Know what equipment costs, how much must be replaced per patient day, and if
any can be recycled.
+ Include the non-medical cost of each bed in the hospital. Include advertising.

3. Know the cost of

Personnel, all employees and ancillary staff, including consultants, outsourced
contracts, perhaps laundry or nurse staffing services.
For all employees of the hospital, from janitorial to hospitalists, figure the fringe
benefits the hospital must pay for each.

4. Add all medical equipment costs, ongoing and expected expansion or replacement of new
diagnostic equipment.

5. Know the medical costs of each bed.

+ 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.

6. What about expansion?

Are you planning a new wing, or the renovation of an old one?
Are you expanding into a new specialty that could bring in extra revenue?
Estimate that revenue when planning your budget.

7. Don't forget parking garages, lots, landscaping, groundskeeping or window washing.

8. Include all insurance for the facility and personnel.

9. Write in an emergency expense fund. Disasters occur and the hospital must be prepared
for them when they arrive.

10. To do the budget, use a spreadsheet

BUDGET FOR EDUCATIONAL INSTITUTION.
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.
The budget is classified into 3 heads as
1. Revenue 2. Expenditure 3. Capital
1. Revenue: It includes assets, fixed deposits, investments, loan, advances and income.
2. Expenditure: It includes capital, recurring annual mandatory and non recurring.

The recurring annual mandatory expenditure includes:
- University Administration Fees Rs. 50,000/
- Affliation Fees Rs.3,00,000/ - and every year
Rs 50,000/- per course
- Inspection Fees Rs 25,000/-
- State council Rs 7000/ every year for recognition.
- INC recognition fees Rs 50,000/ per course.
- INC inspection or affliation fees is 7,500/
- Reinspection fees 7000/
- Affliation fees to other institution.

The recurring monthly expenditure also include
- 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
INFORMATICS
Trends
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."

Framework of nursing informatics:

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.

Management & Processing

Data Information Knowledge

Example:
Data: 140 systolic
Information: 50 year-old male, day 3 of hospitalization, BP 140/70

Knowledge: Pt. demographics, record of BP readings, circulation system: anatomy &
physiology, pharmacokinetics of ordered medication
Decisions: That guide practice.
Nursing Process
Enables the professional nurse to be the Coordinator of each patients care
Communicate & coordinates care with ALL other clinical disciplines
Coordinate discharge planning, education & teaching, transition of care
Manages ALL information related to the nursing process and patient

Because information management is integrated into the Nursing Process and Practice, some
Nursing Communities identify a 5th step in Nursing Process DOCUMENTATION

Well-documented information provides:
What care has been provided and what is outstanding
Outcomes of care provided and responses to the plan of care
Current patient status & assessments
Support decisions based on assessments to drive new plans of care.

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

Successful implementation of information Systems requires
well designed systems that support Nursing Process within the culture of
an organization and/or specific care providers
Acceptance & integration of information systems into the regular workflow
of nursing process & patient care
Resources that can support the above
Support nursing work processes using technology
Design systems to match clinical workflows
Telehealth
Home health
Ambulatory care
Long-term care
Acute care all specialties
Outpatient settings
Software development
Redesign work flows

The Value of Nursing Informatics

Increase the accuracy and completeness of nursing documentation
Improve the nurses workflow
Eliminate redundant documentation
Automate the collection and reuse of nursing data
Facilitate analysis of clinical data
Nursing Informatics promotes and facilitate. Access to resources and references for nurses and
the entire interdisciplinary team in both clinical and administrative settings

Benefits for nurses and the interdisciplinary team:
Support for their mission to deliver high quality, evidence-based care
Support for better service by facilitating true interdisciplinary care
Promotes improvement in key relationships with physicians, peers
Interdisciplinary care team members, patients & families
Benefits in the administrative setting
Support for cost savings and productivity goals
Facilitate change management

The goal of Nursing Informatics is to improve the health of populations, communities,
families, and individuals by optimizing information management and communication. This
includes the use of technology in the direct provision of care, in establishing effective
administrative systems, in managing and delivering education experiences, in supporting life-
long learning, and in supporting nursing research.
Scope of Standards of Nursing Informatics Practice - American Nurses Association 2001

Clinical Work
Information
and
Communication
technologies
Organisation of
medicine and
health care (system)
Three Domains Needing an Effective Fit
Stages of Model of Nursing Informatics

Stages of the model
Involves, informs
persuades,
prepares for these
technologies and
other changes
Creates an
information and
technology
strategy and
financial plan
Plans and
introduces new
technologies
with other
changes
Evaluates,
reviews and
assesses the
impact and
values it
Knows of appropriate
technological
developments & relates
them to information
requirements: knows of
opportunities and
imperatives for change
System
Health care
Organisation of
cl inical work
Sets ofpatients
Singl e pati ent
Clinical
Work
Selects and
prioritises
opportunities,
problems,
imperatives and
requirements
for change
Assesses and
understands the
context & identifies
consequences for
clinical work and
imperatives for
change
Assesses and
understands what
[and for what key
reasons] activities
occur at each
level
Respond
Identify i mpact
Respond
Observe
& enquire
Tel l
Observe
&
enquire
Tel l
Relate & Check
Tel l
Relate & check
Tel l
Observe
& enquire
Tel l
Identify
impact
4.
3.
5. 6.
7.
Real ise
Respond & Implement
2.
1.

Assesses and understands what and for what reasons things happen
Assesses and understands the context and identifies consequences for clinical work and
imperatives for change
Selects and prioritises opportunities, problems, imperatives and requirements for change
Knows of appropriate technological developments and relates them to information
requirements; knows of opportunities and imperatives for change
Creates an information and technology and strategy plan
Involves, informs, persuades, prepares for these technologies and other changes
Plans and introduces new technologies and other changes
Evaluates, reviews and assesses the impact and values it
select the appropriate information and communication technologies,
involve perceived beneficiaries,
identify the prospective benefits,
successfully plan, implement and evaluate the impact of change

General purpose of Nursing Informatics
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.
Nursing informatics is a way of keeping patient information properly organized.
Technologies, including tablet computers and mobile devices, can help nurses keep up
with what they need.
Integrated systems allow nurses to make notes that everyone can access, meaning that
each change of shift runs smoothly, and time isnt taken up with trying to convey
information.
. Nursing informatics can also help with dosing instructions, staff assignments, and lab
results. The idea is that technology and information should be easily accessible to nurses
so that they can do a better job of caring for their patients
Another function of nursing informatics is to help create care plans.
Nursing informatics makes use of the information coordinated by technology to help
nurses make better decisions.

Nursing skill need related to informatics and technology:
Use information and communication technology to document and evaluate patient care,
advance patient education & enhance the accessibility of care.
Use appropriate technology to assess and monitor patients.
Work on an interdisciplinary team to make ethical decisions regarding the application of
technologies and the acquisition of data.
Adapt the use of technologies to meet patient needs.
Teach patients about health care technologies
Protect the safety and privacy of patients in relation to the use of health care and
information technologies.
Use information technologies to enhance ones own knowledge base.

Challenges of Managing Health related informatics and technology
Confidentiality of client health information
Ethics related to new therapies
Evaluating the quality of information
Information security
Potential health and personal problems from too much technology.

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

APPLICATION OF NURSING INFORMATICS IN NURSING PRACTICE,
EDUCATION & RESEARCH
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.
Goal: The goal of Nursing Informatics is to improve the health of populations,
communities, families, and individuals by optimizing information management and
communication. This includes the use of technology in the direct provision of care, in
establishing effective administrative systems, in managing and delivering education
experiences, in supporting life-long learning, and in supporting nursing research. (ANA,
2001)
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 Associations
Congress of Nursing Practice supported the recommendation of the Council on Computer
Applications in Nursing to officially recognize NI as a nursing specialty.

A. APPLICATION OF NURSING INFORMATICS IN CLINICAL PRACTICE:
NURSING INFORMATICS AND NURSING PROCESS
The nursing process is the core of patient care delivery. In the
nursing process continuum, nurses are constantly faced with data and
information. Data and information are integrated in each step of the
nursing process:
Assessment
Diagnosis
Planning
Implementation and
Evaluation
Nursing documentation, which is often identified as the sixth
step in the nursing process, is vital in information management.
Hence, it is necessary for nurses to document accurately and
precisely to determine the desired outcome.
Practical application (Point-of-Care Systems and Clinical
Information Systems)
Work lists to remind staff of planned nursing interventions
Computer generated client documentation
Electronic Medical Record (EMR) and Computer-Based Patient
Record (CPR)
Monitoring devices that record vital signs and other
measurements directly into the client record (electronic medical
record)
Computer - generated nursing care plans and critical pathways, automatic billing
for supplies or procedures with nursing documentation
Monitoring System: Comprehensive patient monitoring systems that can be configured to
measure and display various patient parameters.

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.

Ventilators: Consist of a flexible breathing circuit, gas supply, heating/humidification
mechanism, monitors, and alarms.

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 hospitals 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.

B. APPLICATION OF NURSING INFORMATICS IN NURSING
ADMINISTRATION:
Nursing Administration (Health Care Information Systems)
Automated staff scheduling
E-mail for improved communication
Cost analysis and finding trends for budget purposes
Quality assurance and outcomes analysis

C. APPLICATION OF NURSING INFORMATICS IN NURSING EDUCATION:
1. Computerized record-keeping
2. Computerized-assisted instruction
3. Interactive video technology
4. Distance Learning-Web based courses and degree programs
5. Internet resources-CEU's and formal nursing courses and degree programs
6. Presentation software for preparing slides and handouts- PowerPoint and MS
D. APPLICATION OF NURSING INFORMATICS IN NURSING RESEARCH:

1. Computerized literature searching-CINAHL, Medline and Web sources
2. The adoption of standardized language related to nursing terms-NANDA, etc.
3. The ability to find trends in aggregate data, that is data derived from large
population groups-Statistical Software, SPSS
4. Effective data management and trend-finding include the ability to provide
historical or current data reports.

5. Extensive financial information can be collected and analyzed for trends. An
extremely important benefit in this era of managed care and cost cutting.

6. Data related to treatment such as inpatient length of stay and the lowest level of
care provider required can be used to decrease costs

COMPUTER USES IN HOSPITAL AND COMMUNITY

Uses in community

When it comes to importance of computers in Hospitals, it is undoubtedly an important aspect to
keep in the pace of the technologically advanced world. Healthcare is again a field where
technology has made things lot better and increased the efficiency in patient care. Below are
some of the points which highlight the uses of computers in hospitals.
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.
Basics about a computer system:
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
hospital. These records will be stored in a department called Medical Records section for the
future follow-ups.

Using Computers To Advance Health Care

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.
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
Application of Computers in Hospitals
Importance of computers in medicine is growing and spreading rapidly. The only disadvantage is
that a full fledged installation of all the computerized systems in hospitals is a lengthy and costly
process. There are however, some hospital systems which already work on the basis of
computers. Here's an explanation to all such systems, which work on computers
Uses of Computers in Hospitals:
Medical Data
Every day hospitals and clinics which are attached to it churn out enormous volumes of data
regarding patients, ailments, prescriptions, medications, medical billing details, etc.
Such medical records, are now a days 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.
Advantages of Computers in 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.

To sum up, the advantages of computers in hospitals can be summarized as follows:
Precise 'tests' and medical examinations
Faster medical alerts, which are more accurate time-wise
Enhanced data about a patients medical history
Precision in diagnosis
Precision in billing
Automated updating of medical history
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.

PATIENT RECORD SYSTEM

Electronic patient record system

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.

The 2003 Patient Safety Report describes an EMR as encompassing:
A longitudinal collection of electronic health information for and about persons
Immediate electronic access to person- and population-level information by
authorized users;
Provision of knowledge and decision-support systems [that enhance the quality,
safety, and efficiency of patient care] and
Support for efficient processes for health care delivery.

Need of an hour

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

Need for CPR

To manage escalating health care cost
Evolving role of primary health care
Guidelines are being promoted to reduce the variances of clinical practices

Integrated delivery system
Key Capabilities of an Electronic Health Record System
To capture data at the point of care
To integrate data from multiple internal and external sources
To support caregiver decision making. core capabilities

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.

Electronic communication and connectivity: Efficient, secure, and readily accessible
communication among providers and patients would improve the continuity of care, increase the
timeliness of diagnoses and treatments, and reduce the frequency of adverse events.

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.

Administrative processes: Computerized administrative tools, such as scheduling systems,
would greatly improve hospitals' and clinics' efficiency and provide more timely service to
patients.
Reporting: Electronic data storage that employs uniform data standards will enable health care
organizations to respond more quickly to federal, state, and private reporting requirements,
including those that support patient safety and disease surveillance."

Hall mark of CPR

1. Integrated view of patient record:
2. Improving the access of all patient data, whenever and wherever is necessary
3. Tang et al ,(1998) observational studies of physician they noted 81% physician did not
find all data of the patient for treatment
4. Access to knowledge sources:
5. Personal knowledge reference s data may be useful
6. Physician order entry and clinician data entry:
7. Physician order initiate the clinical intervention
8. When its entered by the clinician responsible for care the accuracy and quality of the data
are high
9. Integrated communication support:
10. Clinicians need integrated communication support for effective functioning of
multidisciplinary outpatient health care system
11. Relying on paper based references become ineffective and fallible
12. Clinical decision support
Advantages
Improve quality of care
1. The implementation of electronic health records (EHR) can help lessen patient sufferance
due to medical errors and the inability of analysts to assess quality.
2.
EHR systems are claimed to help reduce medical errors by providing healthcare workers
with decision support.

3. Computerized Physician Order Entry (CPOE)one component of EHRincreases
patient safety by listing instructions for physicians to follow when they prescribe drugs to
patients. Naturally,
4. Promote evidence-based medicine
5. EHRs provide access to unprecedented amounts of clinical data for research that can
accelerate the level of knowledge of effective medical practices.
6. Realistically, these benefits may only be realized if the EHR systems are interoperable
and wide spread (for example, national or regional level) so that various systems can
easily share information.

Record keeping and mobility
1. EHR systems have the advantages of being able to connect too many electronic medical
record systems.
2. In the current global medical environment, patients are shopping for their procedures.
Coordinating these appointments via paper records is a time-consuming procedure.
3. It is also easier to check in their records whether a patient as been admitted to such a
medical centre or if they have any allergies since they have been admitted before.
4. Replace paper-based medical records which can be incomplete, fragmented (different
parts in different locations), hard to read and (sometimes) hard to find. Provide a single,
shareable, up to date, accurate, rapidly retrievable source of information, potentially
available anywhere at any time. Require less space and administrative resources.
5. Potential for automating, structuring and streamlining clinical workflow.
6. Provide integrated support for a wide range of discrete care activities including decision
support, monitoring, electronic prescribing, electronic referrals radiology, laboratory
ordering and results display.
7. Maintain a data and information trail that can be readily analyzed for medical audit,
research and quality assurance, epidemiological monitoring, disease surveillance.
8. Support for continuing medical education.
9. The meaningful use of EHRs intended by the US government incentives is categorized as
follows:
10. Improve care coordination
11. Reduce healthcare disparities
12. Engage patients and their families
13. Improve population and public health
14. Ensure adequate privacy and security
15. Disadvantages
16. They spend more time entering data into an empty EHR than they used to spend updating
a paper chart with a simple dictation.
17. Such hurdles can be overcome once the software has some data, as physicians learn to
use templates for data entry, and as workflow in the practice changes, but not every
practice gets that far.
18. Surveyors found that hospital administrators and physicians who had adopted EHR noted
that any gains in efficiency were offset by reduced productivity as the technology was
implemented, as well as the need to increase information technology staff to maintain the
system.
19. Often, doctors do not want to spend the time to learn a new system. Some doctors believe
that adopting a system with EHRs could reduce clinical productivity
20. Governance, privacy and legal issues

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 SYSTEM

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)

HEALTH INFORMATION SYSTEM (HIS)
Definition:
A health information system refers to inter-related component parts for acquiring
and analyzing data and providing information (management information, health statistics,
and health literature) for the management of a health programme or system and for
monitoring health activities. (WHO)

HEALTH INFORMATION SYSTEM (HIS)
..Is information system that uses computers, communication equipment and programs to
collect, store, process, retrieve and communicate patient care and administrative
information


Data Needs and Sources at Different Levels of the Health Care system

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.

Challenges continue in terms of reliability, relevance, timeliness, harmonization as well as
quality of data.
Types of Health Information Systems
Clinical (Hospital) Health Information Systems:
They are typically large and complex hospital information systems that focus on patient
specific data.
These sophisticated health information systems that are often large hospital systems have
proven to be difficult to develop both in developed and developing countries.
About three quarters of these systems have failed.

B. Routine Health Information Systems:

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.

What constitutes HIS?
Primary Health Care Information Systems
Hospital Information Systems
Public Health Information Systems

Other information systems that are connected to HIS:
Health insurance funds information systems
PRIMARY HEALTH CARE INFORMATION SYSTEM
Reasons to introduce computers in primary care:
Administration
Patient care
Research
shared care
Coded and quantified data
Quality control
Medical education

Hospital information systems
Clinical department systems
Clinical support systems
Nursing information system

Hospital Information System Business & Administration Components
Material Services
Accumulate payments
Recharge
Budgeting
General ledger
Patient data/Billing/Account receivable
Payroll
Cost accounting

Hospital Information System Operation Components
OR scheduling
Nursing management
Clinical appointment
Dietary
Doctor ID system
Employee health system
Medical record system
Pathology system
Patient Data (ADT)
Pathology system
Pharmacy system
Radiology system
Referring doctor system
Cancer registry system

Hospital Information System

Uses:
- Support of Clinical and Medical Patient Care Activities in the Hospital
- Administration of the Hospitals Daily Business transactions (financial, personnel,
payroll, bed census etc.)
- Evaluation of Hospital Performance and Cost , and projection of the long-term
forecast

Functions of Hospital Information System
Computer based patient record (CPR)
Research
Strategic decisions
Less time spent in paperwork
Better documented work
Follow up of expenses
Reducing number of employees

Public Health Information System
Epidemiology
Morbidity and mortality
Prevention
Attribution of health status to individuals and populations in order to promote health
status
Why HIS?
HIS is essential for strengthening the information management practices within the
Primary Health Care (PHC) sector with the larger aim to improve processes concerning
health care delivery for the rural community.

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.

Why HIS in Developing Countries?

+ To strengthen information management practices within the Primary Health Care (PHC)
sector with the goal to improve more effective health delivery to the rural community.
+ Rationalization of data collection, computerization of information flows from the PHCs
to Districts &State.
+ Developing tools for analysis, and training of health care workers, Medical Officers in
PHCs; District Medical and Health Administration, State Health Department including
Family Welfare.
+ To increase feedback leading to Decentralization.
+ An opportunity to bridge the digital divide by using ICTs in HIS.

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.

Competing interests between different stakeholders further contribute to the generation of
parallel subsystems within the HIS.

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.

Determinants of Performance of 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

For the HIS to work adequately,

Information policiesreferent to the existing legislative and regulatory framework for
public and private providers, use of standards

Financial resourcesinvestment in the processes for the production of health information (e.g.,
collection of data, collation, analysis, dissemination, and use)

Human resourcesadequately trained personnel at different levels of government
Communication infrastructure infrastructure and policies for transfer and management or
storage of information
Coordination and leadership mechanisms to effectively lead the HIS

Issues
- There are many Issues: (Hospital)
- Manual Record keeping system
- Only inpatient data
- Only from Government Hospitals
- ICD10 at Hospital but aggregated groups are transmitted to the centre
- Doctors not very concerned about writing of diagnoses

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

Challenge Hospital System:
Re-designing the hospital record keeping system
Changing of record keeping formats
Adaptation of ICD 10 at all hospitals

Hospital System:
Changing of attitudes of doctors
Introduction of ICD 10 to basic curriculums
Introduction of IT to hospitals (EPR)
Development of IT Networks in hospitals
Training of users
Quality of Medical Records

Public Health System:
- Introducing IT at lowest possible level
- Development of suitable software
- Development of routine NCD, nutrition and occupational disease
surveillance systems
- Integration of disease surveillance systems

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

Patients have a right for their privacy
HIS must enable mechanisms to protect patient data
Who has rights to see patients data?
What data are allowed to see?
Policy on the hospital/governmental level
Integrated Healthcare Information System

Benefits:

o Reduce and/or eliminate medical transcription errors

o Faster and improved health care system response

o Instant linkage to specialists and other providers

o Computerized Clinical Applications - reduce costs

o Electronic Medical Records - available instantly

o Eliminate extra time/trips by physicians and providers

o Automatic checking for drug and other interactions

o Quick availability of data in emergencies around the world

E-nursing and Telenurisng
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 nurses attention.
Technology 1999 vs. 2010
In just 10 short years, the face of technology, inside the classroom and out, has changed
dramatically.
Here is a snapshot of some of those changes.
THEN : 3 inch floppy disks
NOW: Mass volume storage drives and DVDs, 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: Music CDs were bought and listened to on your CD player
NOW : Music can be downloaded online and saved to an
I-Pod, which goes everywhere.
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.
THEN: About 69 million people owned a cell phone in the U.S.
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.
The emphasis is genuinely Client focused.
Client Driven as well
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:
Electronic health records: enabling the communication of patient data between different
healthcare professionals (GPs, specialists etc.);
Telemedicine: physical and psychological treatments at a distance;
Consumer health informatics: use of electronic resources on medical topics by healthy
individuals or patients;
Health knowledge management: e.g. in an overview of latest medical journals, best
practice guidelines or epidemiological tracking (examples include physician resources
such as Medscape and MDLinx)
Virtual healthcare teams: consisting of healthcare professionals who collaborate and
share information on patients through digital equipment (for transmural care);
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.
The Multi-media Electronic Health Record
Integrated Health Information Systems
Home Care Monitoring for the elderly/post inpatient care
Medical services move into the Retail Environment
A more holistic approach to healthcare delivery
- Traditional Medicine}
- Preventive Medicine} At Primary care level
- Self Treating Patients} The Wellness Guardian
- Curative Medicine}
Future eHealth environment
The eHealthcare Team
Doctors, Nurses, Pharmacists, Technicians, Administrators
Grudges and Hindrances- E HEALTH
Perspective of medical nursing practitioners :
Patients fear and unfamiliarity :
Financial unavailability:
Lack of basic amenities:
Literacy rate and diversity in languages :
Technical constraints :
Quality aspect :
Government Support :
Biological consistency :
Nurses and E-Health
Nurses can be primary actors in the virtual arena of E-health, serving as
Health advisors,
Internet guides to help clients select reliable information resources,
Support group liaisons,
Web information providers, and so on.
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;
Advocating for the involvement of nurses in decision-making about information
technology and information systems.
E-nursing internet access
(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)
Internet access assists nurses in
(a) Providing direct client care,
(b) Enhancing client teaching,
(c) Conducting job searches and continuing education.
(d) Collaborating with other health professionals worldwide.
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,
Self-reflection And Expression,
Computer Literacy,
Confidentiality,
Bioethical Decisions,
Networking,
Patient Education, Community Development And
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
ELECTRONIC GAMES AND SIMULATIONS
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
Asynchronous Learning Networks
Technology-Supported/Mediated/Facilitated Learning
Networked Learning
Electronic learning
Collaborative electronic learning
Electronic Performance Support
Workflow-based learning
[Learning/Training]

Blended e-Learning
The e-learning encourages the student
To develop their literacy in a number of computer applications.
Word processing, graphical design,
using databases, desk-top publishing,
spreadsheets, using the Internet,
web page design, multimedia design and
The use of Nursing Information Systems (NIS) is some examples.
E*Value empowers nursing students
to achieve top performance,
While providing school administrators and faculty the resources to ensure they're on
track.
Deans, directors and coordinators receive highly supported, user-friendly assessment
solutions, allowing them to focus on academic improvement, not administrative burdens.
Performance evaluation and surveys
Since 1996, E*Value has been used to ask over 150 million evaluation questions.
Assessment Features:
Course, Rotation & Site Evaluations
Student, Faculty & Alumni Evaluations
Clinical Evaluations
Low Score Notifications
Performance, Outcomes & Trends Reporting
Student Grades, Scores & Ranking Reports
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,
Level of computer literacy,
Commitment and
Access to knowledge about new developments in the field inhibits the process.
e- learning misses the Human touch
Instructor's own philosophical beliefs of teaching are harboured and governed by the
pupil's background knowledge and experiences, d
However e-teaching misses several experiences of the teacher
Websites for reference
Technology-enhanced learning (TEL) MEDLINE and CINAHL - premier databases for
medical and nursing literature.
e-Learning in Health Sciences-
Online Open Access Bibliography
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
Improved access to medical specialists
Quicker , more accurate diagnosis and treatment ---> improved patient outcomes
Reduced travel
Decreased stress
Decreased cost (travel, meals, accommodation, lost work)
Benefits Remote Health Care Provider
Improved access to medical specialists
Increased confidence in management
Increased opportunities for education (CME at a distance, students can attend classes
virtually, can attend conferences virtually)
Decreased professional isolation
Collaborative research
"Electronic housecalls
Benefits of Telehealth
Benefits Central Health Care Provider
Decreased need to travel - "see patients, not the road"
Improved screening of patients
Improved follow-up
Increased educational opportunities
Collaborative research

Benefits - Health Care Payer
Decreased overall health care costs (per patient)
Reduced patient travel costs
Reduced physician travel costs
Improved patient outcomes
Less admissions to hospital
More patients treated at remote site or at home
More specialists can visit region, more often, at less expense
Human resources are used more efficiently, "Do more with less"
Health professionals are attracted to and kept in the region
Back-up nurse practitioners
TELENURSING
Telenursing is a component of telemedicine.
Telenursing is the branch of telehealththat involves actual nursing and client interaction
through the medium of information technology.
Offers health-related activities at a distance between two or more locations using
information and communication technologies (ICT).
Tele - at a distance.
Telenursing - care of patients at a distance.
Evolution:
In the 1970s, several health maintenance organizations began utilizing nurses to give
telephone advicein 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:
Telenursing refers to the use of telecommunications and information technology for
providing nursing services in health care whenever a large physical distance exists
between patient and nurse, or between any numbers of nurses.
Telenursing Definition from International Council of Nursing:
Telenursing refers to the use of telecommunications technology in nursing to enhance
patient care.
It involves the use of electromagnetic channels (e.g. wire, radio and optical) to transmit
voice, data and video communications signals.
It is also defined as distance communications, using electrical or optical transmissions,
between humans and/or computers."
13

It has many points of contacts with other medical and non-medical applications, such as
telediagnosis
Teleconsultation (Teleconsultation is dynamic i.e. it requires interaction from both the
referring medical practitioner and the consulting physician whether simultaneously
(through video-conferencing) or at different times (through store & forward systems)
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:
to deliver care and expertise,
for curative, preventive and rehabilitation
For training and information
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
In sychronous (real time) or
Asynchronous (differed time) mode
Direct (nurse-person encounter)
indirect (nurse-caregiver encounter)
In a real-time (synchronous) videoconferencing link,
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
Telephone triage nursing
Teletriage
Telecare
Telepresence
Telephone nursing
Telehomecare, home telecare
Telehealth nursing is utilizing an older form of technology (telephone lines).
Telephone triage is defined as the management of patient health concerns and
symptoms via a telephone interaction (telecommunications) by advice nurses.
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,
Medical imaging and
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.
How a videoconferencing can benefit people around campus:
Faculty member keeps in touch with class while away for a week at a conference.
Guest lecturer brought into a class from another institution.
Researcher collaborates with colleagues at other institutions on a regular basis without
loss of time due to travel.
Schools with multiple campuses can collaborate and share professors.
Faculty member participates in a thesis defence at another institution.
Administrators on tight schedules collaborate on a budget preparation from different parts
of campus.
Faculty committee auditions a scholarship candidate.
Researcher answers questions about a grant proposal from an agency or review
committee.
Student interviews with an employer in another city.
Teleseminars.
Videoconferencing first demonstrated in 1968.
Factors promoting the requirement for Telenursing:
Increasing shortages of nurses.
Costs of health care.
Need to provide Cost effective, timely and quality healthcare (remote, rural people).
Rise in Aging and chronically ill population.
TELENURSING scope of practice
Assistance to physicians in the implementation of medical treatment protocols.
For E.g.) Immediate post-surgical situations (the care of wounds, atomies, handicapped
individuals).
Nurses can
Actually view healing wounds,
Canaccess physiological monitoring equipment to measure physical indicators
such as vital signs.
Provideroutine assessment and follow-up care without the client having to travel
to the health care agency for an appointment.
New technologies have added a visual component to the interactions that
augments the historic audio exchange
Helps patients and families to be active participants in care, (self management of
chronic illness).
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
For educating the clients,
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.
Helps to keep patients out of hospital.
Sharing valuable medical information with doctors and nurses in other countries around
the world and in all areas of the profession.
Greater job satisfaction among telenurses.
Help solve increasing shortages of nurses.
Telenursing is cost efficient, timesaving and increases patients ability to self-care.
Minimises the length of hospital stay.
Reduce distances and save travel time.
Improvement of resource and time allocation.
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.
The Disadvantages of Telenursing
First of all, one problem is that many fear that it will take away from personal one on one
time.
Conferences and video cant 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.
Technical problems in 3-D imaging
Lack of standardisation and legislation
Problems in assessing qualifications
Problems with security and identification
Missing clinical anamnesis and examination
False diagnosis
Lack of ability to touch or direct delivery of care to a patient by nurse.
Technical skill is needed by nurses.
Network connection error / failure / delay.
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:

Telemedicine is the delivery of health-care services, where distance is a critical factor, by
health-care professionals using information and communication technologies for the exchange of
valid information for diagnosis, treatment and prevention of disease and injuries, and for the
continuing education of health-care providers as well as research and evaluation, all in the
interest of advancing the health of individuals and their communities.
The objectives of telemedicine:
One of the basic ideas of telemedicine can be expressed by the saying: Move the
information, not the patient. When a patient needs to consult a specialist, information about the
patient could be obtained locally and exchanged through a network to a specialist. In many
situations this can replace transporting the patient or the specialist to a given location. This
exchange of information and expertise for medical diagnosing and treatment is a basic concept of
telemedicine.
Evolution of telemedicine:
Telemedicine literally means medicine practiced at a distance. It is not new and has been
practiced since antiquity, using primitive communication technologies. Simple devices such as
bells, flags and signs were used for this purpose in the past. This included the convention of
making lepers ring bells to warn others not to come near. Ships carrying the plague flew yellow
flags to indicate their ship was in quarantine and to keep other ships away. These are early
examples of transmitting health information at a distance. As advances in the telecommunication
technologies have occurred, the medical use of these technologies has followed.

Landmark Events in the history of Telemedicine:
1844: Transfer of medical information using public telegraph.
1876: Alexander Graham Bells invention of the telephone.
1897: A telephone was used to diagnose a child with croup and the case was reported in
the medical journal Lancet.
1906: The First Electro Cardio Graphic (ECG) transmission by phone.
1923: Sahlgrens University hospital in Gothenburg, Sweden offered medical advice to
fleets of trade ships by using Morse code.
1927: The first experimental television transmission was undertaken.
1949: The Jean-Talon hospital in Montreal used a television to perform X-ray data
transmissions.
The initial idea behind telemedicine was, and is, to overcome the barriers of time and
distance. From its inception, the emphasis has been on diagnosis. Since diagnosis usually
requires visual information, one needs a device that enables the physician to SEE the
patient.

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 Comsats Early Bird
satellite.
1967: Physicians provide services for airline passengers at Bostons 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.
7
th
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.

Technologies involved in telemedicine:
Developing countries can benefit from using information technology and telecommunications
networks to improve health care in remote and rural areas. Although advanced telemedicine
applications may require a sophisticated and expensive telecommunications infrastructure, some
solutions require only a basic infrastructure to provide health-care services to remote areas.
The two types of technologies, most commonly used today, are
STORE AND FORWARD:
In this text, audio, static and video images can be captured, stored and then forwarded to
another location for review and / or consultation by a physician. This technology is less
expensive and well suited for non-emergency situations in radiology, pathology and
dermatology.

IATV (two-way Interactive TV):
In emergency medical situations such as a trauma service, video-conferencing equipment at both
ends allows real time or near real time consultation. The key feature of telemedicine equipment
which distinguishes it from simple video conferencing units is the use of peripheral devices:
electronic versions of examination tools such as stethoscopes which allow the distant cardiologist
to listen to the heart-beat of the patient.
Services such as specialist-assisted surgery or psychiatric consultations usually require
live audio. If live, real-time transfer of information is not required, such as in radiology and
pathology, the use of store-and-forward technology can be more convenient and much more cost-
effective.
Standards:
Standards represent universally accepted agreements on how to implement technologies,
allowing interconnection and communication between devices manufactured by different
companies. Health Level Seven (HL 7) is the standard for electronic exchange of health data
(clinical orders, billing information, patient admission, discharge, transfer and registration
information).The Digital Imaging and Communication in Medicine (DICOM) standard defines
common formats for data generated by imaging equipment and routine actions that can be
performed on images, specifies messages about the data and how the processing actions can be
exchanged.

Telemedicine in the international scenario:
As such, telemedicine is not a new phenomenon and work in this field has been going on
since last 30 years. A number of telemedicine projects are being undertaken by NASA, the US
universities, Australia, Europe, International Space University (ISU) Strasbourg, France and
various other organizations and countries.
Telemedicine may in fact have a more profound impact on developing countries than on
developed ones. Satellite stations in Uzbekistan, wireless connections in Cambodia, and
microwave transmission in Kosova have shown that the low bandwidth Internet can reach into
remote areas, some of them with troubled political situations and uncertain economic
environments.
The Internet-email, websites, chat lines, multimedia presentations and occasional
opportunities for synchronous communication via Internet phones and video conferencing
provide an opportunity for medical education and medical care, not to mention collegial support.
Another example of the value of the Internet was the implementation of educational web servers
in Kosovo, established with satellite links only months after the conflict abated. The installation
of an Internet server allowed the local physicians to gain access to literature and websites, which
replaced their 10-year-old collection of journals.
.
Projects in other countries:
Many countries are making headway in the field of telemedicine.
IMPHONE is a research program at the Department of Radiology, University of Pisa,
looking at the application of advanced informatics in medicine.
TeleSCAN project on cancer is being carried out at the Netherlands Cancer Institute. It is
designed to demonstrate the benefits and possibilities of multimedia telematics to the
European oncologists in order to assist in the uptake of IT as an effective tool, both for
clinicians and the staff.
Yale Telemedicine Center, Connecticut provides clinical consultation to various
universities and medical institutions.
Israel has formed Telemedicine and Telecare Development Centre based at Ben Gurion
University of the Negev and at Soroka Medical Centre Beer Sheva.
Japan is at the edge of a major push into telemedicine. The number of active programs in
Japan jumped from 49 in 1995 to 98 in 1996 and to 148 in 1997.
Tripler Army Medical Centers Internet Tumor and Board -a web-based telemedicine
project has let to better care for remote cancer patients and better communication among
military medical specialists throughout the Pacific islands

Telemedicine in the Indian Scenario:
In India, there are many remote areas, which lack basic health care facilities, and patients
have to travel for mile before they can be treated at any hospital/health care centre. With 80% of
Indias population living in rural areas and 80% of the medical community living in cities, there
is an imbalance in health care reaching people. So much so that in new millennium, 11% of the
worlds population (residing in rural areas) remains devoid of quality health care. Hence, it
becomes very essential that telemedicine be introduced and implemented in the country.
Apollo Hospital group has set up a 50-bed telemedicine center at Aragonda village
(Andhra Pradesh, South India). It has also set up freestanding centers at Guwahati and
Kolkata. These centers are equipped with facilities like CT-scan, X-ray, ECG and
integrated laboratory and are linked to Apollos specialized hospitals at Hyderabad,
Chennai, and Delhi for seeking referral services, second opinion, post acute care,
interpretation services and health education.
The hospital group has also a web portal, ApolloLife that allows patients to interact with
doctors via the web, upload all their diagnostics and reports on the net.
Escorts Heart Institute and Research Centre (EHIRC), Delhi through its Escorts Heart
Alert Service (EHAS), utilizes telemedicine in establishing prompt contact with patients
in distress. The EHAS subscribers can record their ECGs at the time of discomfort
through the cardiac beeper provided and transmit them through a telephone to the heart
alert centre. These tele-ECGs can be monitored 24-hours at the dedicated center and
fully equipped mobile cardiac care units from the center can be rushed to provide
intensive care to the patients before they brought to the hospital for medical investigation.
Telemedicine project by Bharat Electronics Limited (BELs) links a General Hospital in
Chennai with a government rural hospital in Wallajah about 100 km away.

Telemedicine project by NIC (National Informatics Centre), Ministry of Information
Technology aims at providing health-related information resources, decision support
tools and data at the time and place of need by health care providers across the country.
Cardiovascular Technology Institute (CVTI), Hyderabad in association with Defence
organizations has successfully tested an indigenous telemedicine field unit capable of
transmitting, all the clinical data including MRI, CT Scan and even X-rays to a doctor of
ones choice through computer and telephone. The facility also offers two-way audio and
video communication for real interaction helping doctors in seeking either expert or
second opinion related to a case particularly for working in the remote corners of the
country.
Technology Development Program for Telemedicine by The Ministry of Information
Technology aims to link three premier medical institutions All India Institute of Medical
Sciences, New Delhi; the Post Graduate Institute (PGI), Chandigarh; and the Sanjay
Gandhi Medical Institute at Lucknow for realizing tele-diagnosis, tele-consultancy and
tele-education.

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.

Tele-Medicine and Army:
The US Armys first portable telemedicine unit was started in 1993 comprising Ruggedish
video-conferencing unit. The unit was operating under the United Nations in Macedonia in 1994
and later in Haiti. These experiences have proved to be adequate for majority of clinical
telemedicine cases and provide major benefit to the commanders in the field, by reducing
evacuation rate and air-lifting-which are hard on men and materials particularly in times of
hostilities.

Rural (Community) Tele-Medicine:
Telemedicine has the potential to provide routine and specialist services to both patients
and physicians in rural areas. The technique is particularly valuable in pediatric patients, in
patients with acute medical emergencies and those suffering from accidental injuries. Since
specialist facilities are located in large cities, physicians in remote areas feel diffident in
handling serious patients, due to lack of experience and expertise. They thus, transfer acute
patients to far off referral centres, which become further sick as they do not receive even basic
initial resuscitative support. If the rural physicians tele-link with big hospitals and with their
seniors, they would have the confidence to initiate elementary care to sick patients in
consultation with the experts and thus transfer them only after stabilising.

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 patients includes faster diagnosis and treatment; reduction of additional
examinations; seamless care; avoidance of the inconvenience of traveling to another hospital or
physician; easier scientific and statistical analysis; better management of the populations health
by governments.

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.

Challenges faced by the practice of telemedicine:
Telemedicine has a number of challenges to overcome before it can be integrated into the
overall fabric of health care. They are:

(1) Infrastructure:
Telecommunications:
Telecommunications constitute an essential link in any telemedicine application.
Telemedicine therefore demands a high degree of telecommunications network security, a high
level of efficiency and adequate transmission capacity.
Medical technologies:
In a modern health service, providing diagnosis, treatment and care depends on the
quality of both the biomedical equipment and professional expertise. Developing countries are
inevitably short of both equipment and well-trained experts.

(2) Quality of transmission:
Accuracy of diagnosis is dependent on the clarity of images and data. If the quality of
transmission is poor or incomplete, the physician must be prepared to decline diagnosis and
treatment to avoid malpractice liability.

(3) Hardware and Software compatibility:
Telemedicine systems and services require that users have compatible hardware at both
ends of the communications link, which reduces inter-operability and the benefits of access to
different sources of telemedicine expertise.

(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.

(5) Dispersion of Liability:
If a local doctor or paramedic treating a patient contacts a telemedicine service and sends
X-ray images for interpretation, who bears the responsibility toward the patient? Is it the local
doctor or the specialist a thousand kilometers away? Although many telemedicine interactions
are already crossing state and national boundaries, legal precedents for remote liability and
licensing have not yet been established in the courts. When a telemedicine consultation crosses
state lines, does the provider have to be licensed in one state, the other, or both?

(6) Privacy and confidentiality:
Remote consultations involve the transfer of medical data that are sensitive, confidential
and private electronically from one location to another. Sensitivity information, which can be
associated with a patients identity, must not fall into the hands of unauthorized persons.
Ensuring privacy of patient information sent across public networks where it may be seen
intentionally or otherwise is another issue to be addressed to avoid public disclosure of private
facts.

(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.

The Suggested Model:

National level Health Coordinating Centre

Super Speciality
Hospitals
Medical Universities/Medical
Libraries
Telemedicine cell at
SuperSpecialityHospit
al
Fibre Optic or
satellite links Telemedicine
cell at District
Hospital
Telemedicine
cell at District
Hospital
Telemedicine
cell at District
Hospital

Primary Health
Centre (PHC)
Primary Health
Centre (PHC)
Primary Health
Centre (PHC)
Internet Based
Links
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 WHOs 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.

Primary Health Centre:
Is a facility providing primary care?
Requires transfer of low volume data.
Has low cost infrastructure.

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.

Super Speciality Hospitals:

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) LEADERS MOTIVATES PEOPLE
A leader motivates employees for higher output through motivational techniques. The
leader himself acts as a motivating factor.
b) LEADER COUNSELS EMPLOYEES
In an organization people needs counseling to reduce the emotional
disequilibrium and to remove barriers to effective performance. A leader solves such
types of problems and makes employees happy. Thus, a leader acts as a counselor.
c) LEADER DEVELOPS TEAM SPIRIT
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.
d) LEADERS AIMS AT TIME MANAGEMENT
Leader is in a position to utilize time productivity in an organization. A leader gets things
done by people by the proper time management.
e) LEADER STRIVES FOR EFFECTIVENESS
A leader brings effectiveness to an organization by providing the workers with the
necessary resources in terms of money, methods, climate, work environment, etc.
FUNCTIONS OF LEADERSHIP-
Executive, Planner, Policy maker, Expert, External group representative, Controller of
internal relation, Purveyor of rewards and punishment
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.
e.g.- financial advisor, legal advisor, etc
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:-

1. TRAIT THEORY/GREAT MAN THEORY-
This theory suggests that leaders have some inborn traits. They have certain set of
characteristics that are crucial for inspiring others towards a common goal. A successful leader is
supposed to have the following traits- good personality, tirelessness, capacity to read others
mind, ability to make quick decision, courage, persuasion, intelligence, reliability, imagination
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
THIS THEORY believes that leadership effectiveness depended on the relationship
among the leaders task at hand, their interpersonal skills and the favorableness the work
situation. This theory considers the challenge of situation and encourages an adaptive leadership
style to complement the issue being faced.
STYLES OF LEADERSHIP
1. AUTOCRATIC LEADERSHIP:
Tleader assumes complete control over the decisions and activities of the group.
CHARACTERISTIC OF THE LEADER
Firm personality, insistent, self-assured, highly directive, dominating.
Has high concern for the work than for the people who performs task
Shows no regards to the interests of the employees
Set rigid standards and method of performance and expects the sudordinates to
obey the rules and follow the same
Makes all decision by himself or herself
Minimal group participation or none from the workers
ADVANTAGES AND DISADVANTAGES
ADVANTAGES

DISADVANTAGES
Efficient in time of crisis, easy to make
decision by one group and less time
consuming
Does not encourage the individuals growth
and does not recognize the potentials,
imitativeness and creates less cooperation
among members
It is useful when there is only leader who is
experienced having new and essential
information, while subordinates are in
experienced and new

Leader lacks supportive power that results
in decision made with consultation
although he may be correct
It is useful when the workers are unsure of
taking decision and expect the leader to tell
what to do
Less job satisfaction leads to less
commitment to goals of the organization

2. DEMOCRATIC LEADER
Participative consultative style of leadership
CHARACTERISTIC OF THE LEADER
Sense of equality among leader and followers
Open system of communication prevails
Interaction between the leader and group is friendly and trusting
Leader works through people not by domination but by suggestions and
persuasions
Encourages all employee in decision
making
It takes more time for taking decision by
the group than the leader alone
Promotes personnel involvement, greater
commitment to work and enhance job
satisfaction

3. LAISSARE-FAIRE LEADERSHIP
Free- Rein, Anarchic and Ultraliberal style of leadership. The leader gives up all
power to the group.
CHARACTERISTIC FEATURES
Encourages independent activity by the group member
Group members are tree to set their own goals determine their own activities and
allowed to do almost what they desire to do
Style effective in highly motivating professional growth
ADVANTAGES

DISADVANTAGES
In limited situations creativity may be
encouraged for specific purposes
May lead to instability, disorganization,
inefficiency, no unity of action
To try new method of action Lack of feeling responsible to solve the
problem that may arise. Individual will lose
interest, initiative and desire for
achievement

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
A. SKILLS OF PERSONAL BEHAVIOUR
- Sensitive to the feeling of the group
- Identifies self with needs of the group
- Does not ridicule or criticize others suggestion
- Does not argue
B. SKILLS OF COMMUNICATION
- Listen attentively
- Make sure everyone understands
- Establish positive communication with the group
- Recognizes that everyones contribution are important
C. SKILLS OF ORGANIZATION
- Develop short and long term objectives
- Break big problem into small ones
- Share responsibilities and opportunities
- Plan, act, follow-up and evaluate
D. SKILLS OF SEF EXAMINATION
- Aware of personal motivation
- Aware of group members
- Helps group to aware of their attitudes and values
S- Self reliant
E- enthusiastic
L- Loyal
F- Factual

DIFFERENCE BETWEEN LEADERSHIP AND MANAGEMENT
Factors Leadership Management
Source of power Personal abilities Authority delegated
Focus Vision and purpose Operating results
Approach Transformational Transactional
Process Inspiration Control
Emphasis Collectively Individualism
Futurity Proactive Reactive
Type Formal and informal Formal

APPLICATION OF LEADERSHIP IN NURSING
1. Patient care coordination :
Even new graduate nurses have leadership responsibilities when they begin in nursing.
Nursing leadership begins with nursing care of the individual patient. The students are
guide to organize nursing care.
+ Establish good and priorities for each day.
+ Establish time
+ Establish success and failure
2. Employee responsibilities :
Nurses have specific tasks or duties to perform. These tasks are determined by the plan
and objective of the health care agency. It is important to read your job description
carefully and to continue to evaluate how institutional factor s influences your own
practice of nursing. Factors that compromise quality care should be noted and addressed
in construction with experience nurses.
3. Guidelines for delegating nursing care :
New graduate nurses use leadership techniques when they direct the work of
nonprofessional staff and volunteers and consider delegating tasks to nonprofessional
staff.
4. Mentorship:
It is a relationship in which an experienced individual advise and assist a less
experienced individual. This is an effective way of easing a new nurse into leadership
responsibilities
5. Preceptor ship:
An alternative model is preceptor ship. The preceptor is selected to introduce an
employee to new responsibilities through teaching and guidance. The relationship is
limited by the new employee s needs.
6. Continuing education : leadership , managerial and administrative skills are needed

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

In todays explosion of information technology, communication continues to be a
complex process. Group dynamics can be very positive and helpful where team members
support each other and do what is best. It can alternately become destructive if individuals are
allowed to continue with more selfish behaviors such as never helping someone else, making
their personal life and personal problems permeate their work, being negative about everything
that happens or complaining all the time. The nurse manager has an important role in this
situation, because it may be necessary to counsel individuals exhibiting negative behavior to
achieve positive group dynamics.

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.

OBJECTIVES OF GROUP DYNAMICS
To identify and analyze the social processes that impact on group development and
performance.
To acquire the skills necessary to intervene and improve individual and group
performance in an organizational context.
To build more successful organizations by applying techniques that provide positive
impact on goal achievement.
PRINCIPLES OF GROUP DYNAMICS
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.

ELEMENTS OF GROUP DYNAMICS
COMMUNICATION
One of the easiest aspects of group process to observe is the pattern of
communication. The kinds of observations we make give us clues to other important
things which may be going on in the group such as who leads whom or who influences
whom.
Who talks? For how long? How often?
Who do people look at when they talk?
Who talks after whom, or who interrupts whom?
Style of communication used?
How are silent people treated? Is silence due to disagreement, disinterest, fear,
fatigue?

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 lotbut 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.

RELATIONSHIP ROLES (which helps group members get along better)
Harmonizer: who mediates, harmonizes and resolve conflicts.
Gate keeper: helping to keep communication channels open; facilitating the
participation of others; suggesting procedures that permit sharing remarks.
Encourager; being friendly, warm, and responsive to others; indicating by facial
expression or remarks the acceptance of others' contributions.
Compromiser: when one's own idea or status is involved in a conflict, offering a
compromise which yields status; admitting error.
Follower: who accepts the groups ideas and listens to their discussion and
decisions.

SELF-ORIENTED ROLES (which contributes to neither group task nor group
relationship)
Dominator: interrupts others; launches on long monologues; is over-positive;
tries to lead group and assert authority; is generally autocratic.
Negativist: rejects ideas suggested by others; takes a negative attitude on issues;
argues frequently and unnecessarily; is pessimistic, refuses to cooperate; pouts.
Aggressor: tries to achieve importance in group; boasts; criticizes or blames
others; tries to get attention; shows anger or irritation against group or individuals;
deflates importance or position of others in group.
Playboy: is not interested in the group except as it can help him or her to have a
good time.
Storyteller: likes to tell long "fishing stories" which are not relevant to the group;
gets off on long tangents.
Interrupter: talks over others; engages in side conversations; whispers to
neighbour.

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.

STAGES OF GROUP DEVELOPMENT
I.BRUCE W TUCKMAN is a respected educational psychologist who first described the four
stages of group development in 1965. The four-stage model is called as Tuckman's Stages for a
group. Tuckman's model states that the ideal group decision-making process should occur in four
stages:
Stage 1: Forming (pretending to get on or get along with others)

Individual behaviour is driven by a desire to be accepted by the others, and
avoid controversy or conflict. Serious issues and feelings are avoided, and
people focus on being busy with routines, such as team organization, who does
what, when to meet, etc. But individuals are also gathering information and
impressions - about each other, and about the scope of the task and how to
approach it. This is a comfortable stage to be in, but the avoidance of conflict
and threat means that not much actually gets done.

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 groups 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 members 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?
Members 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.

An effective problem solving procedure would be to:
Clearly define the problem: Is it what appears on the surface or are there deep hidden
aspects?
Try to thoroughly explore and understand the causes behind the problem
Collect additional information, from elsewhere if necessary, and analyze it to understand
the problem further
The group should suspend criticism and judgment for a while and try to combine each
other's ideas or add on improvements. The objectives should be to generate as many ideas
and suggestions as possible. This is called "brainstorming" in a group, when individuals
try lateral thinking.

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

POWER AND POLITICS
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 ones 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.

THE NEED FOR POWER:
+ To provide competent, humanistic, and affordable care to people
+ To participate in health care policy development
+ To gain leverage proportionate with their numbers
+ To ensure that nursing is an attractive career choice for all who want to provide care,
influence, and improve nursing, heath care, and health policy.

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 ones individuality and rights
requires greater force than that needed for self affirmation.
The power of aggression- Moving into and taking possession of anothers 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 persons 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 persons ability to apply force
to another is contingent on specific circumstances that would not exist at another place or
time. For example, a subordinates power over a superior may result from the subordinates
having held a leadership position in the past; having publicly defended the superior against
attack; or having knowledge of the superiors unwise or unsafe behaviour in a situation that
is unknown to others. A superiors power over a subordinate may result less from their
respective positions in the official table of organization than from the superiors membership
on the subordinates 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 persons 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 managers 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 managers
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
Referent
Association with others
Legitimate
Position
Coercive
Fear
Reward
Ability to grant favours
Expert
Knowledge and skill
Charismatic
Personal
Informational
The need for information
Self
Maturity, ego strength

WAYS TO ACHIEVE POWER:
There are multiple ways to accumulate, or gain power. Methods to acquire power include the
following:
Broad human networks: the more networks and the more extensive they are, the more power
potential.
Broad information networks: the more diverse types of information controlled the more
power.
Multiple formal and informal leadership roles: high engagement and visibility bring
increased power.
Ability to assess situations accurately and to solve problems.
Authority over others and resources via legitimate work organizational roles.
Vision for the future and creativity
Ability to grant services to others, which builds debts.
Expertise that is sought by others.

WAYS TO INCREASE EXPERT POWER:

Participate in interdisciplinary conferences to broaden knowledge, develop skills, and build
networks.
Keep knowledge and skills current to maintain and extend power. Continuing education
offerings, books, and journals are effective means.
Earn higher degrees; education brings expertise and enhances credibility.
Participate actively in professional associations such as the ANA, state nurses associations,
and speciality groups to broaden networks, hone expertise, and develop legitimate and
referent power.
Participate in nursing research to develop knowledge and increase expertise
Problem-solve with colleagues in nursing and other disciplines to develop expertise and
networks and to polish skills.
Participate in nursing and interdisciplinary committees to develop and enhance expert,
referent, and legitimate power.
Publish to develop expert power.
Learn from mentors; be a mentor to develop expertise and connections or referent power.

EXERCISING POWER AND INFLUENCE IN THE WORKPLACE AND OTHER
ORGANIZATIONS:
To use influence effectively in any organization, one must understand how the system works and
develop organizational strategies. Developing organizational savvy includes identifying the real
decision makers and those persons who have a high level of influence with the decision makers.
Recognize the informal leaders within any organization.

Collegiality and collaboration:
An empowering attitude:
Developing coalitions:
Negotiating:

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.

The key factors contributing to ones power image:-
+ Self-image: Thinking of ones self as powerful and effective
+ Grooming and dress: Ensuring that clothing, hair, and general appearance are neat, clean,
and appropriate to the situation
+ Good manners: Treating people with courtesy and respect
+ Body-language: Maintaining good posture, using gestures that avoid too much drama,
maintaining good eye contact, and being confident in your movement.
+ Speech: Using a firm, confident voice; good grammar and diction; an appropriate vocabulary;
and strong communication skills
+ Belief in power as a positive force
+ Belief in value of nursing to society
+ Career commitment: Having a career commitment does not preclude leaving employment
temporarily for family, education, or other demands. Having a career commitment implies
that a nurse views himself or herself first and foremost as a member of the discipline of
nursing with an obligation to make a contribution to the profession.
+ Continuing professional education: Valuing education is one of the hallmarks of a
profession. The continuing development of ones professional skills and knowledge is an
empowering experience, preparing the nurse to make decisions with the support of an
expanding body of knowledge. Returning to school for advanced degrees is also a powerful
growth experience and reflects commitment to the profession of nursing.

Additional personal power strategies:
Be honest
Always be courteous; it makes other people feel good
Smile when appropriate; it puts people at ease
Accept responsibility for your own mistakes and learn from them
Be a risk taker
Win and lose gracefully
Learn to be comfortable with conflict and ambiguity; they are both normal states of the human
condition.
Give credit to others when credit is due.
Develop the ability to take constructive criticism gracefully; learn to let destructive criticism
roll off your back.
Always follow through on promises

TOOLS FOR IMPROVING POWER IMAGE:
Communication skills- The most basic tool is effective verbal communication skills, which
help define a power image. These are same communication skills nurses learn to ensure
effective interaction with patients and families. Listening skills are essential leadership skills.
Manager who are good listeners develop reputations for being fair and consistent. Verbal and
non-verbal skills are important personal power strategies; the ability to assess these messages
is a critical power strategy. Experts in communication estimate that 90% of the messages we
communicate to others are nonverbal. When nonverbal and verbal messages conflict, the
nonverbal message is more powerful.
Networking: Networking is an important power strategy and political skill. A network is a
system of contacts that is developed, nurtured, and maintained as sources of information,
advice, and moral support. Networking supports the empowerment of participants through
interaction and the refinement of their interpersonal skills..
Mentoring: Mentors are competent, experienced professionals who develop a relationship
with a novice for the purpose of providing advice, support, information, and feedback to
encourage the development of another individual. Mentoring has become a significant power
strategy for women in general and for nurses in particular during the last 20 years. Mentoring
provides novices with expanded access to information, power, and career opportunities.
Effective mentoring in nursing can be characterized by certain attributes (Stewart & Kruger,
1996):-
Goal setting: Goal setting is another power strategy. Every nurse knows about setting goals.
Nurse may be expected to write annual goals for performance reviews at work. Goals help one
to know if what was planned was actually accomplished.
Developing expertise: must not be limited to clinical knowledge. Leadership and
communication skills are essential to the effective exercise of power in a range of nursing roles.
Education and practice provide the means for developing such expertise in any of the domains
of nursing: clinical practice, education, research, and management.
High visibility: the strategy of high visibility within an organization also requires volunteering
to serve as a member or the chairperson of committees and task forces. High visibility can be
nurtured by attending the open meetings of committees and other groups of which you are not a
member in the workplace, professional associations, or the community. Use opportunities both
before and after meetings to share your expertise, providing valuable information and ideas to
members and leaders of such groups. Share this expertise at open meetings when appropriate.
Speak up confidently, but have something relevant to say. Be concise and precise.

ABUSE OF POWER:
Abuse of power is the control of people by some kind of force. It is the use of power for
ones 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 womens 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.

THE FOUR STAGES OF POLITICAL DEVELOPMENT FOR THE PROFESSION
OF NURSING: (a model by - Cohen, Mason, Kovner, Leavitt, Pulcini, and
Sochalski, 1996)

1. Buy- in: Recognizing the importance of activism.
2. Self-interest: Developing and using political expertise to further the professions self-
interests.
3. Political sophistication: Moving beyond self-interests, recognizing the need for
activism on behalf of the public.
4. Leading the way: Providing true leadership on broad healthcare interests.

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 ones own career;
the development and use of political expertise to further the professions 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:
Identify and analyze the problem:
Identification and analysis of the problem or issue is the first step. The problem must
be understood in order to frame it in ways that will move elected officials to action. It
must be carefully crafted in terms that make sense. To frame the problem adequately,
state the scope, duration, and history of the problem. An important point is to be
explicit about whom this problem affects. Then collect all data that are available to
describe the issue and its implications. Identify any gaps in the data. Identify whether
more research might be useful and, if so, what types would help.
Outline and analyze proposed solution:
Present possible solutions to public officials along with the identified problem. It is
best to develop more than one solution because costs, effectiveness, and durability
differ from approach to approach
Understand the background, including its history and attempts to solve the
problem:
It is important to understand what attempts have been made to address an issue. The
history, including why and how previous attempts failed, will provide an estimation of
the potential success of the current proposal. Even in a workplace context,
understanding the background of an issue is important. If one believes that the staffing
on a unit needs to be changed to improve patient care, efficiency, and nurse
satisfaction, one must assess how the staffing was structured, why it was done in that
particular way, and why and how that format is outdated before one present ones
proposal to the nurse manager or appropriate committee.

Locate the political situation and its structure:
After the problem and solutions have been delineated, assess and choose the
appropriate political venues. The choice is between the private sector and government.
If the decision made is to approach government, decide on the level and branch. There
are times when both the public and private sectors are involved, but in that case, only
one has the decision making responsibility. When all sectors have equal power, no one
sector has the responsibility to make decision nor the vested interest to prevent a
decision. Be sure to identify the political setting accurately, because making an error
can cause you a loss of credibility and a loss of power. For example, if nurse are
concerned about an aspect of patient care, the employer must be approached through
the organization structure. It is unfair and impolitic to go to public officials before
internal mechanisms have been exhausted. It is also imprudent to exclude the nurse
manager and go directly to the chief nurse executive or a supervisor. Again, so doing
will cause loos of face, credibility, and power.
Evaluate the stakeholders:
The next step is to identify the stakeholders. Stakeholders are those who are affected by
or have influence over an issue or who could be recruited to care about it. Stakeholders
include policy makers who have proposals related to the issue, special interest groups,
and those with a position on the issue.
Conduct a values assessment:
All political issues have or moral aspects. Human rights, international health law, the
right to health, genetic engineering, embryonic stem cell research, genetic technologies,
terrorism, abortion, and the death penalty are among the most visible moral issues
today. Issues necessitate that stakeholders assess their own values and those of their
opponents.
Ascertain financial and personnel needs to attain goals:
Any effective political strategy must include assessment of resources needed to reach
goals. In addition to money, other needed resources include time, connections or
network, volunteers, contributors, and intangibles, such as people who are strategists
and those with creative ideas. The budget structure within an organization or
government agency must be considered. It is important to understand the budget
process, including how money is allocated to a cost center or line budget, who makes
decision regarding expenditures, how use of funds is evaluated, and how an individual
or group can influence budget development and implementation.
Analyze power bases:
In any setting, assessment of power bases of both proponents and opponents is
essential.

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.

Meier (1999) recommended some basic strategies for political action-
Join political organizations
Build a working relationship with a single legislator
Invite a legislator to a professional organization meeting
Invite a legislator or staff person from the legislators office to spend a day with you at
work.
Brendtro and Schwerin offered additional strategies for political action to shape policy:
Use power effectively
Always appear self confident
Empower others to work on policy issues
Build your visibility
Build relationships through coalitions and networks
Identify resources, human and physical, that can support your efforts.
Enhance the image of nursing in all policy efforts
Communicate message effectively and clearly
Develop expertise in shaping policy
Seek appointive positions or elective office to shape policy more effectively.

LOBBYING

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 ones 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.

The enterprise lobbyist:
This is a person who holds a job or has duties in a profit-making organization, whose
duties include, for a significant part, lobbying on behalf of the firm.

The organization lobbyist:
This is a person who holds a job or has duties in a non-profit organization. Like the
enterprise lobbyist, this lobbyist is affected by the Act if a significant part of his or her duties is
to lobby on behalf of this organization.

PREPARING FOR LOBBYING CAMPAIGN:
An effective lobbying initiative takes background work.
1. Develop plan of action. Consider, rework, revamp, and define the plan in advance of the
trip to the legislators office.
2. Be sure one is fully aware of all similar initiatives on the same topic and the position of
those opposing ones idea.
3. Check with other nursing organizations to determine their positions and if they have
information to help support ones position.
4. Fine-tune ones presentation to several key points because time will be limited.
5. Follow up after the meeting with a call or correspondence outlining the points.

PREPARING FOR AN EFFECTIVE LETTER-WRITING CAMPAIGN:
Define the goals of this grass-roots campaign.
Develop a plan
Assess the knowledge level of the participants concerning the legislative process and the
issues that impact the organization. Use this information to plan educational sessions with the
goal of improving the political sophistication of the group.
Give interested participants information about the bill in question and how this bill would
directly affect their practice. Clearly state what action the legislative body needs to take to
meet the goal, and include the specific bill number and name.
Set up effective telephone or e-mail networks that can contact key members quickly. Often
legislative issues are scheduled and moved up quickly on that schedule, requiring an
immediate change of plan.
Identify and set up contacts with the key legislators involved in your issue.
Set numerical goals for how many letters or mailings will be generated.
On large issues, focus groups or polls may be used to acquire information that can be
analysed and send to the legislators.
Get the timing right. The time to begin your campaign is just before the committee hearings
begin or just prior to the vote o the floor. Too early is ineffective; too late is wasted effort.
You must follow the progress of your issue closely so as to mobilize your members at the
right time.

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 organizations 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.
Donts:
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
legislators 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.
National Council for Excellence in Critical Thinking,1987
"Critical thinking in nursing practice is a discipline specific, reflective reasoning process that
guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and
professional concerns. -

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
Bloom identified six thinking levels:
1. Knowledge (knowing things)
2. Comprehension (understanding things)
3. Application (being apply to apply knowledge in the real world)
4. Analysis (ability to pull things apart intellectually)
5. Synthesis (ability to see through the clutter to the core issues)
6. Evaluation (the ability to make good judgments)
Levels 4, 5 and 6 are the most important one for mid and higher levels of management.
Stages of Critical Thinking
Stage One: We Begin as Unreflective Thinkers. We all begin as largely unreflective
thinkers, fundamentally unaware of the determining role that thinking is playing in our
lives. We dont realize, at this stage, the many ways that problems in thinking are causing
problems in our lives. We unconsciously think of ourselves as the source of truth. We
assume our own beliefs to be true. We unreflectively take in many absurd beliefs merely
because they are believed by those around us. We have no intellectual standards worthy
of the name. Wish fulfillment plays a significant role in what we believe.

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 Four: We Reach the Fourth Stage When We Begin to Develop
A Systematic Approach to Improving Our Ability to Think. At this stage, we now know
that simply wanting to change is not enough, nor is episodic and irregular "practice." We
recognize now the need for real commitment, for some regular and consistent way to
build improvement of thinking into the fabric of our lives.

Stage Five: We Reach the Fifth Stage When We Have Established
Good Habits of Thought Across the Domains of Our Lives. We know that we are
reaching the stage we call the Advanced Thinker stage when we find that our regimen for
rational living is paying off in significant ways. We are now routinely identifying
problems in our thinking, and are working successfully to deal with those problems
rationally. We have successfully identified the significant domains in our lives in which
we need to improve (e.g. professional, parenting, husband, wife, consumer, etc.), and are
making significant progress in all or most of them

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.

Components of the Critical Thinking
The eight components that have been identified as part of the critical thinking process include:
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 dont 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 dont 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:
1. it must be valid (structured properly);
2. the premises must be true; and
3. all relevant information must be included.
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 elses 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.
7.

Logic: Traditionally, philosophy has distinguished between two methods of
reasoning: deductive logic and inductive logic. In logic, moving from observations to
conclusions is called induction. Moving from conclusions to predictions that something will
follow, given a set of circumstances and then verifying the prediction is called deduction.
Inductive reasoning is characterized by reasoning from diverse facts, probability,
generalizations, hypotheses, and analogies, leading to inductive strength. Deductive
reasoning is characterized by reasoning from known facts, certainty, syllogisms, validity, and
truth of premises, leading to sound arguments and conclusions.
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 knowns. 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.
5. Use the relationships identified in step (4) to generate a problem-solving strategy.
6. Apply the strategy and solve.
7. If something doesnt 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.
METHODS OF CRITICAL THINKING
a. Debate: it involve enquiry, advocacy, and reasoned judgment on a proposition. A
person or group may debate or argue the pros and cons of a proposition in coming to a
reasoned judgment.
b. Individual decision: an individual may debate a proposition in his or her mind using
problem solving or decision making process. When consent or cooperation of others is
needed, the individual may use group discussion, persuasion, propend, coercions or a
combination of this method
c. Group discussion: five conditions for reaching decision through group discussion are
group members agree that a problem exist, have comparable standard of value, have
comparable purposes, are willing to accept consensus of the group, and relatively few
in number
d. Persuasion: it is communication to influence the acts, beliefs, attitude, and value of
others by reasoning, urging or inducement. Debate and advertising are two forms of
communication which intent is to persuade
e. Propend: it can be good or bad; it is multiple media communication designed to
persuade or influence a mass audience.
f. Coercion: threat or use of force is coercions. An example of coercions is
brainwashing in which subjects are completely controlled physically controlled for a
indefinite period of time.
g. Combination of method: Some situation requires a combination of foregoing
communication techniques to reach a decision.
PROCESS OF CRITICAL THINKING
+ 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.
Step 1:
Identify the problem, the relevant information, and all uncertainties about the
problem. This includes awareness that there is more than one correct solution.
(low cognitive complexity)
Step 2:
Explore interpretations and connections. This includes recognize one's own
bias, articulating the reasoning associated with alternative points of view, and
organizing information in meaningful ways. (moderate cognitive complexity)
Step 3:
Prioritize alternatives and communicate conclusions. This includes thorough
analysis, developing the guidelines used for prioritizing factors, and defending the
solution option chosen. (high cognitive complexity)
Step 4:
Integrate, monitor, and refine strategies for re-addressing the problem. This
includes acknowledging limitations of chosen solution and developing an ongoing
process for generating and using new information. (highest cognitive complexity)

Models of critical thinking

Benjamin Bloom's Model of Critical Thinking
Perhaps most familiar to educators is "BLOOM'S taxonomy." Benjamin Bloom describes the
major areas in the cognitive domain. The taxonomy begins by defining
knowledge as the remembering of previously learned material. Knowledge, according to
Benjamin Bloom, represents the lowest level of learning outcomes in the cognitive
domain.
comprehension, the ability to grasp the meaning of material and goes just beyond the
knowledge level. Comprehension is the lowest level of understanding.
Application is the next area in the hierarchy and refers to the ability to use learned
material in new and concrete principles and theories. Application requires a higher level
of understanding than comprehension.
Aanalysis, the next area of the taxonomy, the learning outcomes require an
understanding of both the content and the structural form of material.
synthesis, which refers to the ability to put parts together to form a new whole. Learning
outcomes at this level stress creative behaviors with a major emphasis on the formulation
of new patterns or structures.
evaluation. Evaluation is concerned with the ability to judge the value of material for a
given purpose. The judgments are to be based on definite criteria. Learning outcomes in
this area are the highest in the cognitive hierarchy because they incorporate or contain
elements of knowledge, comprehension, application, analysis, and synthesis. In addition,
they contain conscious value judgments based on clearly defined criteria. The activity of
inventing encourages the four highest levels of learning--application, analysis, synthesis,
and evaluation--in addition to knowledge and comprehension.

Structural model Jeffrey Ellis
A simple structural model proposed by Jeffrey Ellis illustrates the structural relationships
between major components of critical thinking. It is based on defining critical thinking as a set of
four sets:
CT = { {S}, {H}, {V}, {R} }
where {S} is a set of cognitive skills, {H} is a set of characteristic habits or attitudes, {V} is
a set of values/commitments, and {R} is a set of relationships among the various elements
in {S}, {H}, and {V}.
EVALUATION
SYNTHESIS
ANALYSIS
APPLICATION
COMPREHENSION
KNOWLEDGE

The set of cognitive skills {S} include fundamental reasoning abilities such
as analysis, synthesis, logic, evaluation, interpretation, and so on.
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.
Techniques of critical thinking
Here are 16 basic techniques of critical thinking.
1. Clarify.
State one point at a time. Elaborate. Give examples. Ask others to clarify or give examples. If
youre not sure what youre talking about, you cant 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? Whats the most important thing here? Distinguish your
purpose from related purposes.
6. Identify assumptions.
All thinking is based on assumptions, however basic.
7. Check your emotions.
Emotions only confuse critical thinking. Notice how your emotions may be pushing your
thinking in a certain direction.
8. Empathize.
Try to see things from your opponents perspective. Imagine how they feel. Imagine how you
sound to them. Sympathize with the logic, emotion, and experience of their perspective.

9. Know your own ignorance.
Each person knows less than 0.0001% of the available knowledge in the world. Even if you
know more about relevant issues than your opponent, you still might be wrong. Educate yourself
as much as possible, but still: be humble.
10. Be independent.
Think critically about important issues for yourself. Dont believe everything you read. Dont
conform to the priorities, values, and perspectives of others.
11. Think through implications.
Consider the consequences of your viewpoint.
12. Know your own biases.
Your biases muddle your thinking. Notice how they might be pushing your thought toward a
particular end, regardless of the logical steps it took to get there.
13. Suspend judgment.
Critical thinking should produce judgments, not the other way around. Dont make a decision
and then use critical thinking to back it up. If anything, use the method of science: take a guess
about how things are and then try to disprove it.
14. Consider the opposition.
Listen to other viewpoints in their own words. Seriously consider their most persuasive
arguments. Dont dismiss them.
15. Recognize cultural assumptions.
People from different times and cultures thought much differently than you do. In fact, your
ideas might have arrived only in the last 50 years of human history! Why is your perspective
better than that of everyone else in the world today and throughout history?
16. Be fair, not selfish.
Each persons most basic bias is for themselves.

Benefits of critical thinking
We have too much information. Critical thinking helps you focus on what matters.
We have too many options. Critical thinking helps you do what matters.
Millions of scam artists want to steal your time and money. You can use critical thinking
to defeat them.
Critical thinking helps you avoid false beliefs. Do you believe something because you
read it somewhere? Because your family or government or culture told you so? Because
it makes you feel good? Because you just believe it?
If so, you probably have many false beliefs. Critical thinking can help you avoid those.
Who knows? It might even help you form some truebeliefs.
But we probably already agree that critical thinking is good. How do we do it?

Use of critical thinking skills in nursing:
Nurses use knowledge from other subjects and fields.
Nurses deal with change in stressful environments.
Nurses make important decisions.
Nurses provide care according to nursing process

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.
Stages of Decision making:
Developed by B. Aubrey Fisher, there are four stages that should be involved in all group
decision making. These stages, or sometimes called phases, are important for the decision-
making process to begin
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.
Principles of decision making:
1. Purpose-Driven. People need a reason to participate in the process.
2. Inclusive, Not Exclusive. All parties with a significant interest in the issues should be
involved in the collaborative process.
3. Educational. The process relies on mutual education of all participants.
4. Voluntary. The parties who are affected or interested participate voluntarily.
5. Self-Designed. All parties have an equal opportunity to participate in designing the
collaborative process. The process must be explainable and designed to meet the
circumstances and needs of the situation.
6. Flexible. Flexibility should be designed into the process to accommodate changing
issues, data needs, political environment, and programmatic constraints such as ptime and
meeting arrangements.
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
1. Establishing goal and objectives
3. Analyzing the problem
4. Searching alternative solution
5. Selecting the best possible solution
6. Putting the decision into effect
7. Following up the decision
1. Establishing goal and objectives: goal and objectives can be set prior to beginning the
general process. They will answer the question, what do we want the outcome or
results of this decision to be? When new products or services are the outcome, goals
and objectives are established first and problems or decision are then forecast.
2. Making the diagnosis: 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 problem will start from this incorrect appraisal of the situation. The
diagnosis should not be merely based on one or more visible symptoms but it should
be diagnosed after the whole situation.
3. Analyzing the problem: The problem should be 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. A thorough information search include knowledge of organizational
policy, prior personal experience or training or the experience of others. From the
information gathered, the facts should be identified and separated so as to provide the
solid foundation for making sound decision.
4. Searching alternative solution: after analysing the problem, attempts are made to find
alternative solutions to the problems comparing the potential solutions to the desired
outcome to available resources. Establishing goals with measurable objectives helps
to focus the search the alternatives. This search for alternatives forces the manager to
see things from many view points and to study cases from their proper perspectives.
When comparing potential alternatives, one should certainly consider the cost, time
required and available, and the capabilities of those who will be involved in
implementating a decision.
5. Selecting best possible solution: the selection of one best course of action, out of
several alternatives developed, requires an ability to draw distinction between
tangible and intangible factors as well as facts and guesses. Four criteria suggested by
Drucker for choosing the best possible solution are as
Proportion of risk to the expected gain
Relevance between the economy of effort and the possibility of
results
The time consideration that meet the needs of the situation
The limitation of resources
6. Putting the decision into effect: even the best decision may become inoperative due to
the opposition of employees. The decision can only be made effective through the
action of the people. To overcome the resistance or opposition in the employees,
managers must make necessary preparations for putting the decision into effect. Three
important things related to preparation of this are
Communication of decision
Securing employees acceptance
Timing of decision
7. Follow up the decision for evaluation: inspite of all efforts, the decision taken may
not be accurate mainly because of two reasons:
Some amount of guesswork becomes inevitable in almost every decision.
Because of the cost and time involved in analyzing the problem.
Wrong decision also arise from the limited capacity of the manager itself

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
What is it you wish to achieve?
Step 2 - Do a preliminary survey of your options
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.

Step 5 - Budget your time and energy
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.

Step 6 - Choose a decision making strategy
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.
Step 7 - Identify your options
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.
Step 8 - Evaluate your options
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.
Step 9 - Make your choice - on time, on budget
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.

C. Operational research technique:
It is the analysis of decision problem using scientific method to provide manager the need
quantitative information in making decision.
Steps of operational research are
Construction of a mathematical model that pin points the important
factors in the situation.
Definition of criteria to be used for comparing the relative merits of
various possible courses of action
Procuring empirical estimates of the numerical parameters in the model
that specify the particular situation to which it is applied.
Carrying out through the mathematical process of finding and series of
action which will give optimum solution
c. Delphi technique: The Delphi method is a systematic, interactive forecasting method which relies
on a panel of experts. The experts answer questionnaires in two or more rounds. After each round, a
facilitator provides an anonymous summary of the experts forecasts from the previous round as well as
the reasons they provided for their judgments. Thus, experts are encouraged to revise their earlier
answers in light of the replies of other members of their panel. It is believed that during this process the
range of the answers will decrease and the group will converge towards the "correct" answer. Finally,
the process is stopped after a pre-defined stop criterion.
Advantage is that it is free from anothers 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.

Types of Decision Making
Main types
There are many types of decision making and these can be easily categorised into the following
4 groups:
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.
(ACCORDING TO Ken Shah & Prof. Param J. Shah)
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.
Trial and Error
In this type of decisions, knowledge is derived out of past mistakes. A certain course of
action is selected and is tried out, if the results are positive, the action is carried further, if the
results appear negative, another course is adopted and so on and so forth a trial is made and an
error is occurred. Till the night combination this continues. It allows the manager to adopt and
adjust plans continuously before the full and final commitment. It uses both, the positive and
negative feedback before selecting one particular course 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 outcomes 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 decisionmakers 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.
THEORIES OF DECISION MAKING
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
4. Classical decision theory
Views the decision maker as acting world of complete certain
Classical decision making faces a clearly defined problem. Knows all possible action
alternative and their consequences
Choose the optimum alternative
5. Behavioural decision theory
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
6. Statistical decision theory
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

MODELS OF DECISION MAKING
Vroan and yeltons normative model
The Vroom-Yetton- model is a decision making tree that enables a leader to examine a situation
and determine which style or level of involvement to engage. This model identifies five styles
along a continuum ranging from autocratic to consultative to group-based. Two are autocratic
(A1 and A2), two are consultative (C1 and C2) and one is Group based (G2).
A1: Leader takes known information and then decides alone.
A2: Leader gets information from followers, and then decides alone.
C1: Leader shares problem with followers individually, listens to ideas and then decides alone.
C2: Leader shares problems with followers as a group, listens to ideas and then decides alone.
G2: Leader shares problems with followers as a group and then seeks and accepts consensus
agreement.
Bounded rationality model: is the notion that in decision making, rationality of
individuals is limited by the information they have, the cognitive limitations of their
minds, and the finite amount of time they have to make decisions. The process of
bounded rationality involve 3 mechanism they are as

SEQUENTIAL ATTENTION TO ALTERNATIVE: here person examine possible
solutions of a problem systematically i.e. if first solution fails to work it is discarded and
next solution is considered till he gets acceptable solution

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

SATISFYING: Here the decision maker is looked as a satisfier where an alternative is
satisfactory if there exist a set of criteria that describes minimally satisfactory alternative,
alternative in question meets or exceeds all these criteria.

Factors Affecting the Decision-Making Process

Experience and knowledge
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
SOME COMMON MISTAKES THAT DECISION MAKERS SHOULD BE AWARE OF
INCLUDE:
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 persons 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 individuals 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 neuroendocrine 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.
Anxiety: state of mental uneasiness, apprehension, dread or feeling of helpless. It
can be experienced at conscious, subconscious or unconscious level.
Fear: It is an emotion/ feeling of apprehension aroused by impending or
seeming danger, pain or threat.
Depression: It is an extreme feeling of sadness, despair, lack of worth or
emptiness.
Unconscious ego defense mechanism: It is a psychologic adaptive mechanism
developing as the personality attempts to defend itself and allay inner tensions.
+ Cognitive indicators:
Problem solving: the person assesses the situation or problem analyzes, chose
alternatives, carries out selected alternatives and evaluates.
Structuring: arrangement/ manipulation of a situation so that threatening events
does not occur.
Self control: assuming a manner and facial expression that conveys a sense of
being in control or in change.
Suppression: willfully putting a thought or feeling out of mind.
Day dreaming: unfulfilled wishes and desires are imagined as fulfilled or a
threatening experience is re worked or re played so that it ends differently from
reality.
STRESS CYCLE

An event occurs of neutral
value or meaning
The individual responds to
the threat or challenge
through fight or flight

The bio-chemicals are
depleted through the
exertion to meet the threat
or challenge
Bio-chemicals are released
to enhance the ability of
ones mind and body to
respond

The individual appraises
whether the event is a
threat or a challenge

Fatigue follows the depletion
of bio-chemicals from the
exertion

After a period of rest, the
individual is able to prepare for
and meet a new threat or
challenge

THEORIES OF STRESS
+ SELYES GENERAL THEORY OF STRESS
During 1930s and 40s Selye performed the first extensive studies on stress responses.
His famous treatise the physiology and pathology of stress describes his general theory of
stress and influenced stress research throughout the world. Selye defined stress as a physiological
phenomenon.
Stress in biology is the non specific response of the body to any demand made upon it. It
suffices to keep in mind that by stress the physician means the common results of exposure to the
any stimulus. The bodily changes established when a person is exposed to nervous tension,
physical injury, infection, cold, heat, x-rays or anything are also called stress.
+ HOLMES AND RAHES MODEL RELATING LIFE CHANGES TO ILLNESS
They studied on relationship between change and illness. Change is a form of stress
requiring both psychological and physical adaptations. Adapting to change consumes energy
beyond that needed to maintain a steady state of life.
They developed the Social Readjustment Rating Scale, a ranking of major life change
units. They explored the link between the amount of changes in a persons life and subsequent
illness and discovered that the higher a persons life change score, the greater the likelihood that
an illness will subsequently develop.
+ LASARUSS THEORY OF STRESS AND COPING
This theory emphasizes that cognitive appraisal is central in determining what is stressful and
in coping with stress. He also pointed out that one of the major problems in defining stress is
that, emotions have been treated as a cause of stress response rather than the effect of these
responses. In the process of coping, the individual shapes as well as responds to a demand or
stress. Coping may change the stressful experience and thus may influence what happens next.

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 individuals 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.


+ PSYCHOSOMATIC MODEL:
Stress is unique in the causation of diseases. It has not biological carrier such as germ or
virus. Rather it is the result of how mind and body function or interact. It is psychosomatic in
the true sense of word-psyche meaning mind and soma body. It is the disease created by
the mind leading to different illness. Person may suppress the anger and eventually develop
the mental dysfunction of depression. Emotional stress leads to physiological stress and
results in psychosomatic illness.

+ THE SYSTEM MODEL:
Stress response is here defined as carrying six components.
Environmental stimuli- Some environmental stimuli activate stress response as a
direct consequence of their physical or biochemical properties. Eg. caffeine, nicotine,
and extreme cold and heat.
Cognitive-Affective domain- The individuals interpretation of the environment gives
rise to most of the stress reactions.
Neurological triggering mechanisms- The limbic system and the hypothalamic
nuclei are the anatomical site for the integration of sensory cognitive, affective and
visceral activity. It is the basis for a host of psychiatric and psycho physiological
disorders.
The physiological stress response axis- Stress response occurs sequentially along
the neurological, neuro endocrine and endocrine axes and results in neural and
hormonal activity directed at target organs.
Coping- In this final phase of stress response, the individual attempts to reduce their
level of arousal by manipulating the environment or making cognitive adjustment.
Target organ effects- If coping are unsuccessful and arousal is either excessive or
prolonged, the physiological process of stress response is likely to lead to target organ
dysfunction or disease.

+ TRANSACTION BASED MODEL:
It is based on the works of Lazarus (1966) who states that stimulus theory and
response theory do not consider individual differences. It encompasses a set of cognitive,
affective and adaptive responses that arises out of person environment transactions. As the
person and environment are inseparable, each affects and is affected by other. There are
moderating factors such as ones copying behavior and cognitive appraisal. Effective
preventive and health promotion strategies can be planned based on this model.
+ RESPONSE BASED MODEL:
In this model the word stress is used to describe the experience of a person who feels they
are in a threatening or difficult situation. Stress is thus a persons response to threat as in the
stimulus based model, is not necessarily inherent in the environment or situation. By using
the response based model, it is possible to make sense of an individuals unique stress
response and even of responses that might seem, within the stimulus based model, to be
irrational, such as birds , spiders or flying. It consists of mainly 2 responses,

1) Local adaptation syndrome: It is a localized response of body to stress and it involves
only specific body part (tissues, organs) instead of the whole body. It may be traumatic or
pathologic. eg: inflammatory responses of a body part in response to a trauma or injury. It is
a short term adaptive response which primarily is homeostatic. 2 most common stress
responses that influence nursing care are reflex pain response and the inflammatory response

Reflex pain response:
It is the response of central nervous system to pain. It is rapid, automatic and
serves as a protective mechanism to prevent injury. eg: if you are about to step into a
bath tub filled with dangerous hot water, skin senses the heat and immediately sends a
message to the spinal cord. A message is then sent to motor nerve, which consciously
realize that the water is too hot not safe.
Inflammatory response:
It is a local response to injury or infection. It helps to localize and prevent the
spread of infection and promote wound healing. There are 3 phases:
- First phase: vasoconstriction occurs to control bleeding initially. Histamines are
realized and capillary permeability increases resulting in increased blood flow to
the area. Then the blood flow returns to normal but remain to help resist the
infection.
- Second phase: exudates (made up of fluids, cells and inflammatory by products)
are realized from the wound. The amount of exudates depends up on the site,
severity of wound.
- Third phase: damaged cells are repaired by regeneration (replacement with
identical cells) or formation of scar tissue.
2) General adaptation syndrome: It describes bodys general response to stress. It consists of
3 stages
The alarm reaction: it is initiated when a person perceives a specific stressor,
various defence mechanisms are activated. The autonomic nervous system
initiates the flight or flight response preparing the body to either fight off the
stressor or to run away from it.
Resistance: the body attempts to adapt to stressor, after perceiving the threat.
Vital signs and hormone levels return to normal. If the stress can be managed or
confirmed to small area the body regains homeostasis.
Exhaustion: it results when the adaptive mechanism are exhausted. Without
defence against the stressor, the body either rest or mobilize its defence to return
to normal or reach total exhaustion and die.


+ STRESS ADAPTATION MODEL:
The model was given by Gail Stuart so it is called Stuart stress adaptation model. It
integrates biological, socio-cultural, psychological, environmental and legal- ethical aspects
of patient care into a unified frame work for practice.
The first assumption of Stuart stress adaptation model is the nature is ordered as a
society hierarchy from the simplest unit to the most complex. Each level is a part next
higher level, so nothing exists in isolation. Thus individual is a part of family, group,
community, society and the large biosphere, through which material and information
flows across various levels.

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
SOCIETY
COMMUNITY
GROUP
FAMILY
INDIVIDUAL
BODY SYSTEM
ORGAN
TISSUE
CELL
BIOSPHERE
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.

TECHNIQUES OF STRESS MANAGEMENT
Stress management involves controlling and reducing the tension that occurs in stressful
situations by making emotional and physical changes. The degree of stress and the desire to
make the changes will determine how much change takes place. Some of the techniques of
stress management are:
Laughter
Adopting a humorous view towards life`s situations can take the edge off everyday
stressors. Not being too serious or in a constant alert mode helps maintain the equanimity of
mind and promote clear thinking. Being able to laugh stress away is the smartest way to ward
off its effects.
Benefits of laughter:
Laughter lowers blood pressure and reduces hypertension.
It provides good cardiac conditioning especially for those who are unable to perform
physical exercise.
Reduces stress hormones (studies shows, laughter induces reduction of at least four of
neuroendocrine hormonesepinep hrine, cortisol, dopamine and growth hormone,
associated with stress response).
Boosts immune function by raising levels of infection-fighting T-cells, disease-fighting
proteins called Gamma-interferon and disease-destroying antibodies called B-cells.
Laughter triggers the release of endorphinsbody`s natural painkillers.
Produces a general sense of well-being.

AUTOGENIC TRAINING:
It is a relaxation technique developed by the German psychiatrist Johannes Heinrich
Schultz and first published in 1932. The technique involves the daily practice of sessions that
last around 15 minutes, usually in the morning, at lunch time, and in the evening. During each
session, the practitioner will repeat a set of visualizations that induce a state of relaxation. Each
session can be practiced in a position chosen amongst a set of recommended postures (for eg:
lying down, sitting meditation). The technique can be used to alleviate many stress-induced
psychosomatic disorders. Eg of an autogenic training session are:
Sit in the meditative posture and scan the body
"my right arm is heavy"
"my arms and legs are heavy and warm" (repeat 3 or more times)
"my heartbeat is calm and regular" (repeat 3 times)
"my forehead is cool"
"my neck and shoulders are heavy" (repeat 3 times)
"I am at peace" (repeat 3 times)
Effects of autogenic training:
Autogenic Training restores the balance between the activity of the sympathetic (flight
or fight) and the parasympathetic (rest and digest) branches of the autonomic nervous system.
This has important health benefits, as the parasympathetic activity promotes digestion and bowel
movements, lowers the blood pressure, slows the heart rate, and promotes the functions of the
immune system.
GETTING A HOBBY:
Hobby is an activity or interest that is undertaken for pleasure or relaxation, typically
done during one's leisure time.eg: collecting, games, outdoor recreation, gardening, performing
the arts, reading, cooking and etc.
MEDITATION:
Meditation is a holistic discipline during which time the practitioner trains his or her
mind in order to realize some benefit. Meditation is generally a subjective, personal experience
and most often done without any external involvement, except perhaps prayer beads to count
prayers. Meditation often involves invoking and cultivating a feeling or internal state, such as
compassion, or attending to some focal point, etc. The term can refer to the process of reaching
this state, as well as to the state itself.
DEEP BREATHING:
Diaphragmatic breathing, abdominal breathing, belly breathing, deep breathing or costal
breathing is the act of breathing deep into one's lungs by flexing one's diaphragm rather than
breathing shallowly by flexing one's rib cage. This deep breathing is marked by expansion of the
abdomen rather than the chest when breathing. It is generally considered a healthier and fuller
way to ingest oxygen and is often used as a therapy for hyperventilation and anxiety disorders.
A common diaphragmatic breathing exercise is as follows:
1. Sit or lie comfortably, with loose garments.
2. Put one hand on your chest and one on your stomach.
3. Slowly inhale through your nose or through pursed lips (to slow down the intake of
breath).
4. As you inhale, feel your stomach expand with your hand.
5. Slowly exhale through pursed lips to regulate the release of air.
6. Rest and repeat.
Another diaphragmatic breathing exercise for raising oxygen levels in the blood and
energy in the body is to take several negative breaths, immediately followed by an equal number
of positive breaths.
- During negative breaths, one inhales, immediately exhales and then holds one's breathe
for a short time. The emphasis is on keeping one's lungs empty. Negative breaths reduce
the amount of oxygen in one's blood.

- 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

Always take time for yourself at least 30 min/ day.
Be aware of your own stress meter; know when to step back and cool down.
Concentrate on controlling your own situation, without controlling everybody else.
Daily exercise will burn off the stress chemicals.
Eat lots of fresh fruit, veggies, bread and water; give your body the best for it to perform
at its best.
Forgive others, do not hold grudges and be tolerant; not everyone is capable as you.
Gain perspective on things, how important is the issue?
Hugs, kisses and laughter; have fun and dont be afraid to share your feelings with others.
Identify stressors and plan to deal with them better next time.
Judge your own performance realistically; dont set goals out of your own reach.
Keep a positive attitude, your outlook will influence outcomes and the way others treat
you.
Limit alcohol, drugs and other stimulants, they affect your perception and behavior.
Manage money well, seek advice and save at least 10% of what you earn.
No is a word you need to learn to use without feeling guilty.
Outdoor activities by yourself, or with friends and families, can be a great way to relax.
Play your favorite music rather than watching TV.
Quit smoking; it is stressing your body daily, not to mention killing you too.
Relationships; nurture and enjoy them, learn to listen more and talk less.
Sleep well, with firm mattress and supportive pillow; dont over heat yourself and allow
plenty of ventilation.
Treat yourself once a week with a massage, dinner out and the movies.
Understand things from the other person point of view.
Verify information from the source before exploding.
Worry less, it really doesnt get things completed better or quicker.
Xpress ; make a regular retreat to your favorite space, make holidays part of your yearly
plan and budget.
Yearly goal setting; plan what you want to achieve based on your priorities in your
career, relationships etc
Zest for life; each day is a gift, smile and be thankful that youre the part of the bigger
picture.


Unit XII
LEGAL AND
ETHICAL ISSUES
Laws and ethics
Ethical committee
Code of ethics and professional conduct
Legal system: Types of law, tort law, and liabilities
Legal issues in nursing: negligence, malpractice,
invasion of privacy,
defamation of character
Patient care issues, management issues,
employment issues
Medico legal issues
Nursing regulatory mechanisms: licensure, renewal,
accreditation
Patients rights, Consumer protection act(CPA)
Rights of special groups: children, women, HIV,
handicap, ageing
Professional responsibility and accountability
Infection control
Standard safety measures

ETHICAL COMMITTEE
Hospital Ethics Committee
Introduction
Most Indian hospitals have instituted such a committee principally for the purpose of checking
whether proposals submitted for research meet established guidelines. Once this has been
established, the researcher is permitted to proceed with his work and the committee turns to
subsequent proposals. This approach make a very limited usage of the personnel recruited on
such a committee. Much more can be done to improve not only the quality of research
undertaken by the institution but also the care of patients in the institution.
Mission statement of the committee
The committee must start with an open statement on its aims and objectives. These
should be circulated throughout the institution and feedback sought on how this can be
improved. It is also necessary to review this mission statement periodically and revise it when
necessary.
The following could form the heads under which details can be entered:
Care of the patient in this institution.
Research.
Education of the staff on biomedical ethics.
How should the committee function?
At the helm, There must be at least two senior persons complementing and supplementing each
other. They should, preferably, belong to different disciplines.
Who should be a member?
The obvious answer is anyone with a deep commitment to medical ethics. It is important not
to skew membership by having several persons from the same discipline. It is also essential to
ensure representatives of:
Administration
Clinicians - medical, surgical, other disciplines
Basic sciences
Social workers
Nurses
Rehabilitation personnel
Priests/philosophers
Lawyers
Statisticians
Subcommittees?
If the ethics committee is charged with three principal goals: patient care, research and education
of faculty and other personnel, it is logical to entrust each of these to a subcommittee. Monthly
meetings of a large, single committee once a month over an hour and a half or two hours are
unlikely to do justice to these goals.
Frequency of meetings
This will depend on the goals set for the committee. If the committee is only to restrict
itself to processing applications for research, the number of such proposals will govern the dates
on which meetings are to be held. Most ethics committees meet at least once a month in order to
ensure that no research proposal is held up at the level of the committee.
Each member must attend at least 75% of all meetings.
Structure of each meeting
Silverman (1) suggests that no more than half an hour at the start of each meeting be
devoted to business issues: reading the minutes of the previous meeting, reports from
subcommittees, new issues. The remaining time must be used to discuss and explore the different
moral values within the institution. This is where free discussion on ethics is encouraged and
decisions sought on this basis. He suggests that discussions on specific cases, their reports having
been prepared and circulated in advance, are most likely to yield results. Such cases could be
selected with a view to provoking discussions on informed consent, the means by which
diagnosis is disclosed to the patient and relations, expenditure incurred by patients, the rationale
and justification for expensive tests or therapies, relevance of research being undertaken within
the institute...
He also recommends that time be spent at each meeting on reviewing relevant papers on medical
ethics published in recent issues of journals, the focus being on how these can be used to
improve standards in the institution.
Research
All research proposals must conform to standard scientific and ethical guidelines. These
must be scrutinised by a designated member of the committee to ensure that there is no glaring
deficiency. (In case of such a deficiency, the proposal should promptly be returned to the
researcher with a note on what is needed.)
All proposals received before a stipulated date must be discussed at the next meeting.
The committee must pay special attention to:
- Will the study add substantially to existing knowledge?
- Is the study scientifically, statistically and ethically valid?
- Is it relevant?
- Are the results of this study likely to prove harmful? Pilgaokar (1) points out that we have a
moral responsibility to desist from any inquiry as soon as it becomes clear that it is likely to
endanger mankind.
- If experiments on animals form an essential component, are humane practices built into the
project?
- If human subjects are involved, special attention must be paid to how truly informed consent is
obtained, what measures have been provided in case of complications that may harm the subjects
and how those defaulting from the study will be followed up if a drug or implant with medium or
long term action is being used. Pilgaokar (2) has summed up the requirements of truly informed
consent, listing the various kinds of information that must be conveyed to subjects.
Care of patients
Is the institution providing the best possible medical care? This could be considered under
the following heads:
The art of bedside medicine
Relief of suffering
Cure of disease
Iatrogenic disease: incidence, trend over time
Cost to patient: tests, drugs, other costs. Can these be lowered?
Prompt attention to needs of the patient.
Care of the seriously ill
Dying patients
The dead patient
Education of the staff within the institution
This could cover all aspects of patient care and research. Other activities of an ethics committee
Silverman (2) also recommends that the committee:
Produces guidelines on a broad range of topics. Disclosure of diagnosis, diagnosis of
brain death,requesting permission to harvest organs for trans-plantation,truly informed
consent are some examples.
Sets up and ensures proper functioning of a forum for redressal of complaints from
patients and fami-lies. This forum must receive complaints in writing, helping illiterate
patients to prepare such documents. Complaints, proceedings of hearings on them,
decisions and action taken must be kept on record.
Produces a document for the benefit of patients and their families informing them of
services provided by the institution, rights of patients and relatives, their responsibilities,
means by which they may seek redressal for any harm that may be done to them...
Surveys practices within the institution on a continuing basis: standards of patient care,
unnecessary expenditure enforced on patients, obtaining truly informed consent. Patients
and relatives could be polled on deficiencies/ malpractice witnessed by them and their
suggestions for improvement.
Obtains feedback from faculty, other staff on the functioning of the ethics committee;
perceived deficiencies and suggestions on how it might function more effectively. It may
be necessary to permit anonymity of those making observations in order to safeguard
them from victimisation and encourage free and frank observations.
Conducts seminars/ workshops/ mini- conferences on biomedical ethics, better research...
Why do some ethics committees fail?
Committee set up for the wrong reasons: Such reasons include
a. An attempt at avoiding prosecution under the heads: Consumers Protection Act;
b. Ensuring that research proposals made by members of the faculty sail smoothly through
national and international agencies that offer grants and require clearance by a local ethics
committee before they will take up the proposal for scrutiny;
c. to form yet another power group within the institution that can hold the rest of the faculty to
ransom.
Goals that are too ambitious: Silverman (1) refers to the phase when ethics committees, like
infants, fail to thrive.' When formed, there is much enthusiasm and activity by members of the
committee. A little later, a feeling of frustration emerges as unrealistic goals set for the
committee are not achieved. He refers to plans to educate the entire faculty and resident staff on
medical ethics (including those in research) in a short while as an example of such a goal.
Lack of support by the institution:If all research protocols and matters of ethical concern are not
placed before the committee and if the recommendations of the committee are flouted by the
administration, demoralisation is inevitable.
The committee must also be provided adequate infrastructure for its deliberations, inquiries,
follow up studies and maintenance, analysis of records. It will be necessary for the committee to
enter into correspondence with other experts and groups, record proceedings of its meetings,
circulate the minutes, interact with experts on other ethics committees, funding agencies and
similar groups.
Funds and secretarial help are mandatory for the proper functioning of such a committee.
The entire institution must want and welcome the formation of such a committee, seeing it as a
means for improving standards, providing better care to patients and carrying out research of the
highest standards.
Poor selection of members on the committee:If these individuals are already short of time, it is
unlikely that they will pay much attention to the tasks to be attended to on behalf of the
committee. Cursory inspection of documents, little or no follow up action and frequent absences
from meetings of the committee are expected consequences.
The members must possess a strong motivation for improving the conditions under which
patients are treated and research practiced. They should have already devoted some time and
energy in identifying current slip- ups and malpractice and the means to be employed in
correcting them.
They must also be conversant with current trends in national and international biomedical ethics.
Without continued self- education, they are likely to lapse into rigidity of approach and dogmatic
decisions.
Institutional Ethics Committee
The need for Institutional Ethics Committee (IECs) in medical and research establishments
resulted from the realization that affirms human rights as a prerogative of all members of society.
Individual physicians and research workers may not be able to do what is right in all instances as
evidenced by the number of cases on record.
Institutional ethics committees vary widely in their composition, usually in an attempt to assure a
broad based multi-disciplinary membership. In addition to those with research and clinical
experience, many committees include representation from Pastoral Care, Social Work, and Law
backgrounds, and often a member with a more academic orientation. Moreover, most committees
find it important to include individuals from the lay community to help provide a patient's and
public perspective.
The present medical and research scene in India is rather chaotic and irregular and therefore
vulnerable to unethical practices. With globalization and shift of research focus from the
developed countries to developing countries, the protection of vulnerable populations in
countries like India is of utmost importance and urgency. The apex medical and research bodies
at best have played a passive role till recently on ethical issues by not making a strong enough
stand in public and not being persuasive enough to motivate all institutions to establish ethics
committees. There has been no concerted move to either educate the public on ethical issues
confronting medical practice and research or importantly, to incorporate bioethics as a subject in
the medical, nursing, paramedical and biotechnology courses.
The Indian Council of Medical Research (ICMR) has published detailed guidelines on the
composition and responsibilities of IECs and established ethical guidelines for biomedical
research on human subjects (Published in 2006). A survey of existing IECs of various
institutions in the country was initiated recently by the ICMR. Unfortunately this effort received
a very unenthusiastic response. This sorry situation reflects an inadequate form of control and
governance in the practice of medicine and research because the overseeing institutions are not
given the necessary authority to take action against offenders, and society as a whole has not
established a sensitive and interactive approach to the whole question of unethical practices.
What should be our perception of IEC?
When an ethical dilemma occurs, it is not so much a question of "shall I do the wrong thing or
the right thing", it is, "which good that I am trying to achieve is the better good?"
An IEC is not a scientific review board - working as a gatekeeper and a regulator for
experimental research and clinical trials. An IEC does not have that kind of a mandate - nor does
it wish to.
It is not a morals police force going around looking for research workers doing something
unethical.
It is not a quality review board or risk management committee who is supposed to cover the
institution's legal situation.
Then what should it be?
The IIT-IEC should function like a preventive medicine department (preventing problems from
arising) and concentrate its efforts on conflict resolution.
IIT-IEC must bear in mind that it is a porous bi-layered membrane facing creative research on
one side and maintaining society's human rights on the other.
Composition of IEC
IEC will have a chairman, the member secretary and members nominated by the Director.
IEC will have minimum eight (8) members including
2 medical/ non medical scientists
All members of the IEC should be non-institutional except the member secretary
The chair should be an outsider
The secretary should be a staff of this institution
There should be at least 2 lady members in the committee
There should be at least 5 members for a quorum
No senior administrative officer of the institution should be a member
An office and office staff should be available for the secretary of the IEC
No outside member of the IEC should be connected with the institution or research
project in any way
Some Specific roles the IECs can play are the following
1. Be available through the member secretary for clarifying ethical problems that may arise
from the project and detail the ethical problem for the IEC to debate.
2. Make sure that "informed consent "has been properly obtained. There is a general belief
among doctors and research workers that patients belonging to the lower socio-economic
group are pretty illiterate about medical matters and therefore need not be told much
about their diagnosis, management or prognosis or why a certain quantity of blood or
other specimens are being collected.The findings of a survey are totally at variance with
this observation.
3. Multi-center trials require a uniform protocol and a unified assessment system. There
should be unlimited cross talk between IECs of institutions involved.
4. Periodic follow up should be made by the IEC after an institutional project has been
sanctioned.
5. Use of laboratory animals in research - additional inputs from physiologist,
pharmacologists and pathologists should be sought by the IEC or a separate committee
should be available.
6. Informed consent obtained from volunteers who are to participate in a field trial must be
meticulously executed. The dangers if any spelt out, what legitimate safeguards as
opposed to enticements can be offered ?what sort of compensation will be offered if
something goes wrong, how will confidentially be maintained , can be biological samples
obtained from the person be sent to other laboratories in india and abroad? And the
proper disposal of biological samples.
7. Clinical trials of drugs or therapy conducted by clinicians /research workers attached to
this institution and a collaborating one, should not only be assessed by the IEC ,but it
should have a say in the quantum of largesse offered for the person's services and the
final report should be made available to the IEC before it is submitted to the sponsoring
agency. The ethics committee minutes of the collaborating institution should be available
with the institutional PI.
8. Stem cell research. Experts and details mandatory.
Procedure for Ethical Clearance for Projects
1. Clearance by the 'Technical Committee' is needed. In case of experiments involving
animals, clearance from the Animal Experimentation Committee is required.
2. Submission of the proposal highlighting the Ethical aspects have to be submitted to the
IEC office. Form 1 - must be filled up and attached to the submitted proposal.
Clearance(s) as mentioned in (1) must also accompany the proposal. This must be
submitted to the Member Secretary at least a month before the next meeting of the Ethics
committee.
3. The PI will be informed of the date and time of the IEC meeting when the presentation
has to be made to the IEC.
4. The IEC will issue the clearance certificate subject to all the criteria being met by the PI
for the submitted proposal.
5. Submit 8 hard copies of your proposal to the IEC office with the prescribed forms.
LEGAL ROLE OF THE NURSE
1) Provider of Service
Ensure that client receives competent, safe, & holistic care
Render care by standards of reasonable, prudent person
Supervise/evaluate that which has been delegated
Documentation of care
Maintain clinical competency
2) Responsibility of appointing and assigning
3) Responsibility in quality control
4) Responsibility for equipment
5) Responsibility for observation and reporting
6) Responsibility to protect public
7) Responsibility for record keeping and reporting
8) Responsibility for death and dying

LEGAL AND ETHICAL ISSUES LAWS AND ETHICS
INTRODUCTION
From we were very young we began to learn what was right and what wrong behavior was. We
learned this from our parents, relatives, friends and teachers. By the time we became adults, we had a
personal set of ethics to guide our behavior in daily life. We may believe, for example, that honesty is
important and necessary and important. We will try to be honest because we believe it is right to do so.
Being dishonest would then be wrong for us. This is ethical behavior.
ETHICS
Definition
Ethics refers to the moral code for nursing and is based on obligation to service and respect for
human life.
-Melanie and Evelyn.
Ethics are the rules or principles that govern right conduct and are designed to protect the rights of
human beings. - Sister Nancy.

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
Its 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.

Need for nursing ethics
Helps the students/ RN to practice ethically
Helps the nurse to identify the ethical issues in her work place
Protecting patients right and dignity
Providing care with possible risk to the nurses health
Staffing patterns that limit the patients access to nursing care
Ethical reasoning
Helps the nurse to respond to ethical conflicts
Helps to differentiate right /wrong behavior
Guide for a professional behavior
Help teachers plan education.
Prevent below standard practice.
Protect a nurse if falsely accused and guide direction for legal action

Key Principles of ethics in health care system

Autonomy-The right of self determination, independence and freedom. Right to health
care decision.
Justice-Obligation to be fair with all people.
Fidelity- Obligation of an individual to be faithful to the commitment made to himself,
and to others. It is the main support of accountability.
Veracity: - The duty to tell the truth.
Beneficence- Doing good for the client. What exactly is good for one person may not be
the same for others.
Malaeficence- is the requirement that health care providers do no harm to their client
either intentionally or unintentionally
Deontological:-What causes a good outcome is good action.
Situational: - What causes a good outcome is good action.
Thus a professions ethical code is a collective statement about the groups expectations and
standards of behavior. The ANA and ICN have established widely accepted codes that
professional nurses attempt to follow.
DEFINITION:-
Ethics:-
Ethics is the study of good conduct, character and motives. It is concerned with
determining what is good or valuable for all people. Act that are ethical often reflect a
commitment to standards beyond personal preference standards on which individuals,
professions and societies agree.
Code of ethics:-
Code of ethics is the providing guidelines for safe and compassionate care. Nurses
commitment to a code of ethics guarantees the public that nurses adhere to professional practice
standards.
CODE OF ETHICS
Within any given profession, a code of ethics serves as a means of self-regulation and a
source of guidelines for individual behaviour and responsibility.
I.C.N CODE OF ETHICS FOR NURSES(1993)
Ethical concepts applied to nursing:-
The fundamental responsibility of the nurses is of four fold: to promote health, to prevent
illness, to restore health and to alleviate suffering.

Elements of the code:-
Nurses and people
The nurses primary responsibility is the those people who require nursing care
The nurses provides care, promotes an environment in which the values customs and
spiritual beliefs of the individual are respected
The nurses holds confidence, personal information and uses judgment in sharing their
information
Nurses and practice
The nurse carries personal responsibility for nursing practice and for maintaining
competence by continuous learning
The nurses maintains the higher standards of nursing care possible within the reality of a
specific situation
The nurses assess judgment in relation to individual competence when accepting and
delegating responsibilities
The nurse when acting in a professional capacity should at all times maintain standards of
personal conduct which reflect created upon the profession
Nurses and Society
The nurses with other citizens the responsibility for initiating and supporting action to in edit the
health and social needs of the public
Nurses and Co-workers
The nurse sustains a co-operative relationship with co-workers in nursing practice and
nursing education
The nurse is active in developing a care of professional knowledge
The nurse acting through the professional organization, participants in establishing and
maintaining equitable social and economic working conditions in nursing.

AMERICAN NURSES ASSOCIATION CODE OF ETHICS FOR NURSES
The nurses in all professional relationships practices with compassion and respect for the
inherent dignity, worth and uniqueness of every individual, unrestricted by considerations if
should or economic status personal attributes or the nature of health problems.
The nurses primary commitment is to patient, whether an individual, family, group or
community.
The nurses promote, advocates for the strives to protect the health, safety and rights of the
patient.
The nurse is responsible and accountable for individual nursing practice and determines the
appropriate delegation of tasks consistent with the nurses obligation to provide optimum
patient care.
The nurse owns the same duties to self as others including the responsibility to preserve
integrity and safety to maintain competence and to continue personal and professional
growth.
The nurses participates in establishing, maintaining and improving health care environments
and conditions of employment conducive to the provision of quality health care and
consistent with the values of the profession through individual and collective action.
The nurses participates in the advancement of eh profession through contribution to practice,
education, administration and knowledge development.
The nurses collaborates with others health professional and the public in promoting
community, national and international efforts to met the health needs.
The profession of nursing as represents by associations and their members, is responsible for
articulating nursing values for maintaining the integral of the profession and its practice for
shaping the social policy.

CANADIAN NURSES ASSOCIATION CODE OF ETHICS FOR NURSING
Health and Well being: Nurses value health and well being and assist persons to achieve
their optimum level of health in situations of normal health illness, injury or in the
process of dying.
Choice : Nurses respect and promote the autonomy of clients and them to express their
health needs and values and to obtain the appropriate information and services
Dignity : Nurse value and advocate the dignity and self-respect of human beings
Confidentiality: Nurses safeguard the trust of clients that information learned in the
context of a professional relationship is spread outside the health care team only with the
clients mission or as legally required.
Fairness : Nurses apply and promote principles of equity and fairness to assist clients in
receiving inhibited treatment and a share of health services and resource proportionate to
their needs
Accountability : Nurses act on a manner consistent with their professional
responsibilities and standards of practices
Practice Environment: Conducive to safe, competent and ethical care. Nurses advocate
the practice environments that have the organizational and human support systems and
the resource allocation necessary for safe, competent and ethical nursing care.

TYPE OF ETHICAL THEORIES
1. Duty-oriented ethical theories
A duty oriented ethical theory is a system of ethical thinking having the concept of duty
or obligation as foundation. Duties are strict obligations that take primary over rights and goals.
Keep in mind however each duty has corresponding rights.
Duty-oriented theories are advantages in homogeneous societies in which each person
hold the service values. A duty oriented theory would work well in a tribal society because it is
easier to share values and therefore beliefs among a small group of people.
A disadvantage of a duty-oriented theory is determining how to rank duties. For
example, a nurse may be form between a duty to support life and a duty to prevent suffering.
2. Rights-Oriented Ethical theories
A rights-oriented ethical theory is a system of ethical thinking having the concept of
rights as a foundation. Rights-oriented theories assign the highest value to rights, so that duties
and goals flow from rights, from right oriented perspective, your would first look to the clients
right to privacy flowing from that right to privacy would be your duty to keep care information
confidential to achieve the goal of encouraging clients to communicate information freely.
Duty Oriented Ethical Theories
Duties

Right

Goals
Rights Oriented Ethical Theories
Right

Duties

Goals
3. Goal-oriented ethical theories
A goal-oriented ethical theory is a system of ethical thinking having the concept of
maximizing the overall goal as its foundation- goal-related theories suggest that good choices
result from concern with the consequences of actions
In todays environment of health care reform nurses might choose to support changes that
will provide basic preventive and treatment services for all. Providing both prevention and
treatment could be viewed as maximizing the welfare of society
Goal-Orienetd Ethical Theories
Goals

Duties Rights

4. Intuitionist ethical theory
An ethical theory is a system of ethical thinking that balances goals, rights and duties
according to the situation. Philosophers espousing this theory argue that humans innately know
good from bad and that through intuition, duties, goals and rights can be balanced.

Intuitionist Ethical Theories

Duties Goals Rights
ETHICAL PRINCIPLES
Ethical principles actually control professionalism nursing practice much more than to
ethical theories. Principles are the moral norms that nursing, as a profession, both demands and
strives to implement to every day clinical practice. Ethical principles that the nurses should
consider when making decisions are as follows
1. Respect for persons
2. Respect for autonomy
3. Respect for freedom
4. Respect for beneficence (doing good)
5. Respect for non-malfeasance(avoiding harm to others)
6. Respect for veracity ( truth telling)
7. Respect for justice ( fair and equal treatment)
8. Respect for rights
9. Respect for fidelity ( fulfilling promises)
10. confidentiality ( protecting privileged information )
1. Respect for persons
This principle not only applied to clinical situation, but it applies to all life situations it directs
individuals to treat themselves and other with a respect inherent to main humans. The respect to
persons a need to be simplified as not affects nursing practice.
2. Autonomy
Autonomy means that individuals are able to act for themselves to the level of their capacity. It is
the rights of individuals, governing their actions according to their own purpose and reason.
3. Freedom
Nurses a group believes that patient should be observed freedom of choice within the nations
health care system. This principle should be observed by staff nurses when planning patient care,
by nurses manager when leading subordinates
4. Beneficence: (the ethical principles of upholding doing good)
The beneficence principles states that the actions one takes should promote good. It requires the
balancing the harms and benefits. Benefits promote the clients welfare and health whereas harms
or risks detract from the clients health and welfare. In other words, providing benefits that
enhance the other welfare. Whereas balancing the benefits and harms of intervention made on
the others half.
5. Non- Maleficence
The principle of non- maleficence states that one should do no harm. The nurses should interpret
the term harm to mean emotional and social as well as physical injury. Harm is threading,
defeating or setting back one person./s interest through invasive action by another.
6. Veracity
Veracity concerns truth talking and incorporates the concept that individuals should always tell
the truth. It requires professional care givers to provide with accurate, reality based information
about their health status and care or treatment prospective.
7. Justice
Justice concerns the issue that persons should be treated equally and fairly. This principle of
justice requires treating others fairly and giving persons their due.
8. Rights
Rights is an entitlement to behave in a certain way under circumstances, such as nurses
entitlement to freely express personal beliefs and preferences by voting in a political election.
Right is also used to mean agreement with justice, law and morality. So right may be mental
rights or legal rights to respective profession.

9. Fidelity
Fidelity is keeping ones promises or committeemens. The principles of fidelity hold that a
person should faithfully fulfill his duties and obligations.
10. Confidentiality
Confidentiality is the duty to respect privileged information. The principle of confidentiality
provides that care-givers should respect a patient need for privacy and by personal information
about him or her only to improve care. Nurses should practice confidentiality to decrease patient
vulnerability and share from widespread knowledge of personal information divulged during
care.
ETHICAL DILEMMAS
A dilemma is defined as a situation requiring a choice between two equally desirable or
undesirable alternatives. In ethical dilemma each alternative course of action can be justified by
two ways in which a person views the course of action based on his or her value system.
Increasingly, staff nurses and nurse managers face difficult decisions caused by tensions between
technological capabilities, budgetary strictures, and quality of life concerns.
Nurses in all clinical and functional specialties face the following dilemmas.
Need to ration patient care to conserve scarce resources
Need to make treatment and care of decisions for terminally ill patients
Need to obtain patients informed consent for care treatment orders and measures such as
o Do not requisite order
o With holding/with drawing nutrition and fluids
o Starting / discontinuing life support system
Responses to patient request for assisted suicide
Need to balance the patients need for confidentiality and privacy against societies needs for
protection from unreasonable risk
Need to protect autonomy rights of children and incompetent adults concerning consent for
rese4arch participation
Need to protect justice rights of patients who participate in random trails of experimental
treatment.
Decision Making
The nursing process is a system at the step-by step approach to resolving problems that
deals with a clients health and well-being. The chief goal of the ethical decisions making
process is to determine right and wrong in situation.
The following ethical decision-making progress is presented or a tool for resolving ethical
dilemma.
Step I: Collect, Analyze and interpret the data
Obtain as much information as possible concerning the particular ethical dilemma; unfortunately
such information is sometimes very limited. The clients wishes the clients familys emotional
problems carrying the dilemma, the physicians beliefs about health care and the nurses own
orientation to concerning life and death
Step II: State the Dilemma
After collecting and analysis much information as available the nurses to state the dilemma as
clearly as possible the step. It is important to identify whether the problem is one that can be
resolved only by the client, clients family and the physician.
Step III: Consider the choices of action
After stating the dilemma as early as possible the next step as to attempt to help the
considerations of their consequences all possible covering the action that can be taken to resolve
the dilemma.
Step IV: Analyze the advantage and disadvantages of each course of action
Some of the courses of action developed during the previous step are more relates readily
evident during this step in the decision making process when the advantages and the
disadvantages of each action are considered in detail. Along with each action the consequences
of taking each course of action must be thoroughly evaluated.
Step V: Make the decision and act on it.
The most difficult part of the process is actually making the decision following through with
action and the living in the consequences. Decision are often made with no follow through
because nurses are fearful the consequences of their decisions.
Ethical Decision- making

Identify potential ethical dilemma

Collect analyze and interpret data

State the dilemma


Dilemma cannot be Dilemma can be
Resolved by nurse resolved by nurse

Take no action List potential solutions

Acceptable Unacceptable
Consequences consequences

Ethical decision Take no action

Dilemma resolution

ROLES AND FUNCTIONS OF ADMINISTRATOR IN ETHICAL ISSUES
The leadership roles and management functions of an administrator in ethics as follows
He or she is self aware regarding own values and basic beliefs about the rights, duties and
goals of human beings
Accepts that some ambiguity and uncertainty be a part of all ethical decision-making
Accepts that negative outcomes occur in ethical decision making despite high quality
problem solving and decision-making
Demonstrates risk taking in ethical decision making
Role models ethical decision-making which are congruent with the code of ethics and
inter respective statements
Actively advocates for clients, subordinates and the profession
Clearly communicates expected ethical standards of behavior
Uses a systematic approach to problem-solving or decision making when faced with
management problems with ethical ramifications
Identify outcomes in ethical decision-making that should always be sought to avoided
Uses establishment ethical framework to clarify values and benefits
Applies principles of ethical reasoning to define what beliefs or values from a basis of
decision making
It aware of legal procedures that may guide ethical decision making and is accountable
for possible habitats should they go against the legal precedent.
Continuously re-evaluate quality of won ethical decision making based on the present of
decision making problem-solving used
Recognizes and rewards ethical conduct of subordinates
Takes appropriates actions when subordinates use unethical conduct

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 ones own knowledge and competencies
d. Contribute to the core of professional knowledge and conducting and participating in
research

ICN CODE OF ETHICS FOR NURSES
In 1953 ICN adopted its first code of ethics for nurses and was revised in 2000. The four
principle elements contained within the ICN code involve standards related to nurses and people,
practice, profession and co workers.
ICN recommended that nurses have 4 fundamental responsibilities i.e. to promote health, to
prevent illness, to restore health and to alleviating suffering. And also inherent in nursing is respect for
human rights, like right to life, to dignity and to be treated with respect. And the care should not be
restricted by age, sex, color, creed, culture or nationality.

Nurses and people
The nurses primary responsibility is to those people who require nursing care. The nurse in
providing care promotes an environment in the values, customs, and spiritual beliefs of the individual
are respected .the nurse holds in confidence personal information and use judgement in sharing this
information.
Nurses and practice
The nurse carries personal responsibility for nursing practice and for maintaining competence
by continual learning. The nurse maintains the highest standard of nursing care possible within the
reality of a specific situation. The nurse uses judgement in relation to individual competence when
accepting and delegating responsibilities. The nurse when acting in professional capacity should at all
times maintain standards of personal conduct which credit up on the profession.

Nurses and co-workers
The nurse maintains a cooperative relationship with coworkers in nursing and other fields. The nurse
takes appropriate action to safeguard the individual when his care is endangered by a co-worker or
any person.
Nurses and the profession
The nurses play a major role in determining and implementing desirable standards of nursing
practice. The nursing is active in developing a core of professional knowledge. The nurse acting
through the professional organizations participates in establishing and maintaining equitable social and
economic working conditions in nursing.
FUNCTIONS OF ETHICAL CODES
To inform the public about the minimum standards of the profession and to help them
understand professional nursing conduct.
To provide a sign of the professions commitment to the public it serves.
To outline the major ethical considerations of the profession.
To provide general guidelines for professional behavior
To guide the profession in self regulations.
CODE OF PROFESSIONAL CONDUCT
Code of professional conduct (for nurses in India)
1. PROFESSIONAL RESPONSIBILITY AND ACCOUNTABILITY
To maintain professional responsibility and accountability, the nurse
a. Appreciates a sense of self-worth and nurtures it.
b. Maintains standards of professional conduct, reflecting credit upon the profession.
c. Carries out responsibilities within the frame work of professional boundaries.
d. Is accountable for maintaining practice standards set by the I.N.C.
e. Is accountable for his or her actions.
f. Is compassionate.
g. Practices healthful behavior.
h. Is responsible for continuous improvement of current practices.

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.

3. COMMUNICATION AND INTER PERSONAL RELATIONSHIPS
This plays a key role in the interaction of the nurse with his or her clients. To effect optimal
interaction, the nurse
a. Establishes and maintains effective IPRs with individuals, families and communities.
b. Upholds the dignity of team members and maintains effective IPR with them.
c. Appreciates and nurtures the professional role of team members.
d. Co-operates with other health professionals to meet the needs of the individuals, families and
communities.
4. VALUING HUMAN BEINGS
The nurse values human life. She
a) Takes appropriate action to protect individuals from harmful unethical practices.
b) Considers relevant facts while taking conscientious decisions in the best interest of individuals.
c) Encourage and supports individual in their right to speak for themselves on issues affecting
health and welfare.
d) Respect and supports choices made by individuals.
5. MANAGEMENT
Proper management of resources and infra structure is essential for improving the overall efficiency
of the nurse. Hence the nurses
a) Ensures appropriate allocation and utilization of available resources.
b) Participates in super vision and education of students and other formal providers.
c) Uses judgment in relation to individual competence while accepting and delegating
responsibility.
d) Communicates effectively following appropriate channels of communication.
e) Participates is performance appraisal.
f) Participates in evaluation of nursing services.
g) Participates in policy decision, following the principles of equity and accessibility of service.
6. PROFESSIONAL ADVANCEMENT
To ensure that he or she is at par 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 determining and implementing quality care.
c. Take responsibility of updating ones own knowledge and competencies.
d. Contribute to the core of professional knowledge and conducting and participating in
research.
e. The nurses responsibility for the patient has been changed to a broader term of people. This
includes respect for culture, customs, religious beliefs and confidential treatment of personal
information. One of our greater adjustments in nursing is accepting responsibility for our
own professional behavior.
LEGAL SYSTEM
1. LAW
MEANING
Legal
- Established by or founded upon law or official or accepted rules
Law
- The term law is derived from its tentoric root lag which means something which lies
fixed or events
- Law means a body of rules to guide human action
- Law means that which is laid down or fixed
DEFINITION
1) The law us a system of rights and obligations which the state enforces.
By Green
2) The law constitutes body of principles recognized or enforced by public and regular tribunals
has the administration of justice by pound
3) The law is the body of principles recognized and applied by the state and the administration of
justice by salmaind
4) Law is a rule or standard of human conduct established & enforced by authority, society or
custom
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.

- Contract law: Contract law covers obligations established by agreement (express or
implied) between private parties. Generally, contract law in transactions involving the
sale of goods has become highly standardized nationwide as a result of the widespread
adoption of the Uniform Commercial Code. However, there is still significant diversity in
the interpretation of other kinds of contracts, depending upon the extent to which a given
state has codified its common law of contracts or adopted portions of the Restatement
(Second) of Contracts. Parties are permitted to agree to arbitrate disputes arising from
their contracts. Under the Federal Arbitration Act (which has been interpreted to cover all
contracts arising under federal or state law), arbitration clauses are generally enforceable
unless the party resisting arbitration can show unconscionability or fraud or something
else which undermines the entire contract.
TORTS
The word Tort is derived from French word of the same spelling which means "mischief,
injury, wrong, or calamity", from Latin tortus meaning twisted.
Torts a civil wrong made against a person or property. Tort Law is the enforcement of
duties & rights among independent of contractual agreements. It is a civil wrong committed on a
person or property stemming from either a direct invasion of some legal right of the person,
infraction of some public duty, or the violation of some private obligation by which damages
accrue to the person.
To constitute a tort, it is essential that the following conditions must be satisfied
Act or omission
Wrongful act or omission must be recognized by law
Legal damage
Legal remedy
Categories of torts
Torts may be categorised in a number of ways: one such way is to divide them into
Negligence Torts, and Intentional Torts.
Negligence Torts
Negligence is a tort which depends on the existence of a breaking of the duty of care owed by
one person to another. The tort of negligence provides a cause of action leading to damages, or to
relief, in each case designed to protect legal rights, including those of personal safety, property,
and, in some cases, intangible economic interests. Negligence actions include claims coming
primarily from car accidents and personal injury accidents of many kinds, including clinical
negligence, workers negligence and so forth. Product liability(warranty stuff) cases may also be
considered negligence actions, but there is frequently a significant overlay of additional lawful
content. The elements of negligence are:
Duty of care
Breach of duty in English law|Breach of that duty
Breach being a proximate cause or not too remote a cause in law
Causation law Breach causing harm in fact
Intentional Torts
Among intentional torts may be certain torts coming out of the occupation or use of land.
One such is the tort of nuisance, which involves strict liability for a neighbor who interferes with
another's enjoyment of his real property. Trespass allows owners to sue for entrances by a person
(or his structure, for example an overhanging building) on their land. There is a tort of false
imprisonment, and a tort of defamation, where someone makes an unsupportable reason for
arrest or their speech is not represented to be factual which damages the reputation of another.
Statutory torts
A statutory tort is like any other, in that it imposes duties on private or public parties, however
they are created by the legislature, not the courts. Liability for bad or not working products is
strict in most jurisdictions. The theory of risk spreading provides support for this approach. Since
manufacturers are the 'cheapest cost avoiders', because they have a greater chance to seek out
problems, it makes sense to give them the incentive to guard against product defects.
Nuisance
Legally, the term nuisance is traditionally used in three ways: (1) to describe an activity or
condition that is harmful or annoying to others (example- indecent conduct, a rubbish heap or a
smoking chimney); (2) to describe the harm caused by the before-mentioned activity or condition
(example- loud noises or objectionable odors); and (3) to describe a legal
liability(responsibility)that arises from the combination of the two. The law of nuisance was
created to stop such bothersome activities or conduct when they unreasonably interfered either
with the rights of other private landowners (example- private nuisance) or with the rights of the
general public (example-public nuisance).
Intentional torts
Intentional torts are any intentional acts that are reasonably foreseeable to cause harm to
an individual, and that do so. Intentional torts have several subcategories, including torts against
the person, including assault, battery, false imprisonment, intentional infliction of emotional
distress, and fraud. Property torts involve any intentional interference with the property rights of
the claimant(plaintiff). Those commonly recognized include trespass to land, trespass to
chattels(personal property), and conversion.
Economic torts
Economic torts protect people from interference with their trade or business. The area includes
the doctrine of restraint of trade and has largely been submerged in the twentieth century by
statutory interventions on collective labour law and modern antitrust or competition law. The
"absence of any unifying principle drawing together the different heads of economic tort liability
has often been remarked upon."

LIABILITY (FINANCIAL ACCOUNTING)
Definition
An obligation that legally binds an individual or company to settle a debt. When one is
liable for a debt, they are responsible for paying the debt or settling a wrongful act they may
have committed. [www.investorwords.com]

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.
LEGAL ISSUES IN NURSING: NEGLIGENCE, MALPRACTICE, INVASION OF
PRIVACY AND DEFAMATION OF CHARACTER.
INTRODUCTION:
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, Ill 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.
DUTY TO REPORT OR SEEK MEDICAL CARE FOR A PATIENT:
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.
CONSENT FOR NURSING MEASURES:
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.
COMPETENCE TO GIVE CONSENT:
A person ability to make judgments based on rational understanding is termed competence.
Dementia, developmental disabilities, head injury , stroke and illness creating loss of
consciousness are common causes of an inability to make judgment. Determining competence is
complex issue. Illness ,age or condition alone do not determine competence. Legal competence is
ultimately determined by the courts. When a person is legally determined to be incompetent,
consent is obtain from legal guardian. Competence may change from day to day as person
physical illness changes.

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.
CONSENT AND MINORS:
The consent of minor is usually given by a parent or legal guardian. You should also obtain the
minor consent when he 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.
Types of invasion of privacy
Invasion of Privacy - Intrusion of Solitude
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.
Opening someone's mail is also considered to be intrusion of solitude, seclusion or private
affairs. The information gathered by this form of intrusion need not be published in order for an
invasion of privacy claim to succeed. Trespass is closely related to the intrusion tort and may be
claimed simultaneously.
Invasion of Privacy - Appropriation of Name, Likeness or Identity
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.
Invasion of Privacy - Public Disclosure of Embarrassing Private Facts
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:
Health privacy laws
Financial privacy laws
Online privacy laws
Communication privacy laws
Privacy in one's home
Information privacy law
UNINTENTIONAL TORTS
1. Negligence:
Definition
1. Negligence refers to the act of doing something or refraining from doing
something that any other reasonable medical professional would do or refrain
from doing in a similar situation. It goes without saying that every situation is
different, and that is where the law becomes somewhat cloudy. However, when
reviewing a nursing negligence case, assumptions and circumstantial evidence are
taken into account to determine if there was negligence.
2. The basic and legal definition of negligence means breach of duty or injury.
Standards of care in nursing generally mean those practices that "a reasonably
prudent nurses would use." So a good nurse knows and understands ethics in the
medical field and strives to provide excellent quality of care in order to avoid
negligence. However, mistakes, which will happen, do not necessarily mean
negligence has occurred.
Breach of Duty
Examples of breach of duty, which may be considered negligent under certain
circumstances may include "doing something which a reasonably prudent person would
not do, or the failure to do something which a reasonably prudent person would do, under
circumstances similar to those shown by the evidence. It is the failure to use ordinary or
reasonable care," according to Critical Care Nurse, a journal for high acuity, progressive
and critical care.
Injury
For an injury to be considered caused by negligence, records must show that the nurse
failed to perform 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.
Examples of nursing negligence
Common examples of nursing negligence include malnutrition, inadequate hydration,
physical abuse, medication errors, and mental and emotional abuse. In nursing homes or
other places of long-term care, there are also often injuries due to bedsores, infections and
falls. Malnutrition and dehydration cases come from leaving a patient unattended for too
long, ignoring his needs, or simply refusing to feed and provide water. Abuse comes in a
variety of forms and, in many cases, nurses do not feel they will be reported, especially if
the patient is mentally handicapped. Medication errors, bedsores, infections and falls are
most frequently the result of carelessness and lack of paying attention to their patients as
necessary.
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
Malpractice is defined as improper or negligent practice by a lawyer, physician, or other
professional who injures a client or patient. The fields in which a judgment of malpractice can be
made are those that require training and skills beyond the level of most people's abilities.
Medical malpractice is defined as a wrongful act by a physician, nurse, or other medical
professional in the administration of treatment or at times, the omission of medical treatment,
to a patient under his or her care. Although dentists, architects, accountants, and engineers are
also liable to malpractice suits, most lawsuits of this type in the United States involve medical
malpractice.
Medical malpractice is professional negligence by act or omission by a health care provider in
which care provided deviates from accepted standards of practice in the medical community and
causes injury or death to the patient. Standards and regulations for medical malpractice vary by
country and jurisdiction within countries. Medical professionals are required to maintain
professional liability insurance to offset the risk and costs of lawsuits based on medical
malpractice
Why Nursing Malpractice is Increasing
Nursing is a profession thats critical to the administration of healthcare, and its a
profession thats in high demand. But there are not enough qualified nurses (for instance,
registered nurses and licensed practical nurses) to keep up with this demand, and the result is
chronic understaffing and a population of overworked nurses.
While nursing shortages are not a direct cause of nursing malpractice, it does cause a couple of
serious issues:
1. Nurses who work excessively long shifts may suffer from fatigue, making them more prone to
commit an error. In fact, a 2004 report showed that nurses who worked a shift longer than 12.5
hours were three times more likely to make a mistake.
2. Hospitals and other healthcare facilities may hire inadequately trained nurses or unlicensed
nurse aides to fill a need. The less training a nurse has, the greater the risk of a medical error.
In addition, miscommunication and carelessness are not uncommon in the healthcare setting and
may directly cause a potentially life-threatening complication or mistake.
Types of Nursing Malpractice
Nursing malpractice takes many forms, including:
- Medication errors giving a patient the wrong medication or the wrong dose, or dispensing
medication to the wrong patient
- Failure to follow a physicians orders
- Delaying patient care and/or failure to monitor a patient
- Incorrectly performing a procedure, or trying to perform a procedure without training
-Documentation error
-Failure to get informed patient consent
Consequences of Nursing Malpractice
The consequences of nursing malpractice can range from minor to potentially fatal, and may
include:
Medication overdose
Adverse drug reaction
Coma
Brain, heart, kidney or other organ damage
Infection
Death
What Constitutes Nursing Malpractice?
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 nurses 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 nurses 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 patients

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 patients condition

and failure to properly supervise a patient resulting in harm.

Typically, negligent monitoring cases arise from a nurses

failure to perform an assessment and
notify the treating physician

of changes. Thus, a nurses failure to obtain vital signs

and report a
patients deteriorating condition was held

to constitute negligence.
3
Similarly, when a nurse
observed

that a patients 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

hospitals and nurses duty to keep the patient

safe.

Is the Hospital Responsible for the Actions of Its Nurses?
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.

How Can Malpractice Actions Be Avoided?
The simple answer is that they cannot be avoided. However, by

utilizing the nursing
process and employing critical thinking,

bad outcomes that commonly lead to malpractice claims
can be

reduced.

The steps of the nursing process are described as follows:

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.

7 Tips on avoiding malpractice claims
Careful practice and documentation help keep you out of court.
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?
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.
DOS AND DONTS FOR SAFE PRACTICE:
1. Do document all unusual incidences
2. Do report all unusual incidences
3. Do follow policies and procedures as established by your employing
agency.
4. Do keep current year to practice
5. Do perform procedures that you have been thought and that are within the
standard scope of your practice
6. Do not work as a nurse in state in which you are not licensed
7. Do protect the patient from injury
8. Do not advice that is contrary to the doctors order or nursing care plan
LEGAL RESPONSIBILITIES OF NURSE:
1. Responsibility of appointing and assigning
2. Responsibility in quality control
3. Responsibility for equipment
4. Responsibility for observation and reporting
5. Responsibility to protect public
6. Responsibility for record keeping and reporting
7. Responsibility for death and dying
ROLE AND FUNCTIONS OF NURSE MANAGER IN LEGAL ISSUES.
1. Serves as a role model by providing nursing care that meets or exceeds accepted
standards of care.
2. Reports substandard nursing care to appropriate authorities
3. Fosters nurse-patient relationships that are respectful, caring and honest thus reducing
the possibility of future lawsuits
4. Joint and actively supports professional organizations to strengthen the lobbying
efforts of nurses in health care legislation
5. Practices nursing within the area of individual competence
6. Prioritizes patients right and welfare first in decision making
7. Delegates to subordinates wisely , looking at the managers scope of practice and that
of those they supervise.
8. Uses foreseability of harm in delegation and staffing decision
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.
MEANING OF LEGAL ISSUES
It is a standard or rules of conduct established and inforced by the government. These are
intended to protect the public.
A. PATIENT CARE ISSUES
Nursing covers a wide range of disciplines and health-care issues that are always changing and at
the forefront of what guides this career path. Issues such as health-care reform, nursing
shortages, low salaries and ethics are some of the issues being faced. With nursing being an
integral part of hospitals, nursing homes, home health agencies and colleges, the discipline has to
keep current of changing policies and be prepared to address whatever may arise.
a. Nursing Shortage
The nursing shortage is a major issue facing the biggest licensed profession in the health-care
system. This shortage will affect health care more each day, as it appears not much is being done
to stop it. Many emergency rooms have longer wait times due to less nursing staff, and hospital
floors are feeling the effects as well. This is affecting patient care because the number of patients
to one nurse is increasing, therefore decreasing the quality of care. This shortage is being felt in
hospitals, nursing homes and home-health agencies. Nursing has been lobbying for patients by
seeking legislation to help with the nursing shortage and with funding for nursing schools.
b. Health-Care Reform
Nurses have always been involved with health-care reform as advocates for patients. The
American Nursing Association (ANA) has been working to have the voice of nurses heard.
Nurses are in support of a public plan, so Americans who are underinsured or uninsured will
have access to affordable, quality health insurance. The ANA has taken the stand that health care
is not a privilege but a right. It is lobbying for a reduction in cost and an end to high out-of-
pocket costs for services, as well as ending discrimination pertaining to pre-existing conditions.
c. Low salaries
d. Standard Care
- State Nurse Practice Act
- ANA-Standards of Clinical Nursing Practice
- National Association of School Nurses (NASN)
- School policy and protocols
B. MANAGEMENT ISSUES
Nurses working in doctors' offices and hospitals have a difficult job caring for patients and
meeting the needs of both coworkers and superiors within the institution. Nurse Managers who
work in the medical professional also have a complex and challenging role. It is a considerable
challenge to meet the needs of the organization, the needs of patients, and the needs of the nurse
employees.
a. Turnover
Maintaining adequate staffing levels is a major issue in nursing management. Representatives
working in nurse management and leadership are often faced with the responsibility of
controlling turnover rates. Nurses faced with long work hours for relatively little pay have few
motivations to remain in one position and often seek employment opportunities at competing
hospitals and neighboring clinics.
b. Funding
Lack of funding is an issue for many nurse managers who seek to provide sufficient
compensation to existing nurses as well as offer suitable compensation in an attempt to recruit
new nursing professionals for hire. An underfunded institution cannot attract and provide for the
right professionals, and funding inadequacies can also become a detriment to the level of training
provided to medical staff, in addition to the needs for medical equipment and supplies. When the
medical institution's quality of staff and training standards must be lowered because of budgetary
concerns, the overall level of patient care is unavoidably reduced.
c. Workload
Individual nurse manager workload and overall medical workload are issues in leadership. The
medical profession is one that never sleeps and has an almost constant need for qualified
professionals both in hiring and scheduling. Not only do nurse professionals work long hours and
many days per week, but nurse managers and leaders are also faced with an ever-increasing
workload. Dealing with patient concerns, providing training and support to nurses, and acting as
a liaison between doctors, nurses and medical administration members can be taxing and
stressful. Many nurses are unwilling to enter into the nurse management field because of the
added stress and responsibility. When you add to all that the secondary stresses of budgetary
cutbacks and fewer nurse leadership roles, it means that existing nurse managers are faced with
enormous challenges when it comes to balancing their leadership functions.
d. Issues regarding malpractice in nursing management
Issues of delegation and supervision
The failure to delegate and supervise within acceptable standards of professional practice.
Issues related to staffing
Inadequate accreditation standards- adequate number of staff members in a time of advancing
patient activity and limited resources.
Inadequate staffing, i.e. short staffing.
Floating staff from unit to unit.
e. Ethics
Nurses are held to a high standard of ethics when it comes to patients, co-workers and
themselves. They provide care, promote human rights and values, and help meet the needs of the
less fortunate and vulnerable. A major ethical goal is to also keep patients' information
confidential, and this includes not discussing patients in public places. Another ethical issue is
protecting patients from negligent co-workers who may endanger them. The individual nurse
must not endanger the patient and has to be accountable to the standards of the field.
f. Effect
Effects of reform, shortages, ethics and salaries are issues that keep nurses constantly thinking,
growing and changing.
Nursing instructors make far less money than nurses in the clinical setting. They also make less
than other educators in different fields. In order for nursing to succeed, there needs to be
qualified candidates educated, but with these low salaries nurses are not flocking to this career
path. Without these types of nurses being adequately filled then qualified candidates will not
have the opportunity to be taught. These salaries need to be increased, and colleges and
universities need to see the value in these instructors.
g. Issues in Nursing Curriculum Development
Where are we now?
As nursing faculty we need to answer the question and analyze the present situation whether or
not we are on the road to relevant, which means the validation of curriculum or judgemental
process in which an attempts is to be made to ascribe a degree of worth or value to a curriculum
in the context of professional education and preparation of participants for their professional role.
Walker describes five types of validation
+ Academic validation
+ Professional validation
+ Economic validation
+ Institutional validation
+ Performance validation
Then identify the strengths of present system/situation before starting the program.
Where we want to go?
This deals with the thinking and aspiration for future. Faculty must think whether the educational
program what is designed will help to meet the expectations of individuals, families and
communities in accordance far with the developed countries or not.
What we want to achieve?
Nurse educators must be able to analyze and think critically that we are preparing the students
with the adequate skills to perform their expected roles in all the three domains of professional
tasks such as practical, communication and intellectual skills according to the institutional goals
and educational objectives.
The three types of skills to be achieved:-
+ Domain of attitudes (communication skills)
+ For example, feelings, values and interpersonal relationships
+ Domain of practical skills (imitation control and automatism)
+ Domain of intellectual skills(knowledge and recall of facts)
+ For example, Interpretation of data and problem solving.
How can we achieve?
The faculty must think the ways by which the curriculum can be developed to which is relevant
to meet the needs of the country.
h. Collaboration issues
The nursing profession is faced with increasingly complex health care issues driven by
technological and medical advancements an ageing population, increased numbers of people
living with chronic disease, and spiraling costs. Collaborative partnerships between educational
institutions and service agencies have been viewed as one way to provide research which ensures
an evolving health care system with comprehensive and coordinated services that are evidence-
based, cost effective and improve health care outcomes. These partnerships also ensure the
continuing development of the professional expertise necessary to meet these challenges.
C. EMPLOYMENT ISSUES
a. Issues related to Nursing Shortage
The nursing shortage is another international event. Why is there a nursing shortage? There are
many opinions regarding that question. I have been a nurse long enough to recognize that nursing
shortages wax and wane. This shortage is more noticeable, however and it is lasting longer. The
nurse shortage itself is a contributing factor because the shortage creates staffing problems,
mandatory overtime, and constant calls for additional shift work.
National nursing organizations are making strong efforts at stopping the shortage by mandating
better nurse- to-patient ratios, eliminating mandatory overtime, and increasing salaries and
benefits for nurses.
b. Issues in Nurse Migration
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.
c. The Right to Work and the Right to Practice
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.
d. Exploitation and Discrimination
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.
e. Essential Terms and Conditions in an Employment contract
An employment relationship has traditionally been governed by the terms and conditions of the
employment contract. Previously, the employer retained sole control in respect of the terms and
conditions of employment to be incorporated into the employment contract. However, over the
years there has been an increase in the implied terms and conditions which are also read into the
contract. Additionally, then there are the statutory terms and conditions which also apply. A
badly drafted employment contract which does not correctly express the intentions of the
employer on such matters as working hours, prolonged illness, bonus payments, usage of office
computer facilities, transfers, retirement age, confidentiality, conflict of interest, disciplinary
action and imposition of punishment, etc or the omission to mention some of these items in an
employment contract can give rise to serious consequences for employers. This talk will focus
on what are considered as essential terms and conditions which employers must incorporate into
an employment contract and the consequences of failure to do so.
f. Unsatisfactory work performance and termination of employment

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 persons 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 physicians 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 nurses negligence.
I have never met a nurse whose goal was to be negligent, but it doesnt happen. Examples of
negligent acts are:-
Leaving a patients 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 wouldnt 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 institutions policies regarding physical restraints. To
restrain a person is a serious decision. It requires a physicians order and permission of the
patient or the patients 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 publics 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.
Examples of legal torts
Invasion of Privacy example: a nursing student observing a procedure without the client's
consent or taking photos of the client.
False imprisonment example is telling the client that he/she may not leave the hospital or the
use of restraints.
Battery example: performing procedure without consent such as resuscitation.
+ Rights to Privacy
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.
+ Document, Document, Document
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.
b. Legal Issues in specialty and practice area
+ Maternal and infant Nursing
Many legal issues are involved in the care of mother and her infant. Generally the causes of
lawsuits for malpractice in this area may be divided into two categories who handling the mother
and child. Lawsuits brought against physicians/ doctors and nurses differ, reflecting the well-
recognized differences between these professions and their responsibilities.
A likely against a doctor who is in charge of looking after mother and infant might be one of the
following:-
Failure to diagnose a high risk pregnancy.
Delay in performing a caesarean section.
Improper vaginal delivery or failure to perform a caesarean section.
Improper use of forceps.
Incidence surrounding including labour and the use of oxytocin.
Delay in arriving at the hospital.
Non attendance at the delivery.
The common causes for lawsuits against nurses will include the following:-
- Problems of medication
Nurses are authorized to administration of medication. So many allegations against nurses with
regard to medication dosage, route or time, and failure to monitor side effects, for e.g. nurses are
often involved in the administration of oxytocin for the augmentation of labour.
- Failure in adequate client monitoring.
Nurses are expected to monitor their clients at appropriate time intervals that depend upon the
clients condition. Labour and delivery pose a unique monitoring challenge, in that there are two
clients to monitor, the mother and baby. The delivering mother must be adequately monitored to
prevent any maternal complications during prenatal period. Nurses have legal responsibilities
regarding fetal monitoring during labour. And prompt monitoring will be continued during natal
period, postnatal period to prevent complication related to mother and child in respective
periods.
- Failure to adequately assess the client.
Every nurse regardless of the area of practice is expected by virtue of his or her licensure to be
capable of performing assessment. The nurse is an important member of the health care team
who is the client constantly, and responsible for the minute by minute evaluation of the client
progress. Nurses in all specialty areas must maintain the higher level of assessment skills.
- Failure to report changes in the patient
Whenever the nurses assessment indicates that the clients condition has changed, the nurse
must notify the concerned physician. For example the nurses failure in reporting changes in the
child, denied the physician the opportunity to intervene and possibly save the childs life. When
a nurse reports a clients changed condition to the physician, the nurse feels that the physician
has not responded in a manner that is in the clients best interest, the nurse must proceed up the
chain of command until proper medical care is given to the client. As a patient advocate, nurses
must understand that failing to notify a doctor of a problem often leads to a delay in appropriate
medical care being implemented. This in turn can lead to an injury to the client and a lawsuit.

- Abortions
Abortion is one of the emotionally charged issues confronting nurses. Nurses cannot be forced to
participate in procedures they find morally offensive. Nurses have right to refuse to assist with
abortions. However, nurses cannot attempt to stop an abortion being performed. She can assist
with abortion if it is performed under Medical Treatment of pregnancy Act.
- Nursing care of new born.
There are certain legal requirements in providing nursing care for newborns, such as properly
identifying the infant- mother pair as soon as possible with finger prints, foot prints and wrist
bands. Standards of practice include providing a clear airway, clamping the umbilical cord,
applying antibiotics or silver nitrate to the edges, and minimizing stress of dying and keeping
infant warm. Resuscitation equipment must be in the delivery room. When a still born infant is
delivered, the nurse must record all events about the delivery. Although the atmosphere in a
delivery room is disquieting, the nurse must complete legal requirement by careful
documentation.
- Informed Consent
Before treatment, diagnostic procedures, or experimental therapy, a patient must be
informed of the reasons for the treatment as well as possible adverse effects and
alternative treatments.
The physician must obtain signed consent.
The nurse must ensure that signed consent is in the patients chart before the procedure is
performed.
- Prenatal Screening
Can detect inherited and congenital abnormalities long before birth.
Early diagnosis may allow repair of an abnormality in utero.
May force a patient to choose between having an abortion and assuming the emotional
and financial burden of raising a severly disabled child.
Some feel that the risk it poses to the fetus creates a conflict between the rights of the
fetus and the parents right to know the fetuss health status.
Helps the patient fully understand the procedure.
Pretest and posttest counseling are essential parts of an ethical prenatal- screening
program.
- In vitro fertilization (IVF)
With IVF, the ovum is fertilized outside the body and then implanted into the uterus.
Between 15 and 20 embryos may result from a single fertilization effort.
Only 3 to 5 of these embryos are implanted in the womens uterus.
Ethical questions arise as to what to do with remaining embryos.
Although the procedure has allowed infertile couples to have children, some are
concerned that it is unnatural.
- Surrogacy
A surrogate mother carries a fetus for another couple, with the expectation that the couple
will adopt the neonate after he is born.
Questions have evolved over the surrogate mothers legal rights to the infant.
- Fetal tissue research
Fetal tissue has facilitated scientific research for Parkinsons disease, Alzheimers
disease, diabetes, and other degenerative disorders.
Transplanted fetal nerve cells help to generate new cells in the patient that somehow
reduce symptoms.
Immaturity of the fetal immune system reduces the chances of the recipient rejecting the
tissue.
Some are concerned whether the number of abortions will increase in response to the
need for tissue and whether this is an ethical use of human tissue.
- Preterm and high risk neonate treatment
Medical advances have improved survival rates for high risk neonates.
Some are concerned about the physical, psychosocial and economic costs.
The nurse must present all available options in a compassionate, unbiased manner using
simple terms.
The nurse must help family members consider the pros and cons both initiating and
withholding treatment.
+ Pediatric Nursing
As in all areas of nursing practice, negligence involving pediatric clients is possible. Paediatric
nurses are responsible for preventing children, in their care, from accidentally harming
themselves. Cribs which sometimes have a restraining device over the top are designed to keep
infants and toddlers from climbing out of bed and injuring themselves. All poisonous substances
and sharp objects should be kept out of the reach of children. Children should be kept under
constant surveillance to minimize opportunities for accidental harm.
It is advisable that the health care professional including nurses should report to the concerned
authority if they come across the suspected cases may be liable for civil or criminal legal action.
Every state and province with child abuse legislation requires that suspected child abuse or
neglect be reported. HealthCare professionals such as nurses are mandated to report suspected
cases. Healthcare professionals who dont report suspected child abuse or neglect may be liable
for civil or criminal legal action.
Paediatric nurses are responsible for protecting children from accidently harming themselves. All
poisonous substances and sharp objects should be kept out of reach to the children. Children
should be kept under constant surveillance to minimize opportunities for accidental harm.
+ Medical Surgical Nursing
As in the case of paediatric clients, disoriented adults may require form of restraints to
prevent accidental self injury. Standard care, laws and regulations about the use of restraints and
supervision apply to nursing practice with medical surgical patient. Side rails are available on
most hospital beds for adult patients. Some disoriented older patients may also require belt
restraints to prevent them falling of the bed. If patients fall off bed and injure themselves, they
may bring a lawsuit against the nurses and hospital.
Nurses are responsible for performing all procedures correctly and exercising professional
judgement. A nurse who does not meet the accepted standards of practice or who perform duties
in a careless fashion runs a risk of being found negligence. Some common acts of negligence in
medical surgical nursing are as follows:-
Over looked sponges, instruments needles
In the operation theatre, it is a responsibility of the nurse to count the sponges, instruments,
needles before the closure of the abdomen or any cavity. The nurse may be liable if she makes an
error in their court.
Burns
The professional nurse is required to know the cause and effect of any heat application so as to
avoid burns. Some of the common heat applications are applications, of hot water bags, heating
pads, double sitz bath etc. The nurse could be held liable if she/he neglects to take proper safety
measure prior to application of such measures.
Falls
The nurse could be held liable if a patient falls from the bed or due to improper securing of
patient on examination table or improper application of restraint or provision of a proper bed for
an unconscious patient or a child.

Injury due to the use of defective apparatus or supplies
The defective bed pans infect patients. The nurse could be held liable if she uses equipment or
supplies them which she or he knows to be faulty, e.g. the use of unsterilized gauze of surgical
dressings.
Injury due to administration of wrong medicine, wrong dosage and wrong
concentration.
Administration of medicine without prescription by the concerned authority, mixing up of
poisonous and non poisonous drug in cupboards leading to errors, and failing to identify right
medication for right patient, in right dosage, at right time, considered as negligent act can be
liable to be used.
Assault and battery
Failure to take the informed consent of the patient prior to any procedure, treatment,
investigation or operation, the nurse be held liable.
Failure to report accidents
The nurse has a moral and legal responsibility to report to the concerned authority any accidents,
losses or unusual occurrences. Failure to do this is an act of negligence.
Maintenance of records and reports
Failure to maintain accurate record and reports or removing a position of record may also
make the nurse liable. Nurses working in critical care units are also legally accountable for
performing their duties. Critical care nurses require additional training and ongoing intensive
education to provide them with information about advances in care methods to handle high- tech-
machines and electric and electronic apparatus in addition to other critical care nursing measures.
The possible legal problems for critical care nurses are associated with use of electronic
monitoring devices. No monitor can be considered totally reliable and nurse must not completely
depend on it. These may be electrical hazards. The equipment should be checked routinely by
engineers to ensure that a patient will not receive any electrical shock.
Critical care units
Nurses working in critical care settings are legally accountable for performing their duties.
Critical care nurses require additional training and ongoing in service education to provide them
with information about advances in methods of patient care. Possible legal problems for critical
care nurses are associated with the use of electronic monitoring devices. No monitor can be
considered totally reliable, and the nurse must not completely depend on it. There may also be
electrical hazards. The equipments should be checked routinely.

+ Psychiatric Nursing
The practice of psychiatric nursing is influenced by the law, particularly in concern for the rights
of patients and the quality of care they are receiving. A psychiatric nurse should be sufficiently
acquainted with the legal aspects of psychiatry so that she/he can be aware of the patients rights
and can avoid giving poor advice or innocently involving herself/himself in a legal entanglement.
- Informal Admission
This type of admission to the psychiatric hospital occurs in the same way as a person is
admitted to a general medical hospital, i.e. without formal or written application. The individual
is then free to leave at any time, as he would be in a general medical hospital.
- Restraints
- Discharge
+ Community Health Nursing
In olden days nurses were working under the control and supervision of doctors. But in modern
practice nurses are able to assess, diagnose, plan, implement and evaluate nursing care
independently.
As we begin professional practice, it is essential to understand the law that defines the
nurses responsibility and duties. Especially the community health nurse must be very careful
while doing services in the community. Because there is team of people working in the hospital.
Whereas in the community the community health nurses are alone and most of the time she is in
a position to implement the services at home. So, she must be more careful and she should have
enough knowledge on legal issues.
a. Intentional Torts
Assault: It is a threat or an attempt to make bodily contact with another person without that
persons consent.
Battery: It is an assault that is carried out with willful angry and violent or negligent
touching of another persons body or clothes.
Examples:-
Forcibly removing patients cloth.
Injection with force or when refused by patient.
Pushing a patient in floor or the chair.
Defamation: It is an intentional tort makes derogatory remarks about another.
Slander: oral defamation of character.
Libel: Written defamation (petition)
E.g. About patient or co workers.
Invasion of Privacy
All information should be confidential.
Interacting with the family members.
Avoid unnecessary exposure.
Checking of all graduates or machines.
Carryout research activities.
Using tape recorder, video or photos.
False Imprisonment: A person cannot be legally forced to remain in health centers or
hospital. (Unjustified intension)
Fraud: Willful and purposeful interpretation or misinterpreting the outcome of procedure or
a treatment. (License may be prosecuted under the NP Act.
b. Unintentional Torts
Negligence: An act of negligence may be enacting of omission or commission.
Malpractice or Negligence
Liability: It involves four elements that must be established to prove that malpractice or
negligence has occurred.
Duty: Execution of safety measures.
Breach of Duty: Failure to note and report to the higher authority about the seriousness.
Causation: Failure to use appropriate safety measures.
Damages: Lengthened hospital stay and need for rehabilitation (Injection abscess)
Nurses Responsibilities
Practice within the scope of nurse practice act.
Observe agency policies and procedures.
Establish standards by using evidence based practice.
Always prefer patients welfare.
Be aware of relevant law and understand the limits.
Practice within the area of individual competence.
Upgrade technical skills by attending continuing nursing education (CNE) and seeking
certification.
Following the standards of care and referral services.
Ensure patient safety.
Proper action for needs and problems and appropriate treatment.
Monitor the programme and proper reporting.
Verify the medication errors and reactions.
Legal Safe Guards of Community Health Nurses
Informed consent: Granted freedom, written or oral form (procedures, expected outcome,
complication, side effects, and alternative treatment.
Contracts: Exchange of promises between two parties. The agreement may be written or
oral. (E.g. patient and his family and health care team.)
Collective bargaining: Policies, legal procedures, up to date knowledge.
Competent practice: It is most important and best legal safeguard.
Respecting Legal Boundaries
Institutional policies/ procedures should be adopted.
Respecting individual rights.
Developing rapport and working relationship with the community.
Keeping careful documentation for all activities.
c. Legal, Ethical, Professional Issues in Nursing.
Nurses are subject to a plethora of ethical, legal and professional duties which are too
numerous to discuss within this thesis. Therefore the main professional, ethical and legal duties
will be discussed. These three main duties are generally considered to be to respect a patient's
confidentiality and autonomy and to recognise the duty of care that is owed to all patients. These
three main duties are professional duties, however there are legal implications if they are
breached, therefore they are also legal duties; ethical considerations arise in contemplation of
these duties, such as consideration of when they can be breached and they are therefore ethical
duties as well. Before considering the main duties, consideration will be given to the regulatory
body of nursing, the GMC.
+ The Nursing and Midwifery Council
The medical and nursing professions are bound by their own code of ethics which is enforced
by disciplinary procedures. The professional governing body has for the most part a more
immediate influence over the conduct of its members than does the law, which is invoked
relatively rarely in medical matters.
The NMC is a regulator of professional standards. Central to its regulatory function is the
Register of Medical Practitioners. The register operates as a regulatory tool in two ways; first of
all, by operating the register the GMC is the profession's gatekeeper, allowing entry only to those
who have achieved the required standards for a 'registered medical practitioner' ('RMP').
Secondly, 'fitness to practice' proceedings against RMPs may result in their being suspended or
erased from the register. As a means of pre-empting the necessity for disciplinary proceedings,
the NMC issues guidance on aspects of a practitioner's duties and responsibilities in areas such as
consent, confidentiality and medical research, to prevent poor practice at source. The translation
of NMC guidance into conduct rests primarily, of course, on the individual conscience of
members of the profession whom, it is hoped, adhere to the guidance on a day to day basis.
+ Respecting Confidentiality
The Blue Book sets out the rules on patient confidentiality and it stipulates that Patients have
a right to expect that information about them will be held in confidence by their doctors.
Confidentiality is central to trust between doctors and patients. Without assurances about
confidentiality, patients may be reluctant to give doctors the information they need in order to
provide good care.
Rarely, cases may arise in which disclosure in the public interest may be justified, for example, a
situation in which the failure to disclose appropriate information would expose the patient, or
someone else, to a risk of death or serious harm.
In addition to the civil requirement to maintain confidentiality there is a professional requirement
for to maintain the patient's confidentiality and failure to do so is a breach of good medical
practice and will attract sanctions. There are also professional guidelines on how a nurse must
deal with a situation should she make a mistake.
+ Respecting Autonomy
The right to determine what happens to ones own body is the right to autonomy. The words
autonomy and autonomous are used in respect of a capacity, a condition and a right.
Successful relationships between doctors and patients depend on trust. To establish that trust you
must respect patients' autonomy - their right to decide whether or not to undergo any medical
intervention even where a refusal may result in harm to themselves or in their own death.
Patients must be given sufficient information, in a way that they can understand, to enable them
to exercise their right to make informed decisions about their care.
Any adult, mentally competent person has the right in law to consent to any touching of the
person. If he is touched without consent or other lawful justification, then the person has the right
of action in the civil courts of suing for trespass to the person - battery where the person it
actually touched, assault where he fears that he will be touched. The fact that consent has been
given will normally prevents a successful claim for trespass. However, it may not prevent an
action for negligence arising on the grounds that there was a breach of duty to care and inform
the patient.
Common causes of Legal Issues
Professional negligence. E.g. ignoring the seriousness.
Practicing medical without license in the community.
Obtaining nursing license by fraud or allowing others to use your license.
Felony conviction for any offence.
Participating in criminal abortion. E.g. Quacks.
Not reporting substandard medicine or nursing care.
Providing patient care while under the influence of alcohol or drugs.
Giving narcotics without an order.
Falsely holding oneself as family practitioner of nurse practitioners.
Processes that can be used in Professional and Legal regulation of nursing practice
S.N Process
1. Accreditation Education programme is evaluated and recognized by National
Accreditation Board.
2. Licensure The state determines certain minimum requirement to practice as
nurse. (e.g. Negligence, malpractice, wrong treatment and
alcoholism)
3. Certification Entry level competence. Specific knowledge and experience in
specified areas needed.
4. Standards Guidelines issued by councils, Qualifications, Standards, rules.
5. Nurse
Practice Act
Violation of rule care result in disciplinary action
Legal Safe Guards and nursing practice
Physicians Order: Physician is responsible for directing medical treatment. Nurses are
obligated to follow physicians oders unless they believe that the orders are not accurate or
would be detrimental to the clients. A nurse carrying out an inaccurate order may be legally
responsible for any harm suffered by the client. Verbal orders are not recommended because
they have possibilities for error. If a verbal order is necessary, during an emergency, it should
be written and signed by the physician as soon as possible, usually within 24 hours.
Short- staffing: The issue of inadequate staff may arise sometimes. Legal problems may
arise if there is not enough nurse to provide competent care. If assigned to take care of more
clients than is reasonable, nurse should attempt to reject assignments by informing the
nursing supervisor that they are inappropriate. Nurses should not walk out when staff is
inadequate because charges of ababdonment can be made.ack of experience in taking care of
the type of clients in the new nursing unit. They should also request for an orientation about
the unit.
Floating: Nurses are sometimes required to float from the area in which they normally
practice to other nursing units. Nurses who float should inform the supervisor about any
Informed consent: Granted freedom, written or oral form (procedures, expected outcome,
complication, side effects, and alternative treatment.
Contracts: Exchange of promises between two parties. The agreement may be written or
oral. (E.g. patient and his family and health care team.)
Collective bargaining: Policies, legal procedures, up to date knowledge.
Competent practice: It is most important and best legal safeguard.
List of dos and donts as guidelines for safe practice
Dos
Documention of all unusual incidences.
Report all unusual incidences.
Know your job description.
Follow policies and procedures as established by your employing agency.
Keep your registration updated.
Perform procedures that you have been taught and that are within the standard scope of your
practice.
Protect patients from injuring themselves.
Remain alert and focused.
Establish and maintain rapport with patients and family.
Seek and clarify orders when the patients medical condition changes.
Practise safety with physicians verbal orders.

Donts
Remove side rails from patients bed unless there is an order or hospital policy to do so.
Allow patients to leave the hospital or nursing home unless there is an order or a signed
release.
Accept money or gifts from patients.
Give advice that is contrary to physician orders or the nursing care plan.
Give medical advice to friends and neighbours.
Attempt to practice medicine.
Witness a patients will.
Take medications that belong to patients.
Worked as a licensed practical/vocational nurse in a state in which you are not licensed.
Roles and Functions of Nurse Manager in Legal Issues
The following are the leadership roles and managerial functions of a nurse manager in legal and
legislative issues:-
a. Serve as a role model by providing nursing care that meets or exceeds accepted standards of
care.
b. Is current in the field and seeks professional certification to increase expertise in a specific
field.
c. Reports substandard nursing care appropriate authorities.
d. Fosters nurse/ patients relationships that are respectful, caring and honest, thus reducing the
possibility of future lawsuits.
e. Joins and actively supports professional organizations to strengthen the lobbying efforts of
nursing in health care legislation.
f. Practices nursing within the area of the individual competence.
g. Prioritizes patients rights and welfare first in decision- making.
h. Demonstrates vision, risk taking, and energy in determining appropriate legal boundaries for
nursing practices thus defining what nursing is and should be in the future.
i. Is knowledgeable responding sources of law and legal doctrines that affect nursing practice?
j. Delegates to subordinates wisely, looking at the managers scope of practice and that of those
they supervise.
k. Understands and adheres to institutional policies and procedures.
l. Practices nursing with scope of state nursing within the scope of the state nurse practice act.
m. Monitors subordinates to ensure that they have a valid, current and appropriate license to
practice nursing.
n. Uses foresee ability of harm in delegation and staffing decisions.
o. Increases staff awareness of intentional torts and assists them in developing strategies to
reduce their liability in these areas.

NURSING REGULATORY MECHANISMS AND CONSUMER ACT
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.
NURSING REGULATORY MECHANISMS
The main functions of these regulations include
To protect patient or society
To define the scope of nursing practice
To identify the minimum level of nursing care that must be provided to clients
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
International council of nurses
Indian nursing council
State nursing council
ACCREDITATION
The concept of accreditation of educational programs in nursing is very important. Accrediting is
the process whereby an organization or agency recognizes a college or university or a program of
study as having met certain predetermined qualifications and standard
Accreditation refers to a voluntary review process of educational programs by a professional
organization. The organization is called an accrediting agency is invited to compare the
educational quality of the program with established standard and criteria.
Accreditations has four major purposes which include the following
Maintenance of adequate admission requirements
Maintenance of minimum academic standards
Stimulation of institutional self improvements, and
Protection of institutions of higher education against educationally socially harmful
pressures
Accreditation is vital to the welfare of institution of higher education. Accrediting organizations
in higher education are generally classed into three types
i. National accrediting agency
ii. National professional accrediting agency
iii. State accrediting bodies
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.
India has following all India Educational Councils:
Central advisory board of education
All India council for Elementary education
All India council for secondary education
University grants commission
All India council for technical education
National assessment and Accreditation council
National Professional Accrediting Agency
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.
Medical Council of India
Indian Nursing Council
Dental council of India
Pharmacy council of India
Central council of Indian system of Medicine
Indian nursing council, (INC) is the official accrediting agency for all programs of nursing,
which include Diploma (GNM), Bsc Nursing (both basic and post basic), NM/Msc N /M.phil
(Masters) and PhD (Doctoral programs in Nursing)

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.
Current licensure activities
Efforts to provide common definitions of nursing practice, standards of education, and
testing for entry into practice across state boundaries have been successful, although nurses are
still required to apply for licensure in each state in which they practice. With the mobility of
nurses, the movement toward telecommunications, and care of clients across wide distances,
state boards of nursing recognized the need to provide practicing nurses with more than
procedures of endorsement of their initial license. This need has led to further changes in nursing
licensure. In 1997, the Delegate Assembly of the National council of state Boards of Nursing
moved to a new level of nursing regulation. The assembly approved a resolution endorsing a
mutual recognition model of nursing regulation. Through this model individual state boards will
develop an interstate compact allowing nurses licensed in one state to practice in all other states
and territories. Nurses will be responsible for following the laws and regulations of those states,
although they will not be required to apply for individual state licensure.
COMPONENTS OF NURSING PRACTICE ACTS
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.
ENTRY INTO PRACTICE
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 nurses 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.
CONSUMER PROTECTION ACT
Till recently, all cases of disputes regarding negligence on the part of doctors or hospitals
were raised in a court of law. It was filed either under the law of torts to claim damages or under
the relevant sections (304A, 336,337 and 338) of the 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 productsparticularly 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 laws definitions. First and foremost, the complaint must be made in writing and
should concern an unfair action by a business or individual acting in a commercial setting.
Defects in goods or unsatisfactory service can be the subject of written complaints, as can
excessively high charges for goods or services.
Consumers are not charged a fee for filing such complaints. Decisions may involve
complete removal of any defect in a product and replacement of the product. Refunds are
specifically provided for in the law.
A PRIMER ON CONSUMER PROTECTION ACT(CPA)
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.
CONSUMER PROTECTION COUNCILS
They are at two levels namely Central and State protection councils
Central consumer protection council
The objectives of this council shall be to promote and protect the rights of consumer such as,
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
State consumer protection councils
The state council shall consists of following members
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
It means any allegation in writing made by a complainant that
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
Deficiency is any fault, imperfection, shortcoming or inadequacy in the quality, nature
and manner of performance in pursuance of a contract or otherwise in relation to the service
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
PATIENTS BILL OF RIGHTS
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
1960s patients had few rights; in fact, patients often were denied basic human rights during a
time when they were vulnerable. In 1973, however, the American Hospital association published
its first patient bill of rights.
- The patient has the right to considerate and respectful care
- The patient has the right to and is encouraged to obtain from physicians and their direct
care givers relevant, current, and understandable information concerning diagnosis,
treatment and prognosis
- The patient has the right to make decisions about the plan of care prior to and during the
course of treatment and to refuse a recommended treatment or plan of care to the extent
permitted by law and hospital policy and to be informed of the medical consequences of
this action. In case of such refusal, the patient is entitled to other appropriate care and
notify patients of any policy that might affect patient choice within the institution
- The patient has the right to have an advance directive (such as living will, health care
proxy or durable power of attorney for health care) concerning treatment or designating a
surrogate decision maker with the expectation that the hospital will honor the intent of
that directive to the extent permitted by law and hospital policy
- The patient has the right to every consideration of privacy. Case discussion, consultation,
examination, and treatment should be conducted so as to protect each patients privacy
- The patient has the right to expect that all communications and records pertaining to
his/her care will be treated as confidential by the hospital, except in cases such as
suspected abuse and public health hazards when reporting is permitted or required by
law. The patient has the right to expect that the hospital will emphasize the
confidentiality of this information when it releases it to any other parties entitled to
review information in these records
- The patients has the right to review the records pertaining to his/her medical care and to
have the information explained or interpreted as necessary, except when restricted by law
- The patient has the right to expect that, within its capacity and policies, a hospital will
make reasonable response to the request of a patient for appropriate and medically
indicated care and services. The hospital must provide evaluation, service, and/or referral
as indicated by the urgency of the case. When medically appropriate and legally
permissible, or when a patient has so requested, a patient may be transferred to another
facility. The institution to which the patient is to be transferred must first have accepted
the patient for transfer. The patient must also have the benefit of complete information
and explanation concerning the need for, risks, benefits, and alternatives such a transfer
- The patient has the right to ask and to be informed of the existence of business
relationships among the hospital, educational institutions, other health care providers, or
payers that may influence the patients treatment and care
- The patient has the right to consent to or decline to participate in proposed research
studies or human experimentation affecting care and treatment or requiring direct patient
involvement, and to have those studies fully explained prior to consent. A patient who
declines to participate in research or human experimentation is entitled to the most
effective care that the hospital can otherwise provide
- The patient has the right to expect reasonable continuity of care when appropriate and to
be informed by physicians and other care givers of available and realistic patient care
options when hospital care is no longer appropriate
- The patient has the right to be informed of hospital policies and practices that relate to
patient care, treatment and responsibilities. The patient has the right to be informed of
available resources for resolving disputes, grievances and conflicts, such as ethics
committees, patient representatives, or other mechanisms available in the institution. The
patient has the right to be informed of the hospitals charges for services and available
payment methods.
A bill of rights that has become law or state regulation has the most legal authority because it
provides the patient with legal recourse. Today, patients are more assertive and involved in their
health care. They have more information to review when looking at treatment options and are
demanding to be participants in decision making about their health care. The patients 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
"If you want the credit, you take the responsibility."
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?
Strategies for Building 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.
Tool 2: Using Situational Leadership to Build Environments of Accountability
In the 1980s as organizations moved away from the Taylor model of accountability
(resting solely with management), it became popular for managers to "empower" employees to
build accountability. Often uncertain what the term really meant or how to make it happen,
management's implementation of empowerment often looked more like a "dump and run." It's
only when we apply the Situational Leadership Model (Blanchard) that we begin to understand
how and, more importantly, when to empower and build accountability over the long-term.
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:
D1: Low competence high commitment
Often a new employee (or an experienced employee) who is given a new task. Employee has
high expectations for what will happen; very enthusiastic about the future and own ability to
deliver results. Often eager to please, readily volunteers and tries to do extra in order to be
accepted.
D2: Some competence low commitment
Characterized as a "sophomore" employee who has taken a nose-dive in motivation because
job expectations don't match reality; the work is more difficult than expected, and not as "flashy"
as desired. This employee watches the clock, acts like a know-it-all and is critical of authority.
D3: High competence variable commitment
A long-term employee who has become cynical, bitter and frustrated over time. Although
competent, the employee often displays negativity and procrastination. The D3 has experienced
many disappointments in the work environment and has "collected stamps" about those
disappointments over time.
D4: High competence high commitment
A star employee who brings experience and commitment to the job. They are able to set goals
and deliver results. The D4 is very self-motivated and self-directed.
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:
S1: TEACHING (high directive; high supportive)
The manager provides clear direction about tasks, expectations, responsibilities and
simultaneously builds a strong relationship with the employee. The manager's approach is quite
directive, or what is called the "teaching" style.
S2: COACHING (high directive; low supportive)
The manager continues to strongly direct and teaches with input from the employee, but also
"coaches" proper behavior and job expectations. The manager must correct problem behaviors
using "redirection" strategies. It's also important for the manager to speak to the employee's
potential.
S3: SUPPORTING (low directive: high supportive)
The manager places the focus on rebuilding and restoring the relationship by using a
"supportive" model of listening and engaging with the employee. The goal is to get the "stamps"
out so the energy can flow again. This employee does not need directive strategies, as they are
very component.
S4: EMPOWERING (low directive; low supportive)
This star is ready to be empowered. Challenging goals are identified and the employee is given
great latitude to design and develop own approach. The manager only provides guidance when
needed.
Tool 3: Performance Management: Applying Natural Consequences to Improve
Accountability
A D4 is a terrific employee whom we want to challenge and keep moving along, while
our D2 is a self-proclaimed know-it-all who is ready to leave ten minutes early and never seems
to put in a full day's work. "Moving" the D4s behavior and "stopping" the D2s behavior is what
Performance Management is all about. In order to build accountability, both need to experience
the natural consequences of their own actions, positive and negative. How do we make those
natural consequences occur in the workplace?
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.
Consequences that "move" 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."
Consequences that will "stop" behavior
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?
By position, management has responsibility and accountability. A wise manager knows,
however, that he or she can't do it all and will fail if they try. Getting others to pitch in and accept
accountability will be an enormous load off the manager's back. To succeed, the manager must
use effective tools to build an environment of accountability
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.
Accountability for What?
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
Four-Fold Definition of Responsibility
Causal Responsibility
Liability-Responsibility
Role-Responsibility
Moral-Responsibility
Causal Responsibility
A purely descriptive sense of responsibility
The heavy rain is responsible for the flooding
The operator was responsible for turning off the control switch
The But-For conception of being causally responsible:
X was causally responsible for Y =
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 ones 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
It means that no excusing conditions are applicable or accepted
Responsibility without fault
Strict Products Liability
Part of the debate about legal liability concerns where the line should be drawn when
assigning strict liability
Role-Responsibility
Role-Responsibility: Whenever a person occupies a distinctive place or office in a
Social organization, to which specific duties are attachedhe or she is properly said to
be responsible for the performance of these duties, or for doing what is necessary to
fulfill them.
Such duties are a persons (role) responsibilities.
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).
Moral responsibility is a normative notionit involves an evaluation
Connected to other concepts such as duty, obligation, knowledge, freedom, choice,
accountability, agency, praise, blame, intention, pride, guilt, shame, conscience, and
character
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.
3 Motivations for Accountability
Accountability as a virtue that is desirable in its own right
Accountability as a guideline for answerability which motivates precautionary behavior
that, in turn, caters to social welfare
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"
Competence: qualified or suited for a purpose; showing appropriate skill or aptitude
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
Supererogatory behavior: going above and beyond the call of duty.
Barriers to Responsibility and Accountability
1. The Social Psychology of Identification of Ones Role in Social Interaction (The
Zimbardo Experiment)
2. Obedience to Authority in Social Contexts (The Milgram Experiment)
3. The Problem of Many Hands
4. Diffusion of Responsibility
5. Risky Shift Phenomena

Barriers to Individual Accountability
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 managements 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
Establishing local policy and management of safety and health
Regularly evaluating and reviewing occupational safety and health performance
indicators for the work area
Appointing and supporting the necessary safety personnel
Allocating the necessary resources to the safety and health program
Devising and implementing priority plans to address concerns that cannot be resolved
immediately
Ensuring all staff are adequately trained and competent, with respect to safety and health,
for the tasks undertaken
Ensuring all staff, students (as applicable) and others (as applicable) undertake a
thorough safety induction upon commencement of employment or duties
Ensuring that supervisory staff are aware of and act upon their responsibilities
Ensuring the proper supervision of staff, students and others
Ensuring staff and students are aware of the reporting and resolution process for hazards,
incidents and injuries
Establishing local safety and health consultation and information arrangements
Establishing and actively supporting a local Safety Committee
Annually reviewing the safety and health record of the work area, including occupational
safety and health management plans, and issuing a statement of safety objectives for the
following year
Noting all incident and injury reports, near miss reports, hazard reports, safety inspection
reports and ensuring remedial action has been taken
Keeping staff informed of safety matters, and ensure that procedures are in place to
identify hazards, monitor and control risks and that systems are maintained and reviewed
regularly
Ensuring all necessary records are kept and maintained up to date
Cooperating with the rehabilitation of injured and sick employees in accordance with the
Universitys injury management policy
Ensuring compliance with legislations, University safety and health policies, procedures
and guidelines
4. Safety Committees
Faculties/Schools/Centres and Sections are strongly encouraged to systematically address
safety and health matters through effective Safety Committees involving representatives from
senior management, staff (academic, general), safety and health representatives and
students. Suggested agenda items for these Committees are
Hazards reported and actions arising
Incident/injuries and lost time follow ups
Workers' compensation support (as necessary)
Safety related training (including inductions)
Workplace inspections and follow ups
Implementation of university, faculty and school safety related policies, procedures, and
guidelines
Safety budgets and funding
Promotion of a workplace safety culture
Preparing for workplace audits and submitting for recognition of achievements (eg UWA
Safety Awards)
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
6. University employees, undergraduate and post-graduate students
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
To inspect the workplace or any part of it at such times as agreed with the
Faculty/Department/Centre/Section heads
Immediately, in the event of an accident, a dangerous occurrence, or a risk of imminent
and serious injury to, or imminent and serious harm to the heath of any person to carry
out any appropriate investigation in respect of the matter
To keep informed on the safety and health information provided by the University in
accordance with the Occupational Safety and Health Act
Forthwith to report to the immediate supervisor any hazard or potential hazard to which
any person is, or might be, exposed at the workplace that comes to his/her notice
To refer any matters that he/she thinks should be considered by the local Safety
Committee or the University Safety Committee
To consult, cooperate and liaise with staff or students regarding matters concerning the
safety, health and welfare of persons in the workplace
8. School Safety Officers
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.
10. First Aid Officers
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
Developing and implementing occupational safety and health policies, plans and
procedures
Effective workplace consultation
Conducting hazard identification, risk assessment and control
Providing safety information and training
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
Emergency planning and response
Insurance - property, liability, motor vehicle, travel and student accident plan
Workers' compensation and rehabilitation
Manual handling and ergonomic assessment
Biological, chemical, radiation, laboratory and workshop safety
Hazard, incident and injury investigation
Safety information and training
Workplace visits and inspections
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.
14. UWA Facilities Management
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.
15. Security and Parking
The Security and Parking Offices 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.
16. University Safety Committee
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.
Reporting to the University Safety Committee is a number of specialist safety sub-committees
including
Chemicals and Carcinogen Committee
Emergency Planning Committee
Institutional Biosafety Committee
Radiation Safety Committee
Ventilation Committee
17. Breach of conduct or discipline
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
INFECTION CONTROL & STANDARD SAFETY MEASURES
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:
Injurious contamination of body or parts of the body by bacteria, viruses, fungi,
protozoa and rickettsia or by the toxin that they may produce Infection may be local or
generalized and spread throughout the body.
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
BASICS OF INFECTION CONTROL
Prevention of nosocomial infection is the responsibility of all individuals and services
provided by healthcare setting.
E To practice good asepsis, one should always know: what is dirty, what is clean, what is
sterile and keep them separate.
E Hospital policies & procedures are applied to prevent spread of infection in hospital
PRINCIPLES
Client safety in the health care environment requires the reduction of
microorganism transmission.
Infection control practices are directed at controlling or eliminating sources of
infection in the health care agency or home.
Nurses are responsible for protecting clients and themselves by using infection
control practices.
Nurses and clients must be educated on the types of infections, modes of
transmission, risks for susceptibility, and infection control practices required to
control or prevent further transmission.

CHAIN OF INFECTION
The chain of infection describes the phenomenon of developing an infectious process.
There must be an interactive process that involves the agent, host, and environment. This
interactive process must involve several essential elements, or links in the chain, for
transmission of microorganisms to occur. The six essential links (elements) in the chain of
infection. Without the transmission of microorganisms, an infectious process cannot occur.
Therefore, knowledge about the chain of infection for an infectious process permits control or
elimination of the microorganism by breaking the links in the 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
hosts 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
Commonly used disinfectants and germicides
Bacillocide: - it contains formaldehyde, glutaraldehyde, alkylurea derivatives and benzalkonium
chloride. Use 2% solution by dissolving 200ml of the concentrate in 10 litres of water. It is used
for disinfecting surfaces and for spraying rooms. The fans and air conditioners should be put off
for 30 minutes and surfaces should be kept wet with bacillocide for 30 minutes for good efficacy.
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.
Cidex: - it is a 2% solution of flutaraldehyde with an activator. The solution should remain in
contact for 20 minutes for disinfection and 4 hours for sterilization.
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.
Sterilium: - it contains 2- propanolol, 1- propanolol, and ethyl hexadechyle dimethyl ammonium
ethyl surfate. Rub 2- 3ml of sterilium on the palms and backs of the hands for 30 seconds and
allow it to dry, for disinfection of hands. It can be used in between nursing care or after handling
the babies. It should not replace thorough hand washing before entering the NICU.
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.
Formalin: - (40% formaldehyde aqueous solution) is used for fumigation.

PREVENTION
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 clients 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 .
The main forms are:
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.

PREVENTION OF CROSS INFECTION
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 MANAGEMENT
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
coding
Type of Container Waste Category Treatment options
Yellow Plastic Bags
Human and animal wastes,
Microbial and Biological wastes
and soiled wastes

Incineration/ Deep
Burial
Red
Disinfected container/
Plastic bags
Microbiological and Biological
wastes, Soiled wastes, Solid
wastes

Autoclave/ Microwave/
Chemical Treatment)
Blue/
White/
Transparent
Plastic bag, Puncture
proof container
Waste sharps and solid waste

Autoclave/ Microwave/
Chemical Treatment
Destruction and
Shredding
Black Plastic bag
Discarded medicines, Cytotoxic
drugs, Incineration ash and
chemical waste

Disposal in secured land
fills
Green Plastic Container
General waste such as office
waste, food waste & garden waste
Disposed in secured
landfills

HOSPITAL INFECTION CONTROL PROGRAMME
The main aim of the hospital infection programme is to lower the risk of an infection during the
period of hospitalization.
THREE ASPECTS :
Development of an effective surveillance system to know the risk of nosocomial
infection.
Development of policies and procedures to reduce risk of nosocomial infections.
Maintenance of continuing education programme from hospital personnel
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:
Provide the funds and resources for infection control programme
Ensure a safe and clean environment
Ensure the availability of safe food and drinking water
Ensure the availability of sterile supplies and material, and
Establish an infection control committee and team.

INFECTION CONTROL ORGANIZATIONS IN A HOSPITAL
Infection control organizations are essential features of an infection control programme.
These organizations are:
1. Infection Control Team (ICT)
Each hospital will be having their own infection control team and committee. The
infection control team includes three main posts they are
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 of infection control team
Detects, investigates nosocomial infections.
Investigation of environmental problems related to hospital infection.
Detects community acquired infections in the hospital and refers to the appropriate
authority for follow-up.
Prompts initiation by physicians of hospitals infection report.
Assist in development and review of infection control procedures, to be forwarded to
the central committee annually.
Monitoring the hospital policy compliance on isolation procedures.
Development and implementation of inservice orientation program related to infection control.
Monitoring the effectiveness of infection control programs.
Guiding and monitoring of hospital infection through the cleaning department company,
catering division, water supply department and other environmental.

2. Infection Control Committee (ICC)
The infection control committee includes all the in charge staffs of all the
department of hospital like medical, nursing, paramedical, class four workers etc. The
infection control officer is the member secretary. The committee meets regularly and not
less than three times a year.
FUNCTIONS OF ICC
The committee will:
Conduct periodical review of statistics on nosocomial infections.
Carry out evaluation of routine surveillance activities including reports on
bacteriological swab counts of critical areas surveyed.
Supervise epidemiological investigations.
Review current policies.
Convey infection control information to hospital staff.

3. Infection Control Officer (ICO)
The Infection Control Officer is usually a medical microbiologist or any other physician with an
interest in hospital associated infections.
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.

4. Infection Control Doctor (ICD)
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.
Role and responsibilities of the ICD
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.

TASKS OF INFECTION CONTROL NURSE
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.

Her activities will include the following.
1. Daily visit to all wards and patient holding units.
2. Checking ward sisters report register for tell-tale records suggestive of infection.
3. Collection and tabulation of daily data of incidence of hospital infection. Recorded data of
all infections should include the identification and location of the patient, the type of
infection, the cultures taken and the results (when known), any antibiotics administered,
and the identity of the physician responsible for the care of the patient.
4. Ensuring that the samples of blood, stool, sputum, urine, swab- are collected and
despatched to the laboratory in time. Laboratory records are an important surveillance tool
and data source.The data is gathered by the infection control nurse during ward rounds.
5. Initiating the hospital infection control form while documenting for nosocomial infections,
the registration form used should be different from the routine investigation forms, so that
minimum time is wasted in getting the culture and sensitivity reports.
6. Compilation of wardwise, desciplinewise or procedurewise statsistics.
7. Daily visit to laboratory to ascertain results of previous days samples.
8. Monitoring and supervision of the infection among hospital staff.
9. Training of nursing aides and paramedical personnel on correct use of hygiene practices
and aseptic techniques.
10. Assist in bacteriological studies of all cases.
6. Infection Control Manual (ICM)
It is recommended that each hospital develops its own infection control manual
based upon existing documents but modified, for local circumstances and risks

EFFECTIVE CONTROL MEASURES
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
Strict adherence to aseptic techniques in various invasive procedures. Insertion and
removal of catheters, surgical tubings, drainage tubes and packs need strict no-touch
techniques even while they are done outside of operation theaters in nursing units.
3. Segregation of contaminated Instruments
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
Availability of adequate number of trained nurses is crucial for prevention of
nosocomial infection. Isolation facilities for patients with communicable diseases and
those vulnerable to infection. Such facilities must be made available in ICU, nurseries,
burn unit, transplant unit, etc. Strict control on wearing of mask, gown and gloves must
be exercised while attending to such patients. All articles taken for patient use must be
treated appropriately.

5. Masking and Gowning and Glowing
Gloves should be worn especially while dealing with HIV infected patients..
As for any surgical procedure lumbar puncture Gown and Glove should be
worn by the person who conducts the procedure.
Gowns should be washed and Autoclaved daily.
6. Disinfection Practices
Different kinds of disinfectants vary in their reaction to different kinds of micro-
organisms. Phenolic compounds are active against gram-negative organisms. Quaternery
ammonium compounds against staphylococci, streptococci, and lodophores and
hypochlorites have a broad spectrum of action. Selection of appropriate disinfectant for
different purpose is important. The following should be checked.
Appropriate choice
Appropriate concentration
Appropriate contact time
Appropriate method of use

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, nurses station etc.
Heavy duty gloves should be used while handling and washing sharp
instruments and glass ware.
Post exposure protocol for needle stick injury
Dont panic.
Dont squeeze the injured site
Wash with soap and water immediately.
Report to the casualty and provide proper history of exposure for
immunization.
Post exposure protocol regimen for HIV
(Basic regimen)
Zidovudine [There is risk for79% of infection]
(Expanded regimen)
It goes for 28 days + basic regimen
Post exposure prophylaxis regimen for Hepatitis infection
If vaccinated no problem.
If not vaccinated previously take Immunoglobulins 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.

10. Dietary service
Storage of food articles and appropriate temperatures in refrigerators and deep
freezers must be checked. Control of rodents and insects is a must to prevent
contamination of stored food and supplies Fruits and vegetables eaten raw must be
thoroughly washed before consumption.

11. Handling the laboratory specimens
The specimens should be collected in screw capped plastic disposable
container without soiling laboratory forms.
Never pipette blood or other body fluid with your mouth.

12. Handling the blood spills
The spill should be covered with cotton, news paper or other absorbent
material.
Pour 1% of Hydro chlorate solution or bleach solution over the spill
Wipe the spill soaked area after 20 minutes.
Discard the soiled materials in a polythene lined waste bag(red bag)
The soiled floor should be cleaned with the detergents.

13. Housekeeping routines
Dry dusting and sweeping should be avoided; it is preferable to vacuum
cleaner to suck the dust from the floor, walls and equipments.
Wet mopping of floors with soap and water containing 3% phenol should be
carried out at least thrice daily
The waxing of surfaces and use of oil in water for mopping may limit
dissemination of microorganisms.
The walls should be wiped or sprayed with 2% bacillocide once a week
The sinks should be washed with 3% phenol or 5% Lysol at least once a day.

14. Air hygiene in operation theaters
Clogging of air filters of the AC system renders the ventilation in operation theaters and
such other areas infective. Air filters should be frequently cleaned. Periodical smoke
studies should be carried out for air movement in operation theaters and checking that the
AC system is achieving the desirable number of air changes per hour.
15. Termination Disinfection
Termination disinfection of isolation rooms must be carried out thoroughly on the
principle as operating rooms before permitting the room for reuse. At such times, the staff
must use the same precautions (cap, mask, gown, gloves) used for nursing in such
isolation rooms.
16. Developing a sense of awareness
Developing in all hospital workers a high sense of awareness, and training and retraining in
the precautionary measures, prevention and control.
17. Prevention of occupational exposure
Cover all the cuts and abrasions with water proof dressings.
Use gloves when handling instruments or equipments.
Do not recap needles after use
Never manipulate any sharp that involves directing the point of the needle
towards any part of the body.
Disposal sharps immediately.
Refer to the needles stick injury guidelines.
Health care workers with skin condition must seek the advice of occupational
health nurse.
Advice junior staffs and students to inform to seniors to be reported for any
sign of occupational exposure.
18. Management of patient care equipments
Don not re use single patients equipments to other patients.
Patient care equipments should be decontaminated as per the decontamination
policy.
Wear protective clothings when handling the contaminated articles.
Do not use single use equipments again
Patient related equipments such as pumps, Drip stands etc must be kept clean.
19. Waste disposal
Nurses should have thorough information and knowledge regarding
Biomedical and general waste management.
There should be provision for foot operated bins adjacent to each baby unit for
disposal of used materials and soiled linens
Plastic bags should be kept as hampers in the dust bins and they should be
sealed before their removal.
The dust bin should be mopped with 3% of phenol every day.
To have supervision over segregation of waste in appropriate color bags
according to CDC recommendations
Knowledge and practice regarding transportation of waste should be essential.
EXAMPLE: POLICY GUIDELINES RELATED TO INFECTION CONTROL
Recommended Standards
This set of standards, adapted mainly from Guidelines for Perinatal Care, 4
th
Edition by the
American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists, focuses on the following areas:-
I. Physical Setup
II. Administrative arrangement
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).
3. Traffic to other services shall not pass through the unit
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.
7. Pictorial hand washing instructions should be provided above all sinks.
8. Sinks should be designed so as to control splashing and avoid standing or5 retained water.
9. Faucet aerators may be useful to reduce water splashing in sinks, but they are notoriously
susceptible to contamination with a variety of hydrophilic bacteria. They should not be used.
10. Sinks should be scrubbed clean daily with a detergent.
Air-borne Isolation Room(s)
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.
5. A hands-free two-way emergency communication system is required within the isolation room
to connect to the outside.
6. Remote physiologic monitoring of an isolated infant should be considered.
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
Surveillance for Nosocomial Infection
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.
Prevention and Control of Infections
Staff Health
1. Health care workers should be immune to rubella, measles and chicken pox
2. Yearly influenza vaccination is available
3. Ideally, individuals with a respiratory, cutaneous, mucocutaneous or gastrointestinal infection
should not have direct contact with neonates.
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 patients record, and approval for each
sibling visit should be noted
3. Children should carefully wash their hands before patient contact.

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.
8. Sinks should be scrubbed clean at least daily with a detergent
Cleaning & Disinfecting Patient Care Equipment
Incubators, Open Care Units & Bassinets
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 manufacturers 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
disinfected frequently with freshly prepared mild soap or disinfectant solutions
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

Neonatal Linen clean and soiled
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.
3. Soiled linen should be discarded into bags that prevent leakage.
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:
1. The chemicals trichlorocarbanilide or sodium salt of pentachlorophenol should not be used in
hospital laundering because they may be harmful.
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.
4. Intravenous tubing, stopcocks, flush syringes should be changed

WHAT YOU THINK ABOUT THIS BOOK????

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. Im
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

Anoop: nandakumaranoop@gmail.com
Chetan Kumar: chethur@yahoo.co.in
Lingaraj: lingukindal@gmail.com
Mithun Kumar: mithunbp@yahoo.co.in
Sarath Chandran: sarathchandu1986@gmail.com

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PADMASHREE INSTITUTE OF NURSING. M.Sc.

Nursing II years (2009-2011 batch)

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