SEMINAR

ON
MEDICAL SURGICAL
NURSING
SUBMITTED BY SUBMITTED TO

Mrs. SARANYA .M, Mrs.K.KARPAGAM,

First year M.Sc Nursing. M.Sc Nsg,MBA, PGDGC ,

Department of Medical

Surgical Nursing

SACRED HEART COLLEGE OF NURSING – KUMBAKONAM

SUBMITTED ON

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 Topic
Historical development of medical
surgical nursing in India
Current Status of health and disease
burden in India.
Current concept of health.
Trends & Issues in Medical – surgical
Nursing.
Ethical & Cultural issues in Medical
– Surgical Nursing.
Rights of patients
National Health Policy, special laws
& ordinances relating to older
people.
National goals
Five year plans
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National health programs related to
adult health

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HISTORICAL DEVELOPMENT IN MEDICAL SURGICAL NURSING
IN INDIA :

INTRODUCTION :

In ancient times, when medical lore was associated with

good or evil spirits, the sick were usually cared for in temples and
houses of worship. These women had no real training by today’s
standards, but experience taught them valuable skills, especially in the
use of herbs and drugs, and some gained fame as the physicians of
their era.

Nursing is a profession focused on advocacy in the care of

individuals , families, and communities in attaining, maintaining and
recovering optimal health and functioning. Nursing is an
interpersonal, interactional or partnering , process between the nurse
and the client with the objective of promoting wellness, preventing
illness, and giving the client the tools to be able to functions at an
optimal level of wellness. Nursing is an art and a science by which
people are assisted in learning to care for themselves whenever
possible and cared for others when they are unable to meet their own
needs. Nursing promotes health and helps clients move to a higher
level of wellness. This aspect of nursing also includes assisting a
client with a terminal illness to maintain comfort and dignity in the
final stage of life.

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HISTORY :

 In the history of Indian medicine begins from 3000 BC.

 In the Indus valley civilizations we can see the drainage and we will

understand that they have given importance to health and hygiene.

 In 2000 BC the RIGVEDA marks the beginning of Indian system of

medicine.

 The conditions like fever, cough, constipation, diarrhoea, dropsy

abscesses, seizures, skin diseases including leprosy were treated from that

time.

 The herbs were used for the treatment. In 272 BC king Ashoka built

number of hospitals. He had given his emphasis on the prevention of the

diseases.

 Doctors, Nurses and the Midwifes were also available in that time.

Nalanda and Thaxaxila were the two famous medical schools.

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 In 100 B C, the surgical field was the well known by surgeons Sushruta

and Charaka.

SUSHRUTA & CHARAKA

 Especially two types of operation at those times were outstanding,

Removal of the gall bladder stone and the plastic surgery of the nose.

Nursing in India:

 In the beginning the nursing was hindered by many difficulties like the

cast system among the Hindus, the Pardha system among the Muslims

and the low status of the women.

 In the beginning period the nurse has a servant image so no one was

ready for nursing.

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

 The military nursing was the earliest type of the nursing in 1664 the

British east India company helped to start a hospital for soldiers in

madras (St. George HOSPITAL). The company appointed staff was

served in the hospital.

 In 1854 the government sanctioned training school for the midwives.

 1864 Miss Florence Nightingale starts the efforts to reform the hospitals.

St. Stephens Hospital Delhi .

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 1864 - First to train Indian girls as nurses. .

 In 1871 the government, general hospital of madras took a plan to train

the nurses. The nurses from the England were the in charge of the training

and the students were those who previously received there diploma in

midwifery.

 1905 – T.N.A.I established.

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 1926 – Madras state formed the first registration council .

 1946 – First four year Basic Bachelor degree program established in

R.A.K (Rajkumari Amrit Kaur College of Nursing) Delhi and C.M.C

Vellore.

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 After 1947 the many changes begin to take place. The attitude towards

the nursing begins to change and the nursing begin to see as a profession.

The Indian Nursing Council was passed by ordinance on December 31,

1947. The council was constituted in 1949.

 The development of Nursing in India was greatly influenced by the

Christian missionaries, World War, British rule and by the International

agencies such as the World Health Organization UNICEF, the Red

Cross, UNSAID etc.

 1960 – First Masters Degree program was started in R.A.K College of

Nursing Delhi. .

 In 1970 the WHO recognized nursing as a profession. Nursing today

provides an ever widening scope of opportunity for service. Today nurses

enjoy many rights and privileges, but the desired standards by the

complete dedication for the profession.

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Medical surgical nursing :

 Medical surgical Nursing is a nursing speciality which is

concerned with care of adult patients in a broad range of

settings.

 Traditionally, medical surgical nursing was an entry level

position, a stepping stone to speciality areas.

 Advances in medicine and surgery have resulted in medical-

surgical nursing evolving into its own specialty.

 The ACADEMY OF MEDICAL SURGICAL NURSES

(AMSN) is a specialty nursing organization dedicated to

nurturing medical-surgical nurses as they advance their careers.

 Nursing encompasses autonomous and collaborative care of

individuals of all ages, families, groups and communities, sick

or well and in all settings. It includes the promotion of health,

the prevention of illness, and the care of ill, disabled and dying

people. -WHO

 The unique function of the nurse is to assist the individual, sick

or well, in performance of those activities contributing to health

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 or its recovery (or peaceful death) that he/she would perform

unaided if he/she had the necessary strength, will or knowledge.

-VIRGINA HENDERSON(1966)

 In the 17th cent., St. Vincent de Paul began to encourage women to

undertake some form of training for their work, but there was no
real hospital training school for nurses until one was established in
Kaiserwerth, Germany, in 1846.

 There, Florence Nightingale received the training that later enabled

her to establish, at St. Thomas’s Hospital in London, the first
school designed primarily to train nurses rather than to provide
nursing service for the hospital

 In the United States, nursing modernized rapidly during the late

19th and early 20th centuries. The number of hospitals nationwide
grew from only 149 in 1873 to 4,400 in 1910. With this growth,
new positions for nurses developed, and nursing gained respectable
social status.

 Nursing subsequently became one of the most important

professions open to women until the social changes brought by the
revival of the feminist movement that began in the 1960s.

 During the late nineteenth and early twentieth centuries in the

United States, adult patients in many of the larger hospitals were
typically assigned to separate medical, surgical, and obstetrical
wards.
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 Nursing education in hospital training schools reflected these
divisions to prepare nurses for work on these units

 Early National League of Nursing Education (NLNE) curriculum

guides treated medical nursing, surgical nursing, and disease
prevention (incorporating personal hygiene and public sanitation)
as separate topics.

 By the 1930s, however, advocates recommended that medical and

surgical nursing be taught in a single, interdisciplinary course,
because the division of the two was considered an artificial
distinction. Surgical nursing came to be seen as the care of medical
patients who were being treated surgically.

 The NLNE’s 1937 guide called for a “Combined Course” of

medical and surgical nursing

 Students were expected to learn not only the theory and treatment
of abnormal physiological conditions, but also to provide total care
of the patient by understanding the role of health promotion and the
psychological, social, and physical aspects that affected a patient’s
health.

 1960s, nursing schools emphasized the interdisciplinary study and

practice of medical and surgical nursing.

 1960s and 1970s, standards were developed for many nursing

specialties, including medical-surgical nursing.

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 Standards, Medical-Surgical Nursing Practice, written by a
committee of the Division on Medical-Surgical Nursing of the
American Nurses’ Association (ANA), was published in 1974. It
focused on the collection of data, development of nursing diagnoses
and goals for nursing, and development, implementation, and
evaluation of plans of care.

 A Statement on the Scope of Medical-Surgical Nursing Practice

followed in 1980.

 In 1991, the Academy of Medical-Surgical Nurses (AMSN) was

formed to provide an independent specialty professional
organization for medical-surgical and adult health nurses.

 In 1996, the AMSN published its own Scope and Standards of

Medical-Surgical Nursing Practice

 The second edition appeared in 2000 . Both the ANA and AMSN
documents stated that while only clinical nurse specialists were
expected to participate in research, all medical-surgical nurses must
incorporate research findings in their practice.

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CURRENT STATUS OF HEALTH AND DISEASE BURDEN IN

INDIA:

Introduction :

In 1993, the World Bank proposed using burden of

disease estimation paired with cost-effectiveness and economic
analyses as quantitative tools to set priorities for disease control.
The Bank's measure of the global burden of disease drew upon three
inputs: earlier work at WHO on consistent estimates of death by
cause worldwide, methodologies developed in the 1970s to combine
fatal and non-fatal health events now known as disability-adjusted

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life-years (DALYs)—and an illustration of national burden in Ghana
that combined non-fatal outcomes with cause of death
estimates .Many governments, especially of low-income and middle-
income countries (LMICs), now conduct local cost-effectiveness
studies.
India is presently in a state of transition — economically,

demographically, and epidemiologically — in terms of health. While

the last decade has seen remarkable economic development

particularly in terms of gross domestic product (GDP) growth

rate,unfortunately this progress is accompanied by growing disparities

between the rich and the poor. There is strong evidence to suggest that

this income inequality or disparity between the different

socioeconomic classes is associated with worse health

outcomes.Widening the gap between the rich and the poor has

damaging health and social consequences. While financial inclusion

and social security measures are being implemented by the

Government to bridge economic inequalities, health sector too must

ensure that health disparities between and among social and economic

classes are also addressed adequately.

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 Many countries, including India, seek locally constructed

disease burden estimates comprising mortality and loss of health to

aid priority setting for the prevention and treatment of diseases. We

created the National Burden Estimates (NBE) to provide transparent

and understandable disease burdens at the national and subnational

levels, and to identify gaps in knowledge.

To calculate the NBE for India, we combined 2017 UN

death totals with national and subnational mortality rates for 2010–17

and causes of death from 211 166 verbal autopsy interviews in the

Indian Million Death Study for 2010–14. We calculated years of life

lost (YLLs) and years lived with disability (YLDs) for 2017 using

published YLD–YLL ratios from WHO Global Health Estimates. We

grouped causes of death into 45 groups, including ill-defined deaths,

and summed YLLs and YLDs to calculate disability-adjusted life-

years (DALYs) for these causes in eight age groups covering rural

and urban areas and 21 major states of India.

In 2017, there were about 9·7 million deaths and 486 million

DALYs in India. About three quarters of deaths and DALYs occurred

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in rural areas. More than a third of national DALYs arose from

communicable, maternal, perinatal, and nutritional disorders. DALY

rates in rural areas were at least twice those of urban areas for

perinatal and nutritional conditions, chronic respiratory diseases,

diarrhoea, and fever of unknown origin. DALY rates for ischaemic

heart disease were greater in urban areas. Injuries caused 11·4% of

DALYs nationally. The top 15 conditions that accounted for the most

DALYs were mostly those causing mortality (ischaemic heart disease,

perinatal conditions, chronic respiratory diseases, diarrhoea,

respiratory infections, cancer, stroke, road traffic accidents,

tuberculosis, and liver and alcohol-related conditions), with disability

mostly due to a few conditions (nutritional deficiencies,

neuropsychiatric conditions, vision and other sensory loss,

musculoskeletal disorders, and genitourinary diseases). Every

condition that was common in one part of India was uncommon

elsewhere, suggesting state-specific priorities for disease control.

The health challenges :

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In health sector, India has made enormous strides over the past

decades. The life expectancy has crossed 67 years, infant and under-

five mortality rates are declining as is the rate of disease incidence.

Many diseases, such as polio, guinea worm disease, yaws, and tetanus,

have been eradicated.

In this progress, the communicable diseases is expected to continue to

remain a major public health problem in the coming decades posing a

threat to both national and international health security.

Besides endemic diseases such as human immunodeficiency virus

infection and acquired immune deficiency syndrome (HIV/AIDS),

tuberculosis (TB), malaria, and neglected tropical diseases, the

communicable disease outbreaks will continue to challenge public

health, requiring high level of readiness in terms of early detection

and rapid response. In this regard, vector-borne diseases, such as

dengue and acute encephalitis syndrome, are of particular concern.

Antimicrobial resistance is one of the biggest health challenges facing

humanity that must be tackled with all seriousness.

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In addition, non-communicable diseases or NCDs are now the leading

cause of death in the country, contributing to 60% of deaths.

Four diseases namely heart disease, cancer, diabetes, and chronic

pulmonary diseases contribute nearly 80% of all deaths due to NCDs

and they share four common risk factors namely tobacco use, harmful

use of alcohol, unhealthy diet, and lack of physical activities.

CURRENT CONCEPT OF HEALTH :

Health is defined or understood is important for both health

professionals and patients to plan healthcare interventions and health

promotion programs. However, health concept is considered complex

and includes multiple dimensions.

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Definition :

WHO- 1948.

The WHO provides a definition of health that is holistic: “a

state of complete physical, mental, and social well-being, and not

merely the absence of disease and infirmity”

Henderson (1966)

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Health is viewed in terms of a person’s ability to perform 14 self-

care tasks and a quality of life basic to human functioning.

Peplau (l952, 1988)

Health is defined as forward movement of the personality that is

promoted through interpersonal processes in the direction of creative,

productive, and constructive living.

Rogers (1970, 1989)

Health is defined as a value term for which meaning is determined by

culture or the individual. Positive health symbolizes wellness.

Orem (1971, 1980, 1995)

Health is defined as a state that is characterized by soundness or

wholeness of bodily and mental functioning. It includes physical,

psychological, interpersonal, and social aspects. Well-being is the

individual’s perceived condition of existence.

King (1971, 1981)

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Health is defined as a dynamic state of the life cycle; illness is an

interference in the life cycle. Health implies continuous adaptation to

stress.

Neuman (1989)

Health is defined as reflected in the level of wellness.

Parse (1981, 1989)

Health is defined as a lived experience—a rhythmic process of being

and becoming.

Tripp-Reimer (1984)

Health is defined as encompassing two dimensions, the etic

(objective) and the emic (subjective), which include both

disease/nondisease and illness/wellness.

Lyon (1990)

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Health is defined as a person’s subjective expression of the composite

evaluation of somatic sense of self (how one is feeling) and functional

ability (how one is doing). The resulting judgment is manifested in

the subjective experience of some degree of illness or wellness.

CONCEPT OF HEALTH :

The new concepts are bound to emerge based on the new patterns of

thought. The changing concept of health is mainly of four types :

BIOMEDICAL CONCEPT :

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  Traditionally health has been viewed as “ absence of disease” if

one person is free from disease, they are considered healthy.

This concept is known as Biomedical Concept , it has basis and

it is germ theory of disease.

 The medical profession viewed the human body as a machine ,

disease because of the breakdown of the machine and one of the

Doctor`s tasks as repair of machine.Thus health in a narrow

view became ultimate goal of medicine .

 The limitation of this concept is that, it has minimized the role

of environmental, social , psychological and cultural

determinants of health.

ECOLOGICAL CONCEPT :

 The ecologist put forward another hypothesis, which viewed

health as a dynamic equilibrium between man and his

environment , and disease as a mal adjustment of the human

organisms to the environment.

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  Ecological and cultural adaptations determine not only the

occurrence of disease but also the availability of food and the

population explosion.

 History argues that improvement in human adaptation to natural

environment can lead to longer life expectancies and a better

quality of life.

 The concept supports the need for clean air, safe water, ozonic

layer in the atmosphere , etc.to protect us from exposure to

unhealthy factors.

PSYCHO SOCIAL CONCEPT:

Contemporary development in social sciences related

that health is not only a biomedical phenomenon, but also one , which

is in need by social psychological , cultural, economic and political

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factors of the people concerned. Health is both a biological and social

phenomenon.

HOLISTIC CONCEPT :

 Holistic means viewing a person’s health as a balance of body ,

mind , and spirit. Treating only the body will not necessarily

restore optimal health . in addition to physical needs, nurses

must also consider clients psychological, socio cultural,

developmental, and spiritual needs.

 Holistic model is a synthesis of biomedical & ecological model

& psychosocial concept.It recognises the strength of social ,

economic, political and environmental influence on health.

 It has been defined as unified or multidimensional process

involving the well- being of the whole person in the context of

his environment.

 Holistic concept implies that , all sectors of society have an

effect on health , in particular, agriculture, animal husbandry ,

food , industry, education, housing, public works,

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communications and health sectors the emphasis is on

promotion and protection of health.

TRENDS IN MEDICAL SURGICAL NURSING

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Trends in Medical Surgical nursing:

 Quantification of nursing care costs

 Reduced length of stay
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  Increasing Reliance On High Technology
 Requirement of advanced nursing knowledge
 Need for collaboration and communication
 Innovation in care planning through computerization
 Unification of practice and education
 Greater investment in research and development
 Role blurring and shared competencies
 New areas of nursing specialization
 Nursing seen as a cost effective approach to health
 Telenursing
 Robotic nursing
 Aerospace nursing
 Community based nursing.

Quantification of nursing costs :

 Quantification of nursing contribution to patient care can be

used to determine the cost of providing care to specific patients

 Quantifying nursing time requires the identification of the level

of nursing care necessary for each patient.

 The patient care plan is an integral part of the justification of

nursing care costs .

Reduced length of stay

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  The provision of personalized care must be planned and

provided with continuity as the quality of care time decreases.

 Many patients who leave the hospital earlier are still need of

health care.

 Aggressive discharge planning must begin on admission.

 An effective coordinated plan of care can help ensure continuity

of care.

Increase reliance on high technology

 The evolving technological advances in nursing are the wave

of the future in healthcare.

 Emerging new technologies in EHRs, AI, apps and software

development are becoming increasingly popular as more

hospitals and facilities integrate them into their health system.

Requirement of advanced nursing knowledge

• The medical –surgical nurse needs greater clinical expertise,

maturity, clinical thinking ability, assertiveness and patient

management skills to handle patients.

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 • Certification acknowledges the nurses attaintment of

predetermined standards established by the certifying groups.

Need for collaboration and communication

 The health care delivery becomes more complex and

economically centred that need communication and

collaboration among health care professionals. • Only through

collaboration between departments, services, and facilities the

nursing care can be delivered effectively.

Innovation in planning care through computerisation

 Nurses believe that their better time can be spend at the bedside

giving patient care rather than filling out paperwork.

 Studies shows that institutions using computers reports

increases number of plan of care being generated.

Unification of practice and education

The Unification Model directs nursing education, research, and

practice.
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 Unification is not only a philosophical approach but also an

organizational structure that operationalizes the interdependence

among education, research and practice.

Greater investments and developments

 In the recent years the budget allocation for nursing research has

been increased in the view of increasing the quality of nursing .

 .care.

Role blurring and shared competencies

• Nowadays the role of nurses is not clearly defined

• The work of nurses are shared with other departments .

Nursing –cost effective approach

 The nursing procedures we are doing are evidenced based and

cost effective when compare to medical treatment and

procedures.

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Telenursing

 Tele nursing or telehealth nursing uses technologies to provide

nursing services through computers and mobile devices

 It allows patients to connect with their nurses through mobiles

devices,computers,applications etc.

Robotic nursing

Robots are used in nursing for monitoring elderly patient via

video ,helps in positioning, feeding,shifting etc…

Community based nursing

 The health care delivery concept is now changing from hospital

centered to community based nursing.

Issues in medical surgical nursing

 Staff shortage

 Meeting patients expectations

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 Long work hours

 Workplace violence

 Workplace hazards

 Scope of practice

 Personal health.

Staff shortages

 The world health organization estimates that there will be

shortage of 1.1 million nurses throught out the world.

 This may cause disturbances in health care system .

Meeting the patients expectations

 Due to advanced technology and awareness, the patients

expectation are not met.

 This causes job dissatisfaction among nurses.

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Long work hours

 Shortage of nurses forces the nurses to work for long hours

which causes physical and mental disturbances.

Workplace hazards

 Needle stick injuries,sharp tools, and heavy equipments may

risk the nurses health and life.

Scope of practice

 The scope of practice for nurses makes nurses to work in a

defined area of practice.

 Till now there is no prescribed scope of practice for nurses in

India.

Personal health

 Working in a stressful health care system causes physical and

mental disequilibrium.

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ETHICAL & CULTURAL ISSUES IN MEDICAL- SURGICAL

NURSING :

ETHICS :

 The word Ethics is derived from Greek word “Ethos” which

means customs or guiding beliefs (character).

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  Ethics is the study of good conduct, character and motives. –

POTTER

MEANING OF LEGAL ISSUES

• Law is standard or rules of conduct established & enforced by

government.

• Legal issues in nursing are those in which a person lead to face

legal problems in which nurse face problem when not meeting

proper patient care.

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.

MEDICO LEGAL ISSUES

1.DUTY TO SEEK MEDICAL CARE FOR THE PATIENT

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 • It is the legal duty of the nurse to ensure that every

patient receives safe and competent care.

• If a nurse determine that a patient in any setting needs

medical care, and she does not do everything within power

to obtain that care for the patient, you have breached your

duty as a nurse.

2. CONFIDENTIALITY

 The law requires you to treat all such information with strict

confidentiality. This is also an ethical issue. Unless a patient has

told something that indicates danger to self or others, you are

bound by legal and ethical principles to keep that information

confidential.

3. PERMISSION TO TREAT

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 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.

4.INFORMED CONSENT

5. NEGLIGENCE

 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.

6. MALPRACTICE

 Malpractice specifically refers to negligence by a professional

person with a license.

 Nurse can be sued for malpractice once have your LPN license.

7. ASSAULT & BATTERY

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  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.

 Assault can be verbally threatening a patient.

8. 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 includes using restraints or locking a person in

a room.

 In some situations, restraints and locking patients in a room are

acceptable behaviour.

 This is the case when a prisoner comes to the hospital for

treatment or when a patient is a danger to self or others.

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9. INVASION OF PRIVACY

 Clients have claims for invasion of privacy , e.g. their private

affairs, with which the public has no concern, have been

publicized.

 Clients are entitled to confidential health care.

 All aspects of care should be free from unwanted publicity or

exposure to public scrutiny.

 The precaution should be taken sometimes an individual right to

privacy may conflict with public‘s right to information for e.g.

in case of poison case.

10. REPORT IT / 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).

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  If no report is made, the nurse is liable for negligence or

wrongdoing towards the victimized patient.

11.PATIENT SATISFACTION

 Patient satisfaction is an important and commonly used

indicator for measuring the quality in health care.

 Patient satisfaction affects clinical outcomes, patient retention,

and medical malpractice claims.

ASSESSMENT OF QUALITY OF HEALTH CARE

 Patient as a consumer

 Today the patient sees himself as a buyer of health services.

patient satisfaction is an important tool for the success of their

organization and are regularly monitoring patient satisfaction

levels among their customers.

• SERVICE EXCELLENCE

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Service excellence revolves around three factors: doctor, patient, and

organization.

Doctor- He should do following- See the whole person

Secure confidentiality and privacy

Preserve dignity & Respond quickly

Patient- Patients expect their doctors to keep up the timings, behave

cordially, and communicate in their language. They expect care,

concern, and courtesy in addition to a good professional job.

Hospital There are certain areas where minimum requirements and

standards have to be maintained.

• Good Telephone service

• Good Office appearance

• Minimizing Waiting time

• More Doctor-patient interaction

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 • Proper Patient education

• Feedback

BENEFITS OF PATIENT SATISFACTION

• Patient satisfaction leads to customer (patient) loyalty.

• Improved patient retention

• Consistent profitability

• Increased staff morale with reduced staff turnover also leads to

increased productivity

• Reduced risk of malpractice suits

• Accreditation issues are resolved.

• Increased personal and professional satisfaction.

MANAGEMENT ISSUES

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It is a considerable challenge to meet the needs of the organization,

the needs of patients, and the needs of the nurse employees.

1. TURNOVER

• 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

neighbouring clinics.

2. FUNDING

• An underfunded institution cannot attract and provide

for the right professionals.

• 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.

3. Workload

• 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.

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 • Many nurses are unwilling to enter into the nurse

management field because of the added stress and

responsibility.

4. ISSUES REGARDING MALPRACTICE IN NURSING

MANAGEMENT-

• It can lead to several management problems. Improper

use of administration power, improper managing of supplies,

staff, ward, institution etc.

5. ISSUES OF DELEGATION AND SUPERVISION –

The failure to delegate and supervise within

acceptable standards of professional practice.

6. ISSUES RELATED TO STAFFING

• Inadequate accreditation standards

• Inadequate staffing, i.e. short staffing.

• Floating staff from unit to unit.

7. ETHICS

• Nurses provide care, promote human rights and values,

and help meet the needs

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 • Keeping patients' information confidential.

• Protecting patients from negligent co-workers who may

endanger them.

8. . 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.

• The salaries need to be increased, and colleges and

universities need to see the value in instructors.

9. ISSUES IN NURSING CURRICULUM DEVELOPMENT

• It includes validation of curriculum or judgemental process

• Providing professional education and preparation of

participants

• Updating & upgrading recent knowledge.

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 10. COLLABORATION ISSUES

• There is increased complex health care issues

driven by technological and medical advancements

• Collaborative partnerships has ensured the

continuing development of the professional expertise

necessary to meet these challenges.

C. EMPLOYMENT ISSUES

1. ISSUES RELATED TO NURSING SHORTAGE

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.

2. ISSUES IN NURSE MIGRATION

• Nurse migration has attracted a great deal of political as well

as media attention in recent years.

50
 • 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.

3. THE RIGHT TO WORK AND THE RIGHT TO PRACTICE

• 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.

4. EXPLOITATION AND DISCRIMINATION

 Essential Terms and Conditions in an Employment contract

 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 these items in an employment

contract can give rise to serious consequences for employers.

51
5. UNSATISFACTORY WORK PERFORMANCE AND

TERMINATION OF EMPLOYMENT

 The Courts have time and again reiterated that employees enjoy

security of tenure of employment.

 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

6. MISCONDUCT AND IMPOSITION OF PUNISHMENT :

 It has long been held that the employer has the inherent right to

discipline his workers.

 The Courts will interfere if, the action taken by the

management was perverse, baseless or unnecessarily harsh or

was not just or fair.

52
  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.

7. SEXUAL HARASSMENT AT THE WORKPLACE

8. RENEWAL OF NURSING REGISTRATION :

 In this case, registration office is updated with nurses in

practice.

 Re- registration may qualify its periodicity and qualifications of

nurses e.g. clinical experience, attendance at continuing

education etc.

9. DIPLOMA VS DEGREE IN NURSING FOR REGISTRATION

TO PRACTICE NURSING
• This issue need in depth study of merits and demerits as well as

its feasibility before it could come on the surface.

10. SPECIALIZATION IN CLINICAL AREA

• It could be either through clinical experience or education.

53
 • Specialization in cure and specialized care required for patients

demand that nurses be highly skilled in the unit.

• Standards must be laid down and followed so that clients

understand the quality of care expected from the nurses.

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. Practices nursing within the area of individual competence

4. Prioritizes patients right and welfare first in decision making

5. Delegates to subordinates wisely, looking at the managers

scope of practice and that of those they supervise.

54
 RIGHTS OF PATIENTS :

Patient Rights

1. A patient has the right to respectful care given by competent

workers.

2. A patient has the right to know the names and the jobs of his or her

caregivers.

3. A patient has the right to privacy with respect to his or her medical

condition. A patient’s care and treatment will be discussed only

with those who need to know.

4. A patient has the right to have his or her medical records treated as

confidential and read only by people with a need to know.

Information about a patient will be released only with permission

from the patient or as required by law.

5. A patient has the right to request amendments to and obtain

information on disclosures of his or her health information, in

accordance with law and regulation.

6. A patient has the right to know what facility rules and regulations

apply to his or her conduct as a patient.

55
7. A patient has the right to have emergency procedures done without

unnecessary delay.

8. A patient has the right to good quality care and high professional

standards that are continually maintained and reviewed.

9. A patient has the right to make informed decisions regarding his or

her care and has the right to include family members in those

decisions.

10. A patient has the right to information from his or her doctor in

order to make informed decisions about his or her care. This means

that patients will be given information about their diagnosis,

prognosis, and different treatment choices. This information will be

given in terms that the patient can understand. This may not be

possible in an emergency.

11. A patient given the option to participate in research studies has

the right to complete information and may refuse to participate in

the program. A patient who chooses to participate has the right to

stop at any time. Any refusal to participate in a research program

will not affect the patient’s access to care.

56
12. A patient has the right to refuse any drugs, treatment or

procedures to the extent permitted by law after hearing the medical

consequences of refusing the drug, treatment or procedure.

13. A patient has the right to have help getting another doctor’s

opinion at his or her request and expense.

14. A patient has the right to care without regard to race, color,

religion, disability, sex, sexual orientation, national origin, or

source of payment.

15. A patient has the right to be given information in a manner that

he or she can understand. A patient who does not speak English, or

is hearing or speech impaired, has the right to an interpreter, when

possible.

16. Upon request, a patient has the right to access all information

contained in the patient’s medical records within a reasonable

timeframe. This access may be restricted by the patient’s doctor

only for sound medical reasons. A patient has the right to have

information in the medical record explained to him or her.

17. A patient has the right not to be awakened by staff unless it is

medically necessary.

57
18. A patient has the right to be free from needless duplication of

medical and nursing procedures.

19. A patient has the right to treatment that avoids unnecessary

discomfort.

20. A patient has the right to be transferred to another facility only

after care and arrangements have been made and the patient has

been given complete information about the hospital’s obligations

under law.

21. A patient has the right to a copy of his or her bills. A patient also

has the right to have the bill explained.

22. A patient has the right to request help in finding ways to pay his

or her medical bills.

23. A patient has the right to help in planning for his or her

discharge so that he or she will know about continuing health care

needs after discharge and how to meet them.

24. A patient has the right to access people or agencies to act on the

patient’s behalf or to protect the patient’s right under law. A patient

has the right to have protective services contacted when he or she

or the patient’s family members are concerned about safety.

58
25. A patient has the right to be informed of his or her rights at the

earliest possible time in the course of his or her treatment.

26. A patient has the right to make advance directives (such as a

living will, health care power of attorney and advance instruction

for mental health treatment) and to have those directives followed

to the extent permitted by law.

27. A patient has the right to personal privacy and to receive care in

a safe and secure setting.

28. A Medicare patient has the right to appeal decisions about his or

her care to a local Medicare Review Board. The Facility will

provide the name, address, and phone number of the local

Medicare Review Board and information about filing an appeal.

29. A patient has the right to be free from all forms of abuse or

harassment.

30. A patient has the right to be free from the use of seclusion and

restraint, unless medically authorized by the physician. Restraints

and seclusion will be used only as a last resort and in the least

restrictive manner possible to protect the patient or others from

harm and will be removed or ended at the earliest possible time.

59
31. A patient has the right to designate visitors who shall receive the

same visitation privileges as the patient’s immediate family

members, regardless of whether the visitors are legally related to

the patient.

32. A patient has the right to pastoral care and other spiritual

services.

33. A patient has the right to be involved in resolving dilemmas

about care decisions.

34. A patient has the right to have his or her complaints about care

resolved.

35. A patient and his or her family have the right to request

assistance from the Nash Hospitals, Inc ad hoc ethics committee

for ethical issues, such as starting or stopping treatments to keep

patients alive, differences of opinion or when advance directives

cannot be honored.

36. The patient has the right to appropriate pain management.

37. A patient has the right to be free from financial

exploitation by the health care facility.

60
Children and Adolescents

1. The family/guardian of a child or adolescent patient has the right

and responsibility to be involved in decisions about the care of

the child. A child or adolescent has the right to have his or her

wishes considered in the decision-making as limited by law.

2. A child or adolescent patient has the right to expect that care and

the physical environment will be appropriate to his or her age,

size, and

needs.

3. A child or adolescent patient whose treatment requires a long

absence from school has the right to education services. These

services will be arranged with the local school system.

Patient Responsibilities

1. Patients are responsible for providing correct and complete

information about their health and past medical history.

2. Patients are responsible for reporting changes in their general

health condition, symptoms, or allergies to the responsible

caregiver.

61
3. Patients are responsible for reporting if they do not understand

the planned treatment or their part in the plan.

4. Patients are responsible for following the recommended

treatment plan they have agreed to, including instruction from

nurses and other

health personnel.

5. Patients are responsible for keeping appointments.

6. Patients are responsible for treating others with respect.

7. Patients are responsible for following facility rules regarding

smoking, noise, and use of electrical equipment.

8. Patients are responsible for what happens if they refuse the

planned treatment.

9. Patients are responsible for paying for their care.

10. Patients are responsible for respecting the property and

rights of others.

11. Patients are responsible for assisting in the control of noise

and the number of visitors in their rooms

62
 NATIONAL POLICY , SPECIAL LAWS & ORDINANCES

RELATING TO OLDER PEOPLE

NATIONAL POLICY :

NATIONAL POLICY ON OLDER PERSONS (NPOP) 1999:

The NPOP in India has been formulated as a forward-looking

vision of the government for improving quality of life of older

people in India through

i) increased income security,

ii) ii) health and nutrition,

iii) iii) shelter,

iv) education, empowerment and welfare.

GOAL OF NATIONAL POLICY

 Well being of older persons by strengthening their legitimate

place in society and help to live their life with purpose, dignity

and peace.

63
OBJECTIVES OF POLICY

1. To encourage individuals to make various provisions such as

health and social insurance for their own as well as their spouse’s

old age;

2. To encourage families to take care of their older family

members.

3. To enable and support voluntary and nongovernmental

organisations to supplement the care provided by the family, with

greater emphasis on non institutional care;

4. To provide care and protection to the vulnerable elder especially

widows, frail, physically challenged, abused and destitute elderly.

5. To provide health care facilities specially suited to elderly

6. To promote research and training to train geriatric care givers

and organisers of services for the elderly;

64
 7. To continually evaluate and upgrade existing services and

programs for older people;

8. To facilitate and strengthen inter sectoral partnerships in the

field; and

9. To create awareness regarding elder persons to develop

themselves into fully independent citizens.

ELEMENTS OF NPOP POLICY

1.Financial Security:

Pension scheme (in public and private sector)

Lower income tax rate and exemptions

2. Health care and Nutrition:

Setting up Geriatric wards and training on Geriatric

Specialized care

Expanding Mental Health Services for elderly.

65
3.Shelter:

Government and Private Housing Schemes for elderly

Disposal of cases relating to property transfer, mutation of

property and tax.

4. Education:

Information to elderly about Concept of wellness in old age

Evolving changes in lifestyle and living style.

5. Welfare :

 Identifying extremely vulnerable elderly who are disabled,

chronically sick and destitute.

 Assistance to voluntary organisations to construct and

maintain old age homes, day care centre, multi-service

citizens centres, supply of disability-related aids and

appliances

 Providing welfare funds for elderly with support from

corporate sector, trusts, charities, individual donors and

involvement of NGOs.

66
 6. Research and Training:

 Encourage medical colleges, training institutions for

Nurses and Para medical institutes to introduce

COURSES ON GERIATRIC CARE.

 Research and documentation in elderly care

 NGO supported specialized training in Geriatric care.

7. Sensitizing the Media:

 Involvement of social medias and internet to create

awareness.

List of Ministries/ Department of The Inter-Ministerial

Committee Implementing Indian National Policies On Older

Persons

1. Ministry of Social Justice and Empowerment

2. Ministry of Health and Family Welfare

3. Ministry of Finance

4. Ministry of Rural Development and Employment

67
5. Ministry of Urban Affairs and Employment

6. Ministry of Human Resource Development

7. Ministry of Labour

8. Ministry of Personnel, Public Grievances and Pensions

9. Ministry of Law Justice and Company Affairs

10. Ministry of Home Affairs

11. Ministry of Information and Broadcasting

12. Ministry of Communication

13. Ministry of Railways

14. Ministry of Agriculture

15. Ministry of Surface Transport

16. Ministry of Civil Aviation

68
17. Ministry of Petroleum and Natural Gas

18. Ministry of Food and Consumer Affairs

19. Ministry of External Affairs

Ministries may be considered core as they are responsible for a large

and important chunk of services to older persons. These are:

1. Ministry of Social Justice and Empowerment (MOSJE) is

responsible for coordination across ministries and also for

implementing the central sector IPOP with the objective of improving

the quality of life of senior citizens by providing basic amenities like

shelter, food, medical care and entertainment activities and by

encouraging productive and active ageing.

2. Ministry of Health and Family Welfare (MOHFW) is responsible

for implementing the National Programme for Health Care of Elderly

(NPHCE) through primary, secondary and tertiary services, dedicated

for older persons.

69
3. Ministry of Rural Development (MORD) administers the National

Social Assistance Programme (NSAP) under which old-age pensions

and family benefits are provided to BPL families.

4. Ministry of Panchayati Raj (MOPR) is responsible for

empowerment, enablement and accountability of Panchayati Raj

Institutions (PRIs) to ensure inclusive development with social justice

and efficient delivery of services and participatory self-governance.

Under the Sansad Adarsh Gram Yojana (SAGY), each Member of

Parliament has to adopt panchayat and work towards convergence of

various programmes to improve quality of life in rural areas. When

implemented, this scheme will help rural elderly in many direct and

indirect ways.

VISION OF THE NPOP are covered as

(i)Maintenance and Welfare of Parent and Senior Citizens Act 2007:

 Parents and grandparents who are unable to maintain themselves

from their own income can demand maintenance from their

70
 children, inclusive of food, clothing, residence, medical

attendance and treatment, to a maximum of 10,000 per month.

 The Act provides for a tribunal to receive and take action on

complaints.

 In case the children themselves do not have sufficient means to

maintain them, the state governments are expected to provide

old-age homes in each district to accommodate a minimum of

150 elderly.

 An important provision under the Act legally empowers the

elderly to claim their property back from their children if the

condition of maintenance is not satisfied.

ii) Integrated Programme for Older Persons (Revised 2016):

 The IPOP (implemented since 1992) provides financial

assistance (up to 90 percent) to PRIs/local bodies, NGOs,

educational institutions, charitable hospitals/nursing

homes etc. for implementing a variety of facilities such as

oldage homes, mobile medical units for older persons

living in rural and isolated areas, day care centres,

71
 physiotherapy clinics, provision of disability aids, running

helplines and counselling centres and sensitization of

school and college students to ageing issues.

(iii) National Programme for Health care of Elderly (NPHCE):

 The health care programme for the elderly is being implemented

by the MOHFW from 2011 under the National Rural Health

Mission (NRHM).

 Under National Health Mission Program (NHM) dedicated 10-

bedded wards at district hospitals, strengthening of the eight

regional medical institutes to provide dedicated tertiary-level

medical facilities for the elderly, introducing postgraduate

courses in Geriatric Medicine, and in-service training of health

personnel at all levels. Regional geriatric centres with dedicated

geriatric out-patients’ departments and 30-bedded geriatric

wards are planned with necessary equipment such as video

conferencing facility.

72
(iv) National Social Assistance Programme (1995):

1. National Old Age Pension Scheme(NOAPS): in 2007 renamed

as Indira Gandhi National Old Age Pension Scheme(IGNOAPS).

2. The Annapurna Yojana got added to the National Family

Benefit Scheme in 2000. The Annapurna Yojana aims to provide

food security to meet the requirement of those senior citizens

who, though eligible, have remained outside the old-age pension

scheme. It provides 10 kg of free rice every month to each

beneficiary.

3. Subsequently in 2009, NSAP was expanded to include the Indira

Gandhi National Widow Pension Scheme (IGNWPS) covering

widows aged 40–64 years, and the Indira Gandhi National

Disability Pension Scheme (IGNDPS) for persons with multiple

or severe disabilities aged 18–64 years living below poverty line.

In 2011, the age limit for IGNOAPS was lowered from 65

to 60 years and monthly pension amount for those 80 years

and above was increased from ₹ 200 to 500.

73
 •Age limits for IGNWPS and IGNDPS were changed to

40–79 years and 18–79 years respectively and amount

increased from 200 to 300₹ per month.

After about a decade of implementation of NPOP, the

MOSJE set up expert committee to prepare a revised

“National Policy for Senior Citizens (NPSC) 2011.”

FOCUS OF NEW POLICY NPSC mainly focus on:

1.Elderly women need special attention;

2.Rural poor need special attention;

3.Factoring the advancements in medical technology and

assistive into the revised policy. Specially broad categories

of intervention include income security in old age, health

care, safety and security, housing, productive ageing,

welfare, multigenerational bonding, media and protection

during natural disasters and emergencies.

74
 This policy has resulted in the launch of new schemes such

as

1. Strengthening of primary health care system to enable it

to meet the health care needs of older persons

2. Training and orientation to medical and paramedical

personnel in health care of the elderly.

3. Promotion of the concept of healthy ageing.

4. Assistance to societies for production and distribution of

material on geriatric care.

5. Provision of separate queues and reservation of beds for

elderly patients in hospitals.

6. Extended coverage under the Antyodaya Scheme with

emphasis on provision of food at subsidized rates for the

benefit of older persons especially the destitute and

marginalized sections.

Areas of Intervention in NPSC:

I. Income security in old age

II. Health care

75
 III. Safety and Security

IV. Housing

V. Productive Ageing

VI. Welfare

VII. Multigenerational Bonding

VIII. Social Media

Implementation Mechanism:

1. Establishment of Department of Senior Citizens - under MOSJE

2. Establishment of Directorates of Senior Citizens in - State & Union

Territories

3. Establishment of Commissions - under National & State Level

4. Establishment of Council for Senior citizens

5. Responsibility of implementation – other Ministry

6. Role of BDO, PRI and Tribal Councils /Gram Sabhas

76
Recent Initiatives under NPOP

1. Pradhan Mantri Suraksha Bima Yojana: 2015 All savings bank

account holders 18–70 years old can join the scheme. It offers a

coverage of 200,000 for death or total and irrevocable loss of both

eyes and 100,000 coverage for the loss of an eye or a limb.

2. Atal Pension Yojana: The government started the Swavalamban

Scheme in 2010/11 which was replaced by the Atal Pension

Yojana (APY) in June 2015 for those persons engaged in the

unorganized sector, who are not members of any statutory social

security scheme. The existing subscribers of Swavalamban Scheme

would be automatically migrated to APY, unless they opt out.

3. Health Insurance for Senior Citizen:

 Low premium life insurance (Pradhan Mantri Jeevan

Jyoti Bima Yojana)

 General insurance (Pradhan Mantri Suraksha Bima

Yojana),

 The pension plan (Atal Pension Yojana).

77
  It is proposed to link this to bank accounts of

beneficiaries to directly transfer the subsidy to the

accounts. The government would subsidize the

premium for BPL elderly by up to 90 percent

through direct benefit transfer.

4. Varistha Pension Bima Yojana (2017):

This scheme is a part of the government’s

commitment to financial inclusion and social security

during old age and to protect those aged 60 years and

above against a future fall in their interest income due to

uncertain market conditions. The scheme will be

implemented through LIC.

5. Rashtriya Vayoshri Yojana :

Scheme for providing Aids and Assisted Living

Devices to Senior Citizens below Poverty Line

6. New Pension Scheme for Elderly:

7. Senior Citizen Welfare Fund

78
8. Establishment of South Asia Senior Citizen Forum(SASCF):

A regional body called South Asia Senior

Citizens’ Working Group aims to work closely with the

respective governments, NGOs and civil society members

of the region in order to improve the well-being of the

ageing population.

9. National Portals for ELDERLY:

10. AADHAR Based Digital Life certificate for pensioners.

The policy should emphasise the need for expansion of social and

community services for older persons, particularly vulnerable women

group to get accessible to the user friendly client oriented services.

Special efforts will be made to implement the policy at the rural

populations and unorganized sectors where most of the older

population lives.

FIVE YEAR PLANS:

 First Plan (1951 – 55)

 Second Plan (1956 – 60)

 Third Plan (1961 – 66) PLAN HOLIDAY

 Fourth Plan (1969 -74)

79
  Fifth Plan (1974 – 79)

 Sixth Plan (1980 – 85)

 Seventh Plan (1985 – 90)

 Eighth Plan (1992 – 97)

 Ninth Plan (1997 – 2002)

 Tenth Plan (2002 – 2007)

 Eleventh plan (2007-2011)

 Twelfth plan (2012-2016)

National health programs :

National Health Mission

Communicable Diseases

1. Revised National TB Control Programme(RNTCP)

2. National Leprosy Eradication Programme

3.National Filaria Control Programme

4. National Aids Control Programme

5. Integrated Disease Surveillance Project (IDSP)

6. National Vector Borne Disease Control Programme (NVBDCP)

80
Non-Communicable Diseases, Injury & Trauma

1. School Health Programme

2. National Programme on Prevention and Control of Diabetes, CVD

and Stroke

3. National Programme for Prevention and Control of Deafness

4. Universal Immunization Programme (RTI ACT, 2005)

5. National Cancer Control Programme

6. National Mental Health Programme

7. National Iodine Deficiency Disorder Control Programme

8. National Programme for Control of Blindness

9.National Programme for Prevention and Control of Fluorosis

(NPPCF)

10. National Tobacco Control Program

11. National Programme for Health Care of the Elderly (NPHCE).

Other programs

1. Pradhan Mantri Swasthya Suraksha Yojana (PMSSY)

Ministry of Social Welfare

2. ICDS scheme

81
Ministry of Social Welfare

3. Mid-day meal program

Ministry of Rural Development

4. Rajiv Gandhi National Drinking Water Mission (RGNDWM).

CONCLUSION:

Certain issues lead to decreased standardization like patient care

issue, management &employment issues. 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.

Nurses play an integral role in the healthcare system. This is why

they have been correctly referred to as the heart of healthcare.

Being a nurse is one of the most demanding professions in the

world and needs a lot of dedication and commitment to the job.

82
Nurses have to juggle various roles. It is a nurse’s professional

responsibility to remain safe and competent by being a lifelong

learner and provide effective care to patient to avoid medicolegal

issues, employment issue can be avoided by proper recruitment

system, staffing & keeping adequate salary.

83
BIBLIOGRAPHY :

BOOK REFERENCES :

 Gulani k.k., Community Health Nursing (Principles &

Practices), Kumar publishing, 2nd edition, Pg. 643-750.

 Basheer Shebeer P, A concise text book of Advance Nursing

Practice, EMMESS medical publisher, 1st edition, pg. 97-101.

 Park K, Preventive & Social Medicine, Bhanot publisher (2011)

23rd edition, Pg. 380-420.

 Gupta MC & Mahajan BK, Preventive & Social Medicine,

Jaypee publisher, 4th edition, Pg. 260-341.

 Lewis LS, Dirksen RS, Heitkemper MM, Bucher L. Lewis’s

Medical Surgical Nursing Assessment and management of

clinical problems. Second edition. Volume 1.India: Reed

Elsevier; 2015

 Smeltzer CS, Bare GB, Hinkle LJ, Cheever HK. Brunner &

Suddarth’s textbook of Medical-surgical nursing. Volume I.

Twelvth edition. NewDelhi:Wolters Kluwer (India) ; 2011.

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 Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M.

(2019). Essentials for Nursing Practice (9th ed.). St. Louis:

Elsevier.

 Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M.

(2017). Fundamentals of Nursing (9th ed.). St. Louis:

Elsevier/Mosby.

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JOURNAL REFERENCES :

 Agency for Healthcare Research and Quality. (2006).

TeamSTEPPS instructor guide. AHRQ Publication No. 06-

0020-0. Rockville, MD: Author.

 Gamino, L.A., & Ritter, R.H. (2012). Death competence: An

ethical imperative. Death Studies, 36(1), 23-40.

 Lachman, V.D. (2007b). Patient safety: The ethical imperative.

MEDSURG Nursing, 16(6), 401-403.

 Physician and Patient; or a Practical View of the Mutual Duties,

Relations, and Interests of the Medical Profession and the

Community. Br Foreign Med Chir Rev. 1850 Oct;6(12):503-

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NET REFERENCES :

 https://www.thebetterindia.com/158829/patient-right-hospital-

law/

 https://www.nashunchealthcare.org/patients-visitors/patient-

rights-and-responsibilities/

 https://www.slideshare.net/EDWINjose43/trends-and-issues-in-

medical-surgical-nursing

 researchgate.net/publication/

349123161_Issues_and_Trends_in_Medical_Surgical_Nursing

 https://www.slideshare.net/induviju/gericon-national-policy-for-

elderly

 https://socialjustice.gov.in/writereaddata/UploadFile/dnpsc.pdf

 https://www.nhp.gov.in/nhpfiles/

national_health_policy_2017.pdf

 https://www.nhp.gov.in/healthprogramme/national-health-

programmes

 https://www.slideshare.net/Ipsita077/national-health-programs-

75454974

87
 www.hatepsm.com/blog/list-national-health-programs-along-

brief-description-each

88
ealth is defined or understood is
important for
89
both health professionals and patients to
plan healthcare
interventions and health promotion
programs. However,
health concept is considered complex and
includes multiple
dimensions
health is defined or understood is
important for
both health professionals and patients to
plan healthcare
interventions and health promotion
programs. However,
health concept is considered complex and
includes multiple
dimensio

90