Introduction

The health care system is intended to provide services and

resources for better health. This system includes hospitals,
clinics, health centers, nursing homes and special health
programme in school, industry and community. Health system
operates in the context of socioeconomic and political
framework of the country. Stakeholder encompasses a wide
sector of society. They include consumer or patients,
community health care professionals, hospital health care
professionals, pharmacists, nongovernmental organizations,
supplies etc.
Management of stakeholder Relationship
Diagnose
each
Identify of stakeholder
stakehold
er

Classify
stakeholder
relationship

Implement
strategies
each for
stakeholder

Formulate
genetic
strategies
Evaluate the
effectiveness
of strategies
Identify type of stake holders
External stake holders

Interface stake holders

Internal stake holders

External Stakeholders
A health care organization must respond to large
number of external stakeholders. They fall into
three categories in their relationships to the
organization.
• Those that provide inputs to organization.
• Those that compete with it
• Those that have particular special interest.
External stake holder cont…..

The first category includes suppliers, patients and

financial community. The relationship between the
organization and these external stakeholders is a
symbiotic one, as organization depends on them for its
survival. In turn these stakeholders depend on the
organization to take their outputs. The relationship
between the organization and the stakeholders that
provide necessary input is one of mutual dependence.
As such the both parties cannot, or do not want to, do
without one another.
External stakeholder cont….

The competitor stakeholder seeks to attract the focal

organization dependents. The competitor may be
direct competitor for patients (e.g. other hospital) or
they may be competing for skilled personnel.
Competitor does not need one another to survive,
while co-operation between hospitals and their
competitor has increased in recent years.
External stake holder cont..

External stake holders in third category are special

interest group. These are the government regulatory
agencies, private accrediting association, professional
associations, labour union, the media and political
action group. Because of special interest conflict most
often occur. Compromise and in some cases overt
collaboration generally resolves the conflicts.
Interface Stakeholders

Some stakeholders function on the interface between

the organization and its environment. The major
categories of interface stakeholders include the
medical staff, the hospital board of trustees. The
organization must provide sufficient inducements to
continue to make appropriate contribution. The
organization may offer professional autonomy
institutional prestige or political contacts, special
services and benefits etc.
Internal stakeholders

Almost entirely within the organization and typically

include management, professional and non
professional staff Management attempts to provide
internal stakeholders with sufficient inducements to
gain continual contribution from them. The
stakeholders determine whether the inducements arc
sufficient for the contribution that they are required
to make partly on the basis of alternative contribution
offer received from competitives.
Stakeholder in health care system

Government

Public

Providers

Hospital administrator
Governing boards

Non governmental
Government

The role of government in the administration of

health care cannot be overestimated. Many federal
government health care efforts are headed by a
cabinet level officer, the secretary for health and
human services, who runs the department of health
and human services. The federal government makes
budget and other planning related to expenditure in
health care..
Government cont..

As the major payer, the federal government has been

active in regulating the health care industry.
Therefore, hospitals have great incentive to comply
with regulations promulgated by federal government,
because they can be fined or decertified a provider of
care to Medicare clients if they do not.
Noncompliance can results in the loss of lot of money
& income for the hospital. Government regulation is
frequently opposed by the health care industry
because it often affects the health care practitioner’s
autonomy.
The Public:
The public has a stake in health care from several perspectives.
As consumers of health care i services or as patients, the public s
concerned with quality, cost and access to care. Many people
believe that health care is a right and should be universally
available to all citizens, regardless of the cost. Paradoxically,
however, most do not want to pay these costs. Patients want
compassion as well as skill with clear communication. They
expect an employer to offer a wide variety of option for health
coverage that can be customized to their specific needs. They
also look for the employs to fund the majority of cost of health
insurance. Overall, public values regarding health care arc
changing. People one interested in receiving quality care at a
reasonable cost. In addition, the public has a more positive view
of health promotion and illness prevention than in past. Health
care resources remain focused on illness, however, with only 1%
of health care expenditure going to public health.
The providers
• Community health care professional
• Hospital health care professional
Community health care professionals
Includes nurses, health workers, dais, doctors of the
community health centers, voluntary health workers
etc.
Hospital Health Care Professional
•Physicians
The role of physicians in the health care
system is an important one. Physicians
provide direct medical services to clients in
variety of settings, including offices, clinics,
hospitals and freestanding centers. In
addition, physician control 60% to 70% of
hospital costs through their decisions
regarding the use of resources. Physicians
decide which client to admit, where to
admit, the length of stay, the ancillary
services, whether to perform surgery, when
to initiate and to discontinue treatment
regimens, and which medications to
prescribe.
Nurses
An individual who provides care to
clients. The extent of participation
varies from simple patient care tasks
to the most expert professional
technique necessary in acute life
threatening situations. The ability of
nurse to function independently and
making self directed judgment will
depends on his or her professional
development. Nurses provide a
unique perspective on the health
care system. The greatest impact and
the most frequently discussed aspect
of nursing has been the recurring
shortage of nurses
Pharmacist
The roles of the pharmacist
are changing. Some can
now prescribe as well as
dispense Medicine. They are
more interested in meeting
the requirements of
pharmaceutical industry.
Hospital administrators and
governing boards

The chief executive, chief

financial officer, chief nursing
officer, and governing boards
of hospital, strongly influence
health care delivery in their
institutions. In addition most
hospitals are members of
some association which
represents the industry's
efforts to influence
legislation, regulation, judicial
decisions, and health policy.
Non- governmental stakeholders

The voluntary agencies occupy an important place in

community health care system. These organizations directly
or indirectly act as stakeholder. These organizations are
administered by autonomous boards which hold meeting,
collect funds from private sources and spend money for
providing health services and health education to individual,
family and community.
Indian Red Cross Society

It was established in 1920 and has over

400 branches all over India. It has been
executing programmes for the
prevention of diseases and promotion
of health. Its activities are
• Relief work.
• Milk and medical supplies.
• Armed forces.
• Maternal and child welfare services.
• Family planning.
• Blood hank and first aid.
Hindu Kusht Nivaran Sangh
It was founded in 1950 with its headquarters in
New Delhi. Its precursor was the Indian council of
British Empire Leprosy Relief Association (B.E.L.R.A)
which was renamed as LEPRA in 1950. The
programme of work of the sangh include rendering
of financial assistance to various leprosy homes.'
clinics, health education, training of medical worker
and physiotherapists conducting research and field
investigation. The sangh has branches all over India
and work in close cooperation with the Government
and other voluntary agencies.
Indian council fir child welfare

It was establish in 1952. It is affiliated with

international union for child welfare. The services of
1.C.C.W are devoted to secure for Indian children
those opportunities and facilities, by law and other
mean which arc necessary to enable them to develop
physically, mentally, morally, spiritually and socially in
a healthy and normal manner and in conditions of
freedom and dignity.
Tuberculosis Association of India
It was formed in 1939. It has branches in all states of India. The activities
of this association comprise organizing T.B campaign every year to raise
funds, training of doctors, health visitors and social workers in anti
tuberculosis work, promotion of health education conferences.
Bharat SevakSamaj
The Bharat SevakSamaj which is non-political and nonofficial organization
was formed in 1952. One of the prime objective of the Bharat sevak is to
help people to achieve health by their own actions and efforts. The B.S.S.
has branches in all the states and nearly all the districts. Improvement of
sanitation is one of the important activities of the B.S.S.
The Kastubra Memorial Fund
Created in commemoration of Kastubra Gandhi, Act her death in 1994,
the fund was raised with the main objective of improving the status of
women, especially in the villages, through gram-savikas. The trust has
nearly one crore of rupees and is actively engaged in various welfare
projects in the country.
All India Women’s Conference
It is the only women's welfare organization in the country. Established in
1962, it has now branches all over the country. Most of branches running
M.C.D. clinics, Medical centres, and adult education centres, milk centres
and family planning clinics.

The All India Blind Relief Society

It was established in 1946 with a view to coordinate different institutions
working for the blind. It organizes relief camps and other measures for
the relief of the blind.
 
Professional bodies
The Indian Medical Association, All India Dental Association, The Trained
Nurses Association of India of all men and women who are qualified m
their respective specialties and possess register able qualifications. These
professional bodies conduct annual conferences, publish journals,
arrange exhibitions, foster research, set up standards of professional
education and organize relief camps during periods of natural calamities.
2. Diagnose stakeholder
relationship.
1.Stakeholder potential for threat.
2.Stakeholder potential for co-
operation.
1. Stakeholder’s potential for threat
A health care organization's manager needs to anticipate and evaluate
systematically the actual or potential threats in its relationship with
stakeholder. These threats may focus on obtaining inducements from the
organization that may or may not be provided. The desired inducement may
include financial resource, participation in decision making. Stakeholder
power and its relevance for any particular cause confronting the
organizations manager determine the stakeholder's potential for threat.
Power is primary a function of the dependence of the organization on
stakeholder. Generally, the more dependent the organization, the more
power full the stakeholder will be.
2. Stakeholder’s potential for cooperation
The stakeholder's dependence on the organization and its relevance for any
particular issue facing the organization determine the stakeholder's co-
operative potential. Generally, the more dependent the stakeholder in the
organization is, the higher the potential for
co-operation.
Types of stakeholder relationship

Mixed blessing Supportive

stakeholder stakeholder
relationship relationship

Non
Marginal
supportive
stakeholder
stakeholder
relationship
relationship
• Mixed blessing stakeholder relationship: in this health care
executive faces a situation in which potential both threat and
co-operation rank for stakeholder. Example physician and
hospital relationship
• Supportive stakeholder relationship: in this type there is low
potential threat and high co-operation. Example relationship
of well managed hospital with its trustees, its manager, its
staff employees local community and nursing homes.
o Non supportive stakeholder relationship: there is high
potential threat and low co-operation. Example competing
hospitals, employee union, the federal government and
other govt, regulatory agencies the news media. Marginal
stakeholder relationship: there is neither co-operation nor
threat. Example employees, volunteer groups in community
etc for a well run hospital.
4.Formulate Generic Strategies
1. Collaborate cautiously in the mixed blessing relationship:
The best way to manage the mixed blessing relationship, high
on the dimensions of both potential threat & potential co-
operation may be cautious collaboration. The goal of strategy
is to turn mixed blessing relationship into supportive
relationships.
2. Involve trustingly in the supportive relationship:
As the supportive stakeholder poses a low potential for
threat, they are mostly ignored by organization. However for
maximizing the co-operation from this type of stakeholder,
the health care executives can delegate authority to
manager, involve in decision making and other plans. With
this the manager will more likely to committed to achieve
organizational objective.
3. Defend proactively in the non supportive relationship:
Stakeholder relationship with high threatening potential, but
low co-operative potential is best managed by aproactive
defensive strategy. Relationships with the federal govt. and
indigent patients are non supportive stakeholder relationship
for most health care organization. In stakeholder terms, a
defensive strategy involves proactively preventing the
stakeholder from imposing cost or other disincentives on the
organization.
4. Monitor efficiently in the marginal relationship:
Monitoring helps to manage this marginal relationship in
which the potential for both threat and co-operation is low.
The marginal relationships are unstable; they can move into
any one of the other three types of relationships.
Strategy implementation and outcome evaluation

The filth and sixth step of management of stakeholder

relationships implementation of planned and articulated
strategies and the evaluation of its outcomes. With
conscious, consistent relationship and implementation of
strategies, a quite fully organized health care system can be
developed. The outside of the strategy implementation also
has to be evaluated.
Patterns of nursing care delivery in India

Introduction: Nurses provide care to clients while working

under a variety of care delivery models. A care model is a
philosophy of care delivery and a system for organizing the
relationship and roles of all nursing care personnel.
Historically, several care models have been used in nursing.
Each differs with regard to the types of responsibilities
assumed by registered nurses and other nursing personnel.
The models also differ in the extent to which a registered
nurse directly coordinates the care of all clients' needs
matched with staff abilities.
Types of patient care delivery system

Types of
nursing
care
Functional Nursing
The functional approach to care grew out of a need to
provide care to large number of patients. It focused on
organizing and distributing the tasks, or functions, or care.
Trained nurses provide care that requires high skill levels and
untrained workers with little skill or education performed
many less complex tasks. In functional nursing, personnel
worked side by side, each performing the assigned task. The
goal of functional nursing was efficient management of time,
tasks and energy. Although this practice saved hospitals
money, patient care was fragmented and patients had to
relate to many different people. There was no one person
they could call "My Nurse"
Advantages of Functional Nursing
a. Efficient —We can complete many tasks in a reasonable
time frame.
b. Workers do only tasks they are educated to do and
become very efficient.
c.Romotes organizational skills — each worker must organize
his own work.
d. Promotes worker autonomy.
Disadvantage of Functional Nursing
a. Lack of holistic view of patient - emphasis on task, not
person.
b. Lacks continuity - patients often do not know who their
nurse is.
c. Registered nurses have little lime to talk with patients or
render personal care.
2. Team nursing

Lam bertson (1953) designed team nursing. She envisioned

nursing teams as democratic work group with different skill
Ievels represented by different team members. They were
assigned as a team to group of patients. The intent of team
nursing is to provide patient central care. The patients nursing
care needs arc identified and met through nursing diagnosis
and prescriptions. The ward clerks and unit manager perform
the non-nursing function of the unit. The team leader
ultimately responsible for all the care provided, delegates
(assigns responsibility for) certain patients to each member.
Each member of the team provides the level of care for which
he or she is best prepared.
Nursing care goals
Advantages of Team Nursing:
a. Involves all team members in planning patients nursing care through
team conferences and written nursing care plans.
b. Provides best care at the lowest cost.
c. Each workers ability is used to the fullest.
d. Provides comprehensive care.
e. Decrease non professional duties of registered nurses.
f. Promotes job satisfaction.
Disadvantages of team nursing:
a. Constant need to communicate among team members is time
consuming.
b. Difficult to find time for team conferences and care plans.
c. Team composition varies from day to day which can be confusing and
disruptive and decreases continuity of care.
d. Allows RN who is team leader to have the only significant
responsibility and autonomy.
 Team nursing organization
Hospital Administration

Nursing Superdentent

Deputy Nursing Superdentent

Assistant Nursing Superdentent

Ward Sister

Staff nurses, clerks, dietician, attendant, Class IV workers, Students.

• Primary Nursing
• Primary nursing was designed to promote the concept of an
identified nurse for every patient during the patient's stay on a
particular unit. The goal of primary nursing is to deliver
consistent, comprehensive care by identifying one nurse who is
responsible, has authority, and is accountable for the patients
nursing care outcomes for the period during which the patient's is
in a unit_ in primary nursing, each newly admitted patient's is
assigned to a primary nurse. Primary nurses assess their potion,
plan their care, and write the plan of care. While on duty, they
care for their patients and delegate responsibility to associate
nurses when they are off duty. Associate nurses may be other RNs
or LPN. The primary nurse accepts total 24-hours responsibility
for a patient's nursing care.
The characteristics of primary nursing modality are:
1. The primary nurse has responsibility for the nursing care of
the patient 24 hours a day from hospital admission through
discharging.
2. Assessment of nursing care needs, collaboration with the
patient and other health professionals and formulation of
plan of care are all in the hands of primary nurse.
3. Execution of nursing care plan is delegated by the primary
nurse to secondary nurse during other shifts.
4. The primary nurse consults with nurse manager.
5. Authority, accountability and autonomy rest with primary
nurse.
6. Associate nurses carry out plan of care when the primary
nurse is not on duty
7. Usually implemented as an all-RN model.
Advantages of Primary Nursing:
a. Provides increased autonomy on the part of nurse, thus
increasing motivation, responsibility and accountability
b. It ensures more continuity of care as the primary nurse
gives or direct care throughout hospitalization
c. It makes available increased knowledge of the c. It makes
available increased knowledge of the patients psychosocial
and physical needs, because the primary nurse does the
history and physical assessment, develops the care plan and
act as liaison between the patient and other health workers.
d. It leads to increased rapport and trust between nurse and
patient that will allow formation of therapeutic relationship.
e. It improves communication of information to physicians. I
It frees the charge nurse to assure the role of operational
manager to deal with staff problems and assignments and to
motivate and support the staff.
Disadvantages of Primary Nursing:
a. Difficult to hire all registered nurse staff.
b. Expensive to pay all registered nurse staff.
c. Nurses do not know other patients, difficult to cover'
for each other.
d. May create conflicts between primary and associate
nurses.
e. Heavy responsibility, especially for new nurses.
4. Case Management Nursing
The most recent evolution in nursing care delivery system is
case management. In many ways, it is a return to the type of
nursing practiced before patients were cared for primarily in
hospitals. Case management can be defined as a
collaborative process which assesses, plans, implements,
coordinates, monitors and evaluates options and services to
meet an individual's health and needs through
communication and available resources to promote quality
and cost effective outcome.
 key ●
a. Assessor
Functions
of
●
b. Advocate
The case ●
d. Planner
manager role
includes
●
e. Facilitator
a. Assessor:
• Gather all relevant data and obtain of tent by interviewing
patient/family and performing careful evaluation of the
entire situation.
• Evaluate all information related to the current treatment
plan objectively and critically to identify barriers, clarify or
determine realistic goals and objectives and seek potential
alternatives.
b. Planner:
• Works with patient/family to develop a treatment plan that
enhances the outcomes and reduces the payee's liability.
• Includes the patient/family as a primary decision maker
and goal setting.
• Incorporates contingency plans for each step in the process
to anticipate treatment and service complications
c. Facilitator:
• Actively promotes communication among team members,
patient, family, health care providers and all panics involved.
• Collaborates between the patient and health care team to
maximize outcomes.
• Coordinates the health delivery process by eliminating
unnecessary steps and by promoting timely provision of care.
d. Advocate:
• Incorporates the patients individualized needs and goals
throughout the case management process. Supports and
reduces the patient to become empowered and self reliant in
self advocacy.
Obtains consensus of all parties to achieve optimal outcomes.
Promotes early referral to provide optimum care and cost
outcomes.
Advantages of Case management:
a. Promotes interdisciplinary collaboration.
b. Increase quality of care.
c. Cost effective.
d. Eases patient's transition from hospital to community
services.
Disadvantages of Case management:
a. Nurse has increased responsibility.
b. Requires additional training.
c. Requires nurses to be off the unit for period of time.
d. Time consuming.
e. Is most useful only with high-risk/high-cost/high-volume
patients
The, nurse's Role on the Health Care Team
Whatever the setting is, nurses fulfill a number of roles on
the health care delivery system changes. The evolving role of
registered nurse requires new competencies and skills in
each of the roles described below:
Provider of Care
Nurses provide direct, hands on care to patients in all the
health care agencies and settings. As provides, they take an
active role in illness prevention and health promotion and
maintenance. They offer health screenings, home health
services, and an array of health care services in schools,
workplaces, churches, clinics, physician's offices and other
settings. Their breadth and depth of knowledge, their ability
to care holistically for patients, and their natural partnership
with physicians are making them some of the most sought
aftercare providers.
Educators
Nurse educators teach patients, families the communities,
other healthcare team members, students etc. In hospital set
patient and family educators, nurses provide information
about illness and teach about medications, treatment and
rehabilitation need. In community settings, nurses teach
classes about injury and illness prevention and health
promotion. Nurses al a responsibility to understand and
teach how a healthful or unhealthful environment may affect
both the short-term and term health of the community
Counselor
People who experience illness or injury often have strong
emotional responses. It is clear that emotional the
relationships among the emotions, the mind and the body
are critical to promotion of and restoration to health. As
counselors, nurses pro Counseling and support to patients
and their families.
 
Using therapeutic communication techniques, nurses
encourage people to discuss their feelings, to explore
possible options and solutions to their unique problems, and
to choose for themselves the best alternatives for action.
 
 
Manager
The effective management of nursing resources is essential.
Nurse manager must have strong leadership, financial, stem
design, outcome research and organizational behavior skills.
Nurse executives must ensure the quality of nursing care
within financial, regulatory and legislative constraints.
Researcher
Nurse researchers investigate whether current or potential
nursing actions achieve their expected outcomes, what
option for care may be available, and how best to provide
care. Nursing research looks at patient outcomes, the nursing
pro tem that supports nursing services.
Collaborator
Collaborator role is vital one for nurses to ensure that everyone
agrees on the same patient outcomes, collaboration require nurse
to understand and appreciate what other health professionals have
to offer. They must also be able to inter nursing needs of patients.
 Change Agent
 Role of change agent is one that requires a combination of tact,
energy, creativity and interpersonal skills, most professional nursing
education programs include change theory as part of their
management courses and graduates are prepared to become
agents in their work settings.
Entrepreneur
Nurse entrepreneurs provide consultation and educational service
to nurse and other health team members. They provide service to
business by conducting work site wellness programs and advising
human resource staff on how to provide high quality health
benefits to employees while reducing cost.
Patient advocate
Patient advocate are nurse who realize that policies are
important and govern most situational well but occasionally
can and should be broken.
 
Bibliography:
Navdeep kaur brar text book of advanced nursing practice,
jaypeebrothers, page no:163-174.
 
Shabber p. basher text book of advance nursing practice,
second edition page no 84-93.
www.net.com.