Organisational structure and nursing service management of select Hospitals

Sushma Kumari Saini, Charanjeev Singh Abstract : Organisational structure means the formal structure of authority calculated to define, distribute and provide for the co-ordination of tasks and contributions to the whole which is very essential for fulfilling the objectives of an organisation. In order to understand the functioning of an organisation, it is important to study its organisation structure. Keeping it in mind a study was conducted to study the organisation structure of nursing department and nursing service management of three select hospitals i.e. one Autonomous hospital, one private hospital and one state government hospital. Investigator visited all the three hospitals and information related to organisation structure and nursing service management was collected from the nursing office. Results revealed that all the three hospitals had different organisational structure with different nursing positions and cadres. None of the hospital had all the positions as recommended by the Indian Nursing Council (a statuary body) and High Power Committee 1990. However, there was partial implementation of the recommendations in all the select hospitals. There was a wide scope for improvement in these hospitals as regards the nursing personnel is concerned. If the decision making regarding nursing is vested in the hands of nursing administrators then better nursing services can be rendered which will help in turn in providing better services to patients.

Key words : Organisational structure, nursing service management.

Introduction Whenever a group of people is involved in the accomplishment of a task, some kind of an organisation emerges. A sor t of hierarchy develops; some one assumes the responsibility of leadership and direction in par ticular par t of task, and there is some grouping.1 It is not exaggeration to say that we are living in the age of an 'organisation man' who accepts the organisation goals as the value premises of his decisions. The
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Correspondence at : Sushma Kumari Saini Lecturer National Institute of Nursing Education, Chandigarh

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modern society is termed as 'organisation society' - that is, a society in which a great deal of our working time is spent in organisations, such as schools, universities, work place, places of worship, recreation and health care. 2 Organisation refers to the structure of relationships among position jobs, which is created to achieve cer tain objective and control the activities of man with a mechanism. Organisation is the process of identifying and grouping the work to be performed, specifying the work, defining and delegating the responsibility with authority to the personnel and establishing interpersonal relationship for the purpose of co-ordination of work, so as to get the work done together effectively, and in accomplishing the objectives of the organisation/institution/enterprise. 3 An organisation comes into being when there are persons who are: i) ii) iii) Able to communicate with each other; Willing to contribute their services; and Linked together and who co-ordinate their efforts to accomplish the common objectives. 4

experienced personnel to provide services of curative, restorative preventive and promotive characters of the highest quality possible to all people, regardless of race, colour, creed or economic status. It conducts educational and training programmes for the health personnel particularly required for patient care and hospital services. It also conducts research in assisting the advancement of medical services and hospital services and conducts programmes of health education. 4 Hospitals can be classified as per ownership/control, clinical basis, length of stay of patients and teaching or non-teaching status. As per ownership basis the hospitals can be public, voluntary, private and corporate hospitals. The public hospitals can be further classified as Central Government Hospitals and State Government Hospitals. In the present study we have covered three teaching hospitals, which differ as per their ownership i.e. an autonomous, a private and a State Government hospital. Irrespective of the classification of hospital the primary function of a hospital is the provision of medical care to a community, to be a centre for education and research for all types of health professionals. In order to meet all these needs, the hospital works through many departments, which deal with different kinds of services e.g. medical, nursing, pharmacy, laboratory services etc. Among all these services the nursing service is that par t of the hospital which aims to satisfy the nursing needs of the patient and community. The nursing service is closest to the patients 24 hours of the day and seven
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The hospital is also an organisation and an integral par t of the social and medical organisation, the function of which is to provide for the population, complete health care, both 'curative' and 'preventive' and whose out patient services reach out to the family and its environment; the hospital is also a centre for the training of health workers and biosocial research. A modern hospital is an institution, which possesses adequate accommodation and well qualified and

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days of the week. Nursing personnel also usually constitute the largest proportion of the hospital staff. Planning, organizing, directing and coordinating the individualized care of hospitalised patient is the most impor tant function of a hospital nursing service. All other nursing functions and activities are related to it. A hospital may be soundly organised, beautifully situated and well equipped but if nursing care is not of quality the hospital will fail in its responsibility.4 Therefore, a study is conducted to study the organisational structure of Nursing department and nursing ser vice management in three selected hospitals. Methodology The Union Territory (UT) Chandigarh is surrounded by three states namely Punjab, Haryana and Himachal Pradesh. The teaching hospitals of Chandigarh and its surrounding states were selected for study. UT Chandigarh and States of Punjab, Haryana and Himachal Pradesh have three types of teaching hospitals i.e. State Government Hospitals, Private Hospitals and Autonomous hospitals. There were total seven State Government Hospitals two Private Hospitals and one autonomous hospital. One hospital from each category was selected by lottery method i.e. one Autonomous hospital, one private hospital and one state government hospital was selected for study. Bed strength of the hospitals was 1359, 657, and 1260 respectively. Permission for data collection was sought from Medical Superintendents of the

three select hospitals. Investigator visited all the three hospitals and information related to organisation structure and nursing service management was collected from the nursing office. Secondary data was collected from books, available records, bibliography and review of documents. Results Organisational structure Organisational structure of Nursing Department of all three hospitals is depicted in the organisation chart of nursing services of these hospitals as shown in Figure 2.1, 2.2 and 2.3, respectively. Having a closer look at these char ts, it can be observed that the Director was the overall incharge of the Institute, and the Medical Superintendent was overall incharge of the Hospital under whose supervision the Nursing Department worked. The Chief Nursing Officer headed the Nursing Department in Autonomous hospital and in the other two hospitals nursing depar tment is headed by Nursing Superintendent. She was responsible for administration and management of the Nursing Depar tment. She was directly responsible to Medical Superintendent and through the Medical Superintendent to the Director. In Autonomous hospital the post of Nursing Superintendent was next to the Chief Nursing Officer and she was responsible to the Chief Nursing Officer in the hospital for administration and management of nursing services.
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Next to the Nursing Superintendent in Autonomous hospital were one Deputy Nursing Superintendent Educator, one Deputy Nursing Superintendent Epidemiologist and 11 Deputy Nursing Superintendents. The Deputy Nursing Superintendent (Educator) was responsible for in-service education of nursing staff and Deputy Nursing Superintendent (Epidemiologist) was responsible for infection control in the hospital

in collaboration with the doctor in charge of Infection Control from the Microbiology Depar tment. The Deputy Nursing Superintendent was responsible for the administration and management of nursing services in the area/block assigned to her e.g. Operation Theatre, Emergency, Outpatient Depar tment, Advance Paediatric Centre or different blocks of Nehru Hospitals (A, B, C, D, F, Cobalt and Kidney Block).

Director

Medical Superintendent

Chief Nursing Officer (1)

Nursing Superintendent

Deputy Nursing Superintendent (Educator) (1)

Deputy Nursing Superintendent (11)

Deputy Nursing Superintendent (Epidemologist) (1)

Assistant Nursing Superintendent (53)

Nursing Sister Grade - I (272)

Nursing Sister Grade - II (836)

Figure: 2.1: Organisational structure of nursing department of Autonomous hospital

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Director Principal

Director Principal

Medical Superintendent

Medical Superintendent
Nursing Superintendent/ Professor (1)

NursingSuperintendent Superitendent Nursing

Deputy Nursing Superintendent/ Reader (1)

(1)

Assistant Nursing Superintendent/ Reader (1)

Matron (4)

Supervisor/ Professors/ Readers/ Lecturers (29)

Nursing Sister (92)

Staff Nurse (463)

Figure 2.3: Organisational structure of nursing department of State Government Hospital Each one of them was responsible to the Chief Nursing Officer and Nursing Superintendent. Whereas in Private hospital next to the Nursing Superintendent there was only one Deputy Nursing Superintendent who was responsible to the Nursing Superintendent and assisted her/him in the Nursing Ser vice Administration of the
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Nursing Sisters (33)

Staff Nurse (400)

Auxilliary Nurse and Midwife (84)

Figure: 2.2: Organisational structure of nursing department or Private Hospital

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hospital. While in State Government Hospital next to the Nursing Superintendent there were 4 Matrons/Deputy Nursing Superintendents. Each Matron/Deputy Nursing Superintendent was responsible for the administration and management of nursing services in a specified area (e.g. one floor of main building) assigned to her. She was responsible to the Nursing Superintendent. Next to 11 Deputy Nursing Superintendents in Autonomous hospital there were 53 Assistant Nursing Superintendents who were responsible for management of Nursing Services of one or more wards/areas assigned to her. She was responsible to the Deputy Nursing Superintendent of her area. Whereas, in Private hospital there was only one Assistant Nursing Superintendent who assisted the Deputy Nursing Superintendent and Nursing Superintendent for the over all administration and management of nursing services of the entire hospital. She was responsible to the Deputy Nursing Superintendent. While in State Government Hospital this level did not exist. In Private hospital next to the Assistant Nursing Superintendent there was another level i.e. Super visors. There were 29 Super visors who were responsible for administration and management of nursing services of their respective ward/area where they were posted. This level did not exist in other two hospitals. Next level in all the hospitals was Nursing Sister/Sister Grade-I who was responsible for nursing care management of

a ward or area assigned to her/him. She was responsible for ward management and supervision and helped Sister Grade-II for providing bedside patient care. She was responsible for the safety and comfort of the patient. In Autonomous hospital there were 3-4 Nursing Sister/Sister Grade-I in each ward i.e. total 272 Nursing Sister/Sister Grade-I. They were responsible to the Assistant Nursing Superintendent of their ward/area, whereas, in State Government Hospital there were 92 Nursing Sister i.e. 1-3 Nursing Sisters posted in each ward/area. They were responsible to the Matron/Deputy Nursing Superintendent of their area. While in Private hospital there were 33 Nursing Sisters. Only one Nursing Sister was posted in each ward/ area and she was responsible to the Supervisor of the ward/ area. Next level in all the hospitals was the Staff Nurse/Sister Grade-II. They were the first level professional nurses who provided direct patient care to a patient or group of patients assigned to her/him during duty shift. She was responsible to the Nursing Sister/Sister GradeI of her ward/area. In Private hospital there were 84 Auxiliary Nurses and midwives who assisted the Sister Grade-II in providing nursing care to the patients. This level did not exist in other two hospitals. The difference, which was observed in three hospitals, was that in Autonomous hospital and State Government Hospital the nursing department of the hospital and the nursing faculty of the College of Nursing were working independently, whereas in Private
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hospital they were working in collaboration. Faculty of College of Nursing and hospital nursing staff on senior positions with higher qualification (M.Sc. Nursing and above) are given dual responsibilities i.e. supervision of nursing staff and teaching to Nursing students of College of Nursing. They were given dual designations such as Nursing Superintendents/Professor, Deputy Nursing Superintendent/Reader, Assistant Nursing Superintendent/Reader and Nursing Sister/ Clinical Instructor. Similarly, the college faculty was responsible for the supervision of nursing personnel in hospitals along with the teaching responsibilities of nursing students. They were designated as Professor/Supervisor, Reader/Supervisor or Lecturer/Supervisor whereas Clinical Instructors from College were not given this dual responsibility. The dual responsibility helped the nursing personnel to work in collaboration. Job Cadre and Classification The purpose of a classification scheme is to categorize and rank different positions so that the type and level of each rank can be used as a mean of securing equal pay for substantially equal work. The class or position include those that is sufficiently similar in the content of work, in the level of difficulty and in the responsibility and qualification requirement of the work as to warrant similar treatment in personnel and pay administration. A Grade includes all classes

of position which, they though differ in the kind or content of the work, but are sufficiently equivalent in the level of difficulty and responsibility or qualification, required to warrant including them in one range of basic compensation. 1 Table 2.1 depicts cadre of nursing personnel at select hospitals. A close look at the data reveals that all the three hospitals had different cadre classification. In Autonomous hospital cadre classification of all staff was A, B, C and D. Chief Nursing Officer and Nursing Superintendent were covered under Cadre'A' while Deputy Nursing Superintendent and Assistant Nursing Superintendent were covered under Cadre-B and Nursing Sister Grade-I and II were 'C' cadre employees whereas in Private hospital their employees were grouped under three categories i.e. Group-I, II and III. Here Nursing Superintendent, Deputy Nursing Superintendent, Assistant Nursing Superintendent, Supervisors and Nursing Sisters were covered under Group-I employees and Staff Nurses were covered under Group-II employees. Whereas, in State Government Hospital the employees were grouped in four cadres i.e. Class-I, II, III and IV. The Nursing Superintendent and Matron were Class-II employees and Nursing Sister and Staff Nurses were Class-III employees whereas, no nursing personnel had come under Class-I.

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Table-2.1: Cadre wise distribution of nursing staff of selected hospitals Cadre Designation Chief Nursing Officer Nursing Superintendent Deputy Nursing Superintendent/Matron Deputy Nursing Superintendent (Educator) Deputy Nursing Superintendent (Epidemiologist) Assistant Nursing Superintendent Supervisor Nursing Sister/Nursing Sister Grade-I Staff Nurse /Nursing Sister Grade-II N.A.: Not applicable Pay Scale and Allowances of Nursing Staff of Select Hospitals Pay scales of Nursing Staff of select hospitals are depicted in Table 2.2. It can be observed that Nursing Superintendent, Deputy Nursing Superintendent, Assistant Nursing Superintendents from Private hospital had a higher pay scale than their counterpar ts in Autonomous hospital and State Government Hospital. This was so, because they were getting UGC pay scales, because of their dual responsibility. Fur ther, the Nursing Superintendent and Deputy Nursing Superintendent of Autonomous hospital were getting higher pay scales than their counterpar ts in the State Government Hospital. The Nursing Sister/Nursing Sister Grade-I and Staff. Autonomous Hospital 'A' 'A' 'B' 'B' 'B' 'B' N.A. 'C' 'C' Private State Government Hospital Hospital N.A. Group - I Group - I N.A. N.A. Group - I Group - I Group - I Group - II N.A. Class - II Class - II N.A. N.A. N.A. N.A. Class - III Class - III

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Table 2.2: Pay scale of nursing staff of select hospitals

Pay Scale Designation Chief Nursing Officer Nursing Superintendent Deputy Nursing Superintendent / Matron Deputy Nursing Superintendent (Educator) Deputy Nursing Superintendent (Epidemiologist) Assistant Nursing Superintendent Supervisor/Professor/Reader/Lecturer " Professor " Reader " Lecturer Nursing Sister/Nursing Sister Grade-I Nursing Sister/Nursing Sister Grade-II 5500-175-9000 5000-150-8500 16400-450-500-23000 12000-420-18300 8000-275-13500 5500-180-200-11100 5000-150-200-8100 5500-175-9000 5000-150-7850 Autonomous Hospital 10,000-325-15200 8000-275-13500 7500-250-1200 7500-250-12000 Private Hospital 16400-450-500-23000 12000-420-18300 State Government Hospital 6500-200-10500 6500-200-9900 -

7500-250-12000 6500-200-10500

12000-420-18300

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Table-2.3: Fringe benefits of nursing staff of select hospitals Fringe Benefits Housing Autonomous Hospital Accommodation in campus for senior nurses OR Housing allowance 15% of basic pay Private Hospital State Government Hospital

Medical

Free medical facilities for self and dependents

Accommodation in Accommodation in campus for campus for - All Group-I employees senior nurses - 50% Group-II employees OR OR Housing allowance Housing Allowance 7% of basic pay - Rs. 1000/- for Nursing Sister - Rs. 500/- for Staff Nurse Group-I -50% medicine Rs. 125/- per free and 50% employees month fixed has to pay medical allowance. Group-II -90% medicine For indoor admission free and 10% reimbursement of bills employees has to pay paid for self and Group-III - 90% medicine dependents free and 10% employees has to pay -NA-NARs. 200/- per month Included in nursing allowance -NA-

Nursing Allowance Washing Allowance Transportation Allowance

Rs. 1600/- per month Rs. 400/- per month

Rs. 75/- to Rs. 200/for those who do not stay in campus Staff bus facility

-NA-

Education Allowance

Two special increments for higher qualification Creche Facility A round the clock crche facility

One special increments for higher qualification No

-NA-NA-

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Nurse/Nursing Sister Grade-II in all the select hospitals had more or less similar pay scales. Allowances of Nursing Staff are illustrated in Table 2.3. Findings reveal that all the select hospitals provided free hostel accommodation for nurses, while some married nurses were given quarters and the nursing personnel who did not get accommodation, were given housing allowance. In Autonomous hospital housing allowance was 15 per cent of Basic Pay and in State Government Hospital it was 7 per cent of Basic Pay whereas in Private hospital a fixed amount was given to Staff Nurse (Rs. 500/- per month) and Nursing Sisters (Rs. 1000/- per month) and the rest were provided accommodation within the institute. Regarding medical allowance in Autonomous hospital there were free medical facilities for self and dependents whereas in Private hospital for Group-I employee 50 per cent medicines were free and for Group - II and III employees 90 per cent medicines were free of cost. While in State Government Hospital employees got a fixed Medical Allowance for outdoor treatment and for indoor treatment bills for self and dependents were reimbursed (being a state government owned, the rules applicable to government employees were in vogue).

The nursing allowance and washing allowances were higher in Autonomous hospital as compared to State Government Hospital. No Nursing Allowance was given in Private hospital. While transport allowance/ bus facility was available to the employees of Autonomous hospital, it is not so for the employees of the other two hospitals. Similarly, round the clock crche facility was available for the children of the nursing staff of Autonomous hospital, while such facility was not available in the other two hospitals. Data related to authorised leaves is shown in Table 2.4. It indicates that Autonomous hospital staff got similar number of earned leave irrespective of cadre or length of service whereas in Private hospital GroupI employees gets more annual leaves as compared to Group-II employees, and in State Government Hospital the number of earned leaves increased with the years in service. Regarding casual leaves, State Government Hospital nurses got 25 days casual leave whereas it was 10 days in Private hospital and 8 days in Autonomous hospital. Fur ther, employees of Autonomous hospital and State Government Hospital got 10 days medical leave or 20 half days per year while nurses in Private hospital got 15 days medical leave per year.

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Table 2.4: Leave pattern of nursing staff of select hospitals

Leave Autonomous Hospital
One month in a year

Private Hospital

State Government Hospital

Earned Leave: 1st 10 years - 15 days/year Next 10 years -20 days/year After 20 years - 25 days/year After 25 years - 30 days/year 25 days/year 10 days or 20 half days in a year Eight days off per month for shift duty staff

Earned leave

Annual Leave Group-I: 42 days Group-II: 28 days

Casual Leave Medical Leave

8 days in a year 10 days or 20 half days in a year Nine days off per month for shift duty staff Six days off for straight shift + Gazetted holidays 4 months (Only two permitted)

10 days in a year 15 days in a year

Days off

One and half day per week

Four days off for straight shift + Gazetted holidays

Maternity Leave

Three months (one and half month before delivery and one and half month after delivery (Only two permitted)

Maternity Leave - 6 months (only 2 permitted)

Abortion Leave Tubectomy Leave Education Leave

42 days 15 days Two years with full pay (Permitted only once)

15 days 15 days Two years with 50 percent pay (Permitted only once)

42 days 15 days Two Years with 50 percent pay (Permitted only once)

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Apar t from the above Autonomous hospital staff could avail four and half month duration of maternity leave. Where as, in Private hospital it was only for 3 months i.e. one and half month each before and after delivery and the staff of State Government Hospital could avail 6 months Maternity Leave. All the hospitals staff got equal number of Abortion and/or Tubectomy Leave, Education Leave of two years with pay was permissible to nurses of Autonomous hospital. Whereas in other two hospitals 2 years education leave with 50 per cent basic pay was permissible. Discussion Indian Nursing Council (INC) is a statutory body established by the Act of Parliament in 1947. The INC lays down standards of nursing education through out the country besides recommending the optimum nurse-patient ratio and education requirements for various positions of the nursing staff. Apart from it Government of India had set up various committees from time to time to lay down standards for nursing practice. The latest of these committees was the High Power Committee on Nursing Profession set up by Central Government of India, which presented its report in March 1990, and has been accepted by Government

of India in principle were not in accordance to the recommendations as the High Power Committee, which had recommended a separate Directorate of Nursing in each state/ Union Territory. Under the Directorate of Nursing all the three sections i.e. Nursing Service, Nursing Education and Community Nursing Services. 5,6 However, it was found out that none of the states and the Union Territory had established this directorate and as such none of the select hospitals worked under separate Directorate of Nursing. Apart from a separate Directorate none of the select hospitals had all the nursing positions as recommended by it i.e. post of Chief Nursing Office existed only in Autonomous hospital whereas State Government Hospital did not had the post of ANS and in Autonomous hospital post of Supervisor did not existed. As regards the organisation structure of the select hospitals it was found that in Private hospital nurses working in higher positions were given dual responsibilities i.e. of supervising nursing personnel in hospital and teaching nursing students in College of Nursing. Hence, they were given dual designations i.e. Nursing Superintendent/ Professor,

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Secretary Health

Director Nursing Service Joint Deputy Director Nursing Services

Additional Director Nursing Services Community Nursing

Additional Director Nursing Services Nursing Education and Research

Additional Director Nursing Services Hospital Nursing Service

Deputy Additional Director Nursing Services Community Nursing

Deputy Additional Director Nursing Services Nursing Education and Researh

Deputy Additional Director Nursing Services Hospital Nursing Services

District Nursing Officer

Principal School of Nursing

Nursing Superintendent

Public Health Nursing Officer

Senior Tutor

Deputy Nursing Superintendent

Public Health Nurse at PHC

Tutor

Assistant Nursing Superintendent

Lady Health Visitor (HSP)

Clinical Instructor

Ward Sister

Staff Nurse Auxilliary Nurse and Midwife

Figure 2.4: Recommended organisational structure at State/Union Territory Level by High Power Committee
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DNS/Reader, ANS/Reader, Supervisor/ Professor/ Reader/ Lecturers. This helped in promoting close association and collaboration of nursing education and nursing service department. This kind of collaboration was not there in other two hospitals. It was observed that more than 90 per cent of nurses from Autonomous hospital and State Government Hospital were Group-C/ Class-III employees. In Private hospital more than 85 per cent of nurses were Group-II employees. The High Power Committee had recommended at least Class-II Gazetted Ranks for the positions of Nursing Sister and above. 5,6 However, only Private hospital the grouping of nursing personnel was according to recommendations where positions of Nursing Sister and above were included in Group-I. In other two hospitals, Nursing Sister is included in Group-C/Class-III employees. There is no Class-I position for nurses in State Government Hospital. Staff Nurses and Nursing Sisters in all the select hospitals were placed in more or less equal pay scales. However, a lot of variation was observed for higher positions. The pay scales of nurses in administrative positions were the highest in Private hospital followed by Autonomous hospital and the lowest were in State Government Hospital. Higher pay scales in Private hospital were because they were granted University Grants Commission (UGC) pay scales owing to their dual responsibilities. Similarly, no uniformity was observed for allowances albeit the High Power Committee had recommended that

throughout the countr y the allowances should be similar. Hence, it was concluded from the analysis that none of the select hospitals at the time of present study had all the positions as recommended by the INC and High Power Committee 1990. However, there was partial implementation of the recommendations in all the select hospitals. There was a wide scope for improvement in the hospitals as regards the nursing personnel is concerned, if the decision making related to nursing services is vested in the hands of nursing administrators then there will be improvement in rendering nursing services which will help in turn in providing better services to patients. References
1. Freeman Ruth B, Holmes Edward M. Administration of Public Health Services. 1st edition. WB Saunders Company; Philadelphia 1960. Rosembloom David H, Goldman Deborah D. Public Administration. 2nd edition. McGraw Hill Book Company; New York 1989. Basavanthappa BT. Nursing Administration. 1st edition. Jaypee Brothers Medical Publishers; New Delhi 1998. Trained Nurses Association of India. Nursing Administration and Management. 1st edition. TNAI Publication; New Delhi 2000. Trained Nurses Association of India. Indian Nursing Year Book. TNAI Publication; New Delhi 1990-92. High Power Committee. High Power Committee on Nursing and Nursing Profession conclusion and recommendations. Nursing Journal of India 1990; 81:141-144,161-164

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