TEXT BOOK ON

NURSING

MANAGEMENT

PART II

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 Chapter- IV B.Vallatharasi
ORGANISING NURSING SERVICES AND PATIENT CARE
INTRODUCTION
“A hospital may be soundly organized, beautifully situated and well equipped, but if the nursing care is not
of high quality, the hospital will fail in its responsibility.”
Jean barrett
Who is the effective member of the patient care team? Sir William Osler said that the nurse is one of the
greatest blessings of humanity. Nursing has a large, important and unique role in the health care delivery
system of a country. Nursing care is extremely important for good patient outcome. While the physician
plans the treatment and surgeon carries out the operation, it is the nurse who gives 24 hrs / round the clock
nursing care and looks after the needs of the patient. The success of the patient care depends upon the
competence of the nursing staff. Organizing the high level of nursing care is a big challenge for the nursing
service administrator. Setting of standards and goals for providing care to patients depends upon the
philosophy of nursing in order to organize the patient care.
When closely examined, many of the newer models of patient care delivery systems are merely recycled,
modified, or retitled versions of older models. Indeed, it is sometimes difficult to find a delivery system
true to its original version or one that does not have parts of others in its design. Although some of these
care delivery systems were developed to organized care in hospitals, most can be adapted to other settings.
Choosing the most appropriate organizational mode to deliver patient care for each unit or organization
depends on the skill and expertise of the staff, the availability of registered professional nurses, the
economic resources of the organization, the acuity of the patients, and the complexity of the tasks to be
completed.
Importance of nursing service:
The primary purpose of the division of nursing services is to provide efficient and effective nursing care
services as an integral resource for the achievement of total delivery of comprehensive health programme
offered by the hospital. Importance of the nursing service includes:
(1) management of nursing care and service
(2) education, training and staff development programmes
(3) nursing research
(4) Community health programmes

a) Management of nursing care and service:

* Initiate a set of human relationship at all levels of nursing personnel to accomplish their job and
responsibilities through systematic management process by establishing flexible organization design.
* Establish adequate staffing pattern for rendering efficient nursing service to clients and its
management.
* Develop and implement proper communication system for communicating policies, procedures and
updating advance knowledge.
* Develop and implement proper evaluation and periodic monitoring system for proper utilization of
personnel.
* Develop and revise proper job description for nursing personnel at all levels and units for proper
delivery of nursing care.
* Assist hospital authorities for effective personnel management.

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 * Share nursing information system with other discipline functionaries in the hospital.
* Formulate and interpret nursing service policies in the context of general policies of the hospital for
improvement of nursing care.
* Assist the hospital authorities for preparation of budget by involvement
* Participate in interdepartmental programmes and other programmes conducted by other
disciplinaries for improvement of hospital services.

b) Education, training and staff development programmes

* Encourage a stimulating environment in which the personnel have opportunities to be creating
innovations in the improvement of nursing service.
* Develop and initiate orientation and training programmes for new employees in co-operation with
authorities and other health disciplines.
* Create an atmosphere that conducive to give proper required learning experiences for the students.
* Assist in the development of a sound, constructive programme of leadership in nursing to assure
intellectual administration and management to safeguard, conserve and preserve nursing resources of
the hospital.
* Initiate programme to improve the practice of nursing in keeping with advance in the relative areas
and disciplines affecting the quality of nursing.

c) Nursing research
* Participate in identifying the areas for research
* Participate in the application of data and research
* Provide conducive environment for research

d) Community health programmes

* Participate in community health programme, associate with hospital
* Interpret the roles and responsibilities in community health programmes
* Participate in extramural health programmes of the hospital and other related professional
organization.

ORGANIZING NURSING SERVICES

Meaning of nursing service and nursing service administration
Nursing Service
Nursing service is the part of the total health organization which aims at satisfying the nursing needs of the
patients/community. In nursing services, the nurse works with the members of allied disciples such as
dietetics, medical social service, pharmacy etc. in supplying a comprehensive program of patient care in the
hospital.
Nursing service administration
Nursing service administration is a complex of elements in interaction and is organized to achieve the
excellence in nursing care services. It results in output of clients whose health is unavoidably deteriorating,
maintained or improved through input of personnel and material resources used in a process of nursing
services.

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 DEFINITION OF NURSING SERVICE
WHO expert committee on nursing defines the nursing services as the part of the total health organization
which aims to satisfy major objective of the nursing services is to provide prevention of disease and
promotion of health.
PHILOSOPHY OF NURSING SERVICE IN HOSPITAL
The department of nursing services of hospital recognizes and appreciates the objectives of the hospital
and acknowledges that the primary purpose of nursing is to provide the highest quality care services.
uality in nursing care and management of nursing services is achieved through professional nurses
who assist in the development of comprehensive programs of delivering nursing care.
continuing growth and development
of nursing personnel.

personnel who are organized into self directed work teams.

f nursing care quality, the role of professional nurse must include
responsibility of nursing research and nursing education.

OBJECTIVES OF NURSING SERVICE

The first component of nursing service administration is the planning and it should be based on clearly
defined objectives. The objectives of nursing service department are as follows:
Objectives in relation to Patient care
The primary emphasis is on total patient care that is:
 To give highest possible quality care in terms of total patients need which include physical,
psychological, social, educational and spiritual needs by collaborating with other health tem
members.
 To assist the physician in providing medical care to the patients.
 To provide preventive and rehabilitative services.
 To provide round the clock nursing care to all the patients.
 To render timely and appropriate nursing service to emergency patients.
 To provide cost effective quality care as per the needs of patients.
 Confidentiality and privacy of each patient should be maintained.
 Constant monitoring and evaluating is of utmost importance to improve patient care continuously.
Objectives in relation to Education
 Planning of education and training programme for nurses are must for professional growth and
development needs through in-service education and research support.
 To provide regular staff development, in-service education and guidance services for all members of
nursing staff.
 To conduct regular orientation programme for new entrants and for those have been on the job for a
long time.
 To conduct training for operating procedure of latest gadgets and on handling sophisticated bio-
medical equipment.

Objectives in relation to Administration and Organization


 re that the essential equipment is provided in functional status for nursing care services.
 To provide regular flow of essential supplies to render quality nursingcare.

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  To have a proper system of rotation of staff, provision for annual leave and days off for the nursing
staff without hampering patient care.
 Establish a communication system for nursing personnel, other health worker, patients, health
authorities, government authorities and public.
 Ensure that each nurse identifies her job responsibilities and accountability.
 Counseling for health personnel, patients and the public.
 the formulation of policies, standards, goals of nursing service, education and practice.
 maintaining proper documentation of the personnel employed in nursing service.

Objectives in relation to Research

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

Objectives in relation to Performance appraisal

 Appraise the performance of nursing service personnel regularly against set standards and
performance indicators objectively with a view to maintain quality-nursing services.

PRINCIPLES OF NURSING SERVICE

o Initiate a set of human relationships at all levels of nursing personnel to accomplish their job and
responsibilities through systematic management process by establishing flexible organizational
design
o Establish adequate staffing pattern for rendering efficient nursing service to clients and its
management
o Develop and implement proper communication system for communicating policies, procedures and
updating advance knowledge.
o Develop and initiate proper evaluation and periodic monitoring system for proper utilization of
personnel
o Develop or revise proper job description for nursing personnel at all the levels and all units for
proper delivery of nursing care.
o Share nursing information system with other discipline functionaries in the hospital.
o Assist the hospital authorities for preparation of budget by involvement.
o Participate in interdepartmental programs and other programs conducted by other disciplinaries for
improvement of hospital services.
o Develop and initiate orientation and training programs for new employees in cooperative with
authorities and other health disciplines
o Create an atmosphere that conductive to give proper required learning experience for the students
o Assist in the development of a sound, constructive program of leadership in nursing to assure
intellectual administration and management to safeguard, conserve and preserve nursing resources of
the hospitals.
o Participate in the application of data and research
o Participate in community health programs, associated with hospital
Role of nursing services:

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  In addition to performing many other roles including promoting health behaviors of patients, the
professional nurse in the acute care setting performs functions that are primarily curative and
restorative in nature.
 The nurse’s role including diagnosis as a basis for planning, providing directing, collaboration in and
evaluating direct patient care.
 As a helping professional, nursing ideal characteristics including the ability and commitment to
respond with compassion to human needs and society’s expectations for health care services.
 The attitude of the head nurse towards her patients is of paramount importance never for a moment
is she or members of her staff are supposed to forget that they are dealing with human beings, not
disease.
 A disease or disorder affects each person in a different manner depending upon his or her attitude,
his or her previous experience hospital as patient and the socio-cultural pattern of his or her life.
 To render understanding care the nurse must appreciate the factors which influence attitudes and the
need of the patient for respect of his or her individuality.
Patients, as a rule, wish to maintain a degree of self-dependence and resent having no choice but to accept
whatever is being told to them.

FUNCTIONS OF NURSING SERVICE

o To assist the individual patient in performance of those activities contributing to his health or
recovery that he would otherwise perform unaided has had the strength, will or knowledge.
o To help and encourage the patient to carry out the therapeutic plan initiated by the physician.
o To assist other members of the team to plan and carry out the total programme of care.

The organization of nursing care constitutes a subsystem for achieving the hospital’s overall objective.
Nursing care of patients generally takes forms:

The director of nursing service is delegated the authority and responsibilities for organizing and
administrating the nursing services in hospital. It is her duty to institute the essential characteristics of good
nursing services in her institute such as:

Written statement of purposes and objectives of nursing services:

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

Purposes and objectives of the nursing service:

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

Plan of organization:
Every hospital has the basic system of coordination of vast number of activities i.e. the Director of Nursing
service, she is responsible for maintaining standards for patient care in terms of quality nursing service must
be familiar with the formal organizational structure of the hospital and its relationship in various department
and their functions. The plan of organization should indicate inter as well as intra-department relationship.
The plan also should indicate area of responsibility and to whom and for whom each person is accountable
and the channels of communication.

Policy and administrative manuals:

The policy and procedure manual are required for the operation of the hospital. Policies are established
within the department to guide the nursing staff, which includes duty hrs, rules and regulations etc. These
are periodically revised and reviewed at regular intervals.

Nursing practice manual:

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

Nursing service budget:

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

Master staffing pattern:

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

Nursing care appraisal plan:

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

Adequate infrastructure facilities, supplies and equipments:

The director of nursing evaluates periodically the adequate resources and arranges new facilities needed for
patient care in discussion with the hospital administrator.

Written job descriptions and job specifications:

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

Personnel records:
Personnel records include the information relating to the individual such as recruitment and selection,
medical records, training and development, transfer records, promotion, disciplinary action records,
performance records, absenteeism data, leave record and salary records, etc.

Personnel policies:
It reflects an analysis of the total job of nursing in accordance with the types of functions to be performed. It
also indicates the qualitative and quantity of service to be maintained and the purpose for which the hospital
exist.
Health services:
Supervision of health of each employee by means of pre-employment physical examination, periodic
examination, immunization and provision of diagnostic, preventive and therapeutic measures. The education
of employee in the principle of health and hygiene so that they may develop healthy habit of living and
working.

In-service education:
It is the essential components of staff development programme, which aims at augmenting, reinforcing
nurse‟s knowledge, skill and attitude. It includes orientation programme, skill training, leadership and
management training, on the job training, staff development.

Co-ordination:
Regular consultation and discussion between the heads of departments and with members of the medical
staff could be an integral part of the administration.

Advisory committee:
Each committee has a clear statement and its membership is appropriate to the purpose. After carefully
weighing the advice of the committee, she makes the final decision about the matter within her area of
responsibility and becomes accountable for implementation.

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ROLE AND FUNCTION OF NURSE ADMINISTRATOR
The Principal Matron of the hospital will be responsible to the Commandant of the hospital for the
following duties:
Administration
 Organizes, directs and supervises the nursing services both day and night.
 Coordinates assignments of staff.
 Establishes the general pattern of delegation of responsibilities and authority.
 Formulates standing orders for the nursing care.
 Ensures appropriate allocation of duties and responsibilities to all nursing staff working under her.
 Formulates nursing policies to ensure quality patient care and adequate attention at all times.
 Responsible for efficient functioning of the nursing staff.
 Evaluates the personal performance of the nursing staff.
Discipline
 Ensure that a standard of discipline of nursing staff is high at all times.
 Maintain good order and discipline in wards/departments.
 Makes daily rounds of the hospital wards/departments and also seriously ill patients. In addition she
will make unscheduled rounds in the hospital in the evenings.
 Brings immediately to the notice of the medical superintendent all matters concerning neglect of
duty, insubordination either by nursing staff, patients or visitors or any un-towards incident, which
comes to her notice for taking suitable action as required as per the orders on the subject.
Public Relations
 Promotes and maintains harmonious and effective relationship with the various administrative
departments of the hospital and related community agencies.
 Maintain cordial relationships with the patients and their families.
Office Routine
 Scrutinizes the reports and returns and submits in accordance with existing orders.
Confidential Reports
 Initiates the confidential reports of nursing staff on due dates.
 Responsible for the nursing budget.
Education
 Carries out in-service training for all categories of nursing staff and paramedical personnel and keeps
the records of such trainings.
 Conduct various update courses based on the needs.
 Encourages the personnel to participate in the continuing education programme.
Welfare
 Responsible for health and welfare of nursing staff.
 Ensures annual and periodical health examination and maintenance of health records.
Conferences
 Responsible for organizing and conducting staff meeting of the nursing staff once in three months.
 Holds conference in nursing care problems and discuss policies as regards to working conditions,
working hrs and other facilities.
Supervision
 Supervises nursing care given to the patients and all nursing activities within the nursing unit.
 Supervises the work of all paramedical staff of the hospital.
Records and Reports

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  Maintains various records such as duty roster nursing staff, day off book, personal bio-data, leave
plan, staff conference book, courses file etc.

PROBLEMS AND CHALLENGES FACED BY THE NURSE ADMINISTRATOR

 Lack of adequate training.
 Problem of personnel management.
 Inadequate number of nursing staff.
 Shortage of trained manpower.
 Lack of motivation.
 No involvement in planning.
 No career mobility.
 Poor role model.
 No research scope.
 Professional risk/hazards.
 No autonomy in nursing activities.

Day to day problem in nursing services

 Shortage of nurses.
 Lack of motivation.
 Negative attitude.
 Lack of training.
 Lack of team approach.
 Inactive participation of program
 Lack of interpersonal relationship
 Less involvement in patients care by the nursing supervisors.
 Lack of supervision.
MODES OF ORGANIZING PATIENT CARE / METHODS OF PATIENT ASSIGNMENT
The most well known means of organizing nursing care for patient care delivery are,
o Case method or Total patient care
o Functional nursing
o Team nursing
o Modular or district nursing
o Progressive patient care
o Primary nursing
o Case management

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

CASE METHOD
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Features:
It was the first type of nursing care delivery system. In this method, nurses assume total responsibility for
meeting all the needs of assigned patients during their time on duty. It involves assignment of one or more
clients to a nurse for a specific period of time such as shift. The patient has a different nurse each shift and
no guarantee of having the same nurses the next day. Nurse‟s responsibility includes complete care
including treatments, medication and administration and planning of nursing care. This is the way most
nursing students were taught – take one patient and care for all of their needs. This model is used in critical
care areas, labor and delivery, or any area where one nurse cares for one patient‟s total needs. Here nurses
were self-employed when the case method came into being, because they were primarily practicing in
homes. It lost much of that autonomy when healthcare became institutionalized in hospitals and clinics and
now called as private duty nursing.
o The nurse can attend to the total needs of clients due to the adequate time and proximity of the
interactions.
o Good client nurse interaction and rapport can be developed.
o Client may feel more secure.
o RNs were self-employed.
o Work load can be equally divided by the staff.
o Nurse‟s accountability for their function is built-it.
o It is used in critical care settings where one nurse provides total care to a small group of critically ill
patients.
Demerits:
o Cost-effectiveness.
o The greater disadvantage to case nursing occurs, when the nurse is inadequately trained or prepared
to provide total care to the patient.
o Nurse may feel overworked if most of her assigned patients are sick.
o She/he may tend to „neglect‟ the needs of patient when the other patients „problem‟ or „need‟
demands more time.
FUNCTIONAL NURSING
Features:
This system emerged in 1930s in U.S.A during WWII when there was a severe shortage of nurses in US. A
number of Licensed Practice Nurses (LPNs) and nurse aides were employed to compensate for less number
of registered nurses (RNs) who demanded increased salaries. It is task focused, not patient-focused. In this
model, the tasks are divided with one nurse assuming responsibility for specific tasks. For example, one
nurse does the hygiene and dressing changes, whereas another nurse assumes responsibility for medication
administration. Typically a lead nurse responsible for a specific shift assigns available nursing staff
members according to their qualifications, their particular abilities, and tasks to be completed.

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 Charge nurse

RN RN RN RN LPN
LPN UAP
UAP

Medication nurse
Medication nurse Treatment nurse nurs
Treatment Vital signs
Vital signsnurse
nurse Hygiene
Hygiene nurse
nurse

Patient assigned to the team

Patientsassignedtothe

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Merits:
o Each person become very efficient at specific tasks and a great amount of work can be done in a
short time (time saving).
o It is easy to organize the work of the unit and staff.
o The best utilization can be made of a person‟s aptitudes, experience and desires.
o The organization benefits financially from this strategy because patient care can be delivered to
a large number of patients by mixing staff with a large number of unlicensed assistive personnel.
o Nurses become highly competent with tasks that are repeatedly assigned to them.
o Less equipment is needed and what is available is usually better cared for when used only by a
few personnel.
Demerits:
o Client care may become impersonal, compartmentalized and fragmented.
o Continuity of care may not be possible.
o Staff may become bored and have little motivation to develop self and others.
o The staff members are accountable for the task.
o Client may feel insecure.
o Only parts of the nursing care plan are known to personnel.
o Patients get confused as so many nurses attend to them, e.g. head nurse, medicine nurse,
dressing nurse, temperature nurse, etc.

TEAM NURSING
Features:
Developed in 1950s because the functional method received criticism, a new system of nursing was
devised to improve patient satisfaction. Care through others became the hallmark of team nursing. Team
nursing is based on philosophy in which groups of professional and non-professional personnel work
together to identify, plan, implement and evaluate comprehensive client-centered care. In team nursing
an RN leads a team composed of other RNs, LPNs or LVNs and nurse assistants or technicians. The
team members provide direct patient care to group of patients, under the direction of the RN team leader
in coordinated effort. The charge nurse delegates authority to a team leader who must be a professional
nurse. This nurse leads the team usually of 4 to 6 members in the care of between 15 and 25 patients.
The team leader assigns tasks, schedules care, and instructs team members in details of care. A
conference is held at the beginning and end of each shift to allow team members to exchange
information and the team leader to make changes in the nursing care plan for any patient. The team
leader also provides care requiring complex nursing skills and assists the team in evaluating the
effectiveness of their care.

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 Charge nurse
RN

Team leader RN TEAM LEADER RN

RN LPN NA RN
LPN NA

Group of patients Group of patients

Advantages:
o High quality comprehensive care can be provided to the patient
o Each member of the team is able to participate in decision making and problem solving.
o Each team member is able to contribute his or her own special expertise or skills in aring for the
patient.
o Improved patient satisfaction.
o Feeling of participation and belonging are facilitated with team members.
o Work load can be balanced and shared.
o Division of labour allows members the opportunity to develop leadership skills.
o There is a variety in the daily assignment.
o Nursing care hours are usually cost effective.
o The client is able to identify personnel who are responsible for his care.
o Barriers between professional and non-professional workers can be minimized, the group efforts
prevail.

Disadvantages:
o Establishing a team concept takes time, effort and constancy of personnel. Merely assigning
people to a group does not make them a „group‟ or „team‟.
o Unstable staffing pattern make team nursing difficult.
o All personnel must be client centered.
o There is less individual responsibility and independence regarding nursing functions.

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 o The team leader may not have the leadership skills required to effectively direct the team and
create a “team spirit”.
o It is expensive because of the increased number of personnel needed.
o Nurses are not always assigned to the same patients each day, which causes lack of continuity of
care.
o Task orientation of the model leads to fragmentation of patient care and the lack of time the
team leader spends with patients.
MODULAR NURSING
Features:
Modular nursing is a modification of team nursing and focuses on the patient‟s geographic location for
staff assignments. The concept of modular nursing calls for a smaller group of staff providing care for a
smaller group of patients. The goal is to increase the involvement of the RN in planning and
coordinating care. The patient unit is divided into modules or districts, and the same team of caregivers
is assigned consistently to the same geographic location. Each location, or module, has an RN assigned
as the team leader, and the other team members may include LVN/LPN or UAP. The team leader is
accountable for all patient care and is responsible for providing leadership for team members and
creating a cooperative work environment. The success of the modular nursing depends greatly on the
leadership abilities of the team leader.
Merits:
o Nursing care hours are usually cost-effective.
o The client is able to identify personnel who are responsible for his care.
o All care is directed by a registered nurse.
o Continuity of care is improved when staff members are consistently assigned to the same
module
o The RN as team leader is able to be more involved in planning & coordinating care.
o Geographic closeness and more efficient communication save staff time.
o Feelings of participation and belonging are facilitated with team members.
o Work load can be balanced and shared.
o Division of labor allows members the opportunity to develop leadership skills
o Continuity care is facilitated especially if teams are constant.
o Everyone has the opportunity to contribute to the care plan.

Demerits:
o Costs may be increased to stock each module with the necessary patient care supplies
(medication cart, linens and dressings).
o Establishing the team concepts takes time, effort, and constancy of personnel.
o Unstable staffing pattern make team difficult.
o There is less individual responsibility and autonomy regarding nursing function.
o All personnel must be client centered.
o The team leader must have complex skills and knowledge.

PROGRESSIVE PATIENT CARE:

Features:
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It is a method in which client care areas provide various levels of care. The central theme is better
utilization of facilities, services and personnel for the better patient care. Here the clients are evaluated
with respect to all level (intensity) of care needed. As they progress towards increased self care (as they
become less ethically ill or in need of intensive care or monitoring) they are marred to units/ wards
staffed to best provide the type of care needed.
Principal elements of PPC are:
i) Intensive care or critical care: Patients who require close monitoring and intensive care round the
clock, e.g. patients with acute MI, fatal dysarythmias, those who need artificial ventilation, major burns,
premature neonates, immediate post or cardiothoracic, renal transplant, neurosurgery patients. These
units have 9-15 numbers of beds, life-saving equipment and skilled personnel for assessment, revival,
restoration and maintenance of vital functions of acutely ill patients. Nursing approach in these units is
patient-centered.
ii) Intermediate care: Critically ill patients are shifted to intermediate care units when their vital signs
and general condition stabilizes, e.g. cardiac care ward, chest ward, renal ward.
iii) Convalescent and Self Care: Although rehabilitation programme begins from acute care setting, yet
patients in these areas participate actively to achieve complete or partial self-care status. Patients are
taught administration of drugs, life style modification, exercises, ambulation, self-administration of
insulin, checking pulse, blood glucose and dietary management.
iv) Long-term care: Chronically ill, disabled and helpless patients are cared for in these units. Nurses
and other therapists help the patients and family members in coping, ambulation, pphysical therapy,
occupational therapy along with activities of daily living. Patients and family who need long-term care
are, cancer patients, paralyzed and patients with ostomies.
v) Home care: Some hospital/centers have home care services. A hospital based home care package
provides staff, equipment and supplies for care of patient at home, e.g. paralyzed patients, post-
operative, mentally retarded/spastic patient and patient on long chemotherapy.
vi) Ambulatory care: Ambulatory patients visit hospital for follow up, diagnostic, curative rehabilitative
and preventive services. These areas are outpatient departments, clinics, diagnostic centers, day care
centers etc.
Merits:
o Efficient use is made of personnel and equipment.
o Clients are in the best place to receive the care they require.
o Use of nursing skills and expertise are maximized.
o Clients are moved towards self care, independence is fostered where indicated.
o Efficient use and placement of equipment is possible.
o Personnel have greater probability to function towards their fullest capacity.

Demerits:
o There may be discomfort to clients who are moved often.
o Continuity care is difficult.
o Long term nurse/client relationships are difficult to arrange.
o Great emphasis is placed on comprehensive, written care plan.
o There is often times difficulty in meeting administrative need of the organization, staffing
evaluation and accreditation.
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PRIMARY CARE NURSING
Features:
It was developed in the 1960s with the aim of placing RNs at the bedside and improving the professional
relationships among staff members. The model became more popular
in the 1970s and early 1980s as hospitals began to employ more RNs. It supports a philosophy
regarding nurse and patient relationship.
It is a system in which one nurse is caring for all the needs of a patient or more within a 24 hour from
admission to discharge. He or she is responsible for coordinating and implementing all the necessary
nursing care that must be given to the patient during the shift. If the nurse is not available, the associate
nurse responsible for filling in for the nurse‟s absence will provide hospital care to the patient based on
the original plan of care made by the nurse. In acute care the primary care nurse may be responsible for
only one patient; in intermediate care the primary care nurse may be responsible for three or more
patients This type of nursing care can also be used in hospice nursing, or home care nursing.

patients
Total patient care 24hrs/day

Communicates with Communicates with

supervisors PRIMARY NURSE supervisors

Associate (days) when Associate (afternoon) when Associate (evenings) when

primary nurse is not primary nurse is not primary nurse is not
available available available

Advantages:
o Primary Nursing Care System is good for long-term care, rehabilitation units, nursing clinics,
geriatric, psychiatric, burn care settings where patients and family members can establish good
rapport with the primary nurse.
o Primary nurses are in a position to care for the entire person-physically, emotionally, socially
and spiritually.
o High patient and family satisfaction
o Promotes RN responsibility, authority, autonomy, accountability and courage.
o Patient-centered care that is comprehensive, individualized, and coordinated; and the
professional satisfaction of the nurse.
o Increases coordination and continuity of care.

Disadvantages:

17
 o More nurses are required for this method of care delivery and it is more expensive than other
methods.
o Level of expertise and commitment may vary from nurse to nurse which may affect quality of
patient care.
o Associate nurse may find it difficult to follow the plans made by another if there is disagreement
or when patient‟s condition changes.
o It may be cost-effective especially in specialized units such as the ICU.
o May create conflict between primary and associate nurses.
o Stress of round the clock responsibility.
o Difficult hiring all RN staff
o Confines nurse‟s talent to his/her own patients.
CASE MANAGEMENT
Features:
The case manager (RN or social worker with managerial qualification) is assigned responsibility of
following a patient‟s care and progress from the diagnostic phase through hospitalization, rehabilitation
and back to home care. For eg; case manager for cardiac surgery patients assists them go through
diagnostic procedures, pre-operative preparations, surgical interventions, family counseling, post-
operative care and rehabilitation. Case managers are employed by third party payers (e.g. insurance
companies) by the hospital authorities (e.g. for heart surgeries, renal transplant, reconstructive surgeries,
etc.), by clubs, industrialists and associations or by individuals, e.g. geriatric, family or private patients
case managers. No direct care by the manager whose main roles are of teaching, advocacy and
coordinating with health care providers. Case manager (nurse) ensures quality care that is holistic and
assisting the patient to attain self care status according to his/her potential. It emphasizes achievement of
outcomes in designated time frames with limited resources.
Case management involves critical paths, variation analysis, inter shift reports, case consultation, health
care team meetings, and quality assurance. Critical paths visualize outcomes within a time frame.
Variation analysis notes positive or negative changes from the critical paths, the cause, and the
corrective action taken. Case consultation may be indicated when the client‟s condition differs from the
critical path as noted in the inter shift report. Case consultation is conducted about once a week for a few
minutes immediately after inter shift report to deal with variations.
Health care team meetings provide an interdisciplinary approach to problem solving. The case manager
needs to identify no more than three priority goals and decide what team members should be present
after considering the patient, family physician, social service, various therapists, and others involved.
The case manager should set the time and place for the meeting, make the arrangements, and post the
date, time, place, and people to attend. The case manager calls the meeting to order, states the goals,
initiates discussion, documents the plans, and sets time limits for follow through. The variance between
what is expected and what happened is assessed for quality assurance.
Responsibilities of case managers:
♥ Assessing clients and their homes and communities.
♥ Coordinating and planning client care.
♥ Collaborating with other health professionals in the provision of care.
♥ Monitoring client progress and client outcomes.
♥ Advocating for clients moving through the services needed.
18
♥ Serving as a liaison with third party payers in planning the client‟s care.

Merits:
o Case management provides a well coordinated care experience that can improve the care
outcome, decrease the length of stay, and use multiple disciplines and services efficiently.
o Provides comprehensive care for those with complex health problems.
o It seeks the active involvement of the patient, family and diverse health care professionals

Demerits:
o Nurses identify major obstacles in the implementation of this service, financial barriers and lack
of administrative support.
o Expensive
o Nurse is client focused and outcome oriented
o Facilitates and promotes co-ordination of cost effective care
o Nursing case management is a professionally autonomous role that requires expert clinical
knowledge and decision making skills.

ORGANIZING PATIENT CARE

The overall goal of nursing is to meet the patient nursing needs with the available resources for
providing smooth day and night 24 hrs quality care to patients and to honor his rights. To ensure that
nursing care is provided to patients, the work must be organized. A Nursing Care Delivery Model
organizes the work of caring for patients. The decision of which nursing care delivery model is used is
based on the needs of the patients and the availability of competent staff in the different skill levels. For
organizing function to be productive and facilitate meeting the organization‟s needs, the leader must
know the organization and its members well.
♣ The top level manager who influence the philosophy and resources necessary for any selected care
delivery system to be effective
♣ The first and middle level managers generally have their greatest influence on the organizing phase of
the management process at the unit or departmental level. The managers organize how work is to be
done, shape the organizational climate, and determine how patient care delivery is organized.
♣ The unit leader-manager determines how best to plan work activities so organizational goals are met
effectively and efficiently, involves using resources wisely and coordinating activities with other
departments.

DEFINITION OF PATIENT CARE

The services rendered by members of the health profession and non-professionals under their
supervision for the benefit of the patient. The prevention, treatment and management of illness and the
preservation of mental and physical well-being through the services offered by the medical and allied
health professions.
PATIENT CLASSIFICATION SYSTEMS
Patient classification system (PCS), which quantifies the quality of the nursing care, is essential to
staffing nursing units of hospitals and nursing homes. In selecting or implementing a PCS, a

19
representative committee of nurse manager can include a representative of hospital administration. The
primary aim of PCS is to be able to respond to constant variation in the care needs of patients.
Characteristics
o Differentiate intensity of care among definite classes.
o Measure and quantify care to develop a management engineering standard.
o Match nursing resources to patient care requirement.
o Relate to time and effort spent on the associated activity.
o Be economical and convenient to repot and use.
o Be mutually exclusive, continuing new item under more than one unit.
o Be open to audit.
o Be understood by those who plan, schedule and control the work.
o Be individually standardized as to the procedure needed for accomplishment.
o Separate requirement for registered nurse from those of other staff.
Purposes
 The system will establish a unit of measure for nursing, that is, time, which will be used to
determine numbers and kinds of staff needed.
 Program costing and formulation of the nursing budget.
 Tracking changes in patients care needs. It helps the nurse managers the ability to moderate and
control delivery of nursing service
 Determining the values of the productivity equations
 Determine the quality: once a standards time element has been established, staffing is adjusted
to meet the aggregate times. A nurse manager can elect to staff below the standard time to reduce
costs.

Components
The first component of a PCS is a method for grouping patient’s categories. Johnson indicates two
methods of categorizing patients. Using categorizing method each patient is rated on independent
elements of care, each element is scored, scores are summarized and the patient is placed in a category
based on the total numerical value obtained. Johnson describes prototype evaluation with four basic
categories for a typical patient requiring one –on- one care. Each category addresses activities of daily
living, general health, teaching and emotional support, treatment and medications. Data are collected on
average time spent on direct and indirect care.
The second component of a PCS is a set of guidelines describing the way in which patients will be
classified, the frequency of the classification, and the method of reporting data.
The third component of a PCS is the average amount of the time required for care of a patient in each
category.
A method for calculating required nursing care hours is the fourth and final component of a PCS.

Patient Care Classification:

Area of care Category I Category II Category III Category IV

Eating Feeds self Needs some help Cannot feed self Cannot feed self
in preparing but is able to chew any may have
20
 and swallowing difficulty
swallowing

Grooming Almost entirely Need some help in Unable to do Completely

self sufficient bathing, oral much for self dependent
hygiene …

Excretion Up and to Needs some help In bed, needs Completely

bathroom alone in getting up to bedpan / urinal dependent
bathroom /urinal placed;

Comfort Self sufficient Needs some help Cannot turn Completely

with adjusting without help, get dependent
position/ bed.. drink, adjust
position of
extremities …
General health Good Mild symptoms Acute symptoms Critically ill

Treatment Simple – Any Treatment Any treatment Any elaborate/

supervised, more than once more than twice delicate procedure
Simple dressing per shift, foley /shift… requiring two
catheter nurses
Care, I&O… Vital signs more
Often than every
two hours
Health education Routine
Routinefollow
followup
up Initial teaching of More intensive Teaching of
& teaching teaching
teaching Initial
care ofteaching
ostomies;
of More
items; teaching
intensiveof resistive patients
care
new of ostomies;
diabetics; items;
apprehensive/
teaching of Teaching of
new
patients diabetics;
with mild apprehensive/
mildly resistive resistive patients,
patients
adversewith reactions
mild patients….
mildly resistive
to their illness…
adverse reactions patients….
to their illness…

FACTORS INFLUENCING THE QUALITY PATIENT CARE

Many variable factors influence the number of nurses needed on a ward in order to render a high quality
of patient care.
 The total number of patient to be nursed
 The degree of illness of patients (physical dependency)
 Type of service: medical, surgical, maternity, pediatrics and psychiatric
 The total needs of the patients
 Methods of nursing care

21
  Number of nursing aids and other non professional available, the amount and quality of
supervision available
 The amount, type and location of equipment and supplies
 The acuteness of the service and the rate of turnover in patients according to the degree or
period of illness.
 The experience of the nurses who are to give the patient care.
 The number of non-nurses who involve in the patient care, the quality of their work, their
stability in service.
 The physical facilities
 The number of hours in the working week of nurses and other ward personnel and the flexibility
in hours
 Methods of performing nursing procedures
 Affiliation of the hospital with the medical school
 Methods of assignment-individual, team or functional method
 The standards of nursing care.

Chapter IV bhagyalakshmi .B
Disaster management

INTRODUCTION:

Today, our lives are increasingly disrupted by disasters, both man-made and natural, to such an
extent that we now have to equip ourselves, both at an individual level and at as a city, and nation, to
effectively face and overcome such incidences.

Broadly disaster management consists of three phases of work: immediate rescue and relief,
post-disaster rehabilitation, and long-term mitigation against disasters. The Government has set up
several institutes and agencies to train and equip citizens as well as its personnel to deal with adverse
situations as well as mitigate the effects of disasters. Prominent amongst these are the National Disaster
Management Authority (NDMA) notified to streamline disaster management functioning, headed by
the Prime Minister.

A complementary institutional structure is set up at the State and the District levels too. The State
Disaster Management Authority is headed by the Chief Minister and this Authority is responsible for
preparing the Disaster Management Plans for the State, districts as well as Mumbai. Disaster is an
occurrence arising with little or no warning, which causes serious disruption of life and perhaps death or
injury to large number of people.

It is may be a man made or natural event that causes destruction and devastation which cannot be
relieved without assistance.

Definitions of Disaster
>> A disaster can be defined as any occurrence that cause damage, ecological disruption, loss of human
22
life, deterioration of health and health services, Vs a scale sufficient to warrant as extraordinary
response from outside the affected community or area. -(W.H.O.)

>> An occurrence of a severity and magnitude that normally results in death, injuries and property
damage that cannot be managed through the routine procedure and resources of government. - FEMA
(Federal Emergency Management Agency)

>> A disaster can be defined as an occurrence either nature or man made that causes human suffering
and creates human needs that victims cannot alleviate without assistance. - American Red
Cross (ARC)

>>United Nations defines disaster is the occurrence of a sudden or major misfortune which disrupts the
basic fabric and normal functioning of a society or community.

Definitions of Disaster Nursing:

@ Disaster Nursing can be defined as the adaptation of professional nursing skills in recognizing and
meeting the nursing physical and emotional needs resulting from a disaster. The overall goal of disaster
nursing is to achieve the best possible level of health for the people and the community involved in the
disaster.

@ “Disaster Nursing is nursing practiced in a situation where professional supplies, equipment,

physical facilities and utilities are limited or not available”.
‘DISASTER’ alphabetically means:
D - Destructions
I - Incidents
S - Sufferings
A - Administrative, Financial Failures.
S - Sentiments
T - Tragedies
E - Eruption of Communicable diseases.
R - Research programme and its implementation

2. Types of disaster

23
 .

3. Levels of disaster

 Level iii disaster – considered a minor disaster. These are involves minimal level of damage

 Level ii disaster- considered a moderate disaster. The local and community resources has to be
mobilized to manage this situation

 Level i disaster- considered a massive disaster- this involves a massive level of damage with
severe impact.

4. Disaster mitigation

 Disaster mitigation refers to actions or measures that can either prevent the occurrence of a
disaster or reduce the severity of its effects. (American Red Cross).

 Mitigation activities include awareness and education and disaster prevention measures.

5. Principles of Mitigation

 Save lives
 Reduce economic disruption
 Decrease vulnerability/increase capacity
 Decrease chance/level of conflict
6. Phases of disaster management

 Prevention phase

24
  Preparedness phase

 Response phase

 Recovery phase

6.1. Prevention phase

 Identify community risk factors and to develop and implement programs to prevent disasters
from occurring.

6.2. Preparedness phase

 Personal preparedness

 Professional preparedness

6.3. Community preparedness

 The level of community preparedness for a disaster is only as high as the people and
organization in the community make it.

 Community must have adequate warning system and a back up evaluation plan to remove people
from the area of danger

6.5. Response phase

The level of disaster varies and the management plans mainly based on the severity or extent of the
disaster.

6.6. Recovery phase

 During this phase actions are taken to repair, rebuilt, or reallocate damaged homes and
businesses and restore health and economic vitality to the community.

 Psychological recovery must be addressed.Both victims and relief workers should be offered
mental health activities and services.

7. The Objectives of Disaster Management

Although the actions taken to address a specific disaster vary depending on the hazard, four objectives
of disaster management apply to every situation.
 Reduce Damages and Deaths
Effective disaster management reduces or avoids morbidity, mortality, and economic and physical
damages from a hazard. The methods used to achieve this include hazard and vulnerability analysis,
preparedness, mitigation and prevention measures, and the use of predictive and warning systems.

25
Examples of effective disaster management techniques include completing risk assessments, building
community storm shelters and installing community outdoor siren systems.
 Reduce Personal Suffering
Disaster management reduces personal suffering, such as morbidity and emotional stress
following a hazard. The methods used to prevent suffering include hazard and vulnerability analysis,
preparedness, and mitigation and prevention measures. Examples of efforts to reduce personal suffering
include providing safe food supplies and potable drinking water when water supplies become
contaminated.
 Speed Recovery
The third objective is to speed recovery. The methods to accomplish this objective include
effective response mechanisms and the institution of recovery programs and assistance. Examples of
efforts to speed recovery include providing paperwork assistance for insurance claims, and grant or loan
applications.
 Protect Victims
Disaster management provides protection to victims and/or displaced persons. Facilities utilize
preparedness, response mechanisms, recovery programs and assistance to address shelter needs and
provide protective services.
8. PRINCIPLES OF DISASTER MANAGEMENT:

.  Disaster management is the responsibility of all spheres of government.

No single service or department in itself has the capability to achieve comprehensive
disaster management. Each affected service or department must have a disaster management plan which
is coordinated through the Disaster Management Advisory Forum.
.  Disaster management should use resources that exist for a day-to-day purpose.
There are limited resources available specifically for disasters, and it would be neither
cost effective nor practical to have large holdings of dedicated disaster resources. However,
municipalities must ensure that there is a minimum budget allocation to enable appropriate response to
incidents as they arise, and to prepare for and reduce the risk of disasters occurring.
.  Organisations should function as an extension of their core business.
Disaster management is about the use of resources in the most effective manner. To
achieve this during disasters, organisations should be employed in a manner that reflects their day-to-
day role. But it should be done in a coordinated manner across all relevant organisations, so that it is
multidisciplinary and multi-agency.
.  Individuals are responsible for their own safety.
Individuals need to be aware of the hazards that could affect their community and the counter measures,
which include the Municipal Disaster Management Plan, that are in place to deal with them.
.  Disaster management planning should focus on large-scale events.
It is easier to scale down a response than it is to scale up if arrangements have been based on incident
scale events. If you are well prepared for a major disaster you will be able to respond very well to
smaller incidents and emergencies, nevertheless, good multi agency responses to incidents do help in
26
 the event of a major disaster.
 Disaster management planning should recognise the difference between incidents and
.
disasters.
Incidents - e.g. fires that occur in informal settlements, floods that occur regularly, still require multi-
agency and multi-jurisdictional coordination. The scale of the disaster will indicate when it is beyond
the capacity of the municipality to respond, and when it needs the involvement of other agencies.

 Disaster management operational arrangements are additional to and do not replace

.
incident:
Management operational arrangements Single service incident management
operational arrangements will need to continue, whenever practical, during disaster operations.
 Disaster management planning must take account of the type of physical environment and
8.
the structure of the population
The physical shape and size of the Municipality and the spread of population must be
considered when developing counter disaster plans to ensure that appropriate prevention, preparation,
response and recovery mechanisms can be put in place in a timely manner.
 Disaster management arrangements must recognise the involvement and potential role of
.
non-GOVERNMENT AGENCIES:
Significant skills and resources needed during disaster operations are controlled by
non-government agencies. These agencies must be consulted and included in the planning process.

8.1. PRINCIPLES OF DISASTER MANAGEMENT POLICY

Disaster management is not a separate sector or discipline but an approach to solving

problems relating to disasters impacting any sector - agricultural, industrial, environmental, social etc.
Ultimately, disaster management is the responsibility of all sectors, all organisations and all agencies
that may be potentially affected by a disaster. Utilizing existing resources ensures efficiency in resource
utilization and lower costs.

Every disaster management policy is made on the basis of certain principles. These
principles are designed to provide guidance during all phases of disaster management and are consistent
with internationally accepted best practices. Some of the key principles of disaster management policy
are written hereunder:

8.1.1. Integrating disaster management into development planning:

The objectives of the DM policy or any sectoral policy should sub-serve the overall
goals of the state relating to economic and social development. Hence, policies on sustainable
development should seek to reduce possible losses from disasters, as a matter of course. In other
words, disaster prevention and preparedness should be an integral part of every development policy.
Therefore, the state’s development strategy shall explicitly address disaster management as an
integral part of medium and long-term planning, especially for disaster prone districts in the state.

8.1.2. Multi-hazard approach to disasters:

27
 Disasters can either be man-made, natural or even arising out of technological causes. A
robust DM policy must therefore provide, plan and prepare for all types of hazards and disasters that
may be reasonably expected to occur in a region.

8.1.3. Sustainable and continuous approach:

One of the objectives of sustainable development is to increase the inherent strength of all agencies,
including the community to deal with disaster situations. Achieving this objective requires sustained
initiatives encompassing social, economic and infrastructure issues. Further, once capacity is built, it
must be sustained and this would be an ongoing and continuous activity.

8.1.4. Effective inter-agency co-operation and co-ordination:

Successful disaster response requires a quick and organized response. The active participation of
affected communities, NGOs, private sector and various Government departments like Fire Brigade,
Police, Health etc. is thus critical to any response activity. Therefore, the DM policy shall focus on
establishing response mechanisms that are quick, coordinated and participative.

8.1.5. Capacity building:

Managing disasters using only a handful of stakeholders would be inefficient. Government therefore
should recognize that the DM policy needs to be strengthening the resilience and capacity of NGOs,
private sector and the local community to cope with disasters while simultaneously building the
capacity of the Government machinery to manage disasters. Effective disaster management requires
that the community especially vulnerable groups like women, landless labor etc. be fully aware of
the extent of their vulnerability to disasters to reduce its impact, prior to its actual occurrence.
Further, NGOs, private sector and the community must understand and be familiar with DM
principles and practices, what their own responsibilities are, how they can help prevent disasters,
how they must react during a disaster and what they can do to support themselves and relief
workers, when necessary. Training is an integral component of capacity building. Development of
Disaster Management as a distinct managerial discipline will be taken up to create a systematic and
streamlined disaster management cadre. Gender issues in disaster management will be addressed
and the empowerment of women towards long term disaster mitigation will be focused upon.

8.1.6. Autonomy and equity:

Disasters are catastrophic events whose impact is felt across socio-economic boundaries.
Consequently, any DM effort should be neutral and non-discriminatory. To that extent, it is
necessary that the DM institutions possess the autonomy to make decisions in a fair, scientific and
systematic manner. Disaster assistance and relief must also be provided in an equitable and
consistent manner without regard to economic or social status of beneficiaries. Relief / assistance
must be provided without any discrimination of caste, creed, religion, community or sex.

8.1.7. Legal sanction:

The institutions/ individuals responsible for implementing disaster-management activities
must have the necessary legal sanction and validity with requisite powers for managing emergency
situations. This is necessary to ensure that they are recognized by all stakeholders as the legitimate
28
 policy making and/or implementation authorities.

8.1.8. Accommodating aspirations of people:

The objective of any effort relating to disaster management is to benefit the community. People are
central to the decision-making process for disaster management and their priorities should be
reflected in the programs undertaken.

8.1.9. Accommodating local conditions:

Disaster management efforts should be sensitive to local customs, beliefs, and practices
and be adapted to local conditions. In addition, changes in the community and evolving social and
economic relationships must be borne in mind to avoid confrontation and bottlenecks. This will
ensure participation of the local community and foster a culture of joint responsibility for disaster
management at all levels.

8.1.10. Financial sustainability:

Government should be committed to allocate funds for the sustainability of the disaster management
programs.

8.1.11. Develop, share and disseminate knowledge:

No single organization can claim to possess all the capabilities required to provide effective disaster
management. So there should be an institute dedicated to conducting research, development and
training activities related to disaster management, shall be set up. This institute would aid in the
sharing and dissemination of specialized knowledge related to disaster management among various
implementation agencies, NGOs, private sector and the community in the particular region. Also,
basic concepts related to disaster management and the role of the community therein shall be
included in the curriculum of schools. This shall serve to sensitize people to the participative
approach needed for effective disaster management. Information and knowledge embracing all
facets of disaster- from mitigation to amelioration - shall be infused in schools, colleges and
teacher's training syllabi.
9. PREVENTION STEPS IN DISASTER :

 Everyday Activities / Activities when there is a Disaster

10. KEY ORGANIZATIONS AND PROFESSIONALS IN DISASTER MANAGEMENT:

29
 10.1. Health care community

 Hospitals

 Health professionals

 Pharmacies

 Public health departments

 Rescue personnel
Organizational chart of a disaster management plan applicable to any hospital

10.2. Non-health care community

 Fire fighters

 Municipal or government officials

 Media

 Medical examiners

 Medical supply manufactures Police.

30
 Disaster Management Organization Chart Of India

10.3. Disaster management plans

Aims of disaster plans

 to provide prompt and effective medical care to the maximum possible in order to minimize
morbidity and mortality

Objectives
 To optimally prepare the staff and institutional resources for effective performance in disaster
situation

 To make the community aware of the sequential steps that could be taken at individual and
organizational levels

Disaster management committee

31
The following members would comprise the disaster management committee under the chairmanship of
medical superintendent/ director

 Medical superintendent/ director

 Additional medical superintendent

 Nursing superintendent/ chief nursing officer

 Chief medical officer (casualty)

 Head of departments- surgery, medicine, orthopedics, radiology, anesthesiology, neurosurgery

 Blood bank in charge

 Security officers

 Transport officer

 Sanitary personnel

Disaster control room

 The existing casualty may be referred as the disaster control room.

Rapid response team

 The medical superintendent will identify various specialists, nurses and pharmacological staff to
respond within a short notice depending up on the time and type of disaster.

 The list of members and their telephone numbers should be displayed in the disaster control
room.

Information and communication

 the disaster control team would be responsible for collecting, coordinating and disseminating the
information about the disaster situation to the all concerned.

Disaster beds
 Requirement of beds depends up on the magnitude of the disaster.

 Utilization of vacant beds, day care beds, and pre-operative beds

 Convalescing patients, elective surgical cases and patients who can have domiciliary care or opd
management should be discharged

 Utility areas to be converted in to temporary wards such as wards with side rooms, corridors,
seminar rooms etc.

 Creating additional bed capacity by using trolleys, folding beds and floor beds

Logistic support system

 Resuscitation equipments
32
  Iv sets, iv fluids,

 Disposable needles, syringes and gloves

 Dressing and suturing materials and splints

 Oxygen masks, nasal catheters, suction machine and suction catheters

 Ecg monitors, defibrillators, ventilators

 Cut down sets, tracheostomy sets and lumbar puncture sets

 Linen and blankets

 Keys of these cupboards should be readily available at the time of disaster

Training and drills

 Mock exercise and drills at regular intervals are conducted to ensure that all the staff in the
general and those associated with management of causalities are fully prepared and aware of
their responsibilities.

Elements of disaster plan

A disaster plan should have the following elements

 Chain of authority

 Lines of communication

 Routes and modes of transport

 Mobilization

 Warning

 Evacuation

 Rescue and recovery

 Triage

 Treatment

 Support of victims and families

 Care of dead bodies

 Disaster worker rehabilitation

Activation of disaster management plans

 Standard operating procedures (SOPs)

33
  Reception area

 Triage

o Priority one- needing immediate resuscitation, after emergency treatment shifted to

intensive care unit

o Priority two- immediate surgery, transferred immediately to operation theatre.

o Priority three- needing first aid and possible surgery- give first aid and admit if bed is
available or shift to hospital

o Priority four- needing only first aid-discharge after first aid.

 Documentation

 Public relations.

 Essential services.

 Crowd management/ security arrangement.

11. THE FOLLOWING ARE SOME STEPS THAT MUST BE TAKEN INTO
CONSIDERATION WHEN PREPARING AND PREVENTING DISASTER.

 Public announcement of impending disaster, evacuation of victims, assessment of disaster

situation and surveillance report;
 Fire-fighting, flooding prevention or containment and other response measures;
 Providing temporary accommodation, special protection measures for the disadvantaged
minority affected by the disaster;
 Emergency care for the children who were affected by the disaster;
 Emergency handling of hazardous materials, facilities and equipment;
 Sterilization, epidemic prevention, inspection of food sanitation and any other public health
affairs;
 Delimitation of safety zone, traffic control and crime prevention;
 Search and rescue, emergency medical service and transportation of the injured;
 Supply and allotment of livelihood products and potable water;
 Disaster prevention and emergency repair of water conservancy and agriculture;
 Emergency repair of public facilities including railway, highway, airport, seaport, public gas and
fuel pipeline, power lines, telecommunication, and tap water. Any other measures that may be
necessary for disaster prevention and protection.
 Educate your children wife and other family member in respect of natural and manmade
disasters and other crises. In case of your being unaware, take help of Civil Defence and Home
Guard organisation and other NGOs. Develop habit in you and your children to spare 1% of you
busy time to think about Individual security and security interests
 Guide children to remain at schools in emergency.

34
  Prepare an emergency kit of items and essentials in the house including essential documents and
valuables.
 Store food and water for survival in case you receive a pre-warning.
 Any suspicious incidents observed to be reported to police the on 103. Callers do not have to
give their identity on the phone. Information of immediate use be conveyed to control rooms to
help early relief.
 Carry your identity card, residential telephone number or address or personal card with you.
Have your blood group and any medical allergies recorded with you.
 Check information in case of disasters and crises from ward, civil Defence/Home Guard, and
BMC, TV and All India Radio Control room.
 Support authorities and local NGOs.
 Identify scooters, cars, vehicles parked in society and identify vehicles which are unknown and
parked for long.
 Organize societies and mohalla committees to educate people.

11.1. Natural Disaster Prevention

Not all natural disasters can be prevented. However, the impacts can be lessened with proper
planning and notification systems. Only by managing land and water resources--not for the possibility of
a natural disaster but rather for the reality of it occurring--can higher costs in property damage and loss
of human life be prevented. Planning requires the cooperation of a network of state and local officials
working with federal agencies like the Federal Emergency Management Agency (FEMA) to assess risks
and implement changes where necessary.
According to FEMA, floods are the most common natural disaster. Effects of floods are
complicated by weather patterns such as drought, which hardens soils and increases the possibility of
flash flooding. The amount of impervious surfaces in developed areas can contribute to flood waters and
risk the health of local streams and watersheds.
A reduction in impervious surfaces is another measure that can prevent a natural disaster.
Impervious surfaces include roads, parking lots and sidewalks found in developed areas. These surfaces
often have replaced natural areas such as wetlands. The EPA estimates that a single acre of wetlands can
store up to 1.5 million gallons of floodwater. Replacing wetlands with impervious surfaces sets the stage
for a flood event. By reducing the amount of impervious surface through city and local planning, flash
flooding can be prevented or at the very least lessen impacts.
Monitoring
Climate monitoring by the National Oceanic and Atmospheric Administration and the National
Weather Service can help prevent human losses by notification of severe weather patterns. Storm
warnings allow for proper preparation, even evacuation, in the event of a pending weather event.
Likewise, monitoring of seismic activity by the National Earthquake Information Center (NEIC) can
rapidly inform government agencies and the public of destructive earthquakes.
Prepare
Natural disaster prevention also relies on the individual. The American Red Cross provides training for
individuals to prepare for natural disasters. Having an emergency preparedness kit in your home is

35
important, since some natural disasters can occur without warning. A well-stocked kit will include a
complete first aid kit, a few days' supply of drinking water and canned goods, and other necessities such
as batteries, an extra cellphone battery, matches and flashlights. While having the kit will not prevent
the disaster, it will give you the peace of mind of being prepared.

11.2. Communicable Diseases & Preventive Measures in a Disaster:

In a disaster, whether it's an earthquake, a hurricane or a bomb going off, the initial destruction is
usually just the beginning of the problems you might face. One concern that few people consider is that
following a disastrous event, you may be at higher risk of communicable diseases due to poor sanitation
and an unclean water supply. By taking a few simple steps now to become prepared, you can protect you
and your family from the illnesses that often run rampant after a disaster.

A Clean Water Supply

o In the aftermath of a disaster, clean water is among your highest priorities. Broken water
mains, contamination from untreated floodwaters and malfunctioning sewer systems can
taint water, and make it a disease hazard.
Cean water on hand is paramount. In the event of a disaster, immediately stop the drains and fill every
bathtub in your home. Bathtubs hold several gallons of water, which can meet your family's needs for
several days.
Consider storing water in sturdy, food-grade water drums that you can keep in your garage or basement.
Water storage drums are available in a variety of sizes. In an emergency, each member of your family
needs 1 gallon of clean water a day for drinking and cleaning. You should have at least three days worth
of clean water on hand.
In the event that an emergency situation outlasts your water supply, you can treat water with iodine.
Iodine treatment eliminates risks from bacteria, but not from chemical contaminants. In most
circumstances, this is adequate. Add 10 drops of iodine per qt. of water and allow it to sit for a half hour
before drinking. The water won't taste good, but it will be safe.
BASIC FIRST AID
o Proper first aid supplies can also help reduce the spread of communicable diseases. Wearing
gloves and a mask while bandaging wounds or helping sick people can cut down on your risk
of infection. That in turn reduces the risk of you spreading a disease to others.
A basic first aid kit should have a box of latex or other non-permeable gloves, a box of surgical masks,
topical antiseptic ointments, and lots of sterile bandages.
GOOD HYGIENE
o Good hygiene cuts down on the spread of disease whether you're facing a disaster or just a
regular day. If there is a disease spreading in your community during an emergency situation,
set aside extra water for good hand-washing practices. Remind everyone in your family to
regularly wash their hands, especially before eating and after using the restroom.

36
It's also a good practice to avoid touching your face as much as possible when the disease risk is high.
Most bacteria and viruses enter the body through the nose, mouth and eyes via your hands.

SUPPLEMENTS TO HAVE ON HAND

o Immune support during a natural disaster is especially important. It's likely you won't have
access to your normal diet and you'll be under a lot of stress. Both suppress your immune
system and make you more susceptible to illness.
Echinacea, colloidal silver, olive leaf extract, vitamin C, grapefruit seed extract and astragalus all help to
support your immune system. It's not necessary to take every one, but having one or two on hand to take
in emergencies can give your immune system what it needs to deal with the extra strain. Supplements
that support the immune system can help to keep you and your family healthy in the aftermath of a
disaster
Institutional and Legal Arrangements: Disaster Management Act, 2005

The Act lays down institutional, legal, financial and coordination mechanisms at the national,
state, district and local levels. These institutions are not parallel structures and will work in close
harmony.

Institutional Framework under the DM Act

National Disaster Management Authority (NDMA)

The NDMA, as the apex body for disaster management, is headed by the Prime Minister and has
the responsibility for laying down policies, plans and guidelines for DM (and coordinating their
enforcement and implementation for ensuring timely and effective response to disasters).

o It will approve the National Disaster Management and DM plans of the Central
Ministries/Departments.
o It will take measures for prevention of disasters, or mitigation, or preparedness and capacity
building, for dealing with a threatening disaster situation or disaster.
o Central ministries/ departments and State Governments will extend necessary cooperation
and assistance to NDMA for carrying out its mandate.
o It will oversee the provision and application of funds for mitigation and preparedness
measures.
o NDMA has the power to authorize the Departments or authorities concerned, to make
emergency procurement of provisions or materials for rescue and relief in a threatening
disaster situation or disaster.
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The National Executive Committee

The National Executive Committee (NEC) comprises the Union Home Secretary as the
Chairperson, and the Secretaries to the GOI in the Ministries/Departments of Agriculture, Atomic
Energy, Defence, Drinking Water Supply, Environment and Forests, Finance (Expenditure), Health,
Power, Rural Development, Science and Technology, Space, Telecommunications, Urban Development,
Water Resources and the Chief of the Integrated Defence Staff of the Chiefs of Staff Committee as
members. Secretaries in the Ministry of External Affairs, Earth Sciences, Human Resource
Development, Mines, Shipping, Road Transport & Highways and Secretary, NDMA will be special
invitees to the meetings of the NEC.

 Mandated to assist the NDMA in the discharge of its functions and also ensure compliance
of the directions issued by the Central Government.
 NEC is to coordinate the response in the event of any threatening disaster situation or
disaster.
 NEC will prepare the National Plan for Disaster Management based on the National Policy
on Disaster Management.
 NEC will monitor the implementation of guidelines issued by NDMA.
 It will also perform such other functions as may be prescribed by the Central Government
in consultation with the NDMA
 Lay down policies on disaster management;
 Approve the National Plan;
 Approve plans prepared by the Ministries or Departments of the Government of India in
accordance with the National Plan;
 Lay down guidelines to be followed by the State Authorities in drawing up the State Plan;
 Lay down guidelines to be followed by the different Ministries or Departments of the
Government of India for the purpose of integrating the measures for prevention of disaster
or the mitigation of its effects in their development plans and projects;
 Coordinate the enforcement and implementation of the policy and plan for disaster
management;
 Recommend provision of funds for the purpose of mitigation;
 Provide such support to other countries affected by major disasters as may be
 determined by the Central Government;
 Take such other measures for the prevention of disaster, or the mitigation, or
preparedness and capacity building for dealing with the threatening disaster situation or disaster
as it may consider necessary;
 Lay down broad policies and guidelines for the functioning of the National Institute of
Disaster Management.
.
State Disaster Management Authority (SDMA)

38
 At the State level, the SDMA, headed by the Chief Minister, State Disaster Management
Authority (SDMA)

o Will lay down policies and plans for DM in the State.

o It will approve the State Plan in accordance with the guidelines laid down by the NDMA,
o coordinate the implementation of the State Plan,
o Recommend provision of funds for mitigation and preparedness measures and review the
developmental plans of the different departments of the State.

State executive committee:

The State Government shall constitute a State Executive Committee (SEC) to assist the SDMA
in the performance of its functions. The SEC will be headed by the Chief Secretary to the State
Government and coordinate and monitor the implementation of the National Policy, the National Plan
and the State Plan. The SEC will also provide information to the NDMA relating to different aspects of
DM.

District Disaster Management Authority (DDMA)

The DDMA will be headed by the District Collector, Deputy Commissioner or District
Magistrate as the case may be, with the elected representative of the local authority as the Co-
Chairperson. DDMA will act as the planning, coordinating and implementing body for DM at District
National Institute of Disaster Management (NIDM)

The NIDM, in partnership with other research institutions has

o capacity development
o training,
o research,
o Documentation and development of a national level information base.
o Work with other knowledge-based institutions and function within the broad policies and
guidelines laid down by the NDMA.

National Disaster Response Force (NDRF)

The general superintendence, direction and control of this force shall be vested in and exercised
by the NDMA and the command and supervision of the Force shall vest in an officer to be appointed by
the Central Government as the Director General of Civil Defence and National Disaster Response Force.
o Presently, the NDRF comprises eight battalions and further expansion may be considered in
due course.
o These battalions will be positioned at different locations as may be required.

39
 o NDRF units will maintain close liaison with the designated State Governments and will be
available to them in the event of any serious threatening disaster situation.
o While the handling of natural disasters rests with all the NDRF battalions, four battalions
will also be equipped and trained to respond to situations arising out of Chemical, Biological,
Radiological and Nuclear emergencies.
o Training centres will be set up by respective para-military forces to train personnel from
NDRF battalions of respective Forces and will also meet the training requirement of
State/UT Disaster Response Forces.
o The NDRF units will also impart basic training to all the stakeholders identified by the State
Governments in their respective locations

Existing Institutional Arrangements

Cabinet Committee on Management of Natural Calamities (CCMNC) and the Cabinet Committee
on Security (CCS)

CCMNC had been constituted to oversee all aspects relating to the management of natural
calamities including assessment of the situation and identification of measures and programmes
considered necessary to reduce its impact, monitor and suggest long term measures for prevention of
such calamities, formulate and recommend programmes for public awareness for building up society’s
resilience to them.

High Level Committee (HLC)

In the case of calamities of severe nature, Inter-Ministerial Central Teams are deputed to the
affected states for assessment of damage caused by the calamity and the amount of relief assistance
required. The IMG, headed by the Union Home Secretary, scrutinises the assessment made by the
Central Teams and recommends the quantum of assistance to be provided to the States from the
National Calamity Contingency Fund (NCCF). However, assessment of damages by IMG in respect of
drought, hail-storm, and pest attack will continue to be headed by the Secretary, M/o Agriculture &
Cooperation. The HLC comprising Finance Minister, as Chairman and the Home Minister, Agriculture
Minister & Deputy Chairman, Planning Commission as members approves the central assistance to be
provided to the affected States based on the recommendations of the IMG. The constitution and
composition of HLC may vary from time to time. The Vice Chairman, NDMA will be a special invitee
to the HLC.

Central Government

In accordance with the provisions of the Act, the Central Government will take all such
measures, as it deems necessary or expedient, for the purpose of DM and will coordinate actions of all
agencies.

40
 The Central Ministries and Departments will take into consideration the recommendations of the
State Government departments while deciding upon the various pre- disaster requirements and for
deciding upon the measures for prevention and mitigation of disaster.

It will ensure that Central Ministries and Departments integrate measures for the prevention and
mitigation of disasters into their developmental plans and projects, make appropriate allocation of funds
for pre-disaster requirements and take necessary measures for preparedness and to effectively respond to
any disaster situation or disaster.

It will have the power to issue directions to NEC, State Governments/SDMAs, SECs or any of
their officers or employees, to facilitate or assist in DM, and these bodies and officials shall be bound to
comply with such directions.

The Central Government will extend cooperation and assistance to State Governments as
required by them or otherwise deemed appropriate by it. It will take measures for the deployment of the
Armed Forces for disaster management.

The Central Government will also facilitate coordination with the UN Agencies, international
organisations and Governments of foreign countries in the field of disaster management. Ministry of
External Affairs in coordination with MHA will facilitate external coordination/ cooperation.

Role of Central Ministries and Departments

As disaster management is a multi-disciplinary process, all Central Ministries and Departments

will have a key role in the field of disaster management. The nodal Ministries and Departments of
Government of India (i.e. the Ministries of Agriculture, Atomic Energy, Civil Aviation, Earth Sciences,
Environment and Forests, Home Affairs, Health, Mines, Railways, Space, Water Resources etc.) will
continue to address specific disasters as assigned to them.

National Crisis Management Committee (NCMC)

The NCMC, comprising high level officials of the GoI headed by the Cabinet Secretary, will
continue to deal with major crises which have serious or national ramifications. It will be supported by
the Crisis Management Groups (CMG) of the Central nodal Ministries and assisted by NEC as may be
necessary. The Secretary, NDMA may be a member of this Committee.
State Governments
The primary responsibility for disaster management rests with the States. The institutional
mechanism put in place at the Centre, State and District levels will help the States manage disasters in
an effective manner.
The Act mandates the State Governments inter alia to take measures for preparation of Disaster
Management Plans, integration of measures for prevention of disasters or mitigation into development
plans, allocation of funds, establishment of early warning systems, assist the Central Government and
other agencies in various aspects of Disaster Management

District Administration

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 At the district level, District Disaster Management Authorities (DDMAs), will act as the district
planning, coordinating and implementing body for disaster management and will take all measures for
the purposes of disaster management in the district in accordance with the guidelines laid by NDMA and
SDMA.
Management of Disasters impacting more than one State

At times, the impact of disasters occurring in one State may spread over to the areas of other
States. Similarly, preventive measures in respect of certain disasters, such as floods, etc may be required
to be taken in one State, as the impact of their occurrence may affect another. Management of such
situations calls for a coordinated approach, which can respond to a range of issues quite different from
those that normally present themselves – before, during and after the event. NDMA will encourage
identification of such situations and promote the establishment of mechanisms on the lines of Mutual
Aid Agreement for coordinated strategies for dealing with them by the states and central ministries,
departments and other agencies concerned.

Other Important Institutional Arrangements

Armed Forces

Conceptually, the Armed Forces are called upon to assist the civil administration only when the
situation is beyond their coping capability. In practice, however, the armed forces form an important
part of the Government’s response capacity and are immediate responders in all serious disaster
situations. On account of their vast potential to meet any adverse challenge, speed of operational
response and the resources and capabilities at their disposal, the armed forces have historically played a
major role in emergency support functions.

Central Para Military Forces

The Central Paramilitary forces, which are also the armed forces of the Union, play a key role at
the time of immediate response to disasters. Besides contributing to the NDRF, they will develop
adequate disaster management capability within their own forces and respond to disasters which may
occur in the areas where they are posted. The local representatives of the CPMFs may be co-
opted/invited in the executive committee at the State level.
State Police Forces and Fire Services

The State Police forces and the Fire Services are crucial immediate responders to disasters. The
police force will be trained and the Fire Services upgraded to acquire multi-hazard rescue capability.

Civil Defence and Home Guards

42
 The mandate of the Civil Defence and the Home Guards will be redefined to assign an effective
role in the field of disaster management. They will be deployed for community preparedness and public
awareness. A culture of voluntary reporting to duty stations in the event of any disasters will be
promoted.

State Disaster Response Force (SDRF)

States will be encouraged to create response capabilities from within their existing resources. To
start with, each state may aim at equipping and training one battalion equivalent force. They will also
include women members for looking after the needs of women and children. NDRF battalions and their
training institutions will assist the States/UTs in this effort. The States/UTs will also be encouraged to
include DM training for gazetted and non-gazetted officers.

Role of National Cadet Corps (NCC), National Service Scheme (NSS) and Nehru Yuva Kendra
Sangathan (NYKS)

Potential of these youth based organisations will be optimized to support all community based
initiatives and DM training would be included in their programmes.

International Cooperation

Disasters do not recognize geographical boundaries. Major disasters may often simultaneously
affect several countries. It will be the national endeavour to develop close cooperation and coordination
at the international level in all spheres of DM. level and take all necessary measures for the purposes of
DM in accordance with the guidelines laid down by the NDMA and SDMA. It will, inter alia prepare
the District DM plan for the district and monitor the implementation of the National Policy, the State
Policy, the National Plan, the State Plan and the District Plan. DDMA will also ensure that the
guidelines for prevention, mitigation, preparedness and response measures laid down by the NDMA and
the SDMA are followed by all Departments of the State Government at the District level and the local
authorities in the district.

Local Authorities

For the purpose of this policy, local authorities would include Panchayati Raj Institutions (PRI),
Municipalities, District and Cantonment Boards and Town Planning Authorities which control and
manage civic services. These bodies will ensure capacity building of their officers and employees for
managing disasters, carry out relief, rehabilitation and reconstruction activities in the affected areas and
will prepare DM Plans in consonance with guidelines of the NDMA, SDMAs and DDMAs. Specific
institutional framework for dealing with disaster management issues in mega cities will be put in place

11.3. SPECIFIC PREVENTION IN EACH TYPES DISASTER:

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 EARTHQUAKE:
Prepare your family
Before the earthquake
Now is the time to formulate a safety plan for you and your family. If you wait until the earth starts to
shake, it may be too late. Consider the following safety measures:
· Always keep the following in a designated place: bottled drinking water, non-perishable food
(chura, gur, etc), first-aid kit, torchlight and battery-operated radio with extra batteries.
· Teach family members how to turn off electricity, gas, etc.
· Identify places in the house that can provide cover during an earthquake.
· It may be easier to make long distance calls during an earthquake. Identify an out-of-town
relative or friend as your family’s emergency contact. If the family members get separated after the
earthquake and are not able to contact each other, they should contact the designated relative/friend.
The address and phone number of the contact person/relative should be with all the family members.
Safeguard your house
· Consider retrofitting your house with earthquake-safety measures. Reinforcing the foundation and
frame could make your house quake resistant. You may consult a reputable contractor and follow
building codes.
· Kutchha buildings can also be retrofitted and strengthened.

During quake
Earthquakes give no warning at all. Sometimes, a loud rumbling sound might signal its arrival a few
seconds ahead of time. Those few seconds could give you a chance to move to a safer location. Here are
some tips for keeping safe during a quake.
· Take cover. Go under a table or other sturdy furniture; kneel, sit, or stay close to the floor. Hold on
to furniture legs for balance. Be prepared to move if your cover moves.
· If no sturdy cover is nearby, kneel or sit close to the floor next to a structurally sound interior wall.
Place your hands on the floor for balance.
· Do not stand in doorways. Violent motion could cause doors to slam and cause serious injuries.
You may also be hit be flying objects.
· Move away from windows, mirrors, bookcases and other unsecured heavy objects.
· If you are in bed, stay there and cover yourself with pillows and blankets
· Do not run outside if you are inside. Never use the lift.
· If you are living in a kutcha house, the best thing to do is to move to an open area where there are
no trees, electric or telephone wires.
If outdoors:

44
· Move into the open, away from buildings, streetlights, and utility wires. Once in the open, stay
there until the shaking stops.
· If your home is badly damaged, you will have to leave. Collect water, food, medicine, other
essential items and important documents before leaving.
· Avoid places where there are loose electrical wires and do not touch metal objects that are in touch
with the loose wires.
· Do not re-enter damaged buildings and stay away from badly damaged structures.
If in a moving vehicle:
Move to a clear area away from buildings, trees, overpasses, or utility wires, stop, and stay in the
vehicle. Once the shaking has stopped, proceed with caution. Avoid bridges or ramps that might have
been damaged by the quake.
After the quake
Here are a few things to keep in mind after an earthquake. The caution you display in the aftermath can
be essential for your personal safety.
· Wear shoes/chappals to protect your feet from debris
· After the first tremor, be prepared for aftershocks. Though less intense, aftershocks cause
additional damages and may bring down weakened structures. Aftershocks can occur in the first
hours, days, weeks, or even months after the quake.
· Check for fire hazards and use torchlights instead of candles or lanterns.
· If the building you live in is in a good shape after the earthquake, stay inside and listen for radio
advises. If you are not certain about the damage to your building, evacuate carefully. Do not touch
downed power line.
· Help injured or trapped persons. Give first aid where appropriate. Do not move seriously injured
persons unless they are in immediate danger of further injury. In such cases, call for help.
· Remember to help your neighbours who may require special assistance-infants, the elderly, and
people with disabilities.
· Listen to a battery-operated radio for the latest emergency information.
· Stay out of damaged buildings.
· Return home only when authorities say it is safe. Clean up spilled medicines, bleaches or gasoline
or other flammable liquids immediately. Leave the area if you smell gas or fumes from other
chemicals. Open closet and cupboard doors cautiously.
· If you smell gas or hear hissing noise, open windows and quickly leave the building. Turn off the
switch on the top of the gas cylinder.
· Look for electrical system damages - if you see sparks, broken wires, or if you smell burning of
amber, turn off electricity at the main fuse box. If you have to step in water to get to the fuse box,
call an electrician first for advice.
45
· Check for sewage and water lines damage. If you suspect sewage lines are damaged, avoid using
the toilets. If water pipes are damaged, avoid using water from the tap.
· Use the telephone only for emergency calls.
· In case family members are separated from one another during an earthquake (a real possibility
during the day when adults are at work and children are at school), develop a plan for reuniting after
the disaster. Ask an out of state / district relative or friend to serve as the “family contact”. Make
sure everyone in the family knows the name, address, and phone number(s) of the contact person (s).
CYCLONE

SAFETY TIPS (Before the Cyclone Season)

 Keep watch on weather and listen to radio or TV. Keep alert about the community warning
systems – loudspeakers, bells, conches, drums or any traditional warning system.

 Get to know the nearest cyclone shelter / safe houses and the safest route to reach these shelters.

 Do not listen to rumours.

 Prepare an emergency kit containing:

o A portable radio, torch and spare batteries;

o Stocks dry food – Chura, Chhatua, Mudhi, gur, etc.

o Matches, fuel lamp, portable stove, cooking utensils, waterproof bags

o A first aid kit, manual, etc.

o Katuri, pliers, small saw, axe and plastic rope

 Check the roof and cover it with net or bamboo. Check the walls, pillars, doors and windows to
see if they are secure. If not, repair those at the earliest. In case of tin roofs, check the condition
of the tin and repair the loose points. Cover the mud walls with polythene or coconut leaves mats
or straw mats on a bamboo frame. Bind each corner of the roof with a plastic rope in case of
thatched roof.

 Trim dry tree branches, cut off the dead trees and clear the place/courtyard of all debris,
including coconuts and tree branches.

 Clear your property of loose materials that could blow about and cause injury or damage during
extreme winds.

 If your area is prone to storm surge, locate safe high ground or shelter.

 Keep important documents, passbook, etc. in a tight plastic bag and take it along with your
emergency kits if you are evacuating.

46
  Identify the spot where you can dig holes to store food grains, seeds, etc. in polythene bags.

 Keep a list of emergency addresses and phone numbers on display. Know the contact telephone
number of the government offices /agencies, which are responsible for search, rescue and relief
operations in your area.

If you are living in an area where CBDP exercises have taken place, ensure:

 Vulnerability list and maps have been updated

 Cyclone drill including search & rescue, first aid training have taken place

 Stock of dry food, essential medicines and proper shelter materials

maintained

Upon a cyclone warning

 Store loose items inside. Put extra agricultural products/ stock like paddy in plastic bags and
store it by digging up a hole in the ground, preferably at a higher elevation and then cover it
properly. Fill bins and plastic jars with drinking water.

 Keep clothing for protection, handy

 Prepare a list of assets and belongings of your house and give information to volunteers and
other authorities about your near and dear ones.

 Fill fuel in your car/motorcycle and park it under a solid cover. Tie bullock carts, boats securely
to strong posts in an area, which has a strong cover and away from trees. Fallen trees can smash
boats and other assets.

 Close shutters or nail all windows. Secure doors. Stay indoors, with pets.

 Pack warm clothing, essential medications, valuables, papers, water, dry food and other
valuables in waterproof bags, to be taken along with your emergency kit.

 Listen to your local radio / TV, local community warning system for further information.

 In case of warning of serious storm, move with your family to a strong pucca building. In case of
warning of cyclones of severe intensity, evacuate the area with your family, precious items and
documents and emergency kit. Take special care for children, elders, sick, pregnant women and
lactating mothers in your family. Do not forget your emergency food stock, water and other
emergency items. GO TO THE NEAREST CYCLONE SHELTER.

 Do not venture into the sea for fishing.

On warning of local evacuation

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Based on predicted wind speeds and storm surge heights, evacuation may be necessary. Official advice
may be given on local radio / TV or other means of communication regarding safe routes and when to
move.

 Wear strong shoes or chappals and clothing for protection.

 Lock your home, switch off power, gas, water, and take your emergency kit.

 If evacuating to a distant place take valuable belonging, domestic animals, and leave early to
avoid heavy traffic, flooding and wind hazards.

 If evacuating to a local shelter or higher grounds carry the emergency kit and minimum essential
materials.

When the cyclone strikes

 Disconnect all electrical appliances and turn off gas.

 If the building starts crumbling, protect yourself with mattresses, rugs or blankets under a strong
table or bench or hold on to a solid fixture (e.g. a water pipe)

 Listen to your transistor radio for updates and advice.

 Beware of the calm `eye’. If the wind suddenly drops, don’t assume the cyclone is over; violent
winds will soon resume from the opposite direction. Wait for the official “all clear”.

 If driving, stop – but well away from the sea and clear of trees, power lines and watercourses.
Stay in the vehicle.

After the cyclone

 Do not go outside until officially advised it is safe.

 Check for gas leaks. Do not use electric appliances, if wet.

 Listen to local radio for official warnings and advice.

 If you have to evacuate, or did so earlier, do not return until advised. Use a recommended route
for returning and do not rush.

 Be careful of snake bites and carry a stick or bamboo

 Beware of fallen power lines, damaged bridges, buildings and trees, and do not enter the
floodwaters.

 Heed all warnings and do not go sightseeing.

FLOODS (SAFETY TIPS)

48
This guide lists simple things you and your family can do to stay safe and protect your property from
floods.

Before flooding occurs.

 All your family members should know the safe route to nearest shelter/ raised pucca house.

 If your area is flood-prone, consider alternative building materials. Mud walls are more likely to
be damaged during floods. You may consider making houses where the walls are made of local
bricks up to the highest known flood level with cement pointing.

 Have an emergency kit on hand which includes a:

o A portable radio, torch and spare batteries;

o Stocks of fresh water, dry food (chura, mudi, gur, biscuits), kerosene, candle and
matchboxes;

o Waterproof or polythene bags for clothing and valuables, an umbrella and bamboo stick
(to protect from snake), salt and sugar.

o A first aid kit, manual and strong ropes for tying things

When you hear a flood warning or if flooding appears likely

 Tune to your local radio/TV for warnings and advice.

o Keep vigil on flood warning given by local authorities

o Don’t give any importance to rumours and don’t panic

o Keep dry food, drinking water and clothes ready

 Prepare to take bullock carts, other agricultural equipments, and domestic animals to safer places
or to higher locations.

 Plan which indoor items you will raise or empty if water threatens to enter your house

 Check your emergency kit

During floods

 Drink boiled water.

 Keep your food covered, don’t take heavy meals.

 Use raw tea, rice-water, tender coconut-water, etc. during diarrhoea; contact your ANM/AWW
for ORS and treatment.

 Do not let children remain on empty stomach.

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  Use bleaching powder and lime to disinfect the surrounding.

 Help the officials/volunteers distributing relief materials.

If you need to evacuate

 Firstly pack warm clothing, essential medication, valuables, personal papers, etc. in waterproof
bags, to be taken with your emergency kit.

 Take the emergency kit

 Inform the local volunteers (if available), the address of the place you are evacuating to.

 Raise furniture, clothing and valuables onto beds, tables and to the top of the roof (electrical
items highest).

 Turn off power.

 Whether you leave or stay, put sandbags in the toilet bowl and over all laundry / bathroom drain-
holes to prevent sewage back-flow.

 Lock your home and take recommended/known evacuation routes for your area.

 Do not get into water of unknown depth and current.

If you stay or on your return

Stay tuned to local radio for updated advice.

Do not allow children to play in, or near, flood waters.

Avoid entering floodwaters. If you must, wear proper protection for your feet and check depth and
current with a stick. Stay away from drains, culverts and water over knee-deep.

Do not use electrical appliances, which have been in floodwater until checked for safety.

Do not eat food, which has been in floodwaters.

Boil tap water (in cities) until supplies have been declared safe. In case of rural areas, store tube well
water in plastic jars or use halogen tablets before drinking.

Be careful of snakes, snakebites are common during floods.

TIPS ON FIRE ACCIDENTS

a) High-Rise Fires:

 Calmly leave the apartment, closing the door behind you. Remember the keys!

 Pull the fire alarm near the closest exit, if available, or raise an alarm by warning others.

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  Leave the building by the stairs.

 Never take the elevator during fire!

If the exit is blocked by smoke or fire:

 Leave the door closed but do not lock it.

 To keep the smoke out, put a wet towel in the space at the bottom of the door.

 Call the emergency fire service number and tell them your apartment number and let them know
you are trapped by smoke and fire. It is important that you listen and do what they tell you.

 Stay calm and wait for someone to rescue you.

If there is a fire alarm in your building which goes off:

 Before you open the door, feel the door by using the back of our hand. If the door is hot or warm,
do not open the door.

 If the door is cool, open it just a little to check the hallway. If you see smoke in the hallway, do
not leave.

 If there is no smoke in the hallway, leave and close the door. Go directly to the stairs to
leave. Never use the elevator.

If smoke is in your apartment:

 Stay low to the floor under the smoke.

 Call the Fire Emergency Number which should be pasted near your telephone along with police
and other emergency services and let them know that you are trapped by smoke.

 If you have a balcony and there is no fire below it, go out.

 If there is fire below, go out to the window. DO NOT OPEN THE WINDOW but stay near the
window.

 If there is no fire below, go to the window and open it. Stay near the open window.

 Hang a bed sheet, towel or blanket out of the window to let people know that you are there and
need help.

 Be calm and wait for someone to rescue you.

A) Kitchen Fires:

It is important to know what kind of stove or cooking oven you have in your home – gas, electric,
kerosene or where firewood is used. The stove is the No. 1 cause of fire hazards in your kitchen and can
cause fires, which may destroy the entire house, especially in rural areas where there are thatched roof
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or other inflammable materials like straw kept near the kitchen. For electric and gas stoves ensure that
the switch or the gas valve is switched off/turned off immediately after the cooking is over. An
electric burner remains hot and until it cools off, it can be very dangerous. The oven using wood can
be dangerous because burning embers remain. When lighting the fire on a wooden fuel oven, keep a
cover on the top while lighting the oven so that sparks do not fly to the thatched roof. After the cooking
is over, ensure that the remaining fire is extinguished off by sprinkling water if no adult remains in
the kitchen after the cooking. Do not keep any inflammable article like kerosene near the kitchen
fire.

Important Do’s in the Kitchen:

· Do have an adult always present when cooking is going on the kitchen. Children should not be
allowed alone.

· Do keep hair tied back and do not wear synthetic clothes when you are cooking.

· Do make sure that the curtains on the window near the stove are tied back and will not blow
on to the flame or burner.

· Do check to make sure that the gas burner is turned off immediately if the fire is not ignited
and also switched off immediately after cooking.

· Do turn panhandles to the centre of the stove and put them out of touch of the children in the
house.

· Do ensure that the floor is always dry so that you do not slip and fall on the fire.

· Do keep matches out of the reach of children.

Important Don’ts

· Don’t put towels, or dishrags near a stove burner.

· Don’t wear loose fitting clothes when you cook, and don’t reach across the top of the stove
when you are cooking.

· Don’t put things in the cabinets or shelves above the stove. Young children may try to reach
them and accidentally start the burners, start a fire, catch on fire.

· Don’t store spray cans or cans carrying inflammable items near the stove.

· Don’t let small children near an open oven door. They can be burnt by the heat or by falling
onto the door or into the oven.

· Don’t lean against the stove to keep warm.

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 · Don’t use towels as potholders. They may catch on fire.

· Don’t overload an electrical outlet with several appliances or extension cords. The cords or
plugs may overheat and cause a fire.

· Don’t use water to put out a grease fire. ONLY use baking soda, salt, or a tight lid. Always
keep a box of baking soda near the stove.

· Don’t use radios or other small appliances (mixers, blenders) near the sink.

COMMON TIPS:

· Do keep the phone number of the Fire Service near the telephone and ensure that everyone in
the family knows the number.

· Do keep matches and lighters away from children.

· Do sleep with your bedroom closed to prevent the spread of fire.

Do you know that you should never run if your clothes are on fire and that you should - “STOP –
DROP-ROLL.”

LANDSLIDE

During a Landslide:

· Stay alert and awake. Many debris-flow fatalities occur when people are sleeping.
Listen to a Weather Radio or portable, battery-powered radio or television for warnings of
intense rainfall. Be aware that intense, short bursts of rain may be particularly dangerous,
especially after longer periods of heavy rainfall and damp weather.

· If you are in areas susceptible to landslides and debris flows, consider leaving if it is safe
to do so. Remember that driving during an intense storm can be hazardous. If you remain at
home, move to a second story if possible. Staying out of the path of a landslide or debris flow
saves lives.

· Listen for any unusual sounds that might indicate moving debris, such as trees cracking or
boulders knocking together. A trickle of flowing or falling mud or debris may precede larger
landslides. Moving debris can flow quickly and sometimes without warning.

If you are near a stream or channel, be alert for any sudden increase or decrease in water
flow and for a change from clear to muddy water. Such changes may indicate landslide activity
upstream, so be prepared to move quickly. Don't delay! Save yourself, not your belongings.

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 Be especially alert when driving. Embankments along roadsides are particularly
susceptible to landslides. Watch the road for collapsed pavement, mud, fallen rocks, and other
indications of possible debris flows.

What to Do if You Suspect Imminent Landslide Danger:

· Contact your local fire, police, or public works department. Local officials are the best persons
able to assess potential danger.

· Inform affected neighbors. Your neighbors may not be aware of potential hazards. Advising
them of a potential threat may help save lives. Help neighbors who may need assistance to evacuate.

· Evacuate. Getting out of the path of a landslide or debris flow is your best protection.

Media and Community Education Ideas:

In an area prone to landslides, publish a special newspaper section with emergency

information on landslides and debris flows. Localize the information by including the phone
numbers of local emergency services offices, the Red Cross, and hospitals.

Report on what city and county governments are doing to reduce the possibility of
landslides. Interview local officials about local land- use zoning regulations.

Interview local officials and major insurers. Find out if debris flow is covered by flood insurance
policies and contact your local emergency management office to learn more about the program.

Work with local emergency services to prepare special reports for people with mobility
impairments on what to do if evacuation is ordered.

Support your local government in efforts to develop and enforce land-use and building
ordinances that regulate construction in areas susceptible to landslides and debris flows. Buildings
should be located away from steep slopes, streams and rivers, intermittent-stream channels, and the
mouths of mountain channels.

After the Landslide:

· Stay away from the slide area. There may be danger of additional slides.

· Check for injured and trapped persons near the slide, without entering the direct slide area.
Direct rescuers to their locations.

· Help a neighbor who may require special assistance - infants, elderly people, and people with
disabilities. Elderly people and people with disabilities may require additional assistance. People
who care for them or who have large families may need additional assistance in emergency
situations.

· Listen to local radio or television stations for the latest emergency information.
· Watch for flooding, which may occur after a landslide or debris flow. Floods sometimes follow

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 landslides and debris flows because they may both be started by the same event.
· Look for and report broken utility lines to appropriate authorities. Reporting potential hazards
will get the utilities turned off as quickly as possible, preventing further hazard and injury.

· Check the building foundation, chimney, and surrounding land for damage. Damage to
foundations, chimneys, or surrounding land may help you assess the safety of the area.
· Replant damaged ground as soon as possible since erosion caused by loss of ground cover can
lead to flash flooding.

· Seek the advice of a geotechnical expert for evaluating landslide hazards or designing
corrective techniques to reduce landslide risk. A professional will be able to advise you of the best
ways to prevent or reduce landslide risk, without creating further hazard.

Media and Community Education Ideas:

· In an area prone to landslides, publish a special newspaper section with emergency information
on landslides and debris flows. Localize the information by including the phone numbers of local
emergency services offices, the American Red Cross chapter, and hospitals.
· Report on what city and county governments are doing to reduce the possibility of
landslides. Interview local officials about local land- use zoning regulations.
· Interview local officials and major insurers regarding the National Flood Insurance
Program. Find out if debris flow is covered by flood insurance policies from the National Flood
Insurance Program and contact your local emergency management office to learn more about the
program.

· Work with local emergency to prepare special reports for people with mobility impairments on
what to do if evacuation is ordered.

· Support your local government in efforts to develop and enforce land-use and building
ordinances that regulate construction in areas susceptible to landslides and debris flows. Buildings
should be located away from steep slopes, streams and rivers, intermittent-stream channels, and the
mouths of mountain channels.

Before a Landslide: How to Plan:

Develop a Family Disaster Plan. Please see the "Family Disaster Plan" section for general
family planning information. Develop landslide-specific planning.

Learn about landslide risk in your area. Contact local officials, state geological surveys or
departments of natural resources, and university departments of geology. Landslides occur where they
have before, and in identifiable hazard locations. Ask for information on landslides in your area, specific
information on areas vulnerable to landslides, and request a professional referral for a very detailed site
analysis of your property, and corrective measures you can take, if necessary.

If you are at risk from landslides:

· Talk to your insurance agent.

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 · Develop an evacuation plan.

· Discuss landslides and debris flow with your family. Everyone should know what to do in case
all family members are not together. Discussing disaster ahead of time helps reduce fear and lets
everyone know how to respond during a landslide or debris flow.

VOLCANO:

Volcano Safety Tips:

A volcano can be one of the most destructive forces in nature.If you are in an area that may be affected
by volcanic ash fallout, take these preventative measures:
 Have a supply of filter masks to protect the nose and mouth and goggles to protect the eyes.
 Keep a 3-day supply of canned food and bottled water on hand, as severe fallout may hamper
local travel.
 Close all doors, windows and vents around the house. Temporarily cover roof vents and air
conditioning intakes during periods of ash fall. Place towels under doors and in other gaps.
 Cover air intakes and vent openings on all motorized electronic appliances, stereo components,
and computers. Shut down and discontinue use of these appliances until ash fall has stopped and
appropriate cleaning has occurred.
 Cover boats and recreational vehicles.

Protect your property after a Volcano

For vehicles:
 Remove ash from your vehicle as soon as it is safe to do so. Prolonged exposure to volcanic ash
and dust can damage the paint and glass.
 Carefully wash the ash from your vehicle with a stream of water from a garden hose. Volcanic
ash is very abrasive and can easily scratch your vehicle.
 Never wipe, brush or mop the ash or dust that accumulates on your vehicle or windows.
 Avoid prolonged driving in airborne or accumulated volcanic ash. Volcanic ash or dust can
cause severe damage to your engine.
 If your vehicle is exposed to volcanic ash, change your air filter and have your vehicle checked
by a qualified auto mechanic as soon as possible.
 Avoid using windshield wipers if at all possible as glass scratching may occur. Replace any
windshield wiper blades that are damaged from the effects of the fallout.

For your home and belongings:

 Remove ash and dust from the roof of your home as soon as it is safe to do so. Ash is heavy and
can cause damage to your roof or gutters if allowed to accumulate.

56
  When cleaning ash from a roof, plug drain holes in the gutter and disconnect the downspout.
Sweep the ash off the roof with a broom.
 Avoid using electronic devices where there is still airborne ash, as it can short circuit electronics.
 Don't wash ash down drains.
 Once airborne ash has completely cleared, ash should be vacuumed, not wiped, to prevent
scratching on surfaces like porcelain, enamel, glass, painted surfaces and appliances. A damp
cloth may be used after initial vacuuming.
 Change vacuum filters frequently, and be careful your vacuum is not redistributing ash through
the air discharge.
 Clothing exposed to ash should be shaken out and put through a rinse and pre-soak cycle before
machine washing. Use extra detergent. Laundry additives can help adjust the pH level and make
detergents more effective.

12. DISASTER MANAGEMENT- NURSE’S ROLE IN COMMUNITY

Assess the community

Assessment - the local climate conducive for disaster occurrence, past history of disasters in the
community, available community disaster plans and resources, personnel available in the
community for the disaster plans and management, local agencies and organizations involved in
the disaster management activities, availability of health care facilities in the community etc.

Diagnose community disaster threats

 Determine the actual and potential disaster threats (eg; explosions, mass accidents, tornados,
floods, earthquakes etc).

Community disaster planning

 Develop a disaster plan to prevent or deal with identified disaster threats

 Identify local community communication system

 Identify disaster personnel, including private and professional volunteers, local emergency
personnel, agencies and resources

 Identify regional back up agencies and personnel

 Identify specific responsibilities for various personnel involved in the disaster plans

 Set up an emergency medical system and chain for activation

 Identify location and accessibility of equipment and supplies

 Check proper functioning of emergency equipments

 Identify outdated supplies and replenish for appropriate use.

Implement disaster plans

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  Focus on primary prevention activities to prevent occurrence of manmade disasters

 Practice community disaster plans with all personnel carrying out their previously identified
responsibilities (eg: emergency triage , providing supplies such as food, water, medicine, crises
and grief counseling)

 Practice using equipment; obtaining and distributing supplies

Evaluate effectiveness of disaster plan

 Critically evaluate all aspects of disaster plans and practice drills for speed, effectiveness, gaps
and revisions.

 Evaluate the disaster impact on community and surrounding regions

 Evaluate the response of personnel involved in disaster relief efforts.

MOCK DISASTER DRILL AND EXERCISE

Training and drills

Mock exercise and drills at regular intervals are conducted to ensure that all the staff in the
general and those associated with management of causalities are fully prepared and aware of their
responsibilities.

Effective response to challenging situations and conditions is vital for ensuring personal safety
and protecting lives, property, facilities, equipment, infrastructure and the environment. Personnel,
communities, departments, incident commanders etc must be able to take immediate actions necessary
to safely mitigate the consequences of an unexpected or abnormal and potentially dangerous condition.

The process presents a challenging management problem and becomes even more complex when
all emergency management disciplines come together into one integrated system for managing
emergencies.

Drills and exercises focus on those actions which are necessary to respond to an emergency.
Regular drills and exercises can help communities, governments, industrial bodies, corporate sectors and
other sectoral agencies to test, evaluate and continually improve their emergency management systems.
Drills and exercises should ideally test all the phases of disaster management.
10.1. Purpose of Mock drills and Exercises

Mock-drills help in evaluating response and improving coordination within various government
departments, non-government agencies and communities. They help in identifying the extent to which
the SOPs and Plans are effective and also aid in revising these if required. These drills enhance the
ability to respond faster, better and in an organized manner during the response and recovery phase.

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Drills/Simulations/Exercises are based on a set of assumptions about the circumstances during a
disaster:

• A high level of tension and anxiety under which the concerned personnel would operate both at
the central and field levels
• Highly unreliable information which requires critical assessment
• Criticality of time where rapid decisions must be taken
• Necessity for coordination among technical personnel and government officers, who do not
usually interact
• Prominence of political and social factors in the aftermath of a disaster Therefore, the emphasis
is not on specific solutions, but on the approach to organizing information and establishing
priorities which would lead to efficient solutions.

The approach for conducting a mock-drill varies as per the complexity of scenario depending
upon the potential hazards, response system of the institution and the target community. Therefore, to
ensure proper implementation of a drill programme, roles and responsibilities (SOPs) of the concerned
personnel, departments, corporate bodies, stakeholders, and mechanisms for conducting the drill should
be delineated clearly.

Regardless of the size, complexity and risk involved in the implementation of the drill, an effective
drill/exercise programme should have the following essential elements as prerequisites:

o Emergency Response Plan: explaining institutional response structure, emergency response

functions and standard operating procedures for various departments.
o Team personnel at head quarter and field level trained on their standard operating procedures.
o Trained quick response teams in various possible operations like search and rescue, law and order,
fire-fighting, medical, water arrangements, relief and shelter and electricity restoration etc.
o Updated database of resources1, equipment and manpower available.
o Updated Emergency Directory with important contact details of members of Incident Management
Team and Emergency Response function.
o Mock-drill Scenario and detailed action plan for Mock-drill.
o Evaluation formats for concerned departments and definite criteria for evaluation.
o Observers and Qualified evaluators

The drills and exercises will help to -

� Identify planning gaps
� Revise SOPs to enhance coordinated emergency response
� Increase public awareness and community readiness
� Enhance capacities of professionals, departments and trained volunteers

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 � Test plans and systems in simulation exercises
10.2. Types of Drills and Exercises
There are several different types of drills and exercises.

1. Drill: A drill is a supervised activity with a limited focus to test a procedure that is a
component of the overall emergency management plan. That is, drills usually highlight and closely
examine a limited portion of the overall emergency management plan. For example, a disaster
management unit might conduct a drill for the use of a radio system with those responsible for
communicating on it. Drills are designed to impart specific skills to technical personnel (e.g., search and
rescue, ambulance, firefighting). A perfect drill is one that leads to a flawless repetition of the intended
task under any circumstance.

2. Tabletop Exercise: A tabletop exercise uses written and verbal scenarios to evaluate the
effectiveness of the emergency management plan and procedures and to highlight issues of coordination
and assignment of responsibilities. Tabletop exercises do not physically simulate specific events, do not
utilize equipment, and do not deploy resources. In a tabletop exercise, a facilitator usually coordinates
discussion.

3. Functional Exercise: A functional exercise simulates a disaster in the most realistic manner
possible without moving real people or equipment to a real site. A functional exercise utilizes a carefully
designed and scripted scenario, with timed messages and communications between players and
simulators. The emergency operations center (EOC)—the facility or area from which disaster response
is coordinated—is usually activated during a functional exercise and actual communications equipment
may be used.

4. Full-Scale Exercise or Field Exercise: It tests the mobilization of all or as many as possible
of the response components, takes place in “real time,” employs real equipment, and tests several
emergency functions. Full-scale exercises are generally intended to evaluate the operations capability of
emergency management systems in a community and to evaluate interagency coordination. While these
exercises cannot realistically reproduce the dynamic and chaos of real life disasters, they are useful
when intended to detect the inevitable errors, lack of coordination, or deficiencies of the simulated
response. A critical evaluation is the essential conclusion of these exercises.

5. The Incident Command System (ICS) is an emergency management framework, adaptable

to any scale of natural or man-made emergencies. The ICS seeks to strengthen the existing disaster
response management system by ensuring that designated controlling/responsible authorities at different
levels are backed by trained Incident Command Teams whose members have been trained in the
different facets of disaster response management.

Basic Functions of IC system:

• Maintain integrated communication flow during emergency
• Manage the incident scene

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 • Facilitate procedure and protocols to be followed by ESF departments
• Adopt a comprehensive resource management approach
• Monitor functional areas during the post- disaster phase

The ICS has an integrated organizational structure with the following five command functions:

i. Incident Commander
ii. Operations
iii. Planning
iv. Logistics
v. Finance/Administration
Incident Commander –
The incident commander’s role is to supervise the simulation or overall conduct of the exercise,
to make sure that the exercise proceeds as planned and that the objectives are achieved. The incident
commander monitors the sequence of events, supervises the inputs of messages received and conducts a
de-briefing and critique (verbal & written) with all personnel involved. At the village level, the head of
the village is in charge.

Simulators –
Simulators “act as” and on behalf, of the agencies and services that would normally interact with
the players at the Emergency Operating Centre (EOC). The method of interaction is normally pre-
scripted but responses could be spontaneous. Participants – The participants should be from community
volunteers, DMT members and ESFs, led by decision makers from various departments.
Observers/Evaluators –
Their role is to observe the actions and decisions of the players, in order to later report what went
well and what did not. The main focus is on the performance of functions and or/agencies, institutions
and facilities being tested, keeping in mind the objectives of the exercise.
Quick Response Teams:
Quick response teams are technically trained teams formed by the nodal authority of disaster
management. These teams are resourceful and perform several emergency response actions at the
incident site for immediate recovery of the affected areas.
Community Task Forces –
Disaster Management teams (DMTs) /community task forces (CTFs) are the community
volunteer groups, which perform their roles as per the simulated disaster scenario during the drill.
The DMTs/CTFs should consist of the following groups:
i. Early Warning/Communication
ii. Evacuation and Temporary Shelter Management
iii. Search & Rescue
iv. Damage Assessment
v. First-Aid/Medical Health/ Trauma Counseling
vi. Water & Sanitation
vii. Relief (Food & Shelter) Coordination
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The community themselves are the first responders for carrying out rescue and emergency services.
Community taskforces initiate responses at field level where specialized quick response teams join them
for faster recovery. The field level team leaders of ESFs and local incident commander coordinate with
community taskforces and quick response teams to understand the requirements of the situation and
provide essential assistance to perform operations

Drill Functional Tabletop Full-scale Integrated

Exercise

Scope of Relatively limited, focuses Broader in scope, Very broad in scope,

scenario on procedures focuses on roles, includes others
policy and strategy outside own
organization

Number of Typically less than 10 Less than 20 At least 20 and up to

participants individuals, usually within
the same company or
organization
individuals, includes several hundred
multiple roles within individuals, involves
an organization, or different functions
with other within an organization
organizations and often includes
multiple organizations

Facilities Practice using real or Single room large Participants operate

required simulated equipment enough for from their own
communication, production or backup
without unnecessary locations and use real
distraction. May facilities and tools to
require separate tables the extent possible1.
to simulate different Use normal
roles communications
facilities.

Coaching Coaching may be used, Coaching may be Coaching normally

depending on learning
objectives
used in a limited not used. Instead,
manner to keep evaluators record
scenario on-track observations for after-
action evaluation
report.

Examples Fire or evacuation drill Business continuity IESO-led exercise to

exercise to emphasize test integrated
roles, responsibilities, response to a

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 and communications simulated large-scale
within an organization electricity emergency

Plan for Emergency Support Functions –

The ESF Plan document outlines the objective, scope, organization, setup and Standard
Operating Procedures (SOPs) for each ESF that is to be followed by the respective ESF agencies when
the response plan is activated. SOPs provide a basic concept of the operations and responsibilities of
Disaster Management Teams, Nodal and Secondary Agencies.

The Emergency Support Function Teams (ESFs) could be as follows:

i. Communication
ii. Evacuation
iii. Search and Rescue
iv. Medical Health/Trauma
v. Equipment Support
vi. Helplines, Warning Dissemination (Media)
vii. Drinking Water
viii. Electricity
ix. Relief (Flood and Shelter)
x. Debris and Road Clearance
xi. Law and Order
xii. Transport
xiii. Other Functions

Prior to conducting the drill, the drill team members should be trained in the duties,
responsibilities and activities related to their respective positions in the conduct of the drill. Training
may also be accomplished during the pre-drill briefing where each team member’s duties should be
individually addressed. In addition to training of these teams, additional people should be trained to
account for any mishap.
10.3. Guidelines for drill evaluation
All drills should be conducted in accordance with a drill scenario as approved by the
implementing agencies of Disaster Management; members of the EOCs; ESFs of all line departments;
voluntary agencies such as Civil Defense, NSS, NYKS, Bharat Scouts and Guides, Red Cross; Industrial
Safety Managers/Technical Experts; and groups or individuals specifically identified to conduct the
drills. The number of controllers, simulators and evaluators are decided based on the type of drill to be
conducted, the scenario and the resources available to conduct the exercise (personnel, equipment,
funding etc).
Scope –
Defines the boundaries of the drill, while conducting the mock drill, the scope could also
include the possible collateral hazards associated with the main hazard that triggers other events.

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The following five aspects should be considered while defining the scope:-

1. Hazards – Identify one specific hazard/collateral hazards for the exercise

2. Geographic area – Identify a defined location for the event and identify a hazard impact scenario
3. Agencies and personnel – Identify which agencies will participate and the personnel required
4. Exercise type – Identify the type of exercise to be conducted based on realistically achievable results
within the drill scenario
5. Operating Procedures – Identify SOPs as per the scenario to test emergency response functions and
coordination
Statement of Purpose –
It is a statement to communicate the scope of the exercise to the entities participating in the
mock drill.
Objectives –
Objectives should be clear, concise, specific, performance based and attainable. The number of
objectives needed for an exercise may vary according to the scale and expected output of the exercise.
Objectives can be classified into “general/functional/specific”. General objectives will provide the
overall scope of the exercise with reference to the community, agency, institution, industry or
organization (for example: the community of Nari village will respond and recover from the flash
floods).

Functional or specific objectives form the core of the mock drill. These further define the statement of
purpose for the exercise by clearly describing the expected outcomes
(performance) of the disaster management functions being tested.
Scenario narrative –
The scenario narrative describes the events leading up to the time the exercise begins. It sets the
scene for later events and also captures the attention of the participants. It could include answers to
questions such as:

• What event
• How was the information relayed
• What damages have been reported
• What was the sequence of events
• Was there any advance warning issued and how long before the event
• What factors influence emergency procedures

Drill Activity –
Activities should be planned in such a way that it should provide sufficient scope to test the
pre-identified Standard Operating Procedures (SOPs), drill scenario and the needs of the identified
participants (e.g. members of ESF teams, schools, industries, public/commercial settings).

Termination –

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 States the event(s) that indicate when the drill should be concluded once all the required and
expected actions have been completed. In case of safety problems, procedure violation or an emergency,
the drill may be prematurely terminated.

Expected actions/roles and responsibilities –

It describes the expected response to actions undertaken. Each ESF and its respective team
members should be listed by name so that there is no confusion as to who is responsible for each
function.
Expected response/evaluation criteria –
The expected response is already pre-identified and defined in a procedure. Specific areas need
to be identified for evaluation in the design stage of the mock drill. Details of the procedure must be
included so that evaluation is properly carried out. The criteria for evaluation should focus on response
recovery based on the hazard scenario stimulated and emergency functions conducted.
10.4. Guidelines for Drill Conduction
When conducting drills, a set process should be followed in order to minimize risks of injury to
personnel, damage to equipment or the environment. Participating organizations such as the fire
department, police, traffic authorities, hospitals and emergency response units should be informed. They
should be notified before the commencement of the drill, and should respond accordingly as required by
the drill scenario. They should also be informed as to how they will be notified in the event of an actual
emergency.

Pre-drill Briefing
The drill coordinator should hold a pre-drill briefing with the participating agencies,
observers/evaluators to explain the scene and the ground rules for executing the drill. Operational
procedures should be reviewed and safety precautions should be considered and reviewed with the
participants. The pre-drill briefing should include the outline of the drill procedure and should clearly
specify the inputs required by the participating agencies in terms of human resource support/equipment
support. In a scenario which has a potential to cause damage to the habitat, it is important to involve the
community and discuss the possible chain of events with them.
Drill Initiation
The drill should be initiated by the incident commander in accordance with the planned drill
scenario. The exact actions (such as alarm or announcement) for the initiation should be identified.

Drill Activity
After the drill is initiated, every activity and response should be carried out according to the
scenario and respective SOPs. Methods for receiving and delivery of messages can be verbal or written;
on paper, by telephone, radio or fax. These messages are directed specifically to individuals/primary
agencies that are responsible for coordinating responses with secondary agencies. From the message
input, participants should determine the expected response and consequently coordinate internally and
externally with the concerned agencies/individuals to take the necessary actions.

During the drill, evaluators document all activities based on the criteria of the drill scenario.
Each drill should have specified areas of evaluation so that all actions required are observed and
65
evaluated. Necessary evaluation formats should be circulated in advance to the concerned participating
agencies. The drill scenario should be allowed to continue till completion of the stated objectives or as
stated by the incident commander. An abnormal termination is possible when actions taken by operating
personnel would adversely affect the safety of the participants or cause damage to the facility,
equipment or environment.
11. GUIDELINES FOR DRILL EVALUATION
Evaluation process is an important component of the drill. It is the act of observing and
recording mock drill activity, by comparing the performed actions against the drill objectives.
11.1 Evaluation serves three functions:
 To evaluate personnel actions
 To evaluate the ability of the responding agencies to implement a plan
 To check the effectiveness of the standard operating procedures

During the pre-drill briefing, the drill planner, incident commander and evaluation team will
review the drill activity and SOPs. An evaluation worksheet outlining the action processes to be
observed as per the set timeline decided in the scenario exercise should be circulated. After the drill, an
evaluation report will be prepared and the comments can be incorporated into the SOPs.
11.2. Evaluation Team –
The team members may be identified from within or outside the participating agencies. The
incident commander may also serve as an evaluator. The size of the evaluation team will depend on the
complexity and scale of the drill. Evaluators should be familiar with the local emergency management
system, have expertise and knowledge of the plan and have analytical skills in keeping with the exercise
design.
11.3. Elements for Evaluation
The evaluators should consider the following elements in their evaluation:
1. Notification, alerting and mobilization of disaster response personnel
� Adequacy of alerting procedures
� Timely activation and staffing of response facilities
� Accurate and timely assessment of emergency situation

Mock Drill Evaluation Report

The evaluation report summarizes the development, conduct and results of the drill/exercise. The
report should present an overall evaluation of the exercise, state whether the exercise objectives were
achieved, and cite any areas of noteworthy performance, discoveries, determinations, problems, and
solutions identified as a result of the exercise.
Chapter-V CATHERINE.R

STAFFING PHILOSOPHY, NORMS: STAFF INSPECTION UNIT (SIU), BAJAJ

COMMITTEE, HIGH POWER COMMITTEE, INDIAN NURSING COUNCIL
(INC)ESTIMATION OF NURSING STAFF REQUIREMENT- ACTIVITY ANALYSIS
,VARIOUS RESEARCH STUDIES

INTRODUCTION:

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 Organizations require the services of a large number of personnel. These personnel occupy
varies positions created through the process of organizing. Each position of the organization makes
certain specific contributions to achieve organizational objectives. Hence the person occupying the
position should have sufficient ability to meet its requirement.

Staffing is that part of the process of management which is concerned with obtaining, utilizing and
maintaining a satisfactory and satisfied work force. It is the process of identifying, assessing, placing,
evaluating and developing individuals at work. Staffing is a very important function of the management.

Staffing is a selection, training, motivating and retaining of a personnel in the organization. Before the
selection of the employees, one has to make analysis of the particular job, which is required in the
organization, then comes the selection of personnel.

The 2003 National Student Nurses' Association (NSNA) House of Delegates supported mandatory
patient: nurse staffing ratios to maximize patient safety and quality of care, and minimize professional
burnout in practicing nurses. Staffing is an issue of professional concern because inappropriate staffing
can threaten patients’ safety, health, and the integrity of the professional’s commitment to patients.

• Complications associated with inappropriate staffing include postoperative respiratory and/or

cardiac complications, increased risk for pulmonary failure and re-intubation, and infectious
complications (e,g, septicemia) (Clark et al., 2007.)

• In hospitals with high RN staffing, medical patients had lower rates of urinary tract infections,
pneumonia, shock, upper gastrointestinal bleeding, and decreased hospital stays (Stanton, 2004.)

DEFINITIONS:

Staffing is the function by which managers build an organization through recruitment, selection
and development of individuals as capable employees --- (Mc Farland)

Staffing is the process of determining and providing the acceptable number and mix of nursing
personnel to produce a desired level of care to meet the patients demand.
( Diane, 2002 )

PURPOSES OF STAFFING:

•It establishes and maintains sound personnel relation at all levels of the organization

•It makes effective use of personnel to attain the objectives of the organization

•The purpose of all staffing activities is to provide each nursing unit with an appropriate and acceptable
number of workers in each category to perform the nursing tasks required.

•Too few or an improper mixture of nursing personnel will adversely affect the quality and quantity of
work performed. Such situation can lead to high rates of absenteeism and staffs turn-over resulting in
low morale and dissatisfaction.
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PHILOSOPHY OF STAFFING IN NURSING:

 Nurse administrators of a hospital nursing department should adopt the following staffing
philosophy.
 Nurse administrators believe that it is possible to match employees’ knowledge and skills to
patient care needs in a manner that optimizes job satisfaction and care quality.
 Nurse administrators believe that the technical and humanistic care needs of critically ill patients
are so complex that all aspects of that care should be provided by professional nurses.
 Nurse administrators believe that the health teaching and rehabilitation needs of chronically ill
patients are so complex that direct care for chronically ill patients should be provided by
professional and technical nurse.
 Nurse administrators believe that patient assessment, work quantification and job analysis should
be used to determine the number of personnel in each category to be assigned to care for patients
of each type( such as coronary care, renal failure, chronic arthritis, paraplegia, cancer etc)
 Nurse administrators believe that a master staffing plan and policies to implement the plan in all
units should be developed centrally by the nursing heads and staff of the hospital.
 Nurse administrators believe the staffing plan details such as shift- start time, number of staffs
assigned on holidays, and number of employees assigned to each shift can be modified to
accommodate the units’ workload and workflow.

OBJECTIVES OF STAFFING IN NURSING:

• To provide all professional nurse staff in critical care units, operating rooms, labour and
emergency room
• To provide sufficient staff to permit a 1:1 nurse- patient ratio for each shift in every critical care
unit
• To provide sufficient nursing staff in general, medical, surgical, obstetrics and gynaecology,
paediatric and psychiatric units to permit a 1:5 nurse patient ratio on a day and afternoon shifts
and 1:10 nurse- patient ratio on night shift.
• To involve the heads of the nursing staffs and all nursing personnel in designing the
department’s overall staffing program.
• To design a staffing plan that specifies how many nursing personnel in each classification will be
assigned to each nursing unit for each shift and how vacation and holiday time will be requested
and scheduled.
• To hold each head nurse responsible for translating the department’s master staffing plan to
sequential eight weeks time schedules for personnel assigned to her/ his unit.
• To post time schedules for all personnel at least eight weeks in advance.
• To empower the head nurse to adjust work schedules for unit nursing personnel to remedy any
staff excess or deficiency caused by census fluctuation or employee absence.
• Inform each nursing employee that requests for specific vacation or holiday time will be
honoured within the limits imposed by patient care and labour contract requirements.
• Reward employees for long term service by granting individuals special time requests on the
basis of seniority.

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NATURE OF STAFFING:

o Staffing is an important managerial function- Staffing function is the most important

managerial act along with planning, organizing, directing and controlling. The operations
of these four functions depend upon the manpower which is available through staffing
function.
o Staffing is a pervasive activity- staffing function is carried out by all managers and in
all types of concerns where business activities are carried out.
o Staffing is a continuous activity-This is because staffing function continues throughout
the life of an organization due to the transfers and promotions that take place.
o The basis of staffing function is efficient management of personnels- Human
resources can be efficiently managed by a system or proper procedure, that is,
recruitment, selection, placement, training and development, providing remuneration, etc.
o Staffing helps in placing right men at the right job-It can be done effectively through
proper recruitment procedures and then finally selecting the most suitable candidate as
per the job requirements.
o Staffing is performed by all managers -Staffing is performed by all managers
depending upon the nature of business, size of the company, qualifications and skills of
managers, etc. In small companies, the top management generally performs this function.
In medium and small scale enterprise, it is performed especially by the personnel
department of that concern.
• SIGNIFICANCE OF STAFFING:
o Staffing provides man power which is the key input of an organization.
• It helps in discovering and obtaining competent personnel for various jobs
• It makes for higher performance by placing right persons on the right job
• It improves job satisfaction and morale of employees through objective assessment and fair
compensation of their contributions
• It facilitates optimum utilization of human resources and in minimizing costs of manpower
• It ensures the continuity and growth of organization through the development of organization
• It enables an organization to cope with the shortage of executive talent

CHARACTERISTICS OF STAFFING:

• Staffing is an universal function. It is the responsibility of every management.

• Staffing is a dynamic function
• Staffing cannot be entrusted fully to personnel department or any other service department.
• Staffing helps in the accomplishment of organizational goals through team spirit and optimum
contribution from every employee.
• Staffing is concerned with the management of managers
• Staffing is a difficult function with extraordinary problems of social, philosophical and
psychological in nature.

ELEMENTS OF STAFFING:

The elements of staffing are

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• Procurement

Employment of proper number and kind of personnel is the first function of staffing, this
involves:

1. Manpower planning-It is the process of determining current and future manpower needs in terms
of the number and quality of the personnel.

2. Recruitment -It implies locating sources of acceptable candidates.

3. Selection -It involves choice of right type of people from the available candidates. This requires
evaluating various candidates and selecting those that match the needs of the organization.

4. Placement -It means assigning specific jobs to the selected candidates.

• Development

After placing the individual on various jobs it is necessary to train them so that they can perform
their jobs efficiently. Proper development of personnel is essential to increase their skill in the proper
performance of their jobs. Development involves orientation, counseling and training of the personnel.
Orientation is the socializing process of adjusting newly hired employees in the organization. Training is
the process of improving the knowledge and skills of personnel.

• Compensation levels

Compensating personnel means determining adequate and equitable remuneration of personnel

for their contributions to the organizational goals. Both monetary and nonmonetary rewards are decided
keeping in view human needs, job requirements, prevailing wage levels, organization’s capacity to pay
etc. Compensation involves job evaluation, performance appraisal; promotion etc. Job evaluation is the
process of determining the relative worth of different jobs in the organization. Performance appraisal

70
involves evaluating the employee’s performance in relation to certain standards. Promotions, transfers
etc are other elements of the reward system.

• Integration

It involves developing a sense of belonging to the enterprise. Sound communication system is

required to develop harmony and team spirit among employees. Effective machinery is required for the
quick and satisfactory redressal of all problems and grievances of employees, it is essential to motivate
employees towards the accomplishment of organizational goals. Discipline and labor relation are
important elements of integration.

• Maintenance

It involves provision of such facilities and services that are required to maintain the physical and
mental health of employees. These include measures for health, safety and comfort of employees.
Various welfare services may consists of provision of cafeteria, restrooms, groupinsurance, recreation
club, education of children of employees etc.

STEPS IN STAFFING PROCESS:

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Human resource planning:.

The purpose of human resource planning is to ensure that the personnel need of the organization
will be met. Three elements of human resource planning are:

• Forecasting the personnel requirements

• Comparing the requirements to the inventory of potential candidates within the organization

• Developing specific plans for how many people to recruit or whom to train.

Recruitment :

In this step, management will attempt to identify and attract candidates to meet the requirements
of anticipated or actual vacancies. The actual recruitment of potential employees is traditionally done
through newspaper and professional journal advertisement.

Selection:

Selection is the process of choosing from among the applicants the best-qualified individual or
individuals for a particular job or position. This process involves verifying the applicant’s qualifications,
checking his/her work history, and deciding of a good match exists between the applicant’s
qualifications and the organization’s expectations.

Educational and Credential Requirements:

Consideration should be given to educational requirements and credentials for each job category
as long as a relationship exists between these requirements and success on the job.

Reference Checks

All applications should be examined to see if they are complete and to ascertain that the
applicant is qualified for the position. At this point, references are requested, and employment history is
verified. According to Asselin (2006), the manager should always be cognizant of red flags in
applications such as “unexplained gaps in employment history or frequent changes of employer without

72
acceptable explanation”. Positions should never be offered until information on the application has been
verified and references have been checked.

Pre-employment Testing

Pre-employment testing is used only when such testing is directly related to the ability to
perform a specific job. Although testing is not a stand-alone selection tool, it can, when coupled with
excellent interviewing and reference checking, provide additional information about a candidate to make
the best selection.

Physical Examination as a Selection Tool

A medical examination is often a requirement for hiring. This examination determines if the
applicant can meet the requirements for a specific job and provides a record of the physical condition of
the applicant at the time of hiring. The physical examination also may be used to identify applicants
who will potentially have unfavorable attendance records or may file excessive future claims against the
organization’s health insurance.

Finalizing the Selection:

o Follow up with applicants as soon as possible, thanking them for applying and informing
them when they will be notified about a decision.
o Candidates not offered a position should be notified of this as soon as possible. Reasons
should be provided when appropriate, and candidate should be told whether their
application will be considered for future employment or if they should reapply.
o Applicants offered a position should be informed in writing of the benefits, salary, and
placement. This avoids misunderstandings later regarding what employees think they
were promised by the nurse-recruiter or the interviewer.
o Applicants who accept the job offers should be informed as to pre-employment
procedures such as physical examinations and supplied with the date to report to work.
o Applicants who are offered positions should be requested to confirm in writing their
intention to accept the position.

Placement: The astute leader is able to assign a new employee to a position within his or her sphere
of authority where the employee will have a reasonable chance for success. Nursing units and
departments develop subcultures that have their own norms, values, and methods of accomplishing
work. It is possible for one person to fit in well with an established group, whereas another equally
qualified person would never become part of this group.

Conversely, proper placement fosters personal growth, provides a motivating climate for the
employee, maximizes productivity, and increases the probability that organizational goals will be met.
Managers who are able to match employee strengths to job requirements facilitate unit functioning,
accomplish organizational goals, and meet employee needs.

Indoctrination: Indoctrination refers to the planned, guided adjustment of an employee to the

organization and the work environment. Although the words “induction” and “orientation” are

73
frequently used to describe this function, the indoctrination process includes three separate phases:
induction, orientation, and socialization.

Indoctrination seeks to (a) establish favorable employee attitudes toward the organization, unit,
and department; (b) provide the necessary information and education for success in the position; and (c)
instill a feeling of belonging and acceptance. The employee indoctrination process begins as soon as
person has been selected for a position and continues until the employee has been socialized to the
norms and values of the work group.

Employee Indoctrination Content:

1. Organization history, mission, and philosophy

2. Organization service and service area

3. Organizational structure, including department heads, with an explanation of the functions of the
various departments

4. Employee responsibilities to the organization

5. Organizational responsibilities to the employee

6. Payroll information, including how increases in pay are earned and when they are given
(progressive or unionized companies publish pay scales for all employees)

7. Rules of conduct

8. Tour of the facility and of the assigned department

9. Work schedules, staffing and scheduling policies

10. When applicable, a discussion of the collective bargaining agreement

11. Benefit plans, including life insurance, health insurance, pension, and unemployment

12. Safety and fire programs

13. Staff development programs, including in-service and continuing education for relicensure.

14. Promotion and transfer policies

15. Employee appraisal system

16. Workload assignments

17. Introduction to paperwork/forms used in the organization

18. Review of selection in policies and procedures

19. Specific legal requirements, such as maintaining a current license, reporting of accidents, and so
forth
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20. Introduction to fellow employees

21. Establishment of a feeling of belonging and acceptance, showing genuine interest in the new
employee

Induction:

Induction, the first phase of indoctrination, takes place after the employee has been selected but
before performing the job role. The induction process includes all activities that educate the new
employee about the organization and employment and personnel policies and procedures.

Employee handbooks, an important part of induction, are usually developed by the personnel
department. Managers, however, should know what information the employee handbooks contain and
should have input into their development.The handbook is important because employees cannot
assimilate all the induction information at one time, so they need a reference for later. However,
providing an employee with a personnel handbook is not sufficient for real understanding. The
information must be followed with discussion by various people during orientation. The most important
link in promoting real understanding of personnel is the first-level manager.

Orientation:

Orientation provides information about the activities more specific for the position. The purpose
of the orientation process is to make the employee feel like a part of the team. This will reduce burnout
and help new employees become independent more quickly in their new roles.

Sample of Line-up of Activities Done in Orientation:

- Welcome by personnel department; employee handbooks distributed and discussed

- General Orientation by staff development

- Tour of the Organization

- Fire and safety films, body mechanics demonstration

- Introduction to each unit supervisor

- Report to individual units (time with unit supervisor and introduction to assigned preceptor)

- General orientation of policies and procedures

- Work with preceptor on shift and unit assigned, gradually assuming greater responsibilities

- Carry normal workload as per week schedule. Have at least a 30-minute meeting with immediate
supervisor to discuss progress.

Training and development :

Through training and development the organization tries to improve the employee’s ability to
contribute to the organization’s effectiveness. Training is concerned with improvement of the
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employee’s skills. Development is concerned with the preparation of the employee for additional
responsibility.

Performance appraisal :

A system designed to measure the actual job performance of an employee compared to

designated performance standards.

Employment decisions :

Employment decisions in the areas of monetary rewards, transfers, promotions and demotions
will be made based on the outcome of the performance appraisal.

Separation :

It involves Voluntary turnover, retirements, layoffs and terminations must also be a concern of
management.

FACTORS INFLUENCING STAFFING:

Staffing is basically a dynamic process and is affected by a variety of factors, both external and
internal. Staffing function is affected by various elements of management process but at the same time it
affects other elements also.

For example: planning of an organization decides the number and type of personnel required. At the
same time number and type of personnel also affect what the organization can do. Thus staffing is
affected by different factors which can be grouped into two categories, external and internal.

a. External factors:
There are various external factors which have their impact on staffing policy, and an
organization does not have control over these factors.

1. Legal factors
There are various legal provisions which affect the staffing policy of an organization. Example:
Various acts which provide restrictions to free recruitment are Child Labour Act 1986, Employment
Exchange Act 1959, Factories Act 1948 and Mines Act 1952. Besides provision regarding mandatory
employment of certain categories of personnel such as SC/ST, OBC etc impinge upon staffing policy of
an organization.

2. Socio-cultural factors
Various socio-cultural factors affect the extent to which the organization can employ certain
categories of personnel for certain job.

For example: our socio-cultural factors almost prevent the employment of women in certain
manufacturing operations such as operations involving physical exertion etc.

3. External influences

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 There are various forces in the environment which exert pressures on the employing
organizations. Example: These pressures may be from the political structure in the form of emphasis on
‘sons of the soil’ or pressure for appointing certain individuals, pressure from the community to which
the promoters of an organization belongs.

b. Internal factors:
Besides the various external factors, there are various internal factors which affect staffing. They
are

1. Organizational business plan

Organizational business plan directly affects staffing function because it determines the type of
personnel that may be required in future. Based on the business plan organizations may be divided into
three categories: growing, stagnating and declining.

A growing organization undertakes various new projects either in the same line of business or
different business. Such an organization requires more personnel in future besides maintaining its
existing personnel.

A stagnating organization adopts stability strategy in which growth does not come by way of
additional investment but by making the present investment more effective. Such an organization
focuses more on retaining its present personnel by offering them suitable rewards and financial
incentives.

A declining organization focuses on reducing its business operation by divesting those

businesses which do not match with its core competence. Such an organization goes for downsizing
personnel by offering voluntary retirement scheme and pays below average financial incentives.

2.Size of organization

Size of an organization is the factor which determines the degree of attractiveness to the
prospective candidates. A small organization cannot have the same staffing practices which a large
organization may have.

3. Organizational image

Organizational image is an important factor for attracting personnel for selection. The image of
an organization in human resource market depends on its staffing practices like facilities for training and
development, promotional avenues, compensation and incentives and work culture.

FACTORS AFFECTING STAFFING IN NURSING SERVICES:

o The type, philosophy, objectives of the hospital and the nursing service.
o The population served or kind of patients served whether pay or charity.
o The number of patients and severity of their illness-knowledge and ability of nursing
personnel are matched with the actual care needs of patients
o Availability and characteristics of the nursing staff, including education, level of
preparation, mix of personnel, number and position.
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 o Administrative policies such as rotation, weekends, and holiday off-duties.
o Standards of care desired which should be available and clearly spelled out.
o Layout of various nursing units and resources available within the department such as
adequate equipment, supplies, and materials
o Budget including the amount allotted to salaries, fringe benefits, supplies, materials and
equipment
o Teaching program or the extent of staff involvement in teaching activities.
o Expected hours of work per annum of each employee. This is influenced by 40 hour
week law.
o Patterns of work schedule-traditional 5 days per week, 8 hours per day; 4 days a week,
ten hours per day and three days off; or 3 ½ days of 12 hours per day and 3 ½ days off
per week.

CURRENT TRENDS AND ISSUES IN STAFFING

The scarcity of qualified health personnel, including nurses, is being highlighted as one of the biggest
obstacles to achieving the Millennium Development Goals for improving the health and well being of
the global population.-------- World Health Org. 2004

TRENDS:

1. Changing Demographics and Increasing Diversity

2. The Technological Explosion

3. Globalization of the World's Economy and Society

4. The Era of the Educated Consumer, Alternative Therapies and Genomics, and Palliative Care.

5. Shift to Population-Based Care and the Increasing Complexity of Patient Care

6. The Cost of Health Care and the Challenge of Managed Care

7. Impact of Health Policy and Regulation

8. The Growing Need for Interdisciplinary Education for Collaborative Practice

9. The Current Nursing Shortage/Opportunities for Lifelong Learning and Workforce Development

10. Significant Advances in Nursing Science and Research

Changing Demographics and Increasing Diversity:

Population explosion and greater life expectancies increases the demand for health care and nursing
services. Immigration, migration from one place to other, one state to other or one country to other cause
diversity in population of particular place. Significant increases in the diversity of the population affect
the nature and the prevalence of illness and disease, requiring changes in practice that reflect and respect
diverse values and beliefs.

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Disparities in morbidity, mortality, and access to care among population sectors have increased, even as
socioeconomic and other factors have led to increased violence and substance abuse. Nursing practice,
education, and research must embrace and respond to these changing demographics, and nurses must
focus on spiritual health, as well as the physical and psychosocial health of the population. Schools of
nursing must be prepared to confront the challenges associated with today's more mature student body,
and educational methods and policies, curriculum and case materials, clinical practice settings, and
research priorities need to value and reflect the diversity of the student body, as well as the population in
general. At the same time, schools must focus recruitment efforts on the more traditional, younger
student.

2. The Technological Explosion:

The rapid growth in information technology has already had a radical impact on health care delivery and
the education of nurses. Advances in processing capacity and speed, the development of interactive user
interfaces, developments in image storage and transfer technology, changes in telecommunications
technology, and the increased affordability of personal computers have contributed to the explosion of
information technology applications. Advances in digital technology have increased the applications of
telehealth and telemedicine, bringing together patient and provider without physical proximity.
Nanotechnology will introduce new forms of clinical diagnosis and treatment by means of inexpensive
handheld biosensors capable of detecting a wide range of diseases from miniscule body specimens.

Dramatic improvements in the accessibility of clinical data across settings and time have improved
both outcomes and care management. The electronic medical record will replace traditional
documentation systems. Through the Internet, consumers will be increasingly armed with information
previously available only to clinicians. Electronic commerce will become routine for transacting health
care services and products.

Nurses of the 21st century need to be skilled in the use of computer technology. Already,
distance learning modalities link students and faculty from different locales and expand the potential for
accessible continuing professional education. Technically sophisticated preclinical simulation
laboratories will stimulate critical thinking and skill acquisition in a safe and user-friendly environment.
Faster and more flexible access to data and new means of observation and communication are having an
impact on how nursing research is conducted.

3. Globalization of the World's Economy and Society:

Globalization has been brought about by many factors, including advances in information technology
and communications, international travel and commerce, the growth of multinational corporations, the
fall of communism in Eastern Europe and the Soviet Union, and major political changes in Africa and
Asia. With the "death of distance" in the spread of disease and the delivery of health care, there are both
extraordinary risks and extraordinary benefits. Along with the potential for rapid disease transmission,
there is potential for dramatic improvements in health due to knowledge transfer between cultures and
health care systems.

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 Nursing science needs to address health care issues, such as emerging and re-emerging
infections, that result from globalization. Nursing education and research must become more
internationally focused to disseminate.

4. The Era of the Educated Consumer, Alternative Therapies and Genomics, and Palliative
Care.

The Educated Consumer Despite some information gaps, today's patient is a well-informed consumer
who expects to participate in decisions affecting personal and family health care. With advances in
information technology and quality measurement, previously unavailable information is now public
information, and consumers are asked to play a more active role in health care decision making and
management. The media and the Internet have facilitated this trend.

Technological advances in the treatment of disease have led to the need for ethical, informed decision
making by patients and families. Consumers are thus becoming more interested and knowledgeable
about health promotion as well as disease prevention, and there is increased acceptance and demand for
alternative and complementary health options. The increased power of the consumer in the patient-
provider relationship creates a heightened demand for more sophisticated health education techniques
and greater levels of participation by patients in clinical decisions. Nurses must be prepared to
understand this changed relationship and be skilled in helping patients and families maximize
opportunities to manage their health.

Alternative Therapies and Genomics Amazing growth is taking place at opposing ends of the
technological spectrum. The impact of the Human Genome Project and related genetic and cloning
research is unparalleled. Gene mapping will drive rapid advances in the development of new drugs and
the treatment and prevention of disease. Technological sophistication of the highest order is required for
this research, which has the potential to lead to unparalleled ethical questions and conflicts while
bringing about critical diagnostic and therapeutic developments.

At the low-tech end of the spectrum, the voracious demand by consumers for "alternative" or
"complementary" therapies to enhance health and healing has begun to influence mainstream health care
delivery. Several academic medical centers now have offices of alternative medicine, and the National
Institutes of Health recently funded new initiatives dedicated to this field. Increasingly, major health
systems are seeking ways to provide both traditional, Western medicine while offering the best of the
alternative therapies to their patients.

As is true for many trends, alternative medicine holds both promise and peril. While it is thought that
it may unlock behavioral and spiritual components of health and healing heretofore resistant to most
conventional medicine, risks of consumer fraud, therapeutic conflict, and patient noncompliance are
real. Nursing research has the potential to enhance knowledge regarding what constitutes a "healing"
therapy. Nursing education and practice must expand to include the implications of the emerging
therapies from both genetic research and alternative medicine, while managing ethical conflicts and
questions. The inclusion of nontraditional health care providers may augment the health care team.

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 Palliative and End-of-Life Care Technological advancements in the treatment of illness and disease
have created new modalities that extend life while challenging traditional ethical and societal values
regarding death and dying. Greater recognition of the need to ensure comfort and promote dignity is
reflected in the now nearly universal promotion of advanced directives, organ donation, and palliative
care for the terminally ill. New settings for care, such as inpatient and home-based hospice, and new
forms of care, including pain management, spiritual practices, and support groups and bereavement
counseling, are now likely to be part of well-developed health care systems. A significant gap in the
body of scientific knowledge and clinical education with regard to palliative and end-of-life care
remains, and nursing education must prepare graduates for a significant role in these areas.

5. Shift to Population-Based Care and the Increasing Complexity of Patient Care:

Rising costs and an aging population have led to new settings and systems of care across the health care
continuum. Managed care and risk-based contracting mechanisms have forced a shift from episodic care
with an acute orientation to care management with a focus on population-based outcomes.

6. The Cost of Health Care and the Challenge of Managed Care:

Many reasons have been suggested, including the advanced technology available to virtually all
residents through academic medical centers, the scientific and technologic infrastructure that has led to
most of the diagnostic and therapeutic breakthroughs in medicine, cultural norms regarding aging and
end-of-life, the cost of violence and drug addiction, and the growing economic and health disparity
between segments of the population.

7. Impact of Health Policy and Regulation:

The impact of federal and state health policy and regulation on the practice of nursing cannot be
ignored. Issues surrounding health care are often complex, involving the fields of medicine and
economics, and affecting individuals' rights as well as access to health care. Consumers are concerned
about quality, and corporations and individual providers are concerned about economic survival.

Two major trends will have a significant impact on health care delivery. First, there will be an
increase in state and federal regulation as costs rise and managed care continues to expand. Along with
regulation, there will be attempts to shift to less expensive settings and apply market forces to restrain
costs.

Second, Nursing schools, scholars, executives, and professional nursing organizations must more
actively contribute to the development of health policy and regulation. Ethical issues involved in
working in an integrated system constrained by economic incentives are being defined more and more
by government policy makers, not health care professionals. Nursing leaders should contribute to the
dialogue that defines these issues; students must be prepared for a meaningful role in the political arena.

8. The Growing Need for Interdisciplinary Education for Collaborative Practice:

A wide range of knowledge and skills is required to effectively and efficiently manage the
comprehensive needs of patients and populations. The health care delivery system of the future will rely
on teams of nurses, nurse practitioners, physicians, dentists, social workers, pharmacists, and other
81
providers to work together. While interdisciplinary and collaborative practice is still not the norm, there
has been a heightened awareness of the need for coordinated care and a significant increase in the use of
midlevel providers, such as APNs, as part of the primary care team.

With care management a critical component in health care delivery, nurses must demonstrate
leadership and competence in interdisciplinary and collaborative practice for continuous quality
improvement. Team-based, interdisciplinary approaches have been shown to be highly effective for
improving clinical outcomes and reducing cost. Teaching methods that incorporate opportunities for
interdisciplinary education and collaborative practice are required to prepare nurses for their unique
professional role and to understand the role of other disciplines in the care of patients.

9. The Current Nursing Shortage/Opportunities for Lifelong Learning and Workforce

Development:

Nursing shortages have a negative impact on patient care and are costly to the health care industry. A
significant nursing shortage exists today, particularly in acute and long-term care settings. It results from
many factors. For example, nurses of the "baby boom" generation are beginning to retire; women today
have numerous career opportunities; and there is a lingering perception of nursing as a "trade," versus a
"profession," which contributes to the lack of new individuals entering the field. As the age of entering
students rises, the number of years of practice decreases, also affecting supply. While the number of
male and minority students has been steadily rising, their ranks are still underrepresented.

The current shortage is judged to be deeper than past shortages and probably more resistant to short-
term economic strategies that have worked before. However, as in the past, the current shortage will
almost certainly raise salaries and increase flexibility for nurses. Other recent advances in the profession
and the health care industry are likely to have a positive impact on recruitment. These include the
opportunity to practice in a variety of clinical settings; the dramatic increase in opportunities for APNs;
new careers in care management and case management; and the interest of biotechnology, information
technology, and pharmaceutical companies in hiring skilled nursing professionals. Nursing education
must partner with the health care industry to develop innovative short- and long-term solutions that
address the nursing shortage, including aggressive student recruitment and the initiation of an intense
media/marketing campaign. The public image of the nursing role must be revitalized to change outdated
perceptions.

The need for more sophisticated nursing management and leadership to respond to the clinical,
organizational, and fiscal challenges faced by the health care industry has not gone unrecognized. Nurse
Managers and executives require clinical experience and strong communication skills, as well as
business acumen and knowledge of financial and personnel management, organizational theory, and
negotiation. With the nursing labor budget constituting a significant proportion of total spending, and
cost overruns, in acute care hospitals, long-term care facilities, and home care agencies, nursing
management is too often found to be lacking in fundamental decision science and fiscal knowledge. A
great need exists for educational support for experienced nurses to be developed into nurse executives,
prepared to work competently alongside their business colleagues. Nursing schools are called on to
expand their core and continuing education programs to address these needs.

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 Rapidly evolving technology, increasing clinical complexity in many patient care settings, advances
in treatment, and the emergence of new diseases are all factors contributing to the increased need for a
strong emphasis on critical thinking and lifelong learning among professional nurses. Further, new
clinical roles, the need for managerial and executive talent, the imperative to retain nurses in active
practice over longer careers, and the desire by practicing nurses to move up the economic ladder lead to
the demand for continuing education and career mobility and development. Schools of nursing have
many of the core resources needed to deliver continuing professional education and can provide
appropriate courses efficiently and effectively. Affiliation with schools by nurses in active practice may
lead to an increase in enrollment for advanced degrees. Health care and health-related organizations may
serve as institutional partners in sponsoring such program offerings, which would contribute to their
relevance, increase participation, and lower costs.

10. Significant Advances in Nursing Science and Research:

Nursing research is an integral part of the scientific enterprise of improving the nation's health.
The growing body of nursing research provides a scientific basis for patient care and should be regularly
used by all the nurses. Most studies concern health behaviors, symptom management, and the
improvement of patients' and families' experiences with illness, treatment, and disease prevention.
Research is conducted to improve patient outcomes and promote the health and well-being of
communities, especially of the most vulnerable populations.

Nursing research and scholarship has received significant funding by public and private agencies in the
last decade and is increasingly recognized as an independent body of knowledge. However, the
challenges associated with advancing the research agenda in nursing are complex and varied. Schools of
nursing are not sufficiently focused on the scholarship and science of nursing as top priorities, and,
although graduate degrees in nursing have become more common, doctorally prepared nursing
professionals are not being produced in large enough numbers to meet the growing need. In addition,
there is a need for enhanced mentorship for new researchers to strengthen skills and capacity to conduct
meaningful nursing research. Significant opportunities exist for schools of nursing, especially those
affiliated with academic health centers, to address these challenges and enhance the research
contributions of nursing scholars.

At the dawn of the 21st century and the long-awaited new millennium, nurse educators face a rapidly
changing health care landscape, shifting student and patient demographics, an explosion of technology,
and the globalization of health care, in addition to a myriad of everyday challenges. As we position
ourselves to meet today's challenges and tomorrow's, we must understand the drivers affecting nursing.
To quote Peter Drucker in Managing for the Future, "It is not necessary to be clairvoyant to know the
future; it is only necessary to clearly interpret what has already happened and then project forward the
likely consequences of those happenings" (Truman Talley Books, 2002).

ISSUES:

One of the major issues in staffing nursing services is shortage of nurses. Healthcare manpower
shortages are prevalent throughout the world and are the major obstacle to the achievement of the UN-
WHO Millennium Development Goals (MDGs) by 2015. International and national nursing shortages
83
are at a crisis level. International Council of Nurses has developed a policy paper on the global nursing
shortage that is being employed in many of the developing countries. Within the Nation, systematic
efforts are underway to address the most critical aspects associated with the supply and demand of
nurses.

Whether global in nature or country specific, major issues that must be addressed are creating healthy
work environments, improving communication, developing competency based staffing models, and
leadership development. Wealthy nations should educate enough of their own residents as nurses and
physicians rather than rely on health care workers from other nations. Train workers who are not nurses
but who can provide assistive nursing services, this in turn reduces the workload of nurses on specific
unit and helps to meet nursing shortages. Here are some of the issues in the nursing workforce,

1. UNDERSTANDING THE NATIONAL NURSING SHORTAGE:

Numerous national workforce reports have emerged in the last half decade to define the cause and effect
of the national nursing shortage on healthcare. Most studies agree, RNs constitute the largest healthcare
occupation. Critical nursing shortages are concentrated in specialty care units that require the knowledge
and skill of highly trained nurses, such as the intensive care unit, operating room, and Emergency
departments.

2. SUPPLY OF NURSES:
The supply of qualified nurse is less when compared to the demand. Some of the nurses have less
adequate skills to practice efficiently due to inadequate training during the College days. Many of the
nurses want to go abroad and work as they will get high salary. New graduate nurses want to get
government jobs or jobs in corporate hospitals, work in urban hospitals rather than in rural hospitals. So
adequate supply of nurses to particular field or hospital get decreased.

3. DEMAND FOR NURSES:

Population explosion and increase in elderly population causes more demand for nursing personnel.
Current trends show that the nursing workforce is already transitioning to non–patient care and other
less physically demanding roles. Dr Peter Buerhaus and colleagues also note that more experienced RNs
may have higher expectations of working conditions and require greater autonomy and respect than has
been typically accorded.

4. JOB DISSATISFACTION:
Aggregate levels of job satisfaction vary by the setting where nurses work. Nurses working in hospitals
report the lowest levels of overall job satisfaction, at 67%. Even at 83%, the job satisfaction level among
those in nursing education only approaches the level of job satisfaction in the general population.
Inadequate staffing, heavy workloads, increased use of overtime, and inadequate wages are cited as
leading contributors to the nursing shortage.

5. STAFFING RATIOS:
For many years, one of the key problems challenging EDs has been how to determine
appropriate staffing. Various benchmarks have been used to measure and compare staffing levels,

84
including the prominent standard known as hours per patient per visit or HPPV. Using this system, the
total number of paid nursing staff hours is divided by the total number of ED visits to yield a number in
HPPV. The pitfalls with using this single productivity measure to determine nurse staffing are obvious.
A patient with a minor laceration receives the same consideration for utilization of nursing resources as
a patient with an acute myocardial infarction or major trauma even though the resources needed to care
for each would be much different. In the past few years, nursing organizations, labor unions, and
legislators have been advocating for mandated nurse patient ratios.

6. CAPACITY AND OVERCROWDING:

Difficulties in recruiting and retaining qualified professional staff, shortages of willing on-call
medical specialists, and the overall shrinkage of inpatient hospital capacity are making it difficult for
institutions to provide comfort bed for all clients and adequate nurse patient ratio.

PROMOTE EVIDENCE-BASED SAFE STAFFING:

Having a sufficient number of registered nurses on a patient care unit sounds like a good idea. But is
there proof that it actually provides a benefit? The answer is yes!There is a substantial evidence base for
safe registered nurse staffing. For more than a decade, research has demonstrated appropriate nurse
staffing provides positive return on investments.

There is evidence that:

• Safe staffing is effective in reducing lengths of stay

• Safe staffing results in improved hospital satisfaction ratings by patients.

• Safe staffing has reduced hospital-acquired infections - including those infections that no
longer qualify for Medicare reimbursement.

• Safe staffing improves nurse satisfaction, which reduces costly nurse turnover.

ANA believes its solution to safe staffing - a comprehensive staffing plan that takes into account nurses
and patients on individual units - creates a positive environment for nursing care. ANA is committed to
encouraging research to demonstrate the best way to provide safe staffing and quality patient care.

The National Database of Nursing Quality Indicators®, or NDNQI®, a part of ANA's National Center
for Nursing Quality®, is contributing to the evidence of safe nurse staffing. By comparing factors such
as nursing hours per patient day, staffing skill mix, registered nurse satisfaction, and nursing turnover
against patient outcomes, NDNQI helps hospital administrators and nurses make system improvements
to better their quality of care.

Participation in NDNQI makes a positive difference for nurses, hospitals, and patients, and can help
improve research in nursing patient care quality and promote safe staffing evidence. Safe staffing is
more than just a good idea - it's an evidence-based approach to quality patient care.

NORMS OF STAFFING

INTRODUCTION:
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Decisions about the size and mix of nursing teams are critical areas for health service managers
generally and nursing workforce planners specifically. Overstaffed, undermanned and imbalanced
nursing teams have implications for the quality and cost of patient care. So there should be effective
staffing policies and norms.

NURSE STAFFING COMMITTEE:

• “Nurse Staffing Committee” – Standing Committee responsible for establishing staffing

guidelines

PURPOSE:

The Nurse Staffing Committee is to provide a collaborative effort for establishing minimum staffing
guidelines to meet patient needs and to provide a healthy work environment for registered nurses and
licensed practical nurses. These guidelines should recognize evidence-based standards.

COMMITTEE CORE PRINCIPLES:

• Structure:

Nurse Staffing Committee structure should:

Have not more than 13 members

Have at least 50% staff/direct care RNs

Have a mechanism to ensure representation of shifts

Have a mechanism to ensure representation of nursing specialties

Have a designated term of service for members

Be provided time and resources to participate

Incorporate periodic quality evaluation tools

Have minutes that are accessible to all staff

Be led by the chief nurse executive or designee

• Function:

The function of the Staffing Committee is to establish nurse staffing guidelines that take into
consideration:

Individual and aggregate patient needs and requirements for nursing care

Specialized qualifications and competencies of nurses and support staff

Availability and requirements for specialized equipment and technology

86
 Patient safety as paramount when planning nurse work hours

Nationally recognized evidence-based standards and guidelines

Evaluate care delivery system based on resources

Provision of safe patient care and adequate nurse staffing with emphasis on care delivery models
based on available resources

Availability of resources during emergencies

Committee Duties & Responsibilities:

The role of the Nurse Staffing Committee is to:

Review existing, and/or develop new staffing plans and guidelines for all patient units
Review current nationally recognized evidence-based standards and guidelines as it relates to
staffing recommendations
Offer recommendations for a nursing services staffing plan that is cost effective and that ensures
that the hospital has a staff of competent nurses with the specialized skills needed to meet patient
needs, and addresses the following:
 The complexity of care, patient assessment, volume of patient admissions, discharge and
transfer;
 Patient acuity and the number of patients for whom care is being provided
 Adjustment of nursing staff levels based on patient needs
At least annually review the effectiveness of staffing plan using indicatorssuch as patient
satisfaction, nurse satisfaction, quality indicators, and fiscal management
Make recommendations for revisions to the staffing plan based upon this annual review if
appropriate.
NORMS- S.I.U, INC, BAJAJ COMMITTEE & HIGH POWER COMMITTEE

NORMS FOR STAFFING:

Norms are standards that guide, control, and regulate individuals and communities. For planning nursing
manpower we have to follow some norms. The nursing norms are recommended by various committees,
such as; the Nursing Man Power Committee, the High-power Committee, Dr. Bajaj Committee, and the
staff inspection committee, TNAI and INC. The norms has been recommended taking into account the
workload projected in the wards and the other areas of the hospital.

All the above committees and the staff inspection unit recommended the norms for optimum nurse-
patient ratio. Such as 1:3 for Non Teaching Hospital and 1:5 for the Teaching Hospital.

S.I.U - STAFF INSPECTION UNIT:

Staff Inspection Unit (SIU) was set up in 1964 with the objective of securing economy in the staffing of
Government organizations consistent with administrative efficiency and evolving performance standards
and work norms. The Scientific and Technical Organisations are not within the purview of the SIU but a
87
Committee constituted by the Head of Department, with a representative from SIU as a Core Member,
conducts staffing studies of such organisations.

In the changed scenario and keeping in view the Government emphasis on better governance and
improved delivery of services, the role of SIU has been re-defined. The SIU has been positioned to act
as catalyst in assisting the line Ministries and Autonomous Organizations in improving their
organizational effectiveness. As per the new mandate, SIU would now conduct the studies of
Organizational Analysis primarily to cover the areas of Organizational System, Financial Management
System, Delivery System, Client-Customer satisfaction, Employees concerns etc. and to suggest ideal
organizational structure, re-engineering of processes, optimum utilization of resources and overcome the
delays besides exploring the possibilities of outsourcing some of the activities with a view to achieve
enhanced output/effectiveness with the minimum expenditure.

The Staff Inspection Unit (S.I.U.) is the unit which has recommended the nursing norms in the year
1991-92. As per this S.I.U. norm the present nurse-patient ratio is based and practiced in all central
government hospitals.

Recommendations of S.I.U:

1. The norms for providing staff nurses and nursing sisters in Government hospital is given in
annexure to this report. The norm has been recommended taking into account the workload projected in
the wards and the other areas of the hospital.

2. The posts of nursing sisters and staff nurses have been clubbed together for calculating the staff
entitlement for performing nursing care work which the staff nurse will continue to perform even after
she is promoted to the existing scale of nursing sister.

3. Out of the entitlement worked out on the basis of the norms, 30%posts may be sanctioned as
nursing sister. This would further improve the existing ratio of 1 nursing sister to 3.6. staff nurses fixed
by the government in settlement with the Delhi nurse union in may 1990.

4. The assistant nursing superintendent are recommended in the ratio of 1 ANS to every 4.5 nursing
sisters. The ANS will perform the duty presently performed by nursing sisters and perform duty in shift
also.

5. The posts of Deputy Nursing Superintendent may continue at the level of 1 DNS per every 7.5
ANS

6. There will be a post of Nursing Superintendent for every hospital having 250 or beds.

7. There will be a post of 1 Chief Nursing Officer for every hospital having 500 or more beds.

8. It is recommended that 45% posts added for the area of 365 days working including 10% leave
reserve (maternity leave, earned leave, and days off as nurses are entitled for 8 days off per month and 3
National Holidays per year when doing 3 shift duties).

88
Most of the hospital today is following the S.I.U.norms. In this the post of the Nursing Sisters and the
Staff Nurses has been clubbed together and the work of the ward sister is remained same as staff nurse
even after promotion. The Assistant Nursing Superintendent and the Deputy Nursing Superintendent
have to do the duty of one category below of their rank.

The Nurse-patient Ratio as per the S.I.U. Norms :

1. General Ward 1:6

2. Special Ward - ( pediatrics, burns, neuro 1:4
surgery ,cardio thoracic, neuro medicine
,nursing home, spinal injury, emergency wards
attached to casuality)
3. Nursery 1:2
4. I.C.U. 1:1(Nothing mentioned about the shifts)
5. Labour Room 1:l per table
6. O.T. Major - 1 :2 per table
Minor -1:l per table
7. Casualty-
a. Casualty main attendance up to 100 patients 3 staff nurses for 24 hours 1:1per shift
per day thereafter
b.for every additional attendance of 35 1:353
patients
c. gynae/ obstetric attendance staff nurses for 24 hours1:1/ shift
d.thereafter every additional attendance of 15 1:15
patients.
8. Injection room OPD Attendance upto 100 patients per day 1 staff
nurse
120-220 patients: 2 staff nurses
221-320 patients: 3 staff nurses
321-420 patients: 4 staff nurses
9.OPD
NAME OF THE DEPARTMENT
• Blood bank 1
• Paediatric 2
• Immunization 2
• Eye 1
• ENT 1
• Pre anaesthetic 1
• Cardio lab 1
• Bronchoscopy lab 1
• Vaccination anti rabis 1
• Family planning 2
• Medical 1
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• Dental 1
• Central sample collection centre 1
• Orthopaedic 1
• Gynae 2
• Xray 3
• Skin 2
• V D centre 2
• Chemotherapy 2
• Neurology 2
• Microbiology 1
• Psychiatry 2
• Burns 1
In addition to the 10% reserve as per the extent rules, 45% posts may be added where services
are provided for 365 days in a year/ 24 hours.

INDIAN NURSING COUNCIL:

Staffing:

1. Chief Nursing Officer :1 per 500 beds

2. Nursing Superintendent :1 per 400 beds or above

3. D.NS. :1 per 300 beds and 1 additional for every 200 beds

4. A.N.S. :1 for 100-150 beds or 3-4 wards

Staff Nurse Sister Department Senior Astt. Nursing Supdt

Medical Ward 1:3 1:25 Each Shift 1 for 3-4 wards
Surgical Ward 1:3 1:25 ” -do-
Orthopaedic ward 1:3 1:25” -do-
Paediatric ward 1:3 1:25 ” -do-
Gynaecology ward 1:3 1:25 ” -do-
Maternity ward 1:3 1:25” -do-
(Including new born)
Intensive Care Unit, 1:1 (24 Hrs.) 1 each shift 1 Departmental
Coronary Care Unit Sister/Asst. Nursing
,Special wards ,Eye , Supdtd. for 3-4 units.
ENT etc
Operation Theatre 3 for 24 hrs. per table 1 each shift 1
Departmental
sister/ANS for 4-5
Operation Theatre
Casualty & 2-3 Staff Nurse 1 each shift 1 Depttl. Sister/ANS
Emergency Unit depending on the No. for emergency
90
 of beds casualty etc
Out patient Department (based on actual observation):

a) Minor Operation Theatre 1 Staff Nurse for every 13 Patients

b) Injection Room 1 Staff Nurse for every 86 patients

c) Surgical 1 Staff Nurse for every 120 patients

d) Medical 1 Staff Nurse for every 140 patients

e) Gynae. 1 Staff Nurse for every 35 patients

f) Children (Paediatric) 1 Staff Nurse for every 85 patients

g) Orthopaedic 1 Staff Nurse for every 120 patients

h) Dental 1 Staff Nurse for every 120 patients

i) ENT 1 Staff Nurse for every 120 patients

j) Eye 1 Staff Nurse for every 86 patients

k) Skin 1 Staff Nurse for every 100 patients

Similarly other out patient Department need to be staffed based on actual observation.

It is suggested that for 250 bedded hospital there should be One Infection Control Nurse (ICN).

NURSING EDUCATION:

STAFFING PATTERN

Collegiate Programme

Qualifications & experience of teachers of college of Nursing

S.NO. POST,QUALIFICATION&EXPERIENCE
1. Principal cum Professor 15 years experience after M.Sc.(N) out of which
12 years should be teaching experience with
minimum of 5 years in collegiate programme.
Ph.D.(N) is desirable
2. Vice- Principal cum Professor 15 years experience after M.Sc.(N) out of which
12 years should be teaching experience with
minimum of 5 years in collegiate programme.
Ph.D.(N) is desirable
3. Professor 10 years experience after M.Sc.(N) out of which 7
years should be teaching experience. Ph.D.(N) is
desirable

91
4. Associate Professor 08 years experience after M.Sc.(N) including 5
years teaching experience Ph.D.(N) desirable
5. Assistant Professor 3 years experience after M.Sc.(N)
6. Tutor M.Sc.(N) Or B.Sc.(N)/P.B.B.Sc.(N) with 1 year
experience
S.NO DESIGNATION ANM GNM B.Sc.(N) P.B.B.Sc.(N) M.Sc.(N)
20-60 20-60 40-60 20-60 10-25
1 Professor cum 1
PRINCIPAL
2 Professor cum 1
VICE- PRINCIPAL
3 Professor 0 1*
4 Associate Professor 2 1*
5 Assistant Professor 3 2 3*
6 Tutor 4-12 6-18 10-18 2-10
*1:10 teacher student ratio for M.Sc(N)

Part time Teachers / External Teachers**

(i) Microbiology
(ii) Bio – Chemistry
(iii) Sociology
(iv) Bio – Physics
(v) Psychology
(vi) Nutrition
(vii) English
(viii) Computer
(ix) Hindi / Any other language
(x) Any other – clinical disciplines
(xi) Physical Education.
**(The above teachers should have post graduate qualification with teaching experience in respective
area)

NOTE:

 No part time nursing faculty will be counted for calculating total no.of faculty required for a
college.
 Irrespective of number of admissions, all faculty positions (Professor to Lecturer) must be
filled.
 For M.Sc.(N) programme appropriate number of M.Sc. faculty in each speciality be appointed
subject to the condition that total number of teaching faculty ceiling is maintained.
 All nursing teachers must possess a basic university or equivalent qualification as laid down in
the schedules of the Indian Nursing Council Act, 1947. They shall be registered under the State
Nursing Registration Act.
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  Nursing faculty in nursing college except tutor/clinical instructors must possess the requisite
recognized postgraduate qualification in nursing subjects.
 All teachers of nursing other than Principal and Vice-Principal should spend at least 4 hours in
the clinical area for clinical teaching and/or supervision of care every day.
STAFFING PATTERN

School Of Nursing

Qualification of Teaching Staff:

(i) Principal M.Sc. Nursing with 3 years of teaching

experience or B.Sc. Nursing (Basic) / Post
Basic with 5 years of teaching experience.
(ii) Vice-Principal M.Sc. Nursing or B.Sc. Nursing (Basic) /Post
Basic with 3 years of teaching experience.
(iii) Tutor M.Sc. Nursing or B.Sc. Nursing (Basic/Post
Basic) or Diploma in Nursing Education and
Administration with 2 years of professional
experience.
For School of nursing with 60 students (i.e., an annual intake of 20 students):

Teaching Faculty No. Require

Principal 1
Vice Principal 1
Tutor 4
Additional Tutor for Interns 1
Total 7
Note:

 Teacher student ratio should be 1:10 for student sanctioned strength.

Clinical facilities:

a) 1:5 student patient ratio to be maintained

b) Minimum 300 bedded Parent/affiliated hospital is required to start College of Nursing.

c) Minimum 200 bedded Parent/affiliated hospital is required to start School of Nursing.

BHAJAJ COMMITTEE ON HEALTH MANPOWER PLANNING, PRODUCTION AND

MANAGEMENT (1986):

The Ministry of Health and Family Welfare, Government of India, set up an Expert Review Committee
for Health Manpower Planning and Development with major emphasis on the creation of additional
facilities for vocational training vide Resolution No. U. 11020/2/86-MEP dated the 8th May 1986* and
subsequently dt. 29-5-86, 1-8-86 & 5-9-86 with Prof. J.S. Bajaj, Professor of Medicine, AIIMS, New
Delhi as Chairperson.

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RECOMMENDATIONS OF BAJAJ COMMITTEE:

1. It is necessary to formulate a National Policy on Education in Health Sciences (Medical and

Health Education Policy) which—(i) lets out the changes required to be brought about in the curricular
contents and training programmes of medical and health personnel, at various levels of functioning, (ii)
takes into account the need for establishing the extremely essential interrelations between functionaries
of various grades, (iii) provides guidelines for the production of health personnel on the basis of
realistically assessed manpower requirements, (iv) seeks to resolve the existing sharp regional
imbalances in their availability, and (v) attempts to ensure that personnel of all levels are socially
motivated towards the rendering of community health services.

2. The Committee is of the firm view that social, moral, health and physical education should
constitute a holistic approach. The curricular contents of courses of instruction for school teachers, and
more particularly physical education instructors, should include these components so that the rationale
of such an approach is imbibed during the period of training.

3. Seventh Plan formulations of integrated planning and coordinative implementation on

decentralized and participative basis may be initiated in areas of health and education. Integrated Area
Development Model with suitable changes and modifications may be considered for the purpose.

4. Active participation of the community, a commonly accepted intervention strategy both by

Health and Educational policies, should be strengthened through the village committees, learner groups
and proposed centres for continuing education in rural areas and District Boards of Education, as
envisaged in the National Education Policy.

5. District Institutes of Education and Training, and Training Schools/Institutes in Health Sector
should "develop integrated Training modules for various categories of allied health professionals
including community level workers in both the sectors and organise orientation programmes
accordingly.

6. Voluntary Organisations are playing a vital role in the processes of implementation of national
objectives in Health and Education. Strengthening of this mode of delivery mechanism is emphasised by
both the Policy documents. It is recommended that coordinative machinery be set up at the national
level, to devise methods and procedures for generation and development of holistic programmes with
active involvement and participation by voluntary organisations, and more importantly with appropriate
financial allocations.

7. One of the major tasks before the Committee was related to estimation of para-medical and
auxiliary manpower at the primary and intermediate level of care. Fully operational community health
centres, once developed and well organised, perhaps provide equal level of secondary care as is
available from present district hospital; such level may, therefore, be defined as intermediate level of
care.

8. Health service statistics need to be improved in quality, functioning of registering bodies for-
health professionals needs to be improved and health manpower studies need to be mounted. The
existing situation regarding health manpower supply, demand and projections is unlikely to improve
94
significantly, until and unless definite mechanisms in terms of creation of organisational structures
responsible for health manpower development are brought into existence.

9. The areas where the practitioners of Homoeopathy and Indian Systems of Medicine can be
gainfully utilised are the areas of National Health Programmes like the National Malaria Eradication
Programme, National Leprosy Eradication Programme, Blindness Control Programme, Family Welfare
and MCH Programme, particularly the programme of universal immunisation and nutrition. To ensure
that such practitioners will be used in judicious manner it will be extremely essential to strengthen their
basic training by incorporating appropriate educational components which will enable them to support
the above National Health Programmes.

10. The health manpower requirements for primary health care must take cognisance of the fact that
individuals, families and the community constitute a most important health man power resource.
Educational process at all levels must aim at the incorporation of such learning experiences that may
lead to desired change(s) in the health behaviour.

11. Incorporation of meaningful learning experiences related to health component in universal

education can, therefore, reach quickly and effectively to a large mass of population, constituting a
major means of health education to the community.

12. Action strategies need to be evolved to make health education more pervasive, with potential of
making a discernible impact on health-related behaviour of individuals, families and communities. The
possible areas of intervention include review and restructuring of curriculum so as to build demonstrable
action points as key learning experiences. The socially useful productive work (SUPW) experience
needs to be redesigned so as to effectively demonstrate interdependence of literacy, social and family
welfare, and health. Health component, with well structured pedagogic inputs, needs to be incorporated
in the teacher training and education curriculum. There is a paucity of educational software of health
which could be effectively used in the mass media technology. A coordinated effort by several agencies
in different sectors along with that of voluntary professional organisations working in health and
education, needs to be initiated to meet such software demands for com-munity health education.

13. The present practice or methods of implementing the health component in all educational processes
leave much to be desired. The situation is due to lack of proper orientation, skills and attitudes towards
these themes among instructors and teachers. It would be necessary to strengthen the health related
education component, at all levels especially in grades IX and X. Such strengthening would call for
emphasis and change in methodology of instruction of these themes with a view to adding demonstrable
learning experiences, rather than inclusion of some more topics for didactic exercise. Suitably modified,
these courses should lay strong foundations for vocational courses on health at +2 stage.

14. The Committee strongly recommends health related vocational courses for the following categories
of health manpower:

(i) Auxiliary Nurse Mid-wife (ANM)/ Multi-Purpose Health Worker, Female.

(ii) Multi-Purpose Health Worker, Male.

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(iii) Radiographers/X-ray technicians.

(iv) Laboratory technicians (for clinical, public health, Food and Drug Laboratory).

(v) Ophthalmic Assistants/Refractionists.

(vi) Dental Hygienists.

(vii) Pharmacists.

(viii) Hospital House Keepers.

(ix) Occupational Therapists/ Physio-Therapists.

(x) Sanitary/Health Inspectors.

15. The Committee is of the considered opinion that an in-depth review of education and training
facilities for the above categories of personnel should be undertaken. At present, the training of several
categories of such workers is being undertaken in some Higher Secondary Schools, particularly in the
States of Karnataka, Andhra Pradesh and Maharashtra as a part of vocationalisation organised by the
education department. But in most of the cases and in most of the States, the training of these
professionals is being conducted in schools/institutions especially designed for them or in association
with existing institutions, mostly medical colleges/institutions, through health department. It is,
therefore, mandatory that appropriate linkages and coordination must be developed between the health
and education departments in every State, with establishment of Coordination Committees at district
level.

The Committee recommends that the courses of instruction presently being organised by the health
department should be reorganised so as to be equated with the 10+2 system. To do so, a curricular mix
will have to be evolved wherein languages and related subjects including science, mathematics and
humanities, etc. shall constitute about 25-30% of the total period of instruction, while vocational theory
and practice, including on-the-job training will occupy the remaining 70-75% of the total allocated time.
While the facilities available in the higher secondary schools can be provided for the courses of
instruction in science, mathematics, humanities and languages, the infrastructure available at the schools

of training for allied health professionals like ANMs may be used for imparting the vocational
component of the health-related courses. The Committee recommends that a small sub-committee be
appointed to work out a detailed plan of action. While the Committee would wish to emphasise maximal
utilisation of existing facilities irrespective of the sectoral denomination, a pro-vision must also be made
for ensuring adequate financial outlays to generate requisite infrastructure both in material and
manpower resources.

16. It is recommended that the entry point for all the courses should be after the stage of 10th standard.
The +2 stage of two years can conveniently be broken into 4 semesters in which general educational and
vocational courses of instructions can be imparted to the para-professionals indicated above. The Group
recommends that the first year of the 10 + 2 system, that is, the first two semesters should be for a
common core curriculum for all types of para-professional workers. During the third semester,
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specialised areas should be included in the training of specific categories of personnel whereas the 4th
semester should be for practical training and work experience in the chosen area of para-professional
vocationalisation. Several temporal alignments are possible to achieve such modular organisations.

17. It is recommended that for these coordinated/integrated training courses, the faculty from the
disciplines of Biology, Physics, and Chemistry be drawn from the existing secondary schools. These
schools can also provide faculty support for instruction in languages and humanities, whereas the
instruction in health sciences could be easily imparted by part-time faculty members drawn from the
existing district hospitals, training schools and institutions, medical colleges, etc. wherever available and
even from retired health scientists. Transfer of credits on the basis of common modules of instruction at
the +2 vocational level needs to be ensured on a uniform basis so as to be widely applicable throughout
the country.

18. In view of the curricula: mix of language and humanities courses as a part or + 2 vocational
education, the students should be able to pursue higher courses of training in medical and other
professional colleges and universities, either at the end of +2 stage or after 3-5 years of work experience
in the chosen vocation. This would provide incentive for joining health-related vocational courses at +2
stage.

19. It is recommended that the Government may consider award of stipends/scholarships to students
pursuing health vocational courses. Such awards should be based on merit-cum-means, and would
further add to the incentives for such courses. In order to facilitate employment of those qualifying
health-related vocational courses, the Committee strongly recommends that the State Governments
should initiate steps to secure recognition from the employment sector for these courses. Departments of
Health, following appropriate assessment, should take a lead in according such recognition.

20. As the teachers- of vocational course are drawn from two distinct categories of discipline i.e. general
and medical education, there should be a shared awareness and concern for the educational requirement
of the students. The part-time staff of even highly qualified professional people as well as whole time
teachers would require appropriate orientation in instructional techniques and evaluation methodology.
To keep full-time teachers abreast of the latest practices, periodical refresher training will have to be
conducted.

21. The teachers should be made aware that para-medical vocational education should not only _ focus
attention to train the students for acquisition of skills, attitudes, understanding and knowledge relating to
specific para-medical vocation, but should also aim to educate them in a manner that it should lead to :

(a) an understanding of the emerging trends in the field of health at the national and international level;

(b) the comprehension of the social, political and environmental implication of scientific and
technological change;

(c) the establishment of a new relationship between education, working life and the community as a
whole; and

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(d) the appreciation of vocational education as a part of system of life-long education adapted to the
needs of one's own society.

22. Most important, the teachers should bear in mind that the vocation should not lead to the cul-de-sac
of a mechanical life but should aim for a life of mission as well as of personal growth. A proper
appreciation of the vocational course as well as teaching of non vocational component so as to make it
relevant to the chosen vocation, requires that the concerned teachers of general education also need
appropriate training aimed at generating awareness of job opportunities and task requirements of the
vocation, and of the general outline of the content of vocational component.

23. For effective educational planning of para-medical vocational courses, there is need for proper
assessment of District-wise, State-wise, and Nation-wise para-medical vocational manpower
requirement. The choice of vocation for manpower production at District level or State level should not,
however, be based on need assessment alone, but also on regional employment capabilities of the
employing agencies at .District and State level, both in the public and private sector, self-employment
possibilities, prior recognition of the courses by competent authority, and establishment of proper
linkage between technical collaborating and educational institutions. The Committee would wish to
endorse the recommendation of the National Working Group on Vocationalization , of Education
regarding establishment of a National/Joint Council for Vocational Education and State Councils of
Vocational Education, and would recommend an effective inter- , linkage of such councils with the
proposed Education Commission of Health Sciences and Regional or State Universities of Health
Sciences.

24. A vocational curriculum, to be need-based, must be developed through proper identification of

minimum vocational competencies required in the job market by experts through systematic analysis of
manpower (Supply, demands and projections; tasks and duties demanded in those jobs; and the requisite
skills for various tasks/duties to be performed.

(1) "Minimum competencies based curriculum" will not only act as a corrective measure by way of
helping in the process of revision of curricula already in operation in the States presently implementing
vocationalisation but: it can also accelerate the process of introduction of such courses in other States
which are going to launch the programme, by providing readymade material.

(2 ) Guidelines need to be prepared so as to provide necessary information on various aspects of

programme implementation; reference materials; selection of teachers; training facilities; learning aids
and settings etc. These will be of considerable use to curriculum planners, authors of instructional
materials, supervisors, teachers, students and employers.

(3) The curriculum should be flexible enough to provide local variation for adaptation related to specific
needs.

(4) If the same team which is responsible for planning the curriculum can develop the guidelines as well
as instructional materials (text-cum-practical manuals, supplementary readers, self-learning materials),
not only the continuity of educational process is maintained, but much time would be saved in the final

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dissemination of such materials. A major effort also needs to be initiated to develop instructional
materials in regional languages

26. There is great variation in between different States, in the pattern of "vocational courses and the
credits accorded to different components. Consequently, the products supplied by different States differ
so tars as attainment of skills are concerned. For the establishment of a national standard of health
services, it is desirable to ensure the development of a national norm of standards for each vocation.

27. Maintenance of standards of such a vital segment as allied health professionals is, therefore, very
necessary. Proper evaluation measures during, and following the completion of courses of instruction,
can not only ensure standardization of educational process but also of the quality of the product, thus
leading to appropriate recognition by public and private sector, and regional and central employing
health institutions. Exercise of 'quality' control of the process of education, as also of its product,
indirectly helps in the elimination of non-standardised products, of unauthorized institutions, thus
preventing a backdoor entry into health services, and jeopardizing establishment of health service
standards in the country.

(1) In a vocational area, achievement of goals in the cognitive domain is as important as that in the
psycho-motor domain, because an allied health professional has to demonstrate a homogenous blend of
knowledge, skills and behavioural attitudes. As there is an intimate interaction with suffering human-
beings, such a para-professional is expected to serve as a bridge between common man and professional
expert; thus, attainments m the effective domain also assume significance. It is, therefore, necessary that
evaluation of paramedical personnel, both formative and summative, must be comprehensive so as to
test his vocational competencies of knowledge and comprehension, phycho-motor skills and attitudes,
with balanced assignments of credits.

(2) To evaluate the attainment of competencies in these three domains, a comprehensive framework of
evaluation with appropriate tools and techniques for each vocation, need to be developed.

(3) Evaluation of psychomotor skills and personality traits attitudes) in general education, and much
more so in vocational education, has not attracted as much attention of the evaluators as in the case of
written examination which primarily aims at the assessment of cognitive domain. It is, therefore, time
that serious thought is given to this vital aspect of evaluation which constitutes the very essence and
foundation of health services.

(4) To streamline process of evaluation and make it meaningful and effective, a Com-mittee for each
health-related vocational course, consisting of specialists, profes-sionals, teachers, evaluators and
evaluation experts should be constituted. This Committee should specifically focus on:

— Development of guidelines, framework, methods, tools and techniques of evaluation; and

— Testing, validation, refinement and updating of the above.

28. An all encompassing plan should be drawn up intersectoraly for health manpower production. Three
tier inter-linkages are suggested—

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(a)Central level.—the Ministries of Health and Education should evolve a strategy of the extent of
vocationalism, draw up essentials of a core curriculum valid for the whole country, decide employ
trainers, preparation of teaching materials, identify course objectives and contents.

(b)State level.—Jointly, the Health and Education departments should follow the guidelines provided by
the centre, identify the need of various categories in the state, allocating various categories to +2 schools
and identifying the collaborating hospitals/institutions, providing training of teachers of the vocational
courses and develop local need based in-structional materials. They should make budgetary provisions
for the educational process and professional content as well as for absorption of successful candidates.
Evaluation/examining bodies need to be constituted.

(c) Local institutional level.—The school authorities must interact with the hospital/institutional
authorities for efficient coordination and conduct of the course of instruction with built-in mechanism of
close monitoring and evaluation mechanisms.

29. In the initial stages, the Departments of Health and Education should prepare a plan of action for
health manpower management taking into consideration employment, retention, support and
development of health care personnel.

30. Employment procedures should be fairly uniform all over the country and should be clearly
delineated. Job descriptions for all categories are prepared, subject to a regular review with continual
evolution of the role of allied health professionals. Guidelines for recruitment should be uniform but it
should be decentralised for proper deployment of the health personnel.

31. A career structure for all categories should be drawn up and should be continually reviewed keening
in line with emerging and evolving health care strategies and operation.Central guidelines are
enunciated for a cadre planning with promotional avenues both for vertical movement and a lateral
induction based on seniority and merit. Salary structure should be the same all over the country. In order
to remove the spatial distortions between rural and urban health services, incentives must be given by
way of allowances, better living and working conditions and other fringe benefits to make the rural
service more attractive.

32. Quality of supervision should be optimised and standardised. Clear-cut instructions and guidelines
be included in the job descriptions for supervision procedures. In addition to the assessment of skills and
performance, the supervisors should also assess the skills acquired during the training courses and any
inadequacies' be reported to the educational institutions for a further review of curriculum and teaching
modalities.

33. Effective communication must exist between all categories of staff and they should be jointly
involved4 in planning, implementation and management of the health programmes.

34. Career development and cadre review with focus on promotional avenues, vertical and horizontal
mobility should be drawn up.

35. On-the-job training of successful candidates for a period of 3-6 months should precede confirmation
in the designated job.

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36. Continuing education programmes should be developed with major emphasis on:

(a). Refresher courses.

(b). In-service training.

(c) Bridge courses for advanced professional education.

(d) Provision of study leave after 3-5 years of service.

(e) Dissemination of new information.

37. Mechanism for a national health manpower information system should be developed as an important
support to health manpower development and management.

38. A National Policy on Education in Health Sciences (NPEHS) must be enunciated. The essential
components of NPEHS should be entirely consistent with, and subservient to the stated objectives of the
National Health Policy, 1983 and the National Policy on Education, 1986. A major focus of NPEHS
should be policy guidelines for health manpower development. Indeed, a commitment to this effect has
already been made in the National Health Policy and a reference framework has also been defined.

39. A realistic health manpower survey should be carried out.

40. In order to launch an effective vocationa-lisation, the educational infrastructure should also take into
account availability of teachers training courses, continuous production of teachers, upgrading of
instructional technology and educational software. National institutes such as NCERT may be requested
to develop educational technology and softwares including textbooks for each course in English as well
as in local languages.

41. Education Commission for Health Sciences should be established as a central organisation in the
field of professional education in health related fields. It should be constituted on the lines of UGC.

The operational framework of the Commission should include:—

(1) To provide realistic projections for national health man-power requirements and to recommend the
establishment of mechanism(s) through which such pro11jections could be continuously reviewed in
context of evolving socio-epidemiological needs and demographic requirements. To initiate action for
the creation of educational institutions and facilities, or strengthening of such facilities in already
existing educational institutions, that would facilitate the production of projected health manpower, and
to consider the establishment of one or more Universities of Health Sciences.

(2) To implement desired changes required to be brought about in the curricular contents and training
programmes of health personnel and allied health professionals, at various levels of functioning.

(3) To plan and implement appropriate changes in the educational system that would facilitate the
establishment of essential inter-linkages between health functionaries of various grades.

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(4)To establish a continuing review mechanism for the strengthening of health-related pedagogic and
communication technologies, and to recommend the development of such health-related community
educational programmes that could effectively and optimally utilise these technologies.

(5) To develop in-built mechanisms of review, monitoring, and mid-course corrections so as to ensure
expeditious implementation of recommendations and decisions.

(6) To coordinate intersectoral research by interlinking the education and training of suitable manpower
with mission oriented research needs.

42. Education Commission for Health Sciences should liase with all existing professional councils and
recommend, if necessary, councils, for health professional categories, if these do not exist.

43. The main role of the existing professional councils should be to deal with matters of registration, as
well as regulation and monitoring of professional ethics and professional conduct. However, as these
councils are also expected to prescribe standards of professional education, the other functions have not
received the attention and consideration that they deserve. It would be most appropriate if the existing
professional councils should concentrate on:—

(a) Recognition or derecognition of degrees or diplomas granted by Universities or Institutions.

(b) Development of interlinkages and reciprocities with corresponding councils in other countries.

(c) Registration of qualified professionals and maintenance of an all India register.

(d) Inspection and certification of standards of examinations and available facilities ‘for education and
training.

(e) Monitoring of professional ethics, and

(f) Regulation and surveillance of professionals' conduct.

44. Health Sciences Universities be established in each State and in groups of Union Territories as the
implementing arm of E.C.H.S. for production, evaluation and sustenance of health manpower policy.
However, till such time that a University of Health Sciences can be established in each State and Union
Territory, a beginning may be made in the Eighth Plan to establish such Universities on a regional basis.

45. Health Sciences Universities (HSU) should affiliate all medical and related colleges and award
degrees in these fields.

46. Cognisant of the fact that the scope of medical and health education has evolved considerably in the
recent years, newer faculties should develop such as health management, health economics, social and
behavioural sciences, educational reprographics and health information systems.

47. To coordinate the implementation of health manpower policy at the centre and the states. Health
Manpower Cells may be created at the centre and in the states

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48. The Committee wishes to recommend that there is an urgent need to revamp and strengthen the
primary health care in the urban areas to provide the preventive and promotive services in a
comprehensive manner.

49. There should be a major emphasis on the creation and establishment of necessary infra-structure
including beds to strengthen linkages between already established primary health care system in the
rural areas and the required linkages and referrals to the intermediate health care stations.

50. The Committee wishes to reiterate that the distortions in health man-power production and
utilisation need to be remedied in as short time as possible. To do so would not only require political
will and commitment but should also be reflected in the future allocations of financial resources both in
areas of strengthening the primary health care facilities as well as for generating adequate employment
potential.

HIGH POWER COMMITTEE ON NURSING AND NURSING PROFESSION IN INDIA:

A High Power committee was appointed by the Govt. of India, Ministry of Health and family Welfare
vide No. V-14025/9/87-PMS dated 29th July 1987 to review the roles, functions, status, preparation of
the Nursing Personnel, nursing services and other issues related to the development of the profession
and to make suitable recommendations to the Government.

Dr. (Smt) Jyoti. M. Trivedi was the Chairperson from july 1987, and Dr. Sarojini Varadappan became
the chairperson as per the Notification V. 14025/9/87- PMS dated 10th February 1989. It has also been
decided that the committee shall submit its report by 30-6-1989. This committee studied the reports of
previous committees (Bhore committee 1946- Bhajaj Committee 1986). This committee conducted
meetings, surveys by questionnaire, field visits, collected opinions from nursing councils and nursing
associations. Then the committee did a deep analysis and presented its recommendations as follows.

RECOMMENDATIONS OF HIGH POWER COMMITTEE ON NURSING AND NURSING

PROFESSION

Working conditions of nursing personnel

Employment

• Uniformity in employment procedures to be made.

• Recruitment rules are made for all categories of nursing posts. The qualifications and experience
required for these be made throughout the country.

• There should not be a bond for nursing students as some of the states do not give them
employment during the stipulated period. Keeping in view of the shortage of nurses in hospitals and
community health field states should create posts and appointment these nurses in the appropriate
positions.

Job description

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Job description of all categories of nursing personnel is prepared by the central government to provide
guidelines.

Working hours

The weekly working hours should be reduced to 40 hrs per week. Straight shift should be implemented
in all states. extra working hours to be compensated either by leave or by extra emoluments depending
on the state policy .nurses to be given weekly day off and all the gazetted holidays as per the
government rules.

Work load/ working facilities

Nursing norms for patient care and community care to be adopted as recommended by the
committee.
Hospitals to develop central sterile supply departments, central linen services, and central drug
supply system. Group D employees are responsible for housekeeping department.
Policies for breakage and losses to be developed and nurses not are made responsible for
breakage and losses.
Pay and allowances

Uniformity of pay scales of all categories of nursing personnel is not feasible. However special
allowance for nursing personnel, ie; uniform allowance, washing, mess allowance etc should be uniform
throughout the country.

Promotional opportunities

For promotion to the post of ward sister, post basic B.Sc Nursing is made an essential qualification. The
principle of possessing higher qualification than the category to be supervised, should apply for all
levels and categories of nursing personnel in the rural and urban areas. The committee recommends that
along with education and experience, there is a need to increase the number of posts in the supervisory
cadre, and for making provision of guidance and supervision during evening and night shifts in the
hospital.

Each nurse must have 3 promotions during the service period.

Promotion is based on merit cum seniority.Promotion to the senior most administrative teaching
posts is made only by open selection.
In cases of stagnation, selection grade and running scales to be given.
Career development

Provision of deputation for higher studies after 5 yrs of regular services be made by all states. The
policy of giving deputation to 5 -10 % of each category be worked out by each state. Every nursing
personnel must have an opportunity to attend at least one refresher course every 2 years.

Accommodation

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As far as possible, the nursing staff should be considered for priority allotment of accommodation near
to work place. Hospitals should not build nurse's hostel for trained nurses. Apartment type of
accommodation is built where married/unmarried nurses can be allowed to live. Housing colonies for
hospital s must be considered in long run.

Transport

During odd hours, calamities etc arrangements for transport must be made for safety and security of
nursing personnel.

Special incentives

Scheme of special incentives in terms of awards, special increment for meritorious work for nurses
working in each state/district/PHC to be worked out.

Occupational hazards

Risk allowance to be paid to nursing personnel working in the rural & urban area.

Other welfare services

Hospitals should provide welfare measures like crèche facilities for children of working staff, children
education allowance, as granted to other employees, be paid to nursing personnel.

Additional Facilities for Nurses Working in the Rural Areas

 Family accommodation at sub centre is a must for safety and security of ANM's /LHV.
 Women attendant, selected from the village must accompany the ANM for visits to other
villages.
 The district public health nurse is provided with a vehicle for field supervision.
 Fixed travel allowance with provision of enhancement from time to time.
 Rural allowance as granted to other employees is paid to nursing personnel.
NURSING EDUCATION

Nursing education to be fitted into national stream of education to bring about uniformity, recognition
and standards of nursing education. The committee recommends that;

1. There should be 2 levels of nursing personnel - professional nurse (degree level) and auxiliary
nurse (vocational nurse). Admission to professional nursing should be with 12 yrs of schooling with
science. The duration of course should be 4 yrs at the university level. admission to vocational /auxiliary
nursing should be with 10 yrs of schooling .The duration of course should be 2 yrs in health related
vocational stream.

2. All school of nursing attached to medical college hospitals is upgraded to degree level in a
phased manner.

3. All ANM schools and school of nursing attached to district hospitals be affiliated with senior
secondary boards.
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4. Post certificate BSc Nursing degree to be continued to give opportunities to the existing diploma
nurses to continue higher education.

5. Master in nursing programme to be increased and strengthened.

6. Doctoral programmes in nursing have to be started in selected universities.

7. Central assistance be provided for all levels of nursing education institutions in terms of
budget( capital and recurring)

8. Up gradation of degree level institutions be made in a phased manner as suggested in report.

9. Each school should have separate budget till such time is phased to degree/vocational
programme. The principal of the school be the drawing and the disbursing officer.

10. Nursing personnel should have a complete say in matters of selection of students. Selection is
based completely on merit. Aptitude test is introduced for selection of candidates.

11. All schools to have adequate budget for libraries and teaching equipments.

12. All schools to have independent teaching block called as School Of Nursing with adequate class
room facilities, library room, common room etc as per the requirements of INC.

13. Adequate accommodations are provided to students. A maximum of 3 students to share a room.
Rooms to be furnished with light, study table , chair etc. Adequate dining room, toilets and bathrooms
facilities to be provided in each hostel as per norms recommended.

14. Students should learn under supervision in the wards. Tutors/clinical instructors must go to the
ward with students. Students should not be used for the service of the hospital.

15. Community nursing experience should be as per INC requirements. Necessary transport and
accommodation at PHC be made available for safety, security and meaningful learning of students.

16. INC requirements for staffing the schools and meeting the minimum requirements are followed
by all schools as these are statutory requirements.

17. Speciality courses at post-graduate level be developed at certain special centres of excellence eg;
AIIMS.

18. Institutes like National Institute of Health and Family welfare, RAK College of Nursing and
several others may develop courses on nursing administration for senior nursing leading to doctorate
level.

19. Provision for higher training abroad and exchange programmes is made.

Continuing Education and Staff Development

• Definite policies of deputing 5-10% of staff for higher studies are made by each state. Provision
for training reserve is made in each institution.

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• Deputation for higher study is made compulsory after 5 yrs.

• Each nursing personnel must attend 1 or 2 refresher course every year.

• Necessary budgetary provision be made,

• A National Institute for Nursing Education Research and Training needs to be established like
NCERT, for development of educational technology, preparation of textbooks, media, / manuals for
nursing.

NURSING SERVICES: HOSPITALS/INSTITUTIONS (URBAN AREAS)

1. Definite nursing policies regarding nursing practice be available in each institution .These
policies include:

a) Qualification/recruitment rules

b) Job description/job specifications

c) Organisational chart of the institutions

d) Nursing care standards for different categories of patients.

1. Staffing of the hospitals should be as per norms recommended.

2. District hospitals /non teaching hospitals may appoint professional teaching nurses in the ratio of
1; 3 as soon as nurses start qualifying from these institutions.

3. Students not to be counted for staffing in the hospitals

4. Adequate supplies and equipments, drugs etc be made available for practice of nursing. The
committee strongly recommends that minimum standards of basic equipment needed for each patient
be studied , norms laid down and provided to enable nurses to perform some of the basic nursing
functions . Also there should be a separate budget head for nursing equipment and supplies in each
hospitals/ PHC. The NS and PHN should be a member of the purchase and condemnation committee.

5. Nurses to be relieved from non -nursing duties.

6. Duty station for nurses is provided in each ward.

7. Necessary facilities like central sterile supplies, linen, drugs are considered for all major
hospitals to improve patient care. Also nurses should not be made to pay for breakage and losses. All
hospitals should have some systems for regular assessment of losses.

8. Provision of part time jobs for married nurses to be considered. (min 16-20hrs/week)

9. Re-entry by married nurses at the age of 35 or above may also be considered and such nurse be
given induction courses for updating their knowledge and skills before employment.

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10. Nurses in senior positions like ward sisters, Asst. nursing superintendents, Deputy NS; N.S must
have courses in management and administration before promotions.

11. Nurses working in speciality areas must have courses in specialities. Promotion opportunities for
clinical specialities like administrative posts are considered for improving quality nursing services.

12. Provision of higher training abroad and exchange programme to be made.

The committee recommends that Gazetted ranks be allowed for nurses working as ward sister and above
(minimum class II gazetted). Similarly the post of Health Supervisor (female) is allowed gazetted rank
and district public health nurse be given the status equal to district medical/ health officers.

Community nursing services

• Appointment of ANM/LHV to be recommended.

• ANM/LHV promoted to supervisory posts must undergo courses in administration and

management.

• Specific standing orders are made available for each ANM/LHV to function effectively in the
field.

• Adequate provision of supplies, drugs etc are made.

• Recording system be simplified.

• Posts of public health nurses and above are given gazetted status.

Norms recommended for nursing service and education hospital setting

1. Nursing Supdt -1: 200 beds (hospitals with 200 or more beds).

2. Dy. Nsg. Supdt. - 1: 300 beds ( wherever beds are over 200)

3. Asst. Nsg . Supdt - 1: 100

4. Ward sister/ward supervisor - 1:25 beds 30% leave reserve

5. Staff nurse for wards -1:3 ( or 1:9 for each shift ) 30% leave reserve

6. For nurses OPD and emergency etc - 1: 100 patients ( 1 bed : 5 out patients) 30% leave reserve

7. For ICU -1:1(or 1:3 for each shift) 30% leave reserve

For specialised depts such as operation theatre, labour room etc- 1: 25 30% leave reserve.

Community nursing services

1 ANM for 2500 population ( 2 per sub centre)

1 ANM for 1500 population for hilly areas

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1 health supervisor for 7500 population( for supervision of 3 ANM's)

1 public health nurse for 1 PHC (30000 population to supervise 4 Health Supervisors )

1 Public Health Nursing Officer for 100000 population (community health centre)

2 district public health nursing for each district.

NURSING LEGISLATION

1. INC and state nursing council acts be amended to provide for control by INC on states nursing
councils.

2. Provision of more nurse members.

3. Provision for regulation of nursing education standards by timely inspections and follow up.

4. Provision of maintaining of minimum standards of nursing practice

5. Provision of regulation for nursing care standards in private nursing homes.

6. Provision for regulation for private nursing bureaus and practice by unqualified nurses.

7. Provision of approval of INC before opening a SON or CON.

8. Provision of renewal of registration every 5 yrs.

9. Provision of independent practice of nursing by nurses.

10. INC to set up a national examination system in about 10 yr time to regulate standards of nursing
education.

Ø Also, the positions up to the DADG level are proposed to be at the office of the Directorate General
of Health Services. The positions below the level of DADG are to exist at the institutions governed by
the central govt.

Ø The Principal, College Of Nursing will be equal to the rank of ADG (N) and will be eligible for
promotion to the post of DDG (N)/ Addl. (N). The salary scales and structure of the staff of colleges of
nursing will be as per norms of INC and the UGC.

ORGANISATION OF NURSING SERVICES

The position and status of nursing personnel working in the directorates need up gradation and
expansion of the nurse to enable the nurses to participate in policy making and decision making. Total
nursing components, i.e., nursing education, nursing service and community nursing should be under the
control of nursing personnel at all the levels. I.e. At centre, stateand district level. At every level
adequate provision of budget should be made for development of nursing profession.

The organisational structure recommended for centre, state and district level is as follows.

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1. Each ADG level nurse to deal with continuing education /research component for specialised
areas.

2. Selection to these posts is made on merit and not by seniority alone.

3. Nurses appointed these posts must have courses in administration, management and fiscal
management.

4. Railway board, state insurance (labour minister), post $ telegraph union, territories (Delhi),
municipal corporations etc to create such posts for control, co-ordination and development of nursing
personnel.

The principal, college of nursing will be equal to the rank of ADG (N) and will be eligible for promotion
to the post of DDNS/ DNS. The salary and structure of college of nursing will be as per as norms of INC
and UGC.

Recommendations on preventive and primary health care:

i) The epidemiological surveillance system should be geared up with the support of the field staff as
well as the Panchayat Raj Institutions.

ii) Primary health care, public health programmes, nutrition schemes, and school health programmes
should be coordinated with a view to reducing incidence of diseases.

iii) Steps should be initiated to ensure the effective functioning of rural hospitals by placement of
Specialists, particularly Anaesthetists and Radiologists.

iv) Simple labour cases without complication should be tackled in PHCs and rural hospitals for which
necessary infrastructure is to be organized.

v) Special hands-on training programmes need to be organised in a nodal institution for newly recruited
medical officers for at least one month. Management/administrative training programmes also need to
be organised for the Superintendents of secondary level hospitals.

vi) Refresher training programmes on public health should be organized regularly for CMOH, Dy.
CMOH, ACMOH and Programme Officers.

vii) Speciality and super speciality facilities outside the Kolkata metropolitan area should be organised
on a regional basis, most importantly in the area of Neurosurgery and Trauma Centre, Dialysis units,
Cardiology, Cardiac Surgery, Casualty and ICCU, preferably on public private partnership.

viii) Regular periodic visits of senior level health administrators to the field units for the purpose of
implementation, monitoring, supervision and evaluation should be insisted upon.

ix) The present nurse-bed ratio (1:5) which was laid down in 1957 should be reviewed in the light of
developments since and a more realistic ratio arrived at.

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x) Adequate supply of modern Tissue Culture Anti-rabic Vaccine (ARV) is to be ensured at the earliest
in the interest of a better health care delivery system.

xi) The fact remains that almost 50% of deliveries still take place in home situations. Recognising this
fact it is necessary that facilities for ante-natal checkups and home delivery should be augmented in
terms of expertise and infrastructure.

111
112
DDHS- Deputy Director of Health Services

BMO- Block Medical officer

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BHS- Block Health Supervisor

CHN- community Health Nurse

BEE- Block Extension Educator

SHN- Sector Health Nurse

HV- Health visitor

SK- Storekeeper

HW- Hospital worker

CHV- Community Health Volunteer

VHN- Village Health Nurse

HW (Female) - Health worker

HI- Health Inspector

Safe Staffing of nursing unit is appropriate levels of registered nurses (RNs) to always meet the care
needs of the patient. Safe Staffing reduces hospital-acquired infections, length of stay, nurse turnover,
and hospital costs. Safe Staffing improves patient satisfaction, nurse retention, and productivity. Safe
Staffing saves lives!

ESTIMATION OF NURSING STAFF REQUIREMENTS – ACTIVITY ANALYSIS

DEFINITION:

Scheduling is defined as the ongoing implementation of staffing pattern by assigning individual

personnel to work specific hours, days or shifts and in a specific unit ---- (Barnum & Mallard, 1989)

METHODS OF ESTIMATION OF NURSING STAFF REQUIREMENTS:

i. Patient Care Classification System

ii. The Professional Judgement Method of Estimating the Size and Mix of Nursing Teams

iii. NPOB- Nurse per occupied bed method

iv. Time/ Task Activity Method

Patient Care Classification System:

The patient care classification system is a method of grouping patients according to the amount
and complexity of their nursing care requirements and the nursing time and skill they require. This
assessment can serve in determining the amount of nursing care required, generally within 24 hours, as
well as the category of nursing personnel who should provide that care.

114
As a result, of patient classification systems (PCS), also known as workload management, or patient
acuity tools, was developed in the 1960s. Because other variables within the system have an impact on
nursing care hours, it is usually not possible to transfer a PCS from one facility to another. Instead, each
basic classification system must be modified to specific institution.

Adomat and Hewison (2004) suggest that most PCSs can be classified as robust measures for severity of
illness. However, they maintain that although they are helpful, they are not accurate tools for
determining nurse-patient ratios, and that all PCS measurement tools need nursing input if they are to
measure nurse-patient needs accurately.

There are several types of PCS measurement tools. The critical indicator PCS uses broad indicators such
as bathing, diet, intravenous fluids and medications, and positioning to categorize patient care activities.
The summative task type requires the nurse to note for frequency of occurrence of specific activities,
treatments, and procedures for each patient. For example, a summative task-type PCS might ask the
nurse whether a patient required nursing time for teaching, elimination, or hygiene. Both types of PCSs
are generally filled out prior to each shift, although the summative task type typically has more items to
fill out than the critical incident or criterion type.

Once an appropriate PCS is adopted, hours of nursing care must be assigned for each patient
classification. Although an appropriate number of hours of care for each classification is generally
suggested by companies marketing PCSs, each institution is unique and must determine to what degree
that classification system must be adapted to that institution. White (2003) suggests that average length
of stay, and practitioner specialty in defining its patient population. In addition, staff competency, core
staff versus visiting staff, and skill mix must be considered (White, 2003).

To develop a workable patient classification system, the nurse manager must determine the
following:

1. The number of categories into which the patients should be divided;

2. The characteristics of patients in each category;

3. The type and number of care procedures that will be needed by a typical patient in each
category; and

4. The time needed to perform these procedures that will be required by a typical patient in each
category.

The number of categories in a patient classification may range from three to four, which is the
most popular, to five or six. These classes relate to the acuity of illness and care requirements, whether
minimal, moderate, or intensive care. Other factors affecting the classification system would relate to
the patient’s capability to meet his physical needs to ambulate, bathe, feed himself, and other
instructional needs including emotional support.

Patients care classifications have been developed primarily for medical, surgical, pediatrics and
obstetrical patients in acute care facilities.

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 a. Classification Categories:
The various units must develop their own ways of classifying patient care according to the acuity
of their patient’s illness. Following is an example of a patient care classification in the medical-surgical
unit.

Level I – Self Care or Minimal Care – Patient can take a bath on his own, feed himself, feed
and perform his activities of daily living. Falling under this category are patients about to be discharged,
those in non-emergency, those newly admitted, do not exhibit unusual symptoms, and requires little
treatment/observation and/or instruction. Average amount of nursing care hours per patient per day is
1.5. Ratio of professional and non-professional nursing personnel is 55:45.

Level II – Moderate Care or Intermediate Care – Patients under this level need some
assistance in bathing, feeding, or ambulating for short periods of time. Extreme symptoms of their
illness must have subsided of have not yet appeared. Patients may have slight emotional needs, with
vital signs ordered up to three times per shift, intravenous fluids or blood transfusion; are semi-
conscious and exhibiting some psychosocial or social problems; periodic and treatments, and/or
observations and/or instructions. Average nursing care hours per patient per day is 3 and the ratio of
professional to non-professional personnel is 60:40.

Level III – Total, Complete or Intensive Care – Patients under this category are completely
dependent upon the nursing personnel. They are provided complete bath, are fed, may or may not be
unconscious, with marked emotional needs, with vital signs more than three times per shift, may be on
continuous oxygen therapy, and with chest or abdominal tubes. They require close observation at least
every 30 minutes for impending hemorrhage, with hypo or hypertension and/or cardiac arrhythmia. The
nursing care hours per patient per day is 6 with a professional to non-professional ratio of 65:35.

Level IV – Highly Specialized Critical Care – Patients under this level need maximum nursing
care with a ratio of 80 professionals to 20 non-professionals. Patients need continuous treatment and
observation; with many medications, IV piggy backs; vital signs every 15-30 minutes; hourly output.
There are significant changes in doctor’s orders and care hours per patient per day may range from 6-9
more, and the ratio of professionals to non-professionals also ranges from 70:30 to 80:20.

b. Patient Care Classification Using Four Levels of Nursing Care Intensity:

Area of Care Category 1 Category 2 Category 3 Category 4
Eating Feeds self or needs Needs Cannot feed self Cannot feed
little food some help in but is able to self and may
preparing food chew and have difficulty
tray; may need swallow swallowing
encouragement

Grooming Almost entirely Needs some help Unable to do Completely

self-sufficient in bathing oral much for self dependent
hygiene hair
combing and so

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 forth
Excretion Up and to Needs some help In bed needs Completely
bathroom alone or in getting up to bedpan or urinal dependent
almost alone bathroom or using placed; may be
urinal able to partially
turn or lift self
Comfort Self-sufficient Needs some help Cannot turn Completely
with adjusting without help get dependent
position or bed drink adjust
(e.g. tubes, IVs) position of
extremities and
so forth
General Health Good – in for Mild symptoms – Acute symptoms Critically ill –
diagnostic more than one – severe may have
procedure simple mild illness mild emotional severe
treatment or debility mild reaction to illness emotional
surgical procedure emotional or surgery more reaction
(D & C Biopsy reaction mild than one acute
minor fracture) incontinence (not illness medical or
more than once surgical problem
per shift) severe or
frequent
incontinence
Treatments Simple – Any Any treatment
Any elaborate
supervised category 1 more than twice
or delicate
ambulation treatment more per shift
procedure
dangle simple than once per medicated IVs
requiring two
dressing testshift Foley complicatednurses vital
procedure catheter care I & dressings sterile
signs more
preparation not O bladder procedures often than
requiring irrigations sitz care of
every 2 hours
medication baths compresses tracheostomy
reinforcement of test procedures Harris flush
surgical dressing requiring suctioning tube
x-pad vital signs medications or feeding vital
once follow-ups simple signs more than
per shift enema for every 4 hours
evacuationvital
signs every 4
hours
Medications Simple routine not Diabetic High amount of Extensive
needing pre- cardiac category 2 category 3
evaluation or post hypotensive medications; medications;
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 evaluation; hypertensive control of IVs with
medications no diuretic refractory frequent close
more than once per anticoagulant diabetes (need to observation
shift medications prn be monitored and regulation
medications more more than every
than once per 4 hours)
shift medications
needing pre-
evaluation or post
evaluation
Teaching and Routine follow-up Initial teaching of More intensive Teaching of
emotional teaching; patients care of ostomies; category 2 items resistive
support with no unusual or new diabetics; teaching of patients; care
adverse emotional tubes that will be apprehensive or and support of
reactions in place for mildly resistive patients with
periods of time; patients; care of severe
conditions moderately upset emotional
requiring major or apprehensive reaction
change in eating patients;
living or confused or
excretory disoriented
practices; patients patients
with mild adverse
reactions to their
illness (e.g
depression overly
demanding)

Categories or levels of care of patients, nursing care hours needed per patient per day and ratio of
professionals to non-professionals

Levels of Care NCH Needed Per Pt. Per Day Ratio of Prof. to Non-Prof.
Level I 1.50 55:45
Self Care or Minimal Care

Level II 3.0 60:40

Moderate or Intermediate Care

Level III 4.5 65:35

Total or Intensive Care

Level IV 6.0 70:30

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Highly Specialized or Critical 7 or higher 80:20
Care

The Hospital Nursing Service Administration Manual of the Department of Health has recommended
the following nursing care hours for patients in the various nursing units of the hospital.

Nursing care hours per patient per day according to classification of patients by units.

Cases/Patients NCH/Pt/day Prof. to Non Prof. Ratio

1. General Medicine 3.5 60:40
2. Medical 3.4 60:40
3. Surgical 3.4 60:40
4. Obstetrics 3.0 60:40
5. Pediatrics 4.6 70:30
6. Pathologic Nursery 2.8 55:45
7. ER/ICU/RR 6.0 70:30
8. CCU 6.0 80:20
Percentage of Nursing Care Hours

The percentage of nursing care hours at each level of care also depends on the setting in which
the care is being given. For primary hospitals, about 70 percent of their patients need minimal care, 25
percent need moderate care. Patients needing intensive care are given emergency treatment and when
their condition becomes stable or when immediate treatment is necessary and the hospital has no
facilities for this, the patient is transferred to a secondary of tertiary hospital.

In a secondary hospital, 65 percent of the patients need minimal care, 30 percent need moderate
care, and only 5 percent need intensive care. In tertiary hospitals, about 30 percent of patients need
minimal care; 45 percent need moderate care, 15 percent need intensive care, while 10 percent will need
highly specialized intensive care. In special tertiary hospitals about 10 percent will need minimal care;
25 percent need moderate care; 45 percent need intensive care; while about 20 percent will need highly
specialized intensive care.

Computing for the Number of Nursing Personnel Needed

When computing for the number of nursing personnel in the various nursing units of the
hospitals, one should ensure that there is sufficient staff to cover all shifts, off-duties, holidays, leaves,
absences, and time for staff development programs.

The Forty-Hour Week Law (Republic Act 5901), provides that employees working in hospitals
with 100-bed capacity and up will work only 40 hours a week. This also applies to employees working
in agencies with at least one million populations. There are also benefits that have to be enjoyed by each
personnel regardless of the working hours per week. The employees should get casual leave, sick leave,
earn leave, maternity leave, paternity leave, child care leave etc, for occasions like birthdays, weddings,

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anniversaries, funerals (mourning), relocation, enrollment or graduation leave, hospitalization, and
accident leaves.

Total number of working and non-working days and hours of nursing personnel per year.

Rights and Privileges Given Working Hours Per Week

Each Personnel
Per Year 40 Hours 48 Hours
1. Earn Leave 15 15
2. Sick Leave 15 15
3. Legal Holidays 10 10
4. Special Holidays 2 2
(restricted holidays)
5. Special Privileges 3 3
6. Off-Duties 104 52
7. Continuing Education 3 3
Program
Total Non-Working Days Per 152 100
Year
Total Working Days Per Year 213 265
Total Working Hours Per Year 1704 2120
Relievers Needed:

To compute for relievers needed, the following should be considered:

1. Average number of leaves taken each 15

year
a. Vacation Leave 10
b. Sick Leave 5
2. Holidays 12
3. Special Privileges 3
4. Continuing Education Program for 3
Professionals
Total Average Leaves 33

It will be noted that although an employee is entitled to 15 days sick leave and 15 days vacation
leave, 12 holidays, 3 days for continuing education, plus 3 days of special privileges or 48 days total, he
or she gets only an average of 33 days leave per year.

To determine the relievers needed, divide 33 (the average number of working days an employee
is absent per year) by the number of working days per year that each employee serves (whether 213 or
265). This will be 0.15 per person who works 40 hours per week and 0.12 per person for those working
48 hours per week.

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 Multiply the computed reliever per person by the computed number of nursing personnel. This
will give the total number of relievers needed.

Distribution by Shifts

Studies have shown that the morning or day shift needs the most number of nursing personnel at
45 to 51 percent; for the afternoon shift 34 to 37 percent; and for the night shift 15 to 18 percent.

Staffing Formula

To compute for the staff needed in the In-Patient units of the hospital the following steps are
considered:

1. Categorize the number of patients according to the levels of care needed. Multiply the total
number of patients by the percentage of patients at each level of care (whether minimal, intermediate,
intensive or highly specialized).

2. Find the total number of nursing care hours needed by the patients at each category level.

a. Find the number of patients at each level by the average number of nursing care hours needed
per day.

b. Get the sum of the nursing care hours needed at the various levels.

3. Find the actual number of nursing care hours needed by the given number of patients. Multiply
the total nursing care hours needed per day by the total number of days in a year.

4. Find the actual number of working hours rendered by each nursing personnel per year. Multiply
the number of hours on duty per day by the actual working days per year.

5. Find the total number of nursing personnel needed.

a. Divide the total number of nursing care needed per year by the actual number of working hours
rendered by an employee per year.

b. Find the number of relievers. Multiply the number of nursing personnel needed by 0.15 (for
those working 40 hours per week) or by 0.12 (for those working 48 hours per week).

c. Add the number of relievers to the number of nursing personnel needed.

6. Categorize the nursing personnel into professionals and non-professionals. Multiply the number
of nursing personnel according to the ratio of professionals to non-professionals.

7. Distribute by shifts.

ILLUSTRATION:

Find the number of nursing personnel needed for 500 patients in a tertiary hospital.

1. Categorize the patients according to level of care needed.

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 500 (pts) x .30 = 150 patients needing minimal care

500 (pts) x .45 = 225 patients needing moderate care

500 (pts) x .15 = 75 patients need intensive care

500 (pts) x .10 = 50 patients need highly specialized nursing care

500

2. Find the number of nursing care hours (NCH) needed by patients at each level of care per day.

150 pts x 1.5 (NCH needed at Level I) = 225 NCH/day

225.5 pts x 3 (NCH needed at Level II) = 675 NCH/day

75 pts x 4.5 (NCH needed at Level III) = 337.5 NCH/day

50 pts x 6 (NCH needed at Level IV) = 300 NCH/day

Total 1537.5 NCH/day

3. Find the total NCH needed by 500 patients per year.

1537.5 x 365 (days/year) = 561,187.50 NCH/year

4. Find the actual working hours rendered by each nursing personnel per year.

8 (hrs/day) x 213 (working days/year) = 1,704 (working hours/year)

5. Find the total number of nursing personnel needed.

a. Total NCH per year = 561,187.50 = 329

Working hrs/year 1,704

b. Relievers x Total Nursing Personnel = 329 x 0.15 = 49

c. Total Nursing Personnel needed 329 + 49 = 378

6. Categorize to professional and non-professional personnel. Ratio of professionals to non-

professionals in a tertiary hospital is 65:35.

378 x .65 = 246 professional nurses

378 x .35 = 132 nursing attendants

7. Distribute by shifts.

246 nurses x .45 = 111 nurses on AM shift

246 nurses x .37 = 91 nurses on PM shift

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246 nurses x .18 = 44 nurses on night shift

Total 246 nurses

132 Nursing attendants x .45 = 59 Nursing attendants on AM shift

132 Nursing attendants x .37 = 49 Nursing attendants on PM shift

132 Nursing attendants x .18 = 24 Nursing attendants on night shift

Total132 Nursing Attendants

It should be noted that the above personnel are only for the in-patients. Therefore, additional
personnel should be hired for those in supervisory and administrative positions and for those in special
units such as the Operating Room, the Delivery Room, the Emergency Room, and Out-Patient
Department.

A Head Nurse is provided for every nursing unit. Likewise, a Nursing Superior is provided 1) to
cover every shift in each clinical department or area specialty unit; 2) for each geographical area in
hospitals beyond one hundred (100) beds and; 3) for each functional area such as Training, Research,
Infection Control, and Locality Management.

Strengths and Weaknesses of patient classification system:

Strengths:

1. Changing ward variables, especially patient numbers and dependency mixes, is easily accommodated
by the acuity-quality algorithm.

2. The ward manager can turn the acuity-quality method around and adjust the ward’s occupancy and
patient dependency mix to suit the available nursing resources. Either way, nurses are matched to the
peaks and troughs of ward activity. This method is one way of deploying nurses where the need is
greatest thereby making workloads more equitable.

3. If a computer is set up then it is possible to calculate staffing numbers for individual shifts. Software
also allows manipulation of a single or a combination of variables in a ‘what if?’ way.

4. Nursing benchmarks and performance indicators (such as nursing cost per occupied bed) for any
speciality at different times are a natural spin-off from the acuity-quality method. These data are often
staggering; for example, the daily nursing cost per occupied bed in some wards can be double that in
apparently similar ward.

Weakness:

1. Compared to the professional judgement and the NPOB staffing formulas, the acuity quality method
is complex. However, it is felt that the extra effort pays dividends since more variables, known to
influence nursing workload, are accommodated.

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2. The daily direct care minutes for each dependency category have to be accepted unless local nursing
activity values can be obtained. Adopting patient and nursing activity from other hospitals may be
unpalatable to some nurses. Moreover, the sense of ownership that is engendered by using local data,
may be lost by using values from elsewhere.

3. In order to capitalise on the acuity-quality method’s power and flexibility, computer software such as
spreadsheets are needed.

4. Collapsing patient numbers and related nursing activity data into dependency groups may ignore
individual patient characteristics. The effect of one patient’s special care needs has little effect on
acuity-quality staffing formulas. A similar criticism levied at acuity methods is that nursing activity,
used to obtain the amount of nursing time required, sometimes fails to measure the psychological
component of patient care. However, most of the alternative methods are even less sensitive to these
issues.

5. Acuity-quality methods in some situations can recommend nursing establishments insufficient to

provide at least one qualified nurse per shift because the formula is workload as well as occupancy-
based. Patient populations less than 12, especially if the patients are low dependency for example, can
create this problem. We saw in the professional judgement method above that 5.1 WTE nurses are
needed to have at least one nurse on duty each shift.

6. Acuity-quality systems add to ward nurses’ workload because additional patient information is
required. For example, the patient’s named nurse is the best person to assess dependency. Obtaining up-
to-date data can also be expensive. For example, finding representative, independent nursing activity
and nursing quality data may mean two nonparticipant nurse observers spending several days in the
ward.

7. Despite matching nursing activity with nursing quality, the relationship between the two can be
confounded. That is, some understaffed wards achieve high-quality care and vice-versa. The relationship
between staffing and outcomes is complex and uncertain.

8. Even though the grade mix proportions in Table 5 are designed to overcome inappropriate working,
the grade mix configurations may not suit your ward’s context. For example, it may not be local policy
to employ Level 3 or 4 health care assistants. Reconfiguring the grade mix according to local policy, and
adjusting the acuity-quality algorithm at the same time, takes considerable fieldwork and skill.

9. The acuity-quality method lends itself less well to forecasting the number of staff needed than other
methods .

The Professional Judgement Method of Estimating the Size and Mix of Nursing Teams
Telford’s early work using expert health care professional judgment to agree the most appropriate size
and mix of ward nursing teams has stood the test of time. Simply put, this technique helps managers
convert duty rotation decisions into whole time equivalents (WTE’s). This method is simple to use and
is an excellent starting point for ward managers.

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In the following example from a 15 bed surgical ward, a decision is made to employ three nurses for the
morning and afternoon shifts, and two nurses for the night shift. A 30 minute morning shift to afternoon
shift hand-over period and a 15 minute afternoon shift to night shift hand-over is included because it is
part of the usual work pattern. You can substitute local times and your preferred number of staff for
different contexts.

Seven Day Ward Professional Judgement Staffing Formula

Step 1. Calculate the number of working hours needed:

Early shift: 0700 to 1430 = 7.5 hrs x 3 nurses x 7 days 157.5 hrs

Late shift: 1400 to 2130 = 7.5 hrs x 3 nurses x 7 days 157.5 hrs

Night shift 2115 to 0715 = 10 hrs x 2 nurses x 7 days 140 hrs

Total = 455 hrs

However, these hours assume that nurses are never sick or don’t take holidays, etc. A ‘timeout’
adjustment to cover paid, unpaid, sick and study leave, therefore, is necessary. The 22% allowance used
in the formula was obtained from a ‘time-out’ study of 300+ general wards in a selected hospital survey.
However, if you wish then you can substitute a local figure (probably obtainable from your personnel
department).

Step 2. Adding the time-out allowance.

455 hrs x 1.22 (time-out) = 555.1hrs/37.5hrs (1 WTE) = 14.8 WTE’s.

A staffing pattern of three nurses for the morning, three nurses for the afternoon and two nurses at night,
therefore, requires almost 15 full-time nurses for this small surgical ward.

The same approach can be used for five-day wards.

Five Day Ward Professional Judgement Formula

Early shift: 0700 to 1445 = 7.75 hrs x 3 nurses x 5 days 116.25 hrs

Late shift 1400 to 2145 = 7.75 hrs x 3 nurses x 5 days 116.25 hrs

Night shift 2115 to 0730 = 10.25 hrs x 2 nurses x 4 days 82 hrs

Total = 314.5 hrs

The time-out value would not be as great as a seven-day ward; therefore, 315 hrs x 1.18 (time out) =
371. 7 hrs/37.5 hrs = 9.9 WTE. Again, you can substitute local time-out values.

Calculating Nurses per Shift One spin-off from the professional judgement staffing formula used in
the seven-day and five-day ward examples above is that the technique can be ‘reversed’ to calculate the
available nurses per shift from a ward’s actual (names on the duty rotation) or funded (what the budget
allows) nursing establishment. The process goes as follows:
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1. A seven day ward requires 21 shifts (7 days x 3 shifts per day) to be staffed by nurses.

2. Each full-time nurse works 5 shifts.

3. Therefore, 4.2 WTE nurses provides 1 nurse per shift (21/5 = 4.2).

4. Two nurses per shift require 8.4 WTEs, and so on.

5. However, we’re faced with the same time-out problem discussed above. That is, the 4.2

WTE nurse figure lacks an allowance for paid, unpaid, sick and study leave.

6. Therefore, 4.2 x 1.22 (22% time out) = 5.1 WTE nurses provide one nurse per shift.

Calculating Shift WTE from Funded Nursing Establishments

Grade Funded WTE’s Divisor per Nurses per

Shift Shift
G 1 5.1 0.2
F 1.5 5.1 0.3
E 2.5 5.1 0.5
D 5.5 5.1 1.1
C 5 5.1 1
B 5 5.1 1
A 5 5.1 1
TOTAL 25.5 5.1 5
The funded nursing establishment in Table above allows:

1. One G or F Grade nurse on duty every other shift.

2. One E grade nurse on duty every other shift.

3. One D grade nurse on duty every shift.

4. One C grade health care assistant on duty each shift.

5. One B grade nursing assistant on duty each shift.

6. One A grade nursing assistant on duty each shift.

7. In total nearly five nurses per shift. In practice, the 25.5 nurses would be equitably distributed
between day, night and weekend shifts.

8. The next logical step would be to build a nurses’ duty rotation from these findings.

Strengths and Weaknesses of the Professional Judgement Approach to NursingWorkforce

Planning

Strengths:

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1. Quick, simple and inexpensive to use. The method can be applied to any specialty, no matter how
many hours a day the service operates.

2. Acts as an excellent springboard to more sophisticated methods.

3. The method is often used to triangulate results from other approaches, a kind of belt and braces
approach to operational management. Similar results from two or more methods adds confidence.

4. Easy to update.

5. Little adjustment required for different care groups.

6. New and sometimes unmeasurable variables; for example, the introduction of new technologies are
easily handled by simply agreeing how many/fewer nurses are needed to deal with new ways of
working.

7. The effects of adjusting staffing on the quality of care and job satisfaction can be measured by one of
several nursing quality and nurses’ job satisfaction surveys.

Weakness:

1. The relationship between staffing and nursing quality is hard to explain using this method. That is,
how do we know if 25.5 WTE nurses is enough to maintain an acceptable standard of care, or to ensure
equitable workloads, job satisfaction and therefore, a desire to stay in the job? Following on from point
7 above, a follow-up study of nursing care quality and nurses’ job satisfaction is essential to check the
adequacy of the ward’s establishment.

2. This relatively fixed nursing establishment is inflexible to changing patient numbers and especially
patient dependency mix. That is, sometimes the ward will be over staffed and sometimes vice-versa.

3. Viewed too subjective by some managers.

4. The calculations get awkward when unusual shifts are worked such as long days.

However, computer spreadsheets ease the burden.

Nurses per Occupied Bed Method

Using average nurses per occupied bed is another popular method of determining or evaluating ward
staffing. The formulas in Table below are compiled from a study of 308 hospital wards. The 1.34 WTE
nurses per occupied bed (NPOB) figure for the medical wards for example, was obtained from the
wards’ actual nursing establishments. The actual establishment differs from funded in that actuals
include overtime, agency and bank hours. A ward ‘overhead’ is built into the formulas below. This
factor adds the indirect care and associated work components of nursing. A 22% time out allowance also
is added to cater for paid and unpaid leave.

If nothing else, these data provide opportunities to benchmark your wards. The method can be used to
verify professional judgement method finds. Clearly, the NPOB method comes into its own if your ward
bed complement changes and you need to modify the nursing establishment accordingly.
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Calculating Staffing from Average NPOB

Care Group Medic Elderly Surgical Ophth. ENT Gynae. Ortho. Paed.
al
Number 5 9 1 5 2
ofwards 83 54 66 1 3 6

Average 1 1 2 2 1
Occupancy 24 24 22 3 6 0 2 5
G/H/I per 0 0 0
occ.bed 0.06 0.05 0.05 .11 .09 .06 0.05 0.13
F grade 0 0 0 0 0
0.12 0.06 .07 .09 .15 0.09 .05 .2
E grade 0 0 0 0 0
0.32 0.24 .27 0.22 .45 .14 .24 .49

D grade.
0.48 0.31 0.38 1.03 0.55 0.45 0.38 0.53

C grade 0 0 0 0 0
0.07 0.04 .06 0.07 .03 .02 .05 .11

Nursing 0 0 0 0 0
Assistant 0.3 0.51 .31 .25 .23 0.12 .44 .27
Total 1.35 1.21 1.14 1.77 1.50 0.88 1.21 1.73

Interpreting and Applying Table above, In the elderly ward example, one patient requires 1.21 WTE
nurses to meet his or her needs. An average of 24 patients requires a nursing establishment of 29 WTE
nurses (24 x 1.21), or put another way, 30 full-time nurses on the duty rotation. Remember, leave of all
kinds comes out of this establishment, and we saw above that at any time one nurse in five is away from
the ward. These formulas are less generous in this light. Calculating grade mix follows the same process
- multiplying the average number of occupied beds with the grade mix proportion.

Strengths and Weaknesses of NPOB Staffing Formula

Strengths:

1. This method, like the professional judgement one above, epitomizes the-keep-it-simple approach to
demand-side workforce planning.

2. Staffing and grade mix formulas are empirically derived. The formulas use data collected routinely;
for example, bed occupancy and payroll information.

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3. Formulas for the main care groups (for example, medical wards) are unique because they are derived
from data collected only in medical wards. Moreover, the wards providing these data have passed a
quality test; that is, none fell below a pre determined quality standard.

4. Learners are supernumerary in the staffing projections. Also, if the base wards’ staffing is fair, then
an allowance for mentoring and supervision ought to have been included.

5. This approach not only makes determining establishments easy but also generating the ward’s grade
mix too since the formula is broken down by grade. The C grade in Table 4 is a health care assistant.

6. Even though you may not have the financial or staffing resources to boost your establishment to
levels recommended by NPOB formulas, then at least you can benchmark your own establishments.

7. The data are easily built into a computerised spreadsheet for what-if? Purposes

Weakness:

1. This methods assumes that the base staffing data were rationally determined. However, there’s
evidence in the literature that ward establishments can sometimes bare little relationship to ward size or
occupancy.

2. As it happens, the averages in Table 4 are derived from ‘quality assured’ wards. That is, staffing and
grade mix averages projected from these base data should maintain the same standard of patient care.
There’s no guarantee, on the other hand, that averages derived from other sources (such as ones that you
find in the literature) come from wards that deliver an acceptable standard of care. If you decide to
gather your own data then you should try accommodating this important issue.

3. These staffing formulas are insensitive to dependency changes; that is, the formulas recommend the
same number of nurses for patient populations that are predominantly low dependency as it does for
high dependency inpatients. As we’ll see later, patient dependency can have a striking effect on nursing
workload.

4. Formulas are costly to update. Extensive fieldwork is required to alter formulas for a care group that
changes nursing practice in some way.

5. Routinely collected data, such as bed occupancies used in staffing formulas, are more error-prone
than those that are deliberately and systematically collected because accuracy and reliability of the latter
are usually confirmed.

6. Learner nurses’ contributions or alternatively their demand on qualified staffs’ time warrant special
consideration to which the NPOB method may be insensitive.

7. The formulas contain hidden structures and processes that need to be made explicit. For example, the
ophthalmic ward data are drawn from wards where nurses also staff the operating theatres, hence what
seems to be a generous number of nurses per occupied bed. Similarly, some of these data may be drawn
from wards that are geographically different from yours; for example hub and spoke vs. Nightingale-

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type wards have subtle staffing differences because nursing activity is different in wards with different
layouts. However, ward layout is a much less important workload variable than say patient dependency.

Timed-task/Activity Method:
This method of estimating or evaluating the size and mix of nursing teams arose from a belief that
acuity-quality staffing methods, for example, were inferior staffing predictors. The type and frequency
of nursing interventions required by patients, on the other hand, are felt to be a better guide because the
number of patient variables impinging on nursing time is more fully considered. If nurses are
comfortable with constructing care plans for their patients then the timed-task/activity method simply
adds nursing minutes to each intervention thereby generating the number of nursing hours needed. This
method will suit wards in which care plans are systematically constructed, and for those wards where
patients’ nursing needs can be confidently predicted; notably wards that admit from waiting lists.

In practice each patient’s direct care nursing needs for the day are recorded on a locally developed check
list of nursing interventions. The number of nursing interventions from which to choose for patient care
varies from system to system. Because each intervention is paired with a locally agreed time required
for its completion, the patient’s care plan and nursing time requirement is systematically built. This
value attached to each intervention is generally the amount of time needed to carry out the care for one
patient over a 24 hour period. As with the acuity-quality method, a ward ‘overhead’ has to be added to
cater for the indirect care and other aspects of nurses’ time. Similarly, breaks and time-out have to be
considered. In short, there are four main activities:

1. The patient’s care plan is completed or updated each day.

2. The total hours for all patients generated by all the care plans in the ward are aggregated.

3. All wards’ nursing hours are collated enabling the manager to distribute nursing staff equitably.

4. Validity checks are done by experienced staff to ensure consistency in the selection and recording of
nursing interventions. The validator also checks that the predicted nursing care is required by the patient
over the ensuing 24 hours.

Nursing interventions making up the 13 main categories in Table 6 are subsumed under activities of
living classification to help nurses search for specific interventions. Two times are given: a one-off set-
up time when the intervention is first implemented and a maintenance time that is activated each time
the intervention is carried out.

Armed with the full list the nurse selects nursing interventions according to his or her patient’s needs.
As each intervention is selected the required time is summed and added to the nursing time for other
patients in the ward. The total nursing time becomes the nursing hours required for the ward. The
required nursing hours are converted into WTE after the overhead, breathing time and a time-out
allowance are added to the required hours. Obviously, nursing care plans must be regularly updated so
the required nursing hours always correspond to patients’ nursing needs. Ideally, the method should be
computerised.

Broad Timed-task/Activity Nursing Interventions

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Time in Minutes

Set Up Maintain

1. Maintaining a safe 117 612

environment
2. Physical and psychological 199 571
comfort
3. Breathing 51 1592

4. Eating and drinking 35 485

5. Eliminating 95 388

6. Personal cleansing and 240 253

dressing
7. Communicating 0 207

8. Controlling body 33 114

temperature
9. Mobilising 16 122

10. Sleeping 0 16

11. Spiritual 0 30

12. Social care 41 20

13. Special needs and requests 40 140

Strengths and Weaknesses of the Timed-task/Activity Method

Strengths:

1. Easily computerised so that the method becomes part of a nursing information system.

2. Commercial systems, such as GRASP, are readily available.

3. The base information is easily updated. Indeed, periodic reviews of nursing interventions and times
are a good idea.

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4. Adopting the system in other care settings is possible without destroying its integrity. However,
protagonists warn users to check validity and reliability if grand care plans are transplanted into new
nursing settings.

Weakness:

1. The effort needed to maintain detailed care plans for each patient every shift adds considerably to the
ward ‘overhead’. One of the first rules of workforce planning is that it shouldn’t add to the nurses’
workload.

2. Commercial systems are the most expensive of all the methods described. Setting up and
implementing the system is also time consuming and expensive. But like the acuity quality method,
these are largely capital rather than recurrent costs.

3. Reducing nursing care to a work study type list horrifies some nurses. However, the completed
detailed list of required nursing interventions for an individual is no different to a thorough nursing care
plan.

Chapter-V ( Hemapriya )
Recruitment: Credentialing, Selection, Placement, Promotion, Retention, Personnel Policies,
Termination
INTRODUCTION:
Recruitment is an important function of health manpower management, which determines,
whether the required will be available at the work spot, when a job is actually to be undertaken.
Recruitment procedures include the process and the methods by which vaccines are notified, post are
advertised, applications are handled and screened, interviews are conducted and appointments are made.
Recruitment of nurses are major concern. Recruitment means finding out of the further workers. It is
process of searching for prospective employees and stimulating them to apply for job in an organization.

DEFINITION:
1) According to B Flippo: ―Recruitment is defined as the process of searching for prospective
employees and stimulating them to apply foe job in the organization‖.
2) According to IGNOU Module: ―It is a process in which the right person for the right post is
procured‖.
3) According to Yoder: ―Recruitment is a process to discover the sources of manpower to meet the
requirements of the staffing schedule and to employ effective measures for attracting that manpower in
adequate numbers to facilitate effective selection of an efficient working force.

CONCEPT /AIMS OF RECRUITMENT:

The aim of an effective recruitment program is to attract the best people for the job and
aids the recruiter by making a wide choice available. A good job description helps in attracting
the right kind of candidates for the job. The recruitment efforts and costs involved are generally
in proportion to the critically of the vacant position and urgency of the need

PURPOSE OF REQUIREMENT:
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  To seek out, evaluate and obtain commitment from an individual, who is willing to do
job.
 To place and orient the persons for the successful conduct of work in an organization.
 To find out the source of man power to meet job requirements.
 To bring linkage activity among those with jobs and those seeking jobs.
 To stimulate people to apply for jobs to increase the hiring ratio.
 To precede the selecting process.
 To attract the man power in adequate numbers.
 To facilitate effective selection of an efficient working force.
 Determine the present and future requirements of the organization in conjunction with the
personnel planning and job analysis activities
 Increase the pool of job candidates with minimum cost
 Help increase the success rate of the selection process reducing the number of obviously
under qualified or over qualified job applicants.
 Help reduce the probability that the job applicants, once recruited and selected will leave
the organization only after short period of time.
 Meet the organization‘s legal and social obligations regarding the composition of its
work force
 Start identifying and preparing potential job applicants who will be appropriate
candidates
 Increase organizational and individual effectiveness in the short and long term.
 Evaluate the effectiveness of various recruiting techniques and sources for all types of
job applicants.

BASIC ELEMENTS OF SOUND RECRUITMENT POLICY:

 Discovery and cultivation of the employment market for post in the public service

 Use of the attractive recruitment literature and publicity

 Use of the scientific tests for determining abilities of the candidate

 Tapping capable candidates from within the services

 Placement program which assigns the right man to the right job.

 A follow up probationally program as an integral process.

OBJECTIVES OF RECRUITMENT:
 To attract people with multi-dimensional skills and experiences that suit the present and future
organizational strategies

 To induct outsiders with new perspective to lead the company

 To infuse fresh blood at all levels of organization

 To develop an organizational culture that attracts competent people to the company

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  To search or heat hunt/ head pouch people whose skills fit the company‘s values

 To devise methodologies for assessing psychological traits

 To seek out non-conventional development grounds of talent

 To search for talent globally and not just within the company

 To design entry pay that competes on quality but not on quantum

 To anticipate and find people for positions that does not exist yet.
PRINCIPLES OF RECRUITMENT:
ICN ethical nurse recruitment principles:
1. Effective human resource planning and development
2. Credible nursing regulation
3. Access to full employment
4. Freedom of movement
5. Freedom from discrimination
6. Good faith contracting
7. Equal pay for work of equal value
8. Access to grievance procedure
9. Safe work environment
10. Effective orientation / mentoring/supervision
11. Employment trial periods
12. Freedom of association
13. Regulation of recruitment
According to TNAI the main Principle of recruitment is

1. Recruitment should be done from a central place e.g. administrative officer /nursing services
administration
2. Termination or creation of any post should be done by responsible officers, e.g. regarding
nursing staff the nursing superintendent along with her officers has to take the decision and
not the medical superintendent
3. Only the vacant position should be filled and neither less nor more should be employed
4. Job description /work analysis should be made before recruitment
5. Procedure for recruitment should be developed by an experienced person
6. Recruitment of workers should be done from internal and external sources.
7. Recruitment should be done on the basis of definite qualification and set standards.
8. Chance of promotion should be clearly stated
9. Policy should be clear and changeable according to the need.
According to M.K.Sharma principle of recruitment are

1. Clear policy of recruitment

2. Observation of government rules & regulation
3. Policy of recruitment in accordance with the objects of enterprise

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 4. Impartiality
5. Flexibility
6. Recruitment by a committee
7. Job security
8. Opportunity of development to the employees

1. MODELS OF RECRUITMENT :
I) Optimal control models in manpower planning
a) Markov (cross sectional model)
b) Renewal model
c) Cambridge model
d) Longitudinal model
e) Cambridge multi stream model
f) Simulation model
a) MARKOV (CROSS SECTIONAL MODEL):
An early example of a distance time MARKOV MODEL was described by young and
Almond (1961). They had 30 stock categories in all, with people in the same grade and with
similar length of service being in the same category.
Flows between the stock categories are described by the flow rates. The model assumes
that each year the number moving out of categories A into category B would be the same
fixed proportion of the number in category A. this proportion is estimated from historical
data. Each year a fixed proportion leave from each category and recruits are assigned, also in
fixed proportion, to the different categories. The total number of recruits can be determined
either by fixing the total size of the manpower system in each year. The model is used to
predict the long –term distribution of the stock between categories if these flow rates are
maintained. This result is obtainable from the theory of Markov chain.
There are two common forms for the prediction equation in a markov model:
1. n (t+1)-n(t)P+R(t+1)r
Where n (t) is the vector of stock at time t (i.e. the number in each categories)
r - is the vector of possibilities of a new recruit being to each categories
R(t) - is the number of new recruits at time t
P - is the transition matrix between categories and on wastage rates
The form 1 is used to predict the stocks n(t) which will result from a given initial state
n(0) and a recruitment policy described by r and R(i)

The second form is too used in the more usual case where the total number of staff N (t)
at time t has been specified. If we write
N (t)=N(t)-N(t-1)
b) RENEWAL MODEL:
One criticism often leveled against Markov models of manpower system is that they
allow the size of the various categories to fluctuate too much, whereas in practice many
category sizes are quite tightly constrained. One way to avoid large variation in category

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 sizes is to regard the stock as fixed and predict flows such as wastage, recruitment and
promotion from them.
The simplest form of renewal model occurs when each vacancy is filled from outside
the system, and was first described by Bartholomew (1959).Bartholomew later (1973)
extended this work to cover organizations with several grades of staff, and various policies
on promotion, such as promotion in order of seniority. Further work by Forbes(1974) led to a
model which described a renewal process .

III Conceptual models

The process recruitment and retention model is multidimensional and based on balancing
needs and responsibilities of health professional, agencies they work for and communities they
services. Other conceptual models have been described in the health workforce recruitment and
retention literature. for example, Crandall and colleagues described four types of models ,
namely
1) Affinity models (recruitment of rural students into training programs and promotion rural
practice
2) Practice characteristics model(technical and collegial support)
3) Indenture models (recruitment of fixed term provider through scholarships and other
incentives).although the model are simple, describe concrete mechanism and contain
important elements that pertain to some of the needs and responsibilities within three
domains(i.e. individual ,community &organization needs), they have been designed for one
discipline(i.e. medical practice) and do not sufficiently recognize needs of other
discipleines.it can be argued that for models to be sustainable , needs and responsibilities
within each of the three domains need to be recognized and respected.
A multi dimensional interactive allied health workface recruitment and retention conceptual
model

Different companies have different hiring needs. So depending on level of engagement,

exclusivity, long term prospects and other factors many different recruitment models are
followed in the market.
III Different recruitment models:
 Contingency Hiring
 Retained Search
 Exclusive Requirements:

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  Recruitment Process Outsourcing(RPO)
 Outplacement
 Executive Search
a) Contingency Hiring:
In contingency hiring whenever a company comes across any requirement it gives it to
many consultants at the same time and asks all of them to send resumes. Only the consultant
whose candidate is offered gets money from the company. Here recruiters don't get any assured
and fixed salary. Their revenue depends entirely on whether they can make offers or not. As risk
factor is high here, consultants charge more percentage for such type of recruitment. Generally
company pays in terms of a specific percentage of the candidate. This is the most prevalent way
of recruitment.
b) Retained Search:
Here a recruitment consultant works exclusively for a specific requirement and payment
is divided into two parts. He is paid a fixed amount by the company for search activity. It is
called retainer fee. Other than that if he makes offer he gets more money. For recruitment of
senior executives like CEO, Sales head very focused approach is required, so
this method is preferred.
c) Exclusive Requirements:
Sometimes companies give some requirements exclusively to recruiters. Here recruiter
assures the client to close the position within specific date. If he can’t close the position by that
time he needs to either close the position with lesser commission or bear some other penalty. All
the conditions are clearly decided before the contract. Here percentage of commission is less
than contingency hiring because there is no competition.
d) Recruitment Process Outsourcing (RPO):
RPO model is gaining lot of popularity recently. Here a company outsources whole
recruitment process to another consultant. Some people from the consultant side seat in the
company itself and manage the whole process by themselves. The sources can either sit in the
client place or in their own office. Here RPO partner is responsible for closing all the
requirements. They take care of the whole recruitment process right from sourcing, scheduling,
interviews; offer to joinings.The benefit for the company is that- they don't have to manage their
own recruitment team which reduces costs. But on the other hand risk is high, because if
consultants don't understand the company culture and hiring plans properly it can get disastrous
also. So companies should be careful while choosing recruitment partners. Because we are
talking about high scale and longer duration engagement here.
e) Outplacement:
Outplacement came into picture during recession period. Here if a company wants to lay
off some people employees to cut costs, they can hire a consultant to place those employees in
other companies. The recruitment cost is borne by the current employer. Outplacement is not
very popular till now.
f) Executive Search:
Executive search teams only focus on senior level i.e.: CEO, CTO, Sales head and
similar kind of requirements. Method of sourcing for such positions is quite different from junior
level requirements. Here numbers of potential candidates are less and they don't prefer to show
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 their resume on the portals. So head-hunting, searching in networking sites and personal
networks help a lot. For such requirements commission is much higher. Executive search teams
do retained search activity also.
Other than the above models recruitment can be divided in other two types.
 Permanent recruitment

 Contract or Temporary staffing:

Permanent staffing: Here after recruitment the candidate stays in the company payroll as a permanent
employee.

Temporary staffing: In case of temporary staffing/ contract staffing the candidate remains in the
payroll of the consultant and works with the company for a limited time period. Companies
generally prefer this model if the project is small or uncertain. Again it reduces their long term
costs also. So this model is gaining good popularity now a day. Both permanent and temporary
staffing can be applied to all the above recruitment models.

TYPES OF RECRUITMENT:

There are three types of recruitment:

1. Planned: arise from changes in organization and recruitment policy

2. Anticipated: by studying trends in the internal and external organization.

3. Unexpected: arise due to accidents, transfer and illness.

Planned
Anticipated
Unexpected

LIKAGES OF REQUIREMENT TO HUMAN RESOURCE ACQUISITION

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

Manpower
planning
Selection Placement
Job analysis Recruitment

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FACTORS EFFCTING RECRUITMENT:
All organization, whether large or small, do engage in recruiting activity, though not to the same extent.
This differs with:
1) The size of the organization

2) The employment conditions in the community where the organization is located

3) The effects of past recruiting efforts which show the organization‘s ability to locate and keep good
performing people

4) Working conditions an salary and benefit packages offered by the organization- which may influence
turnover and necessitate future recruiting

5) The rate of growth of organization.

6) The level of seasonality of operations and future expansion and production programs.

7) Culture, economical and legal factors etc.

There are many factors that affect the recruitment program. These factors can be
classified as organizational or internal factor and environmental or external factors

9.1ORGANIZATIONAL FACTORS:

9.1.1. The major factors that determine the success of a program is the reputation of the
organization. An organizations reputation depends on its size, area of business, profitability,
management etc, in addition to its philosophy and values. For example, a profitable firm known
for its strong values would attract a better response to a recruitment drive than a loss- making
firm known for its lack of values.
9.1.2. The organization culture and the attitude of its management towards employees
into influence a candidate’s decision to apply to an organization. An organization that is known
for its employee- friendly policies would certainly be preferred over an orthodox and rigid
organization.
9.1.3. Another factor that contributes to the success of a recruitment program is the
geographical location of the vacant position. Prospective candidates might not be too eager to
work in a remote place unless they belong to that place
9.1.4. The amount of resource allocated also determines the success of recruitment drive.
This resource allocation in turn dependent on the criticality of the vacant position and the time
available to fill the vacancy. For example, if the critical position in an organization needs to be
filled up in a month’s time, substantial resources may have to be allocated to the task. In
contrast, if a non –critical position is to be filled up in three months time, the quantum of
resource s to be allocated for the recruitment would be much lower.
9.1.5. The channel and method used to advertise the vacancy also determine the success
of a recruitment program. The reach of advertising has to be wide and its effect deep enough to
attract the right talent.

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 9.1.6. The emoluments that the company offers also influence the decision of a candidate
and thereby the success of the recruitment program.
9.2. ENVIRONMENTAL FACTORS:
9.2.1. The situation in the labor markets, the demand for manpower, the demographics,
the knowledge and skill set available all determine the response to a recruitment program. For
example, today there are more fresh nursing graduates available in the job market than ever
before. Therefore, aim looking for fresh nursing graduates might get a phenomenal response.
9.2.2. The stage of development of the industry to which the organization belongs also
influences the results of a recruitment program.
9.2.3. Culture, social attitudes and beliefs also impact the effectiveness of a recruitment
program. For example, a hospitals might attract more talent than a cigarette manufacturing
company, especially in a culture which has strong values and traditions.
9.2.4. Finally, the law of the land and the legal implications involved also play a role in
designing a recruitment program and determining its effectiveness.
RECRUITMENT STEPS:
As was stated earlier, recruitment refers to the process of identifying and attracting job seekers
so as to build a pool of qualified job applicants. The process comprises five inter-related stages, via

PROCESS OF RECRUITMENT :
Human resource planning

Demand Identify the human resource Surplus

Retrench
requirement
Determine the number, levels
and critically of vacancies

.-
Organizational
recruitment policy

Choose the resource &

methods of recruitment

Analyze the cost &time

involved

Job analysis

Start implementing the

recruitment program

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Select &hire the candidates

I.MAN POWER PLANNING

Man power Planning which is also called as Human Resource Planning consists of putting right
number of people, right kind of people at the right place, right time, doing the right things for which
they are suited for the achievement of goals of the organization. Human Resource Planning has got an
important place in the arena of industrialization and institution. Human Resource Planning has to be a
systems approach and is carried out in a set procedure. The procedure is as follows:

1. Analyzing the current manpower inventory

2. Making future manpower forecasts

3. Developing employment programmes

4. Design training programmes

Steps in Manpower Planning

1. Analyzing the current manpower inventory-

Before a manager makes forecast of future manpower, the current manpower status has to be
analyzed. For this the following things have to be noted-

 Type of organization

 Number of departments

 Number and quantity of such departments

 Employees in these work units

Once these factors are registered by a manager, he goes for the future forecasting.

2. Making future manpower forecasts-

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 Once the factors affecting the future manpower forecasts are known, planning can be done for
the future manpower requirements in several work units.

The Manpower forecasting techniques commonly employed by the organizations are as follows:

i. Expert Forecasts: This includes informal decisions, formal expert surveys and Delphi
technique.

ii. Trend Analysis: Manpower needs can be projected through extrapolation (projecting
past trends), indexation (using base year as basis), and statistical analysis (central
tendency measure).

iii. Work Load Analysis: It is dependent upon the nature of work load in a department, in a
branch or in a division.

iv. Work Force Analysis: Whenever production and time period has to be analyzed, due
allowances have to be made for getting net manpower requirements.

v. Other methods: Several Mathematical models, with the aid of computers are used to
forecast manpower needs, like budget and planning analysis, regression, new venture
analysis.

3. Developing employment programmes- Once the current inventory is compared with future
forecasts, the employment programmes can be framed and developed accordingly, which will
include recruitment, selection procedures and placement plans.

4. Design training programmes- These will be based upon extent of diversification, expansion
plans, development programmes,etc. Training programmes depend upon the extent of
improvement in technology and advancement to take place. It is also done to improve upon the
skills, capabilities, knowledge of the workers.

Importance of Manpower Planning

1. Key to managerial functions- The four managerial functions, i.e., planning, organizing,
directing and controlling are based upon the manpower. Human resources help in the
implementation of all these managerial activities. Therefore, staffing becomes a key to all
managerial functions.

2. Efficient utilization- Efficient management of personnel’s becomes an important function in the

industrialization world of today. Setting of large scale enterprises require management of large
scale manpower. It can be effectively done through staffing function.

3. Motivation- Staffing function not only includes putting right men on right job, but it also
comprises of motivational programmes, i.e., incentive plans to be framed for further participation
and employment of employees in a concern. Therefore, all types of incentive plans become an
integral part of staffing function.

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 4. Better human relations- A concern can stabilize itself if human relations develop and are
strong. Human relations become strong trough effective control, clear communication, effective
supervision and leadership in a concern. Staffing function also looks after training and
development of the work force which leads to co-operation and better human relations.

5. Higher productivity- Productivity level increases when resources are utilized in best possible
manner. Higher productivity is a result of minimum wastage of time, money, efforts and
energies. This is possible through the staffing and its related activities ( Performance appraisal,
training and development, remuneration)

Need of Manpower Planning

Manpower Planning is a two-phased process because manpower planning not only analyses the current
human resources but also makes manpower forecasts and thereby draw employment programmes.
Manpower Planning is advantageous to firm in following manner:

1. Shortages and surpluses can be identified so that quick action can be taken wherever required.

2. All the recruitment and selection programmes are based on manpower planning.

3. It also helps to reduce the labor cost as excess staff can be identified and thereby overstaffing
can be avoided.

4. It also helps to identify the available talents in a concern and accordingly training programmes
can be chalked out to develop those talents.

5. It helps in growth and diversification of business. Through manpower planning, human resources
can be readily available and they can be utilized in best manner.

6. It helps the organization to realize the importance of manpower management

Which ultimately help in stability of concern

Following are the main obstacles that organizations face in the process of recruitment planning:

1. Under Utilization of Manpower: The biggest obstacle in case of manpower planning is the fact
that the industries in general are not making optimum use of their manpower and once
manpower planning begins, it encounters heavy odds in stepping u the utilization.

2. Degree of Absenteeism: Absenteeism is quite high and has been increasing since last few years.

3. Lack of Education and Skilled Labour: The extent of illetracy and the slow pace of
development of the skilled categories account for low productivity in employees. Low
productivity has implications for manpower planning.

4. Manpower Control and Review:

a. Any increase in manpower is considered at the top level of management

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 b. On the basis of manpower plans, personnel budgets are prepared. These act as control
mechanisms to keep the manpower under certain broadly defined limits.

c. The productivity of any organization is usually calculated using the formula:

Productivity = Output / Input

. But a rough index of employee productivity is calculated as follows:

Employee Productivity = Total Production / Total no. of employees

d. Exit Interviews, the rate of turnover and rate of absenteeism are source of vital
information on the satisfaction level of manpower. For conservation of Human Resources
and better utilization of men studying these conditions, manpower control would have to
take into account the data to make meaningful analysis.

e. Extent of Overtime: The amount of overtime paid may be due to real shortage of men,
ineffective management or improper utilization of manpower. Manpower control would
require a careful study of overtime statistics.

Few Organizations do not have sufficient records and information on manpower. Several of
those who have them do not have a proper retrieval system. There are complications in resolving the
issues in design, definition and creation of computerized personnel information system for effective
manpower planning and utilization. Even the existing technologies in this respect are not optimally used.
This is a strategic disadvantage.

II. MANPOWER ESTIMATION:

Human resource is planning or preparing a plan to estimate the demand of the staff for a
period of time, based on assumptions about the productivity, service aspects, and the cost
associated. It gives the position about the available human resource in the organization, hospitals
or health care institution in our case, as well as the likely short fall which may occur and entail
the need to be fulfilled by getting the people from outside. The estimates of the demand are
usually made vis-à-vis the job analysis data.
The following are some easy methods to help the managers in human resource planning.
In manpower estimation the following indexes will help the hospital administrators to estimate
the demand for the staff and update human resource plans.

Employee turnover index:

Number of employee leaving in a year

= 100

Average number of employees

Employee stability index:
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 Number of employees exceeding one year’s service

= 100

Number of employees employed one year ago

Absenteeism index:

Number of man hours lost

= 100

Total number of possible man hours worked

Accident index for frequency:

Number of lost times accidents

= 100

Number of man hours worked

III. Organizational recruitment policy:

The hospital authorities should frame a recruitment policy for the guidance of the human
resource department. The management should clearly spell out the objectives and major principles they
intend to pursue while recruiting employees. They should also lay down a promotion policy.

Considerations for framing recruitment policy:

The following points should be kept in mind for the recruitment and selection of employees:

i)internal vs external resources:

Recruitment can be classified into two main types internal & external .promotion within the
hospital is a widely accepted policy because this has the advantage of building loyalty, ensuring
stability, and creating a sense of security among the employees. The hospital authority should use
external sources of recruitment for such jobs whose specification cannot be met by the present
personnel.

ii) Appointment of relatives of employees:

The relatives or friends recommended by employees are accepted as a reliable source of

recruitment .however it is not safe practice as it sometimes leads to groupism among the employees. In
any case, no two relations should be employed in the same department.

iii) Over and under qualified staff:

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 The candidate to be selected should neither be under – qualified nor over qualified, he will not be
able to do his work efficiently. On the other hand, if he is over – qualified, he would soon become
frustrated and ultimately leave the hospital. Hence the candidate to be selected should be suitably and
adequately qualified.

iv) Exit interview:

Exit interview are considered essential to get a feedback regarding the hospital’s policies. In –
fact the exit- interview is a very tool to study labor turnover. Weak spots in the organization’s policy are
revealed which help in reducing turnover and building the morale of the remaining employees in the
hospital.

IV. Job analysis: -

A job is defined as a collection of duties and responsibilities which are given together to an
individual employee. Job analysis is the process of studying and collecting information relating to
operations and responsibilities of a specific job. Information thus collected is analyzed and the facts
about nature of job working condition and qualities in employee can be easily known.

Objective of job analysis:

Work simplification: - Job analysis provides the information related to job and this data can be
used to make process or job simple. Work simplification means dividing the job into small parts i.e.
different operations in a product line or process which can improve the production or job performance.

Setting up of standards: -Standard means minimum acceptable qualities or results or

performance or rewards regarding a particular job. Job analysis provides the information about the job
and standard of each can be established using this information

Support to personnel activities:- Job analysis provides support to various personnel activities
like recruitment, selection, training and development, wage administration, performance appraisal etc.

Process of job analysis

Planning and organizing of Programme: - The first step is to plan and organize the job
analysis programme. A person is designated as in-charge of programme and required authority and
responsibility is assigned to him. Schedule of the programme and budget estimation is prepared.

Obtaining current information: - Current job design information is collected and study of job
description, job specification, process used, manuals and organisation flow charts is done by the analyst.

Conduct needs research: - The analyst determines that which manager, department requires the
job analysis. Purpose of the job analysis is determined, extent to which job analysis is to be done is
decided and how the information will be used concluded.

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 Establishing priorities: - Identification and priorities of the jobs to be analyzed should be
established by the human resource department executives with help of various executives of the related
departments

Collecting Job Data: - The next step is to collect the data related to the job selected for the
analysis as they are being performed in the organisation at present.

Preparation of Job Description:-Using job information obtained from job analysis job
descriptions is being prepared. It states the full information of job including working conditions nature
of job, processes used machines and materials used.

Developing Job Specification:- Job specifications are developed using information given in job
description. Job specification is statement regarding human qualities that are required for a particular
job. Such information is used to select the person matching the requirements of the job.

Methods:

There are different methods used by organization to collect information and conduct the job analysis.
These methods are

1. Personal observation: - In this method the observer actually observes the concerned worker.
He makes a list of all the duties performed by the worker and the qualities required to perform
those duties based on the information collected, job analysis is prepared.

2. Interview method: - In this method an interview of the employee is conducted. A group of

experts conduct the interview. They ask questions about the job, skilled levels, and difficulty
levels. They question and cross question and collect information and based on this information
job analysis is prepared.

3. Critical incident method: - In this method the employee is asked to write one or more critical
incident that has taken place on the job. The incident will give an idea about the problem, how it
was handled, qualities required and difficulty levels etc. critical incident method gives an idea
about the job and its importance. (a critical means important and incident means anything which
takes place in the job)

4. Questioner method: - In this method a questioner is provided to the employee and they are
asked to answer the questions in it. The questions may be multiple choice questions or open
ended questions. The questions decide how exactly the job analysis will be done. The method is
effective because people would think twice before putting anything in writing.

5. Log records/Daily Diary:-Companies can ask employees to maintain log records or daily
diary and job analysis can be done on the basis of information collected from the record. A log
record is a book in which employee records /writes all the activities performed by him on the
job. The records are extensive as well as exhausted in nature and provide a fair idea about the
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 duties and responsibilities in any job. In this method worker actually does the work himself and
idea of the skill required, the difficulty level of the job, the efforts required can be known easily.

6. HRD records: - Records of every employee are maintained by HR department. The record
contain details about educational qualification, name of the job, number of years of experience,
duties handled, any mistakes committed in the past and actions taken, number of promotions
received, area of work, core competency area, etc. based on these records job analysis can be
done.

Human Resource Management: Need / importance / purpose / benefits of Job Analysis

1. Organizational structure and design: - Job analysis helps in preparing the organization chart
and the organizational structure. Classification of the jobs relation of each job with one another
and various positions and hierarchy of the positions is determined.

2. Man power planning:- Job analysis provides the qualitative aspect of the jobs in the
organisation. It determines the demands of job in terms of duties to be performed, qualification
of person skills required in the employee. It is a tool which is used for matching job with men.

3. Recruitment and selection: - Job analysis helps to hire future human resource. It helps to
recruit and select the right kind of people for the jobs available in the organisation. It provides
information necessary to select the right person by its immediate products i.e. job description and
job specification.

4. Performance appraisal and training/development: - Based on the job requirements

identification of the training needs of the persons can be done easily. Training is given in those
areas which will help to improve the performance on the job. Training programme can be
designed according to the need and can be made effective.

5. Job evaluation: - Job evaluation refers to studying in detail the job performance by all
individual. The difficulty levels, skills required and on that basis the salary is fixed. Information
regarding qualities required, skilled levels, difficulty levels are obtained from job analysis and
worth (price) of the job is determined.

6. Promotions and transfer: - When we give a promotion to an employee we need to promote

him on the basis of the skill and talent required for the future job. Similarly when we transfer an
employee to another branch the job must be very similar to what he has done before. To take
these decisions we collect information from job analysis.

7. Career path planning / Employee counseling: - Many companies have not taken up career
planning for their employees. This is done to prevent the employee from leaving the company.
Employees are informed about the limitations of jobs in terms of development and are guided to
take required steps for their future development. Job analysis provides such information
regarding the areas in which a person requires modification for better career options.
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 8. Health and safety: - Job analysis provides the risk factor related to particular job and thus
action required for the safety of the employees can be taken. Unsafe operations can be eliminated
or can be replaced by safe one or the safety equipments can be installed.

9. Performance Appraisal: - By comparing actual performance of the employees to the

standard established organisation can decide the personnel activities like promotion increments
incentives or corrective actions to enhance job performance. These standards are established
using information provided by job analysis.

RECRUITMENT POLICY:

According to Yoder, ‘the recruitment policy is concerned with quantity and qualifications
of manpower’. He also says that a recruitment policy establishes broad guidelines for the
staffing process.
A good recruitment policy
i) Complies with government policies on hiring.
ii) Provides optimum employment security and avoids frequent lay-offs or lost time.
iii) Assures the candidates of the management’s interest in their development.
iv). Prevents the formation of cliques (small exclusive groups) which results in employing the
members of the same household or community in the organization.
v). Reflects the social commitment of the organization by employing handicapped people and
other underprivileged people of the society whenever there is a possibility of jot fit.
vi).Is in alignment with the objectives and people-policies of the organization.
Vii) Is flexible enough to accommodate changes in the organization.
viii). Is designed in such a way that it ensures long term employment opportunities for its
employees.
ix.) Stresses and reflects the importance of job analysis.
X) Is cost effective for the organization.
A good recruitment policy is based on the organization’s objectives, identification of the
recruitment needs, preferred sources of recruitment, criteria for selection and preferences, the
cost of recruitment, and other financial implications. It should reflect the reputations and image
of the organization.

12. SOURCES OF RECRUITMENT:

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 SOURCES OF RECRUITMENT

External sources
Internal sources

-advertisement
-employee referral
-preesent employee -employment agencies
-former employee -educational institution
-employee referrance -interested applicant
-previous applicant -othetr sources

12.1. Internal sources

They include those who are already on the pay roll of the organization and those who
served the organization in the past and would to return if the organization likes to re employ.
Whenever vacancy occurs, somebody from within the organization is upgraded, transferred,
promoted or sometimes demoted.
The various internal sources are:
Present employees:
Promotions and transfers from among the present employees can be good source of recruitment.
Promotion implies upgrading of an employee to a higher position carrying higher status, pay and
responsibilities.
Former employees:
Former employees are another source of applicants for vacancies to be filled up in the
organization. Retired or retrenched employees may be interested to come, back to the company
to work on a part time basis. Some former employees, who left the organization for any reason,
may again be interested to come back to work.
Employee referrals:

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 The existing employees refers their family members, friends and relatives to the company as
potential candidates for the vacancies to be filled up most effective methods of recruiting people
in the organization because employees refer to those potential candidates who meet the company
requirement by their previous experience.
Previous applicants:
Those who applied previously and whose applicants though found good was not selected for one
reason or other may be considered at this point of time. Unsolicited applications may also be
considered.
11.2. External sources:
There are various methods of recruiting from external sources. Some of the popular
methods are advertisement, campus recruitment, employee referral, employment exchange,
private placement agencies etc.
Advertisements

Advertisements have the widest reach and are quite effective for an organization in
search of external talent. Different media can be used for advertising, depending on the cost the
need, and the reach desired. The nature of the job, its level and critically in the organization, all
together determine the mode and medium of advertisement.

For example, an advertisement for unskilled labor might just be displayed on the walls of
the manufacturing unit.

-The advertisement for the position of a Manager in the same unit might find its way into
the classified pages of popular regional dailies.

- However, the advertisement for the Vice President of the Operations division of
the same company might be carried in the employment pages of a national daily or a business
magazine. The costs involved would also vary with the changing importance of the position in
question and the availability of manpower.

Job search and talent search have both benefited immensely with the onset of the internet
era. Communication has become much easier and faster. Many internet portals like jobs ahead.
Com, monsterindia.com and naukri.com cater exclusively to the needs of various companies
which are in search of suitable people, and individuals who are in search of a suitable job. Most
of the large organizations today maintain their own websites which give information on
vacancies in the organization to visitors to the website. Interested candidates can contact the
organization through the internet itself. All these have made recruitment easier and faster.

The important information that has to be furnished in an advertisement includes:

- Nature of business and size of the organization

- The nature of the job
- Location or place of work
- Tasks and responsibilities attached to the position.
- Reporting hierarchy and work culture

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- Emoluments benefits and other facilities available
- Requirements of the job in terms of qualification, knowledge, skills and experience
- Last date to respond
- Ways to respond-by e-mail, telephone or post

Some of these companies of information are optional. For example, if an organization is proud
of its work culture, it might talk about it in the advertisement. Information of the requirement of
the job, the nature of work and location etc. are however essential as the candidate would not
have complete information about the job, in their absence.

Employee referrals
Employee referrals form a very good source of recruitment, especially of the lower and
middle level management. Employees working with an organization recommend their friends
or acquaintances for vacant positions in the organization. The reputation and credibility of the
employee is at stake when he or she recommends of refers a candidate. Hence, the employee
would take care to recommend good candidates. The second advantage of the referral system is
that the candidate seeking employment has second an insider’s view of the job as he has gathered
information from the employee and is more realistic in his expectations from the company.

Employees may sometimes refer relatives or friends, who may not be suitable for the job. It
might also lead to the formation of clieques in the organization, with the members of the same
group or clan getting together.
Employment agencies:
Based on the type of clientele they serve, employment agencies can be broadly classified
into public or state agencies, private agencies, and head hunters.

Public or State agencies –

Till a few years ago, Employment Exchanges (state sponsored placement agencies) were
extremely popular in India. Fresh graduates and techniques in search of suitable employment
would first register themselves with the local employment exchange.
The exchange facilities communication between the candidates it finds suitable, and the
company. Employment exchanges were initially established to handle the problem of
unemployment in the country. Today however, they have become somewhat outdated. With the
changing market needs and demand for different skill sets, more and more companies and job-
seekers are looking at other contemporary avenues for recruitment.

Private agencies or management consultants perform many of the jobs traditionally done by the
HR department of the company. They invite application from interested candidates, scan them
for the first round of short listing, test them or interview them for a second round of short listing
and finally arrive at the list of the most suitable candidates for the vacant positions in the
organization. Private agencies normally cater to the recruitment needs at the junior, middle and
top levels of management. They charge a percentage of the pay package offered to the candidate
as fees for their services. ‘Head hunters’, a more specialized category of private agencies, cater

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 mostly to top management level recruitment needs. They handle ‘executive search’ for
organizations and usually charge high fees for their services.
Education Institutions

During the placement season, educational institutions, especially the reputed ones turn
into hunting grounds for organizations looking for fresh talent. These institutions offer
placement services to their students by trying to get some of the best companies in the market to
their campus for recruitment. Organizations shortlist the institutions which can provide the kind
of resources that they are looking for and visit them during the placement season.
For example, a technology company would have most of the top engineering colleges on
its list of institutes for campus recruitment. Similarly, an organization looking for management
trainees would visit the top ranking management schools. Long-term relationships are built
between organizations and educational institutions through this exercise of campus recruitment.
Campus placements at some of the top institutions in the country reflect the condition of the
economy and the industry.

Interested applicants. One of the sources of recruitment for an organization might be

unsolicited applications of candidates interested in working with the organizations. Such
candidates send in their applications the management either through post or e-mail or in person
and express their interest in employment with the company. If the organization does not have a
suitable vacancy at that time, it can store these applications in its data bank and use them
whenever the need aries. It is important that these application s are categorized and maintained
in a proper way so that they can be used when there are vacancies. For example, Tata Indicom
(Tata Teleservices Ltd.) Has the concept of CV drop boxes. They maintain these boxes all their
offices for interested candidates to drop in their CVs. These CVs are collected, stored and stored
in the CV databank on a monthly basis. Whenever there is a need for recruitment, the HR
department checks its CV bank to find suitable candidates before proceeding with selection
process.
Other sources
Organizations can consider non-traditional sources of recruitment while searching for
certain type of applicants. For instance, recruiting from associations of the handicapped can
provide a highly motivated workforce and also help the organization in building the image of a
good corporate citizen.
Most of the organizations, especially the large ones, use a mix of various methods and
sources of recruitment and do not rely on any one particular method. Changing needs and market
dynamics also determines the sources of requirement.

SOURCE MERITS DEMERITS

Internal sources  Improves morale  Limited options

 Proper evaluation  Lack of originality.
 Economical
 Promotes loyalty

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External sources  Availability of suitable  Demoralization
persons  Lack of Co-operation
 Bring new Ideas Expensive
 Problem of
Maladjustment.

MODERN SOURCES OF RECRUITMENT:

 Walk-in

 Consult in

 Tele recruitment: Organizations advertise the job vacancies through World Wide Web (WWW)
13.METHODS OR TECHNIQUES OF RECRUITMENT

According to Runn and Stephens the recruiting methods are of three categories. They are

direct
meth
od

techniques
of
recruiotmen
third t indire
party ct
meth meth
od od

13.1. Direct methods

This includes sending recruiters to educational and professional institutions, employee

contacts with public, manned exhibits and waiting list.

a) school and college:

The schools can be extensively used for recruiting labor, clerical cadre people. For
technical, managerial and professional jobs, colleges, university department and specialized
institute, like the IITs and IIMs are used. These institutions provide help in attracting
employers arranging interview, furnishing space and other facilities and providing student
resumes. The companies maintain a list of such institution, keep in touch with them, and send
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 their brochures indicating job openings, future prospects, etc. on the basics of these students
who want to be considered for the given jobs are referred to the company recruiter.

b) Employees friends, relatives etc:

The employees of the organization sometime, inform their friends and relatives of the
vacancies and bring them to companies.

c) Waiting lists:
The companies would maintain their own application files. These records list individual
who have indicated their interest in jobs, either after visiting the organizations employment
office or making enquires by mail or phone. Such records prove a very useful source, when
they are properly maintained.
Advantage of direct recruitment:

1. This method of recruitment is a direct the most modern democratic method as everybody has
a chance on equal footing to enter a public office.
2. The best talent person can be appointed to the posts as area is too wide and open to all
contestents throughout the country. But if the area is limited to the upgrading of the juniors
to the senior office, then it is not possible to requisition the services of the best talent from
the open market.
3. The direct recruitment generates latest thinking in the personnel staff and effect the dynamics
change in the outlook of the service. Hence new ideas with changing situation come to rescue
of the old traditional feeling in the field
4. In the field of technical knowledge, outside or direct recruitment is found more useful
because the newcomers bring new ideas, new techniques, new methods and above all short
cut expenses with development new and hence they prove to be the best leaders of the day.
5. It try to mould the personnel to work accordingly
6. The youth world is aware of the competitions and hence they know the current events
updates, while they enter the personnel staff they act according to the existing environment.
Disadvantage:

1. Personnel of new recruitment have no experience

2. Direct recruitment inexperience person arouse the feeling of hatred and jealousy among
the older generation towards the new arrival of personnel.
3. If there is competition between inside and outside recruitment, it is conceived that new
personnel will acquired more advantage over the older personnel due to fresh knowledge
of the environment and current affair.
13.2. Indirect methods

This includes advertising in mass media like newspaper, radio, TV, net in trade and
professional journals, technical journals and brochures. When a qualified is experience persons
are not available through other source, advertising through newspaper and professional and
technical journals is made. When all types of advertisement can be made in newspaper and

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 magazines, only particular types of posts should be advertised in the professional and technical
journal;

For examples, only engineering jobs should be inserted in journal of engineering. A clear
advertisement for an appointment reduces the possibility of unqualified people applying when
the advertisement is clear and to the point and the candidates can assess their abilities and
suitability for the position and only those who possess the requisite qualification will apply.

13.3. Third-party methods

This includes

 State or public Employment agencies.

They provide people for general office help, salesmen, technical workers,
accountants, computer staff, engineers and executives, etc. there are two types of
exchange (a) private, (b) government. Private exchange provides people immediately to
the employer, the required type of people.
Public employment exchange are the main agencies for public employment they
also provide a wide range of services, like counseling, assistance in getting jobs,
information about the labor market, labor and wage rates etc.


Trade unions.
They also supply whatever additional employees may be needed. Unions may be
asked for recommendations largely as a matter of courtesy and evidence of goodwill and
cooperation
 Professional Societies.
They provide information regarding candidates for engineering, technical and
management position. Some of these maintain mail order placement services.
 Casual labor sources.
 Deputation.
 Unconsolidated application
 Voluntary organization.
 Computer data banks.
 Private employment agencies
 Friends and Relatives of present employees unions.
14.FORMS OF RECRUITMENT :

The organizations differ in terms of their size, business, processes and practices. A few
decisions by the recruitment professionals can affect the productivity and efficiency of the
organization. Organizations adopt different forms of recruitment practices according to the
specific needs of the organization. The organizations can choose from the centralized or
decentralized forms of recruitment the explained below:

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 CENTRALIZED RECRUITMENT

The recruitment practices of an organization are centralized when the HR / recruitment

department at the head office performs all functions of recruitment. Recruitment decisions for all
the business verticals and departments of an organization are carried out by the one central HR
(or recruitment) department. Centralized from of recruitment is commonly seen in government
organization

Benefits of the centralized form of recruitment are:

 Reduces administration costs

 Better utilization of specialists

 Uniformity in recruitment

 Interchangeability of staff

 Reduces favoritism

Every department sends requisitions for recruitment to their central office

DECENTRALIZEDRECRUITMENT

Decentralized recruitment practices are most commonly seen in the case of conglomerate
operating in different and diverse business areas. With diverse and geographically spread
business areas and offices, it becomes important to understand the needs of each department and
frame the recruitment policies and procedures accordingly.

Each department carries out its own recruitment. Choice between the two will depend upon
management philosophy and needs of particular organization. In some cases combination of both
is used. Lower level staffs as well as top level executives are recruited in a decentralized manner.

15.EVALUATION OF RECRUITMENT PROGRAM:

Recruitment strategies, policies and objectives need to be evaluated from time to time to test
their effectiveness and their conformance to the organizational strategies, policies and objectives

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 Similarly the source and methods of recruitment also have to be evaluated from time to time
to match the recruitment policy and changing needs and to check their effectiveness and
efficiency

The success of a recruitment program can be judged based on a number of criteria. Some of
these are:

1. The number of successful placement

2. The number of hiring
3. The number of offer made
4. The number of applicant
5. The cost involved
6. The time taken for filling up the position

16.RECENT TRENDS IN RECRUITMENT

The recent trends in recruitment are

 Outsourcing
 E – recruitment
 Poaching / Raiding
OUTSOURCING

In India, the HR processes are being outsourced from more than a decade now. An
institution may draw required personnel from outsourcing firms. The outsourcing firms help the
organization by the initial screening of the candidates according to the needs of the organization
and creating a suitable pool of talent for the final selection by the organization.

Outsourcing firms develop their human resource pool by employing people for them and
make available personnel to various institutions as per their needs. In turn, the outsourcing firms
or the intermediaries charge the organizations for their services.

Advantages of outsourcing are

 The institution need not plan for human resources.

 Value creation, operational flexibility and competitive advantage.
 Turning the management’s focus to strategic level processes of HRM
 The institution is free from salary negotiations, weeding the unsuitable resumes/candidates.
 The institution can save a lot of its resources and time
E-RECRUITMENT

Many big organizations use Internet as a source of recruitment. E-recruitment is the use
of technology to assist the recruitment process. They advertise job vacancies through worldwide
web. The job seekers and their applications or curriculum vitae i.e., CV through E-mail using the
Internet. Alternatively, job seekers can place their CVs in worldwide web, which can be drawn
by prospective employees depending upon their requirements
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 Advantages of E-Recruitment are

 Low cost.
 No intermediaries
 Reduction in time for recruitment.
 Recruitment of right type of people.
 Efficiency of recruitment process.
Disadvantages of E-Recruitment

Apart from the various benefits, e-recruitment has its own share of shortcomings and
disadvantages. Some of them are:

 Screening and checking the skill mapping and authenticity of millions of resumes is a problem
and time consuming exercise for organizations.

 There is low Internet penetration and no access and lack of awareness of internet in many
locations across India.

 Organizations cannot be dependant solely and totally on the online recruitment methods.

 In India, the employers and the employees still prefer a face-to-face interaction rather than
sending e-mails.

POACHING/RAIDING

“Buying talent” (rather than developing it) is the latest mantra being followed by the
organizations today. Poaching means employing a competent and experienced person who is
already working with another reputed institution in the same or different institution.

17. RECRUITMENT PROCESS IN SCHOOL/COLLEGE OF NURSING:

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19 LEADERSHIP & MANAGEMENT ROLE IN RECRUITMENT OF NURSING FACULTY

LEADER

 Predicts the future

 Plans for the future
 Role models for recruitment people
 Uses interview process to promote image of the organization
 Identifies and recruits well-qualified people
 Assigns new personnel so as to promote success
 Serves as role model for continued professional development
 Encourages career planning and development for all employees
 Encourages mentorship
 Coaches employees
 Assesses the learning deficits of staff
 Plans strategies to minimize the deficit
MANAGER

 Shares responsibility for recruitment and retention of staff

 Structures interview process
 Increases validity and reliability of recruitment process
 Helps establish criteria for selection
 Applies knowledge of legal requirement for hiring
 Monitors orientation, in-service and continuing education
 Disseminates career information
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  Selects preceptor for staffs
 Encourage role modeling and mentorships
 Evaluates staff development needs
 Helps formulate staff development policies
20. INSTRUCTION TO PLAN A STRATEGY FOR RECRUITING AND RETAINING
NURSING FACULTY

 Step 1
Consider loan forgiveness. A major factor for recent graduates is money, no matter what field. If
a new nurse faculty takes a job with an institution, even without loan forgiveness, the significant
starting salary will help them immediately. To offset this draw, the nurse recruiter needs to find a
way to offer loan forgiveness either with local, state or federal aid.

 Step 2

Offer faculty housing. Another difficulty for new nurse faculty is making the move to a new city
where faculty members are in demand. If the institution can offer housing assistance, that
institution will be ahead of the competition.

 Step 3
Establish hospital partnerships. If you can manage to allow your faculty to work part-time at a
local hospital, they will be more enticed—greater earning potential and the best of both clinical
and education worlds.

 Step 4
Provide competitive retirement plans. For an aging workforce, it is important to find ways to
keep older nurses working as faculty. Through retirement incentives, you can attract retiring
clinical nurses and maintain your older faculty longer.

 Step 5
Offer internships. Encourage current nursing students to learn about becoming nursing faculty.
Internships can foster mentor relationships and loyalty to your institution either immediately
following graduation or down the line with clinical work becomes too demanding.

21. STRENGTHENING RECRUITMENT IN COMMUNITY:

In addition to recruiters, managers, nurse leaders and nurse administrators, staff nurses can play
a vital role as recruiters in their communities. Staff nurse often network with local or regional specialty
association and with colleagues and friends at social events (Christmas 2007)

Preparing the staff nurse to be effective recruiters includes helping them identify the positive
aspects of working in their organization.

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 A model for the enhancement of health recruitment and retention, based on Langley, Nolan and
Nolan

Successful performance of the allied health recruitment and retentention concept requires the
design , implementation, evaluation and adjustment of sets of actions that leads to optimizing workforce
outcomes for each of the communities or health agencies .factors that may affect recruitment and
retention outcomes and health services delivery could include marketing strategies, size location of the
community, type of health agency, demand for particular discipline, interdisciplinary teams that utilize
trained allied health assistants to enhance quality and quantity of service delivery and that reduce
workload, and availability of recruits from particular generation.

Recruitment is enhanced by effective and efficient marketing strategies and there is a need for
human resource administrators to constantly evaluate and improve the outcomes of these

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Creating survey program:

More and more, employers conduct employee satisfaction surveys with nurses to gauge their
involvement and attitude. Because nurse interact with clients far more than any other employee low
nurse satisfaction could point to trouble.

This approach can backfire if the nursing staffs share their opinion with management and their
concerns are not addressed. The most successful organizations have a budget for marketing and act on
the information they receive, making the necessary change to improve their employee work environment

Using ambassador cards:

Ambassador cards are like business cards and are provided to staff nurses to make it easy for
them to invite outstanding colleague to join the organization. The cards include recruitment phone
numbers, the appropriate web site address and a space for nurse to insert their names and titles.

22. Legal and political considerations:

The constitution provides for the following as the fundamental rights of a citizen:

“Article 16(1): there shall be quality of opportunity for all citizens in matters relating to
employment or appointment to any office under the state”.

“Article 16(2): No citizen shall , on ground only of religion, race, caste, sex, descent, place of
birth, residence or any of them, be ineligible for or discriminated against in respect of any
employment or office under the state”.

“ Article 16(3): Nothing in this article shall prevent parliament from making any law
prescribing, in regard to a class or classes of employment or appointment to an office, any

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 requirement as to residence within that state or union territory prior to such employment or
appointment.

“Article 46: the state shall promote with special care the educational and economic interests of
the weaker sections of the people, and in particular, of the scheduled castes and scheduled tribes,
and shall protect them from social injustice and all forms of exploitation.

Child labour (prohibition and regulation) Act, 1986 This Act, which replaces the
employment of children Act, 1938, seeks to prohibit the engagement of children below 14 years
of age in certain employments and to regulate the conditions of work of children in certain other
employments. Penalties on employers who contravene the provisions include fine and
imprisonment.

The employment exchanges (Compulsory Notification of Vacancies) Act, 1959 The Act
requires all employers to notify the vacancies (with certain exemptions) occurring in their
establishments to the prescribed employment exchanges before they are filled. The Act covers all
establishments in public sector and non agricultural establishments employing 25 or more
workers in the private sector. Employers are also requires to furnish quarterly return in respect of
their staff strength, vacancies and shortages and a biennial return showing occupational
distribution of their employees. While notification of vacancies is compulsory, selection need not
be confined only to those who are forwarded by the concerned employment exchanges.

The Apprentices Act, 1961 The Act seeks to provide for the regulation and control of training
of apprentices and for matters connected therewith. The Act provides for a machinery to lay
down syllabi and prescribe period of training, reciprocal obligations for apprentices and
employers, etc. the responsibility for engagement of apprentices lies solely with the employer.
The Apprentice Rules, 1962, formulated under the Act, were amended in 1986 prescribing
revised rates of compensation for apprenticeship as also for failure on the part of the employer to
carry out the terms and conditions of the contract.

CREDENTIALING
INTRODUCTION
Credentialing is the process of establishing the qualification of licensed professionals,
organizational members or organizations, and assessing their background and legitimacy. Many health
care institutions and provider networks conduct their own credentialing, generally through a
credentialing specialist or electronic service, with review by a medical staff or credentialing committee.
It may include granting and reviewing specific clinical privileges and medical or allied health staff
membership.
DEFINITION
1) Credentialing is the process by which selected professionals are granted privileges to practice within
an organization. In health care organizations this process has been largely confined to physicians.
Limited privileges have been granted to psychologists, social workers and selected categories of nurses,
such as nurse anesthetists, surgical nurses, and midwifes. Russell C Swan‘s burg.
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2) Credentialing is the process of establishing the qualifications of licensed professionals, organizational
members or organizations, and assessing their background and legitimacy.

3) A credential is an attestation of qualification, competence, or authority issued to an individual by a

third party with a relevant de jure or de facto authority or assumed competence to do so.
PURPOSE OF CREDENTIALING
The purpose of credentialing is:
1) To prevent a problem before it happens.

2) To research the qualifications and backgrounds of individuals and companies. Credentialing is also
the process of reviewing and verifying information.

SIGNIFIANCE
Credentialing is very significant because it shows that an individual or company performing a
service is qualified to do so. For example: your doctor must have certain credentials to prescribe
medicine to you.

LEGAL PROTECTION
It is a good idea to have credentialing process to protect you and your business from a lawsuit or
other legal problems. For instance, let‘s say you hire a teacher to work in your day care center, and this
person is a sex offender. The credentialing process could have prevented this through a background
check.

PROFESSION
Almost all professions require, to a certain degree, some sort of credentials. Police departments,
Firefighters, lawyers, accountants and nurses all need credentials. You need credentials to drive a car or
semi-truck. All states require citizens to take a driving test.

HEALTH CARE CREDENTIALING

DEFINITION:
Health care credentialing is a system used by various organizations and agencies to ensure that
their health care practitioners meet all the necessary requirements and are appropriately qualified. The
credentials may vary depending on the specified area of the practitioner. For example: An X-ray
technician may have different credentialing forms than an osteopathic physician.

WHO IS CREDENTIALED?
1) Practitioners: Medical Doctors (MD), Doctor of osteopathy (DO), Doctor of Podiatric Medicine
(DPM), Doctor of Chiropractic (DC), Doctor of dental Medicine (DMD), Doctor of Dental Surgery
(DDS), Doctor of Optometry (OD), Doctor of Psychology (PhD) and Doctor of Philosophy (PhD).

2) Extenders: Physician of assistant (PA), Certified Nurse Practitioner (CRNP), Certified Nurse
Midwife (CNM).

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Facility and Ancillary service Providers:
Hospitals , Nursing Homes, Skilled Nursing Facilities, Home Health, Home Infusion Therapy,
Hospice, Rehabilitation Facilities, Freestanding Surgery Centers, Freestanding Radiology Centers,
Portable X-ray Suppliers, End Stage Renal Disease Facilities, Clinical Laboratories, Outpatient Physical
therapy and Speech Therapy providers, Rural Health Clinics, Federally Qualified Health Centers
Orthotic and Prosthetic providers and Durable Medical Equipment (DME) providers.

COMPOTENTS OF CREDENTIALING
As with physicians, the components of a credentialing system for nurses would be:
1) Appointment: Evaluation and selection for nursing staff membership.
2) Clinical privileges: Delineation of the specific nursing specialties that may be managed types of
illnesses or patients that may be managed within the institution for each member of the nursing staff.

3) Periodic reappraisal: Continuing review and evaluation of each member of the nursing staff to
assure that competence is maintained and consistent with privileges.

Criteria for appointment.

Criteria for appointment would include proof of licensure, education and training, specialty
board certification, previous experience and recommendations. Clinical privileges criteria would include
proof of specialty training and of performance of nursing procedures or specialty care during training
and of performance of nursing procedures or specialty care during training and previous appointment.
During the credentialing process the committee should look for red flags of high mobility,
graduation from foreign schools, professional liability suits and professional disciplinary actions. Each
red flag is a reason for exercising extra care in reviewing the applicant.
While professional nurses have mostly been hired through personnel offices, nurse managers
should give consideration to increasing the professional status of nursing through the credentialing
process.
The American nurses association (ANA). A report of the committee for the study of
credentialing in nursing, made in 1979, included fourteen principles of credentialing related to the
following.
1. Those credentialed
2. Legitimate interests of involved occupation, institution, and general public
3. Accountability
4. A system of checks and balances
5. Periodic assessments.
6. Objective standards and criteria and persons competent in their use.
7. Representation of the community of interests.
8. Professional identity and responsibility

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 9. An effective system of role delineation
10. An effective system of program identification
11. Coordination of credentialing mechanism
12. Geographic morbidity
13. Definition and terminology
14. Communications and understanding

Clinical privileges:

Permission given to an individual profession nurse to practice specific skills based on credentials,
experience, and demonstrated competence / performance.

When patient-care problem arise in areas that require qualification or certification, the nurses’
credentials are checked first. If the nurse is credentialed for that activity, counseling may reveal the need
for remediation if the nurse is not credentialing, immediate steps are taken to correct the deficiency.

1. First step is to complete application for entry. In completing this form, please do not leave any
blanks. Indicate information that does not apply as N/A. Submit this completed form to the nurse
manager of the designed area for which application is made.
2. Secondly, general nursing oriented must be completed as scheduled. Demonstrating entry – level
requirement at six months credential nurses to practices at this institution.
3. The third step, meeting the requirement criteria for distinct specialty areas allows nurses working
in these specialty areas to practice advanced skills. These nurses must complete critical care or
other specialty care skills and a preceptor ship with a senior staff member. We identify skills on
particular specialty units that require training beyond that encompassed in basic orientation
Review of departmental and /or individual practice and results of care will be an ongoing
process through the hospitals of quality assessment & improvement program professional
nursing practices is expected to assist the department of nursing in meeting standards of
practices. It is further expected that results of nursing care reveal patients attaining desirable
outcomes and without any adverse effects related to individual performance
SELECTION

INTRODUCTION
“The selection process starts when applications are screened in the personnel department.
Selecting includes interviewing, the employer‘s offer, acceptance by the applicant, and signing of a
contract or written offer‖.
Those applicants who seem to meet the job requirements are sent blank job-application forms
and are directed to fill them up and return the same for further action. The job application form is one of
most important tools in the selection process.

DEFINITION
―It is the process of choosing from among applicants the best qualified individuals,
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Selecting includes interviewing, the employer‘s offer, acceptance by the applicant, and signing of a
contract or written offer‖. Selection may be carried out centrally or locally, but in either case certain
policies or methods are adopted.
SELECTION POLICIES
1. Application forms
The issue and receipt of application forms is the administrative responsibility, and much of the
preliminary work is handled by the clerical staff under the supervision of the administrative head of the
college.
The information contained in the application form and reports received in connection with them
should be systematically tabulated and filed as they are useful for evaluating the effectiveness of the
form, analyzing entrance standards, assessing academic achievement with subsequent performance, and
knowing from which parts of the state or country the students are most frequently admitted or apply for
admission.
The application form should elicit the following information
 Name
 Address
 Age of the candidate
 Name of parents or guardians
 Occupation of father
 Details of education
 Details of employment
 Particular aptitudes or abilities.

It may also ask the student to write short easy on her interests and her reasons for choosing nursing
as a career. It should give details of any material she should submit such as a medical certificate,
evidence of date of birth etc. and should give the exact address to which it should be sent.
The names of the persons given as references should be asked to furnish information regarding
the candidate‘s character and personality, and the information to be given by the head teacher should
include candidate‘s attendance at school, studies completed, grades, rank in class and his or her own
evaluation of the candidate‘s suitability of nursing.
A job application form serves three main purpose:

1) It enables the hospital authorities to weed out unsuitable candidates.

2) It acts as a frame of reference for the interview.

3) It forms the basis for the personal record file of the successful candidates.
2. Selection committee:
Usually the selection occurs in the college itself. Otherwise, if the selection is carried outside the
college, it is important that at least representatives of the college be a part of committee and as far as
possible students is selected from a specific college according to its individual admission policies and
the programme it offers.
The members of the selection committee should include
a) The head of the college of nursing.

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b) Professor.

c) Representative of the local controlling authority.

d) Representative of the nursing division of the state.

e) An educational psychologist.

The procedure for selection should consist of a personal interview of the candidate and possibly
a separate interview with her parents. It may also include tests of previous achievements, both written
and oral, to assess her knowledge of various subjects such as Arithmetic, English, the regional language
and general science and her ability to express herself orally and in writing. If psychological tests are
given, only those devised by experts in their field should be used.
It should be made clear to them that final acceptance for the course will be subject to a
satisfactory medical report and assessment during the preliminary training period. The college should
make every effort to start the course on the appointed day with the full quota of students. Only in
exceptional circumstances should students be admitted later and in their cases, special arrangement
should be made for them to cope up with the other students.

3. Orientation programme:
After admission an orientation programme is to be conducted to make the students aware of the
college rules, hostel rules and the hospital and the college building and associated parallel medical
education departments. Orientation should be given by a senior faculty of the college of nursing.
Orientation programme may take three to five days.
4. Development of master plan:
When a particular batch is admitted the class teacher may draw a master plan according to which
the whole programme is planned. Date of examinations and periodic evaluation measures etc are
formulated.
5. Parent teachers association:
All parents are enrolled in the parent teachers association and this will help to have a contact
between the family members and teachers. This will help to improve the administration. Meetings of
PTA are held frequently and the parents are kept informed of the students progress.
Before taking any disciplinary actions PTA members are called when students unrest occurs due
to certain problems. Thus parents are also involved in the administration of students.
STEPS IN SELECTION:

The steps which constitute the employee selection process are the following:

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1) Interviewing:
Interviewing is the main method of appraising an applicant‘s suitability for a post. This is the most
intricate and difficult part of the selection process. The employment interview can be divided into four
parts:
 The warm-up stage

 The drawing-out stage

 The information stage

 The forming an-opinion stage

Main objectives of an interview:
1) For the employer to obtain all the information about the candidate to decide about his suitability for
the post.

2) To give the candidate a complete picture of the job as well as of the Organization.

3) To demonstrate fairness to all candidates.

THE INTERVIEW LETTER:

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FUNCTIONS OF THE PERSONNEL MANAGER:
The responsibilities of the personnel manager are:
A) To screen the application of the candidate

B) To give information about General nature of work hours of work

E) pay-scale, allowances and starting total salary

F) Fringe benefits

G) Leave policy

H) Brief information about the background of the hospital

I) To discover any differences in the expectations of the hospital and those of the candidate.
The responsibilities of the department head are:
A) To review the job-application form to check pertinent data on experience;

B) To assess the professional competence of the candidate

C) To give detailed picture of the job requirement to the applicant;

D) To advise the personnel manager if he thinks that the previous training or experience or both of the
applicant justifies a higher starting salary.

2) Pre-employment tests:

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 To ensure selection of the most suitable candidates for various posts, interviews should be
conducted carefully & pre-employment tests should be held in a systematic manner wherever necessary
& possible.
For certain Categories of post, there is a need for testing the professional competence of the
candidates. These tests can broadly be divided in to four types:
1) Tests of general ability- intelligence

2) Tests of specific abilities- aptitude tests

3) Tests of achievement-trade tests

4) Personality tests- Tests of emotional stability, interest, values, traits etc.

1) Tests of general ability: These tests can give a useful indication of candidate‘s mental caliber. It has
been observed that for various professions, there is an optimum level of I.Q. while selecting individuals
who have I.Q.s within the required optimum range-not higher or lower.
2) Tests of aptitude: aptitude tests measure whether an individual has the capacity or latent ability to
learn a new job, if given adequate training .These tests measure skills & abilities that have the potential
for later development in the person tested.

3) Tests of achievement: Tests of achievement measure the present level of proficiency that a person
has achieved. In hospitals, these tests can be used for typists, stenographers, laboratory technicians,
radiographers, etc. These tests can also be used at the end of training programmers to assess the level of
proficiency achieved.

4) Personality tests: Personality tests are used to assess certain personality characteristics. These tests
are used in selecting candidates for sales jobs, supervisory job, management trances, etc., because
certain personality characteristics are essential to succeed in such jobs.

2) Final approval by the head of the hospital:

In some hospitals, the selection committee consists of one person from the personnel department,
the department head/supervisor of the concerned department and one representative of the head of the
hospital. After the interviewing all the candidates, the selection committee submits its recommendations
for approval to the head of the hospital, who is generally the hiring authority.
In other hospitals, the head of the hospital may prefer to interview all the candidates himself for the key
jobs and leave it to the selection committee for the less vital jobs. In case of appointment of a
department head, one expert is also usually included in the selection committee.
Different hospitals adopt different policies according to their own convenience for the selection
of their employees. Generally this authority lies with the Medical superintendent or Administrator or
Business Manager or Chief Executive who is legally termed the ‗Occupier‘.
4) References:
The references provided by the applicant should be cross-checked to ascertain his past
performance and to obtain relevant information from his past employer and others who have knowledge
of his professional competence.
The references letters should be brief and should require as little writing as possible by the
person to whom it is sent. If it is directed to a former employer, it should ask for the following data:
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 ons

-employ?

5. Medical examination:
The medical examination of a prospective employee is an aid both to the employee and to the
management. The selection of the right type of employee who can give his best and be happy requires a
thorough knowledge of his physical capacities and handicaps. The purpose of the medical examination
is threefold:
a) It is for the protection of the applicant himself to know whether that job will suit him or not from the
medical point of view.
b) It is for the protection of the other employees so that they are not at risk of any communicable or
other disease which the prospective employee may have.
c) It is for the protection of the employer as well, so that he may avoid selecting a wrong person.
The medical examination will eliminate an applicant whose health is below the standard or one who is
medically unfit.

6) Joining report by the employee:

When new employees reports for joining, he should be given an appointment letter, his job
description and handbook of the hospital. He should be asked to submit his joining report. A model
appointment letter and joining report form are given.

PLACEMENT
INTRODUCTION:
Placements are a credit bearing part of a degree course and all placements optional. If a student
opts out of a placement or there is no placement available, this means that placement is not guaranteed.
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DEFITION:
The determination of the job to which an accepted candidate is to be assigned and his
assignment to that job .it is a matching of what the supervisor has reasons to think he can do with
the job demands (job requirement), it is a matching of what he imposes (in strain, working
conditions) and what he offers in the form of payroll, companionships with others, promotional
possibilities, etc”.
-Paul Pigors and Charles A. Myers
A proper placement of an employee results in low employee turnover, low absenteeism
and low accident rates in shop floor jobs and improved morale and commitment of the employee
IMPORTANCE PLACEMENTS:
The school of service management believes that taking a placement is one of the most important
decisions you can make in your university carrier. Not only will you benefit from building personal
confidence during your placement year but you will also establish contacts in your chosen sector which
may provide invaluable for graduate opportunity.
IMPORTANCE OF SELECTION AND PLACEMENT:
 Fairly and without any element of discrimination evaluate job applicants in view of individual
differences and capabilities.

 Employee qualified and competent hands that can meet the job requirement of the organization

 Place job applicants in the best interests of the organization and the individual.

 Help in human resources man power planning purposes in organization.

 Reduce recruitment cost that may arise as a result of poor selection & placement exercises.
PLACEMENT TEAM:
Our current placement team consists of a placement coordinator & four academic tutors, each
with specialist knowledge relevant to the degree courses you under the supervision are studying. These
tutors advice and support you throughout your preparation for placement.

1. INDOCTRINATION
 Definition
“Indoctrination, as a management function, refers to the planned, guided adjustment
of an employee to the organization and the work environment”.

Although the words “induction “and “orientation” are frequently used to describe this
function, indoctrination process includes three separate phases: induction, orientation, and
socialization.

Indoctrination denotes a much broader approach to the process of employments adjustment

than either induction or orientation. It seeks to

1) Establish favorable employee attitude towards the organization, units, and department

2) Provide the necessary information and education for the success in the position

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 3) Instill a feeling of belonging and acceptance.

The effective programs result in higher productivity. Fewer rule violation, less attrition
and greater employee satisfaction. The employee indoctrination process begins as soon as a
person has been selected for a position and continues until the employee has been socialized to
the norms and values of the work group.

 Employee indoctrination content:

1. Company history, mission , and philosophy
2. Company services and services area
3. Organization structure , including department heads, with an explanation of the functions
of the various departments
4. Employee responsibilities to the company
5. Organizational responsibilities to the employee
6. Payroll information, including how increases in pay are earned and when they are given
7. Rules of conduct
8. Tour of the company and of the assigned department
9. Work schedules , staffing and scheduling policies
10. When applicable , a discussion of the collective bargaining agreement
11. Benefits plan, including life insurance, health insurance , pension and unemployment
12. Safety and fire programs
13. Staff development programs, including in – service and continuing education for re
licensure
14. Promotion and transfer policies.
15. Employee appraisal system.
16. Workload assignment.
17. Introduction to paper work/ forms used in the organization.
18. Review of selection in policies and procedures.
19. Specific legal requirement, such as maintaining a current license , report of accident and
so froth.
20. Introduction to fellow employees.
21. Establishment of a feeling of belonging and acceptance , showing genuine interest in the
new employee.

INDUCTION;
Definition:

Induction is the process of introducing new employees to an organization and to their

work responsibilities in that organization.

Induction, the first phase of indoctrination, takes place after the employee has been
selected but before performing the job role. The induction process includes all activities that
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educate the new employee about the organization and employment and personnel policies and
procedures.
Induction activities are often performed during the placement and pre employment
functions of staffing or may be included with oriented activities. However, induction and
oriented are often separate entities, and new employees suffer if content from either program is
omitted. The most important factors are to provide the employee with adequate information.
Employee handbooks, an important part of induction, are usually developed by the
personnel department. Managers, however, should know what information the employee
handbooks contain and should have input into their development. Most employee handbooks
contain a form that must be signed by the employee, verifying that he or she has received and
read it. The signed form is then placed in the employee’s personnel file.
Objectives:
The generic objectives of the induction programme include
1) To develop realistic job expectation, positive attitudes and satisfaction
2) To reduced anxiety and employee turnover
3) To reduce time of supervision of the supervisor
4) To develop a sense of belonging and
5) To adopt oneself according to the culture of the organization.
Induction by human resource department
This should be cover
a) A brief history of the institution
b) Its aims and objectives
c) The terms and condition of the appointment letter
d) Personnel policies
e) An explanation of services available to the employee in the employee in the hospital,
such as bank , canteen, fair – price shop , library ,social club, etc
f) The attitudes expected of him with regard to patient and visitors
g) Promotion policy
h) The name of the key officials
i) A tour of the hospital
j) Fire precaution and safety regulation
k) General discussion
Induction by department head

This should cover

a) An introduction to the department

b) The location of the changing room, rest room , toilet etc
c) The use of lifts , telephones
d) An explanation of the job description of others
e) An explanation of his own job description
f) An introduction to all the supervisors in the department
g) A tour of the department
h) General discussion
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Techniques of induction:

The following techniques may be adopted to orient new employees:

i) The general orientation letter. In those hospitals where the number of new employees is
more than ten per month, it is advisable to hold a group orientation session. It should be
compulsory for all new employee to attend this session. Such a meeting should be held in
a comfortable room. Devices such as charts, slides, handbooks, etc should be used to
make it interesting
ii) General tour: a tour of the hospital can prove very informative for new employees. It
should be arranged to show to the new employee
a) How patient , arrive
b) Where patients are cared for
c) How patients are fed
d) Where different tests are conducted
e) Where patient linen is washed
f) Where the hospital’s payroll is made and
g) Any other place of major interest
iii) Employee hand book: a well – prepared employee handbook is an important document. It
can set out a wide range of useful information for new employees. It can be read at leisure. It is
prepared for the use of employees but is also read by his friends and family members as well.
This booklet should cover a brief history of the hospital, its aim and objectives, condition of
employment, employees health programme , grievance procedure , safety precaution. Etc.

iv) Buddy system. Under this plan, the new employee is introduced to an old employee- a
specially chosen buddy. This buddy assumes the responsibility of sharing the general
information about the department and hospital such as locker, uniform, toilet , daily routine
duties , canteen , leave procedure , bus routes etc. the buddy should be carefully selected , lets
the new employee receives wrong information. If possible, some training should be given to
some good employees in each department so that their services may be utilized under this buddy
system. Thus a new employee will not fall into the wrong hands and not collect false information
about the hospital in general and the department in particular.

Advantages of induction

For employees

 A chance to get a clearer picture of the organization with a comprehensive introduction to its
philosophy, objectives, culture, policies etc.
 Introduction to relevant people, which makes easier for new employees to approach them at
the time of need in future.
 Time to settle into a new environment with new people
 A valuable opportunity to gather all sort of information according to one’s needs, likes and
taste
For the organization
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  A chance to watch closely new employees in order to know them better
 Helps the new employees to shape up according to the requirement of the organization
 A system that ensures new employees are well settled
 An opportunity to inject fresh blood into the DNA of an organization
 ORIENTATION
Orientation activities are more specific for the position. Organization may use wide
variety of orientation program. For example, a first –day orientation could be conducted by the
hospitals personnel department, which could include a tour of the hospital. The next phase of the
orientation program could take place in the staff development department where aspect of
concern to all employees, such as fire safety, accident prevention, and health promotion would
be presented. The third phase would be the individual orientation for each department. At this
point, specific departments, such as dietary, pharmacy and nursing would each be responsible for
developing their own program.
Importance of orientation program:
 Orientations programs can help to reduce turnover by making employees feel more at
home in the workplace in a shorter period of time
 establishing an orientation program will help to alleviate “new job stress”
 orientation programs also allow employees to become more productive in a shorter
period of time
 orientation is also important because it introduces the employee to the rules and culture
of the organization

Members involved in orientation program

 The senior manager to welcome the person on behalf of the organization and provide
information about the organization, workplace rules and so on
 The supervisor to provide information about the workplace, introduce the person to staff
and provide information about the job
 The human resources specialist to provide information about pay and benefits, leave
entitlements, pensions and so on
 A member of the Board, Association or Council to welcome the new employee
Time of orientation program
An orientation program should start the day that the new employee accepts the position.
 As part of the orientation program the new employee should be provided with some basic
information about the organization such as the organization structure, organizational
rules and information about the job and the pay and benefits
 the orientation should include introductions to staff, showing the
 employee around the office and providing the employee with time to meet with the
Senior Manager and the supervisor
Uses of orientation program

The primary purpose of an orientation program is introducing the new employee to the job and
the workplace and to make him/her comfortable.
Other important purposes include:
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  Reducing employee turnover –most employee turnover occurs within the first six months
of work
 reducing errors – employees who are familiar with the work environment and the job
make fewer mistakes
 saving time – employees who have been given an orientation spend less time trying to
figure out how things work and more time being productive
 develop clear job and organizational expectations – employees are less likely to end up
doing the wrong thing and/or doing the right thing in the wrong way
 introduce the employee to the culture of the workplace –it is important for new
employees to have an understanding of both the culture of the workplace and the cultures
of the people that work there
Tools and resource:

There are a number of tools and resources that can use to assist in the staffing process.
These tools and resources include:
 manual and workbook: you can use the manual and workbook to develop your own
orientation program
 current job descriptions – current job descriptions should be included in the orientation
program

Guide for the orientation program

Orientation programs consist of essential information that employee needs to be comfortable

and productive in the workplace.
 not all information should be provided at once, as it will result in information overload
 all important information should be provided to the employee in a booklet or handbook
 Orientation programs should include information on the following topics:

- organizational matters: the employee should be introduced to the purpose and structure of
the organization
- job related matters: the employee should be provided with specific information about
his/her job
- employment related matters: the employee should be introduced to matters related to
employment
- general introductions: it is important to introduce new employees to others in the
workplace so they feel at home as soon as possible.

Steps in orientation program:

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It is important to have the information the employee will need in a simple format that the
employee can review at his/her leisure. Information to put in the folder includes organizational,
job related and general employment information
. 1. Organizational Information:
- history and structure of the community government (include an organizational chart)
- organizational vision, mission, mandate, principles, values, goals and objectives
- rules of the organization
- programs and services provided by the organization

Job Related Information:

- a current job description
- relationship to other jobs
- supervisory positions
- layout of physical facilities and equipment
- important processes and procedures (i.e. how and where to get tools, supplies, etc.)
- safety procedures and processes

General Employment Information related matters

- pay scales
- probationary period
- disciplinary process
- training and development procedures
- performance appraisals procedures
- rules of the organization
- benefits including pensions, insurances and so on
- entitlements such as rest breaks, holidays (including process for applying for holidays)
2. Introduce the employee to others

Even though the new employee is likely to know most, if not all of the other employees,
he/she should be taken around to let everyone know he/she has started and to help build a
sense of team.
 at the same time it is important to let the employee know where things are such as
washrooms, supplies, filing cabinets and other materials and resources that he/she will
need as part of the job
 the employee should also be formally introduced to others that he/she will be working
with on a regular basis such as Regional MACA Staff, contractors and suppliers, other
government officials and so on
3. Go over the important information:

Before the new employee starts the job, the supervisor should sit down with him/her to go
over important aspects of the job.

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  this includes a review of the job description, providing the employee with a performance
evaluation form and training needs assessment form and going over the rules of the office
 the senior manager should also spend some time with the supervisor and the employee to
go over the mission, mandate, goals and objectives of the organization as well as the orga
4. Sign up for the benefit and entitlements:

An important part of the orientation process is to ensure the employee is set up on the
pay and benefits systems and that he/she signs all the necessary benefits paperwork.
 this should be done with the supervisor and the person responsible for administrating pay
and benefits
5. Follow up sessions:

Follow-up orientation sessions should be scheduled with the employee after one to two
weeks, one month and after six months.
 This will provide the employee with a scheduled time to ask any questions they have and
to clarify policies and procedures
 At the six-month orientation session you may want to complete a performance appraisal
and training needs assessment form

PROMOTION
INTRODUCTION:
The promotion policy is one of the most controversial issues in every organization. The
management usually favours promotion on the basis of merits, and the unions vehemently oppose it by
saying that managements resort to favoritism. The unions generally favour promotions on the basis of
seniority. It is hence essential to examine this issue and arrive at an amicable solution.
DEFINITION:
A change for better prospects from one job to another job is deemed by the employee as a
promotion.

KOONTZ O`DONNEL observed that promotion is "a change within the organization to a
higher position with greater responsibilities and used for more advanced skills than in previous
position. It usually involves higher status and increase in pay." Promotions can be from within or
can be from outside depending upon the need of the organization as both have certain advantages
and disadvantages. So also are the arguments for and against the concept of promotion on
seniority or merit. A wise policy which is followed by many organizations is a proper blending
of both. Opposite to promotion is demotion. It is more as a punishment. In certain cases it can be
on cost reduction considerations

PIGORS & MEYERS: Define promotion as "the advancement of an employee to a better job -
better in terms of greater respect of pay and salary. Better houses of work or better location or
better working conditions-also may characterize the better job to which an employee seeks
promotions, but if the job does not involve greater skill or responsibilities and higher pay, it
should not be considered a promotion." This definition takes into consideration only a Vertical
promotion.
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 DALE YODER: According to Dale Yoder, it is a "movement to a position in which
responsibilities and presumably the prestige are increased. Promotion involves an increase in
rank ordinarily; promotion is regarded as a change that results in higher earnings, but increased
earnings are essential in a promotion." This definition talks of both vertical and horizontal
promotions.

Purpose of promotion:

The main purposes of promotion in organization are the following

1. To recognize and reward the effort of an employee

2. To attract and retain the competent personnel
3. To inculcate enthusiasm in employees to acquire knowledge , skills and jobs in the
organization
4. To develop a competitive spirit in the workforce
5. To motivate employee for higher productivity
6. To envelop a ready internal pool of competent personnel within organization who can
take the higher level of challenging job
7. To promote a sense of belonging in the employees
8. To boost the morale in the workforce
9. To increase an employee’s effectiveness
10. To place a worker in apposition where he or she is more valuable to the organization
11. To fill up the vacancies from within the organization
12. To reduce discontent and labor unrest
13. To promote interest in training and development programme
14. To increase job satisfaction.
Types of promotion:
Seniority based promotion

Seniority is the oldest and widely used basis of promotion especially in government
owned organization , unionizes industrial establishment and educational institutes

Advantages :

It has the following advantage

1. it is easy to measure the length of the services and judge the seniority
2. It brings objectivity in distinguishing among personnel so less scope for subjectivity
or favoritism
3. It is simple to understand and easy to administer
4. Trade union provide full support to this system
5. This ensures a more experienced person takes higher position first
6. It creates a sense of security
7. It helps to reward loyal workers

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 8. Less scope of grievances and conflict
9. Employees are willing to work under an older and experienced person
10. It is economical
11. It reduces labor turnover, as employee will not be willing to lose their seniority in
case of quitting
Disadvantage:

1. Employees with longest services need not necessarily be the more competent
2. Young , ambitious and able persons with little service may get frustrated and leave the
organization
3. Seniority fails to differentiate between efficient and in efficient workers
4. It kill the enthusiasm to do better as everyone will promote as his or her turn comes
5. It acts as a hurdle in attracting capable persons
6. It is not a valid assumption that employee learns more with length of services. up to
ascertain age employees learns and beyond that learning capabilities may diminish.

Merit based promotion:

When promotion given to the an employee on the basis of his qualification , ability,
competency, or performance ignoring of his or her seniority in the organization , then the
promotion is known on the basis of merit. It is just like a reward or incentives for hard work,
dedication and excellent performance. Management favor promotions on the basis of merit
Advantage :
Its advantages are has follows:
1. It encourages , recognizes and rewards extras knowledge, competence and efficiency
of employees
2. It motivates the competent person to work hard
3. It helps to retain the capable persons.
4. It increases the productivity
5. It increases the efficiency and profitability of the organization
6. It encourages employees to keep on learning , adding knowledge and skills , enhance
their personal growth also
7. It result in maximum utilization of employee
Disadvantage
1. Accurate measurement of merit Is highly difficult
2. Scope for subjectivity and favoritism
3. Trade unions distrust management integrity in judging merit
4. Loyal senior persons are not rewarded
5. Feeling of discontent among senior employees
So, whether it is seniority or merit as the basis for promotion, each has its own merits
and demerits. Management mostly prefers merit base for promotions as it increases the
productivity and profitability of organization. Moreover, it rewards those who deserve it.

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 But trade unions prefer seniority as the sale basis for promotion in order to protect the
interest of their workers.
A combination of both seniority and the merit can be considered as a basis for promotion.
Horizontal promotion:
This type of promotion includes an increase in responsibilities, pay and change in
designation. However, the employee doesn’t shift the job classification. For example a
production worker shifted to HR department to develop new skill. Another example can
be that enrich the job and provide training to enhance the opportunity for assuming more
responsibility.

Vertical promotion:

In this type of promotion, an employee is moved to higher level in the hierarchy.

This involve s increases in pay , status and responsibilities.

Dry promotion:

This type of promotion involves increase in responsibilities and status without

any increase in pay

Procedures for Promotion of Faculty

1. Each professional staff member holding academic rank desiring to be considered for
promotion will complete the Promotion Recommendation Form and return it to the
department chair.

2. The appropriate department committee will review each completed form in accordance
with the criteria of the Policies of the Board of Trustees and specific procedures
developed by the individual department.

3. The department chair, in conference with each candidate for promotion who requests
such a meeting, will review his/her form and recommendations. A copy of the chair's
recommendation will be given to the candidate for promotion at the time of the
conference. The appropriate department committee will review the promotion application
if the candidate for promotion requests such action. Should the committee deem it
necessary, a conference of the department chair and the committee will be arranged.

4. Recommendations on promotion will be forwarded by the department chair to the dean of

the faculty for his/her recommendations.*

5. Faculty personnel committees, where they exist, shall review applications for promotion
and submit their recommendations to the dean of the faculty for transmittal to the vice
president/provost/CIO.

6. The deans of the faculties will forward recommendations on all promotions to the
Provost for his/her recommendations.*If a dean rejects any of the recommendations for
promotion made by department chairs or a departmental committee, the Provost will
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 schedule a meeting with that dean, the department chair, and the appropriate department
committee. At that meeting a careful and full review of the case will take place.

7. The Provost will forward recommendations to the president.*

8. The president will notify in writing each individual who has applied for promotion as to
whether the promotion has been approved or denied.*

9. The individual faculty member may request a review of the president's action and may be
accompanied for this review by his/her department chairs, chair of the appropriate
department committee, and the dean of his/her faculty.

FACTORS IMPLYING PROMOTION:

The factors which are considered by employees as implying promotion are:

NATURE AND SCOPE OF PROMOTION:

Seniority versus merits: There has been great deal of controversy over the relative values of
seniority and merit in any system of promotion. Seniority will always remain a factor to be considered,
but there be much greater opportunity for efficient personnel, irrespective of their seniority, to move up
speedily if merit is used as the basis for promotions. It is often said that at least for the lower ranks,
seniority alone should be the criterion for promotion. One cannot agree with this.
The quality of work is more important in the lower ranks as in the higher.
There are some who argue against this plea and advocate the merit policy for the following reasons:
1) They believe that mere length of service evidence only of continued service but are surely no
indication of vast experience.

2) Promotion on the basis of seniority saps the initiative of the employees. Once they realize that
promotions in the organization are on the basis of seniority alone, they lose all enthusiasm for showing
better performance. Therefore, in terms of getting the best out of employees, the merits of the individual
employee will have to be considered.

3) There are individual differences amongst persons working o the same of them are most efficient,
some barely average and some below average. If their differences are not distinguished and they are
uniformly rewarded, all individual will gradually sink to the level of the below-average employee.
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PROMOTION POLICY:
The promotion policy is one of the most controversial issues in every organization. The
management usually favors promotion on the basis of merits, and the unions vehemently opposite by
saying that management resort to favoritism. The unions generally favor promotions on the basis of
seniority. However, in practice, both seniority and ability criteria should be taken into consideration; but
in order to allay the suspicious of the trade unions, there should be written promotion policy which
should be clearly understood by all.
Promotion policy may include the following:
1) Charts and diagrams showing job relationships and ladder of promotion should be prepared. Those
charts and diagrams clearly distinguish each job and connect various jobs by lines and arrows showing
the channels to promotion. These lines and arrows are always based on analysis of job duties. These
charts do not guarantee promotion but do point out various avenues which exist in an organization.

2) There should be some definite system for making a waiting list after identification and selection of
those candidates who are to be promoted as and when vacancies occur.

3) All vacancies within the organization should be notified so that all potential candidates may
complete.
4) The following eight factors must be the basis for promotion:
 Outstanding service in terms of quality as well as quantity

 Above average achievement in patient care and for public relations

 Experience

 Seniority

 Initiative

 Recognition by employee as a leader

 Particular knowledge and experience necessary for a vacancy and

 Record of loyalty and cooperation

 In some instances, it may be possible to use pre-employment test, to determine
eligibility for the vacant position.
5) Though the department heads may initiate promotion of an employee, the final approval should be
with top management because a department head can think only of the repercussions of the promotion in
his department while top management looks at it from the point of view of the organizations a whole.
The personnel department can help at the stage by proposing the names of prospective candidates out of
the existing employees in the organization and also submit their performance appraisal record of the last
few years to the department head.

6) All promotion should be for a trail period. In case the promoted person is not found capable of
handling the job. Normally, during this trail period, he draws salary at the higher pay-scale, but it should

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specially be made clear to him in writing that if his performance is not found up to the work, he will be
reverted to his former post at the former scale.

7) In case of promotion, the personnel department should carefully follow the progress of the promoted
employees. A responsible person of the personnel department should hold a brief interview with the
promoted person and his department head to determine whether everything is going on well or not. The
promotional post should be continued after the satisfactory report of the department head.

Policy guidelines for faculty promotion

General Statement
Three major promotion criteria are outlined in the Board of Trustees Policies:

1. Effectiveness in Teaching
2. Scholarly Ability
3. University and Public Service

Scholarly ability will be evaluated in the context of the approved departmental statement
on research, scholarship, and creative activity. The other two criteria, mastery of subject matter
and continued growth, are interrelated with the major criteria in the forms of sustained
contributions and demonstrated excellence.

Instructor

The rank of "instructor" should be used for a full-time academic appointment when a
regular (i.e., not "qualified") appointment is appropriate but the candidate is minimally short of
the requirements for an assistant professor, i.e., absent of a finished terminal degree or absent
minimal experience in fields traditionally requiring a terminal master's degree plus experience
prior to the assistant professorship. The initial appointment may be for two years, but
reappointment should normally be for not more than one year. Initial appointments for those who
are some years away from the terminal degree might better be made in a lecturer rank so that the
faculty member can have sufficient time after the terminal degree, but prior to the determination
of continuing status, in which to build scholarly credentials.

Promotion to Rank of Assistant Professor

Assistant professor is the normal beginning rank for a faculty member with a terminal degree or
its equivalent and less than five years' experience elsewhere. A person promoted to the rank has
established himself or herself as being qualified in the discipline/profession. In addition, there is the
expectation that the person has the potential for achieving excellence in the discipline/profession and for
attaining the highest rank in the department.

The "terminal degree" is a doctorate in most fields but may be the master's in certain applied and
studio fields. Some departments may require a doctorate for certain posts and less than a doctorate
for others, depending on the particular teaching and scholarly expectations.

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 I. Teaching - The person demonstrates knowledge of the discipline/profession, skills of pedagogy,
including clear and precise communication and methods of instruction, and interest in the
educational achievements of students. The person should provide the following evidence: syllabi
which reflect the use of contemporary sources; a good correlation of method, content, and
student interest and need; student evaluation appropriate to the course objectives and academic
standards of the institution; and other appropriate indices of teaching effectiveness.

II. Scholarship, Research, and Creative Activity - In the area of scholarship, research, and creative activity,
competency is demonstrated by completing successfully a doctoral dissertation or project that is
required for the terminal degree. In addition, there should be some indication from the individual that he
or she will continue scholarly/creative work.

III. Public, University, and Professional Service - The person demonstrates a willingness to serve the
department, college, university, community, and discipline/profession by participating on departmental
program and service committees, by providing students regularly with accurate academic advisement
and information about college services, and by involvement in community service activities and
professional organizations.

Promotion to Rank of Associate Professor

Promotion to associate professor requires both a high and a consistent level of performance on all
of the Trustees' Policies criteria. Evaluation and recommendation for promotion to associate professor
and for continuing appointment will normally take place within the same cycle of departmental, faculty,
and administrative considerations. Although the Trustees' Policies do not permit continuing appointment
being made contingent upon promotion to associate professor, or vice versa, a recommendation for one
substantially reinforces a recommendation for the other.

I. Teaching - The person's teacher effectiveness dossier evidences continued excellence in the
classroom in the rank of assistant professor. This is to be done in the following ways:

a. By demonstrating that courses taught are in a continuous state of development and reflect
extensive and current resources.

b. By undertaking successfully new course assignments; by designing, developing, and successfully

teaching new courses not previously part of a department's offerings; and by participating
successfully in the college-wide instruction programs.

c. By providing whole-class student evaluations of teaching effectiveness in a variety of courses

over a reasonable period of time since appointment or promotion to the rank of assistant
professor.

d. By confirmation of teaching excellence by departmental colleagues who are directly familiar

with the person's work.

e. By demonstrating consistent and successful involvement with independent studies, research

projects, final major student works, and/or theses.

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 II. Scholarship, Research, and Creative Activity - The person has advanced significantly in the area
of scholarship beyond the level of assistant professor. This progress is demonstrated by providing the
following evidence:

a. Scholarly/creative work or performance record beyond that demonstrated for the terminal
degree. (There should be evidence that the person promoted to the rank of associate professor
has completed substantial work in new or continuing investigations that demonstrate a cohesive
line of thought in the discipline.)

b. Scholarship, creative works, and performance record (documented in visual media or through
reviews) should be national in scope. (Reputation of the journals, sources of reviews, and extent
of the performance record will be an important consideration.)

c. Significant work/research conducted, but not yet published, can also be provided at this stage of
professional development. (The significance of the creative research/work should be attested to
by reputable and established individuals in the field. It is important in these cases to attain a
number of objective evaluations that testify to the quality and the value of the research, product,
or performance.)

d. Invitations (particularly if unsolicited) to give readings, presentations, exhibitions,

demonstrations, or workshops at major conferences, institutes, or universities should also be
included.

e. Grants, awards, and particularly the quality of the works resulting from them are important for
promotion to associate professor.

III. Public, University, and Professional Service - The person ought to be able to demonstrate
excellence on a continuous basis in the area of service during the period of tenure as assistant professor.
This is demonstrated by providing the following evidence:

a. Increased administrative responsibilities and major leadership roles. (The important point is that
the assistant professor has consistently played an active and constructive role in departmental
meetings and committees and in college-wide service, including academic advisement,
recruiting, and in student service activities.

b. Substantive letters of recommendation which cite and describe the success of specific
contributions in providing initiative and direction in committee efforts.

c. Active role in the resolution of issues in professional and/or community organizations.

Those assistant professors already holding continuing appointments should be considered periodically
for promotion, at least by their chairs and deans. Although not all of these assistant professors on
continuing appointment can be expected to be promoted, chairs and deans should consider each case and
discuss with the candidate whatever criteria are still being insufficiently met, to the end of facilitating
the promotion to associate professor of those "tenured assistants" that are meeting our expectations for
promotion and continuing status.

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 Promotion to Rank of Professor
The promotion to professor should signal maturity and demonstrated excellence as scholar,
teacher, and contributing member of the college. Promotion to professor demands substantial and
sustained growth and evidence of contributions beyond the level upon which promotion to associate
professor was based. There are no hard and fast rules for time in rank or promotion to the next higher
rank, and faculty may apply for promotion at any time.

I. Teaching - The person must demonstrate continued excellence in the classroom in the rank of
associate professor. This is to be done in the following ways:

a. By demonstrating that the courses taught are in a continuous state of development and provide
students with extensive resources.

b. By undertaking successfully new course assignments and by designing, developing, and

successfully teaching new courses not previously part of curricular offerings.

c. By providing whole-class evaluations in a variety of courses since promotion to the rank of

associate professor.

d. Confirmation of teaching excellence by departmental colleagues who are directly familiar with
the person's work.

e. Evidence of a major contribution to the department or college-wide instructional program.

f. External assessment/reviews of student accomplishments/creative works which have a direct link

to the faculty member.

II. Scholarship, Research, and Creative Activity - Accomplishment in this area should be
significantly greater than was expected to achieve the rank of associate professor. There should be
evidence of new and more sophisticated levels of achievement. Successful research has led by now to
publication or creative work which has been subject to further review. Furthermore, the significance of
the person's accomplishment is attested to by peers and reputable figures in the field away from
campus.

a. Recognition of the quality of the work (publications, works of art, or performance record) should
be made evident and available in the form of reviews, comments, and citations in the works of
others; direct letters of assessment by recognized authorities off campus solicited by the
department and by the candidate; and such evidence as invitations from leaders in the field to
contribute to publications, conferences, and exhibitions, to serve on editorial boards, to review
books, etc. (Reputation of the place--journal, gallery, theatre--in which the articles, research
projects, poems, short stories, works, etc., have appeared will be an important consideration, as
will the publishers or sponsors.)

b. Honors or awards serve to recognize the person's contributions for long-term work in the field
and/or new interpretations and applications of research.

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III. Public, University, and Professional Service - Accomplishment in this area should be
significantly greater than was expected to achieve the rank of associate professor. Not only has the
person consistently played a constructive role in departmental meetings, committee, academic
advisement, and in college-wide faculty governance since the last promotion, he or she is now accepting
leadership roles in the department, the college, and the profession. This is demonstrated by providing the
following evidence:

a. Increased complexity in administrative duties. (For example, the person has chaired a variety of
committees, both inside and outside the department.)

b. The excellence of his or her contributions to the committees is testified to by colleagues and can
be illustrated in tangible ways.

c. The work/product of the committees is exemplary and significant to the college or organization.

As a general guideline, from associate to professor could come as quickly as four or five years
after promotion for the most exceptional faculty, i.e., those who are clearly outstanding on all
promotional criteria. Most associate professors should aspire to and seek promotion to full professorial
status from six to ten years after their promotion to associate status. Those associate professors whose
further growth is undistinguished or poorly balanced (i.e., very strong on some promotional criteria but
undistinguished on others) may expect to serve longer as associate professor before promotion to
professor. Some associate professors can be expected never to become professors.

ADVANTAGES OF A SOUND PROMOTION POLICY:

From a scientific management view point, a sound promotion policy has many advantages.
It provides an incentive to employee to work more and show interest in their work. They put in their
best in their best and aim for promotion within the organization.

It develops loyalty amongst the employees, because a sound promotion policy assures them of
their promotions if they are found fit.

It increases satisfaction among the employees.

It generates greater motivation as they do not have to depend on mere seniority for that
advancement.

A sound promotion policy retains competent employees, and provides them ample opportunities
to rise further

It generally results in increased productivity as promotion will be based on an evaluation of the

employee‘s performance.

Finally, increases the effectiveness of an organization

SOLUTION TO PROMOTION PROBLEMS:
Difficult human relations problem can arise in promotion cases. These problems may be reduced
to the minimum if extra and following principles are observed.

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  In promoting an employee to a better job, his salary should be at least one step above his present
salary.

 Specific job specifications will enable an employee to realize whether or not his qualifications
are equal to those called for.

 There should be a well-defined plan for informing prospective employees may know the various
avenues for their promotion.

 The organization chart and promotion charts should be made so that employees may know the
various avenues for their promotion.

 The promotion policy should be made known to each and every organization.

 Management should prepare and practice promotion policy sincerely.

RETENTION
NURSE RETENTION
By Lee Ann Runy
An Executive’s Guide to Keeping One of Your Hospital’s Most Valuable Resources
With no end in sight for the nation‘s nursing shortage, hospitals are placing greater emphasis on
retaining their current RN staff. It‘s a complex process, requiring in-depth knowledge of the needs and
wants of the nursing staff and lots of creativity. ―You have to know what motivates nurses to stay, say
Pamela Thompson, CEO of the American Organization of Nurse Executives. To that end, many
hospitals regularly conduct retention or exit surveys to understand what‘s on nurses‘ minds.
For hospitals that have successfully implemented retention programs, the trick seems to be in
providing good working environments and professional development and to accommodate individual
lifestyles.
―The stresses of the job can be compounded by responsibilities outside of the workplace. Hospitals are
doing what they can to support nurses on a personal level, which is where creativity mostly comes into
play. From concierge services that help nurses with errands to day care to flexible scheduling, hospitals
are doing whatever it takes to allow nurses to focus on their work and keep them in their jobs for years
to come.
DEFINITION:
Staff choose to stay for long periods within a cost centre, turnover is under is 10% annually.
Retention is the act of retaining. It is defined as the ability to continue the employment of
qualified individuals, that is, nurses and / or other health care providers / associates who might otherwise
leave the organization (dictionary.com, 2004b)

Importance of retention:

Being able to attract and retain is a key measure of the organization’s success. Success requires
excellence across the value chain. Excellence across the value chain is not only excellence in products
and services for customers but includes excellence in being a great place for employees to work.
Retention is not the absence of turnover or a soft issue that’s contrary to business goals.
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Retention is:
 loyalty and commitment from key people
 minimized voluntary turnover
 the value added equivalent for human capital

Retention means being built to last and being build to last means creating retention best practices.
Retention best practices create an environment where people want to come to work and give their best to
the organization.
Community governments cannot be successful unless they are able to provide excellence that
attracts and retains.

IMPORTANCE OF STAFF RETENTION:

• The advantages of staff retention are fairly clear. Most importantly perhaps, key skills, ideas,
knowledge and experience remain within your organization. Client relationships and networks
are also preserved in conjunction with all the income that these areas generate.

• Conversely, losing your key employees lays open the possibility that these people will than
assume roles with your direct competitors. As a result those invaluable skills, ideas, knowledge,
experience, relationships and networks are all transferred to another organization.

• On top of all these there are also direct costs involved in losing key employees. The cost of
replacing such an individual includes advertising, recruitment agency fees and the time spent
conducting actual interview process.
• Further more it is also worth considering the time and expense spent on the induction new
employees and lost revenue during the recruitment and bedding in process.
• All though an element of employee churns is both inevitable and healthy. It is nevertheless clear
that retention brings substantial benefits to your organization. Whilst attrition involves
significant direct and indirect financial costs.
PRINCIPLES ELEMNTS OF A HELPFUL PRACTICE AND WORK ENVIRONMENT:
To foster staff retention, organizations need to develop environments in which nurses want to
work. Among other things, nurses want safe workplaces that promote quality health care.
―It‘s the role of the nurse executive and nurse manager to establish a work environment that
supports professional practice,says Pamela Thompson, CEO of the American Organization of Nurse
Executives.
―That‘s one key piece to retention.‖ It‘s also important that nurses play an active role in shaping
their environment.
―Nurses want to work in a place that brings high quality to patients and know they have a role
in the process,‖ says Susan Shelander, director of recruitment and retention for Memorial Hermann,
Houston. Creating such an environment is not easy.
-The Nursing Organizations Alliance developed a set of principles to help hospitals and other
health care entities create positive work environments. More than 40 nurse organizations, including
AONE, have endorsed the principles.
NINE PRINCIPLES TO HELP

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FOSTER STAFF RETENTION:
1)Respectful collegial communication and
behavior
2) Communication-rich culture • Clear and respectful
• Open and trusting
3) A culture of accountability • Role expectations are clearly defined
• Everyone is accountable
4) The presence of adequate numbers of • Ability to provide quality care to meet
qualified nurses client/patient needs • Work and home life
balance
5) The presence of expert, competent, • Serve as an advocate for nursing practice
credible, visible • Support shared decision-making
leadership • Allocate resources to support nursing.
6)Shared decision-making at all levels • Nurses participate in system,
organizational and process decisions •
Formal structure exists to support shared
decision-making • Nurses have control
over their practice.
7)The encouragement of professional • Continuing education/certification is
practice and continued growth/ supported/encouraged • Participation in
development professional association encouraged • An
information-rich environment is supported.
8) Recognition of the value of nursing‘s • Reward and pay for performance.
contribution
9) Recognition of nurses for their • Career mobility and expansion
meaningful contribution to the practice

Members Involved in the Attracting and Retaining Process

Leadership sets the tone for the organization but everyone who works for the organization is
responsible for the final outcome. The total contribution has the impact of making the organization a
place where people want to come to work and do a good job. Leaders make the organization a great
place to work by providing: competitive salaries and benefits, information through policies, guidelines
and ongoing communication, positive feedback for a job
Well done, a safe and harassment free work environment. Employees follow the rules and are able to
give their best with the supports provided.
When Should Attracting and Retaining Take Place
Attracting and retaining employees should be ongoing. The organization must continually work
to be the best. Key to being the best is leadership always working to improve the organization in every
way possible. Leaders must set a positive expectation, follow-up to ensure the expectation is being met
and deal with any thing in the organization that has a negative impact; such as harassment, conflict or
discrimination.
Guide lines for retention

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 The key to attracting and retaining lies in treating people well and being competitive in the
market. Providing policies and procedures for people to follow, promoting a respectful workplace and
providing opportunities for people to develop and utilize their skills are key to attracting and retaining.
The organization must also be able to provide benefits that are competitive with other organizations.
These other organizations include: other businesses in the community, across the territory and across the
country. The competition will depend on the type of individual(s) the organization is trying to attract
and retain.
What does Attracting and Retaining Include
Attracting and retaining includes having policies for and being competitive in the following areas:
 EMPLOYMENT CATEGORIES
All employees must be placed in an employment category. The employment category varies
depending on the nature of the position. The type of employment category and any changes in the
employment category should always be in writing, signed by the employee and a copy placed on the
employee’s personnel file. The employment categories include:
 probation – most employees are placed on probation when beginning employment with the
organization or changing duties within the organization
 indeterminate – employment on a continuing basis, unless another period of employment is
specified
 part-time – employment on a continuing basis for hours less than the standard workday, week or
month
 Casual – employment on a casual basis with no set work hours. Employees are called to work as
required
 Term – employment for a fixed period of time. At the end of the specified period, the term
employee ceases to be employed
 job share – when two employees share the hours of work of one full time position
 Contractors – contractors are not employees. Contractors are independent employers that must
meet the test of being a contractor. Contractors should be awarded by a Request for Proposal
process
 Salary Administration
All aspects of salary administration for all employment types should have detailed policies and
procedures. This information provides clear direction and rules for all aspects of paying
employees. The policies should include:
 salary rates
 allowances
 overtime
 pay periods
 increments
 deductions
 Pay

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 Salary is determined by market pay rates for people doing similar work in similar industries
in the same region. Salary is also determined by the pay rates and salary ranges established by an
individual employer. Salary is also affected by the number of people available to perform the
specific job in the employer’s employment locale.

Rates of pay should be set for all employment categories. Rates of pay for unionized
employees are negotiated between the employer and the union. Rates of pay must be in writing and
available to employees.

The initial job offer and changes in employment category provide the rate of pay in writing to
the employee.

 When the pay is reduced for a job classification, new employees receive the reduced salary.
Employee(s) in the position when the pay is reduced do not receive a reduction in pay. Their
salary is maintained as long as they are in the position. This is referred to as Present
Incumbent Only and the rule is the pay for an employee with PIO status is held at the higher
range until the employee leaves the position.

 A term employee is paid based on an hourly pay rate within the pay range of the position.

 A part-time employee is paid a salary within the pay range for the position.

 On promotion to a position with more than one rate of pay, the pay increase must be at lest
equal to the last increment of the new position.

On transfer, pay does not change unless the employee was paid on a present incumbent only
basis before the transfer. If so, the employee’s pay upon transfer is set as on initial
appointment.
 Overtime
 To deliver programs and services effectively, organizations may require employees to work
outside of their regularly scheduled hours of work. The requirement for overtime is driven by
operational need.

 Compensation for overtime is paid when work is authorized in advance by an official of the
organization authorized to approve overtime. Overtime is compensated according to the
collective agreement or the applicable legislation. The employer controls the duration of the
overtime worked.

 The employer should make every reasonable effort to assign overtime work equitably to
readily available and qualified employees who are normally required in their regular duties to
perform that work. The employee needs to provide reasonable advance notice of the
overtime. An employee may, for cause, refuse to work overtime. The refusal must be in
writing. Cause may, for example, involve religious beliefs.
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  Instead of paying overtime, the organization may agree to grant equivalent leave with pay at
the appropriate overtime rate (lieu time). The leave with pay must be taken at a time
agreeable to both the organization and the employee. A maximum accumulation of lieu time
should be set by the organization.
Pay periods
 All employees should be paid within the same pay period. The pay period is usually weekly,
biweekly or semimonthly. Employees are notified of the pay period on hire.
 Employees are given at least two months notice of any change in a pay period or method of
payment. The timing of the pay periods depends on the needs of the organization and the
ability to process pay on a timely basis.
Allowances
 Organizations sometime provide allowances to compensate employees. Allowances can
include: northern allowance and safety allowances. Policies and procedures for determining
the types of allowances, who gets the allowance and how the allowance is administered,
should be developed and available to employees.
Safety footwear and gloves allowance
The Worker’s Compensation Board (WCB) or the NWT Safety Act requires some
employees to wear safety footwear and gloves. Sometime organizations either provide an
allowance to employees to purchase safety footwear and gloves OR the organization purchases
the safety footwear and gloves and provides these articles to the employees. The requirement for
employees to wear safety footwear and gloves should be included in the job description.
Northern allowance
 Employees in the north are sometimes paid a northern allowance to offset community
differences in cost of living and travel. The allowance is based on the community in which
an employee is employed.
 Northern allowances are taxable. Northern allowances can be paid in various ways: annual
lump sum, pro-rated to an hourly rate by dividing the annual rate by the standard yearly
hours of work.
 The allowance is not paid for periods of overtime of periods of leave without pay. Northern
allowance rates should be set and available to all employees.
Increments
 Increments are granted to employees in recognition of service and satisfactory
performance. Increments are adjacent steps in a pay range. Employees in positions with
more than one rate of pay are granted pay increments until the maximum rate is reached.
Employees should not be accelerated through the steps.

 The increment date is based on the anniversary date of the employee‟s appointment or
most recent promotion or the date the individual was hired to perform the same duties as
the new appointment if there was no break in service between the appointment dates. Pay
increments should be processed the first day of the month of the increment due date.

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  Rules should be set for receiving increments on promotion, demotion, transfer, and part-
time work. Increment dates are usually postponed for employees on leaves of absences.
The exceptions are: leaves of absence of less than six months; leaves of absence without
pay to work for another government department, board or agency; and paternity/adoption
leave. Increments postponed by a leave of absence is due when the employee returns to
work and completes a year of paid full-time employment from the effective date of the
last increment. This includes the periods of service before and after the absence.

 When an increment and a salary revision are due on the same date, the increment is to be
applied first.

 If an increment is denied the employee must be informed of the date of the next review,
which should be no later than 12 months from the date the increment is denied. At this
time, the employee should be entitled to the withheld pay increment, in addition to the
current pay increment, should performance be deemed to meet the required standard.
Deductions
An employee is required to pay and the organization is obligated to make mandatory
deductions from an eligible employees pay, at prescribed rates, premiums and amounts for the
following:
o Canada Pension Plan
o Employment Insurance
o income taxes
o staff accommodation rent
o court-ordered payments
o mandatory benefit plans

 Optional deductions may include:

o parking charges
o Canada Payroll Savings
o optional benefit plans

Employees are responsible for ensuring their pay is correct. Employers are responsible for
ensuring the proper deductions are taken and submitted on behalf of the organization. Policies on
deductions should include the types and amounts of deductions as well as a process for
employees‟ repaying overpayments. Usually a 10% maximum is the rule for repayment of any
overpayment to employees. Employees must be informed of any errors in pay and the
requirement to repay as well as the repayment schedule. Benefits
 The community government may provide a variety of benefits. Benefits make the organization
competitive and contribute to attracting and retaining employees. Benefits can include any or all
of the following:
o medical coverage, insurance(s)
o pension plan
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 o dental plan
o disability insurance
o clothing allowance
o medical travel assistance
o northern allowance and staff housing
Medical travel assistance
 The government of the Northwest Territories provides medical travel to residents. Some
organizations supplement the governments medical travel benefits through medical travel
assistance.

 Community governments should determine if they will provide medical travel assistance
to employees. Decisions should include what would the medical travel assistance look
like and how employees would be reimbursed for medical travel assistance.
 Medical travel assistance could include: accommodation, meals & expenses, travel,
medical escort, non-medical escort, juvenile escort, and compassionate escort.
Staff housing
 Housing is sometimes in short supply in many northern communities. To facilitate the
hiring of employees, some organizations provide staff housing. Where an employee is
provided accommodation, the employee and the organization need to enter into a formal
lease agreement. The rent for the staff housing should be deducted from the employee‟s
pay on a monthly basis.
Hours of Work
 The community government should establish a regular schedule of hours of work for
employees based on work requirements. The standard hours of work should include the
days and the hours that the community government will provide services. Employees in
some occupational groups may be required to work shifts where their days of rest may be
other than Saturday and Sunday, or their hours may be other than the standard hours.
When employees are directed to work
 Outside of the standard hours, they are to be compensated with overtime pay at the
applicable rate.
 Employees may make a request to work outside the standard hours, on an ongoing-basis
by submitting an alternate schedule to their supervisor for approval. The approval of such
requests would be based on the needs of the community government.
 The standards hours are exclusive of a minimum half hour lunch period scheduled as
close as possible to mid-day. 15-minute breaks should also be provided in the morning
and afternoon.
 The employer has a right and responsibility to know where employees are during
scheduled hours of work. Employees must attend work during their regularly schedules
hours of work. Each employee must provide reasonable notification to and seek approval
from the employer for any absence, including lateness and illness. Employees are notified
of the standard hours of work for their position by their supervisor.
Leave

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 Various types of leave are granted to employees. The community government’s policies
should outline the types and amounts of leave that employees are entitled to. Leave can
be paid or unpaid. An employee is responsible for understanding the types of leave set
out in the collective agreement/community government’s policies. An employee who is
unsure of what leave he/she is entitled to should speak to his/her supervisor.
 An employee is expected to report to duty and work unless on authorized leave. An
employee who is unable to report to duty and work is required to call their supervisor or
designate, personally, at the start of the workday. Employees are required to request
conditional approval of the leave and to provide an indication of the expected length of
the absence.
 Employees are entitled to be paid for authorized leave in the following circumstances:
o special occasions approved by the senior manager
o time off for voting for federal, territorial and municipal elections
o vacation leave (as set out in the private/government’s policies)
o sick leave (as set out in the private/government’s policies)
o some types of Civic Leave including court leave
o work related training
o union leave
o statutory holidays
 The employee should discuss the leave request with the supervisor. This should be done
as far in advance as possible so that the supervisor can plan for operational requirements
and service delivery during the employee’s absence. A request for time off work form
should be completed (an electronic format is useful). After the employee’s leave credits
are verified, the leave is approved or denied by the authorized approver. When the leave
is denied or modified, the authorized approver will contact the employee and explain the
reasons for the denial or modification. When the leave is approved, the authorized
approver will advise the employee in writing of the approval.
 Employee Recognition To attract and retain employees, private/governments institution
need to recognize the accomplishments made by employees. People need to feel that they
are a valuable and important part of their organization. Organization should be
committed to honoring and encouraging individuals and teams who contribute through
their efforts and actions to the success of the organization. Recognition can include:
o giving praise
o granting awards
o celebrating and communicating successes

 Recognition should be linked to the organization’s corporate objectives by supporting

defined goals and values. Recognition should focus on creating a lasting effect for
employees and the organization. Guidelines should be developed for each type of
employee recognition. Employee recognition programs could include:
o organization wide recognition
o department recognition
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 o long service with the organization
o appreciation for service on resignation and/or retirement
Code of Conduct
 Community governments are entrusted with the protection of the public interest in many
significant areas of society. In view of the importance of this trust, it is essential that the
high professional standards demanded of and adhered to by community government
employees‟ be recognized and documented. Recognition and documentation of these
standards will ensure continued public confidence in the impartiality and integrity of the
community government.
 A conflict of interest occurs when an employee’s‟ private interests and activities are at
odds with the responsibilities of government employment. Conflicts should not exist, or
appear to exist, between official duties and an employee’s private interests.
 Employees must perform official duties and arrange private affairs so public trust in the
integrity and objectivity of the government is conserved and strengthened. Employees‟
actions must withstand close pubic scrutiny. Employees must arrange all private matters
so conflicts of interest do not arise. Employees may not:

o Ask for any money or other benefit in addition to compensation and expenses for
any public service duties.
o accept any one of other benefit, except compensation and expenses, incidental
gifts, usual hospitality and other nominal benefits
o Step out of official roles to help others in dealings with the government if this
would result in preferential treatment.
o Take advantage of, or benefit from, confidential information gained as a result of
official duties.
o Directly or indirectly use, or allow the use of government property of any kind,
except for officially approved activities. This includes property leased to the
government.

 Employees should get prior approval from their senior official before having outside
employment or getting involved in any activity where there could be a conflict of
interest. The senior government official will decide whether outside employment or
activity is a conflict of interest.
Community Governments should develop a guideline for employees Code of Conduct to include
the following:
o principles for community government employees
o compliance
o discipline
o outside activities
o releasing information
o political activity

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 o gifts, hospitality and other benefits
o post employment
o complaints from the public
o appeal procedure
o dealings with family, friends and relatives
o public statements
o responsibilities

Conflict of Interest
Community governments have a duty to ensure that the government remains above
reproach. This involves ensuring that community government’s have political activity guidelines
and that employees follow the guidelines. If engaging in political activities, employees must be
able to maintain impartiality in relation to their duties and responsibilities. Within the constraints
established in the Code of Conduct, employees are free to participate in political activities,
including belonging to a political party, supporting a candidate for elected office and actively
seeking elected office, as along gas the political activities are clearly separated from their
activities related to his or her employment. The community government‟s guideline for Conflict
of Interest should include:
o a list of restricted employees
o circumstances requiring written disclosure from the senior government official
o when a leave of absence is required to participate in political activity
o the rules for political activity leave of absence
o the rules for employees having to resign when elected to a political office
Use of company vehicle guidelines
Community governments should develop vehicle use guidelines. Employees who drive
vehicles in the performance of their duties are required to abide by the vehicle use guidelines.
 Employees who use community government vehicles are required to have the appropriate
license. All government vehicles must be insured and registered. Registration and insurance
cards are to be in the vehicle are required by the Motor Vehicles Act. Government employees
must obey all traffic laws and follow the procedures in the guidelines when driving community
government vehicles and rental vehicles on community government business.
 All accidents must be reported in accordance with the policies and procedures for reporting
accidents whether or not another party is involved.
 Community government vehicles may not be used for personal reasons unless express written
permission has been obtained from the senior government official. This applies to employees
who use a community government vehicle while on stand-by and call outs, as well as during
regular working hours.
 A photocopy of each employee’s drive license must be on file. The employee has to have the
appropriate class of license for the vehicle they will be driving. Employees and contractors must
be informed of the vehicle use guidelines. The vehicle use guidelines should include
responsibilities for the following: drivers, supervisors, and vehicle fleet administrators.

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Workplace Health & Safety
Occupational health and safety is a means of controlling workplace hazards, by reducing or
eliminating occupational injuries or illnesses. Employers must ensure compliance with all
applicable provisions of Northwest Territories health and safety legislation and take reasonable
measures and precautions to make sure that working conditions are safe. Under Section 7 of the
Safety Act, community governments must establish a joint worksite Health & Safety Committee.
 Community governments need to recognize the importance of providing a safe and
healthy work place. Employees must take all reasonable precautions to make sure that
they and their fellow employees are working in safe conditions. Such reasonable
provisions include personal protection devices (such as alarms) for employees who are
routinely required to work in potentially dangerous situation and immediate help is not
available Where the employer requires an employee to undergo a specific medial, hearing
or vision examination by a designated qualified medical practitioner, the examination
will be conducted at no expense to the employee. The employee must, on written request,
be able to provide results of all specific medical, hearing or vision examinations
conducted. Specific, requested medical, hearing, or vision examination information
supplied by employees to the employer must be maintained in a confidential manner in
the employees personnel file.

 The employer must pay for medication examinations required to qualified for or maintain
a license or other qualifications required in the performance of those employee’s duties.
The employer must also pay for vaccinations, inoculation or other immunization when
required for employment.

Employees sometimes develop or present with impairments that impact their ability to carry out
work in a safe and proper manner. Symptoms that may indicate impairment include:
o slurred speech
o staggering
o lack of coordination or mobility
o marked change in personality or appearance

 Employees have the right to refuse work where it poses a safety hazard to themselves or
others. Managers must arrange necessary training and guidance that employees need to
carry out their duties in a safe manner. Managers do not allow impaired workers who
pose a safety risk to themselves or to others to remain at the workplace. The manager
must take reasonable steps to ensure the employee has safe passage to an appropriate
destination. Managers must make the workplace safe for employees by:
o monitoring workplace conditions
o limiting entry to authorized personnel
o correcting safety hazards
o providing protective devices
o providing protective clothing
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 o monitoring employees‟ performance
o providing training on safety procedures
o correcting problems, as required

Managers should take the following steps when an employee shows symptoms of impairment:
 accurately document all information about the perceived impairment
o the date, time and location of the incident
o behavior and mannerisms of the employee in question
o the names of witnesses, if any
o an explanation of how the employee presents a safety risk
 prevent the employee from entering or remaining at the work site
 provide an explanation to the employee
o how the employee’s condition prevents the employee from performing duties in a
safe and proper manner
o why the employee cannot return to the workplace until the employee is fit to carry
out duties in a safe and proper manner
o Conditions under which the employee will be permitted to return to the workplace
(medical evaluation, etc.)
o arrangements for safe passage to an appropriate destination
 ensures safe passage for the employee to an appropriate destination away from the work
site

When an employee feels there is an unusual safety hazard in the workplace, the employee should
take the following steps:
 immediately notify other employees near the unsafe working conditions of the potential
danger
 immediately report the circumstances of the unsafe working conditions to the manager
When a manger receives notice that an employee refuses to work, the manager:
 investigates the reported unsafe working conditions
 takes corrective action required to remove the unusual danger
 takes the corrective action in the presence of the worker who refused to work and a
representative of the employee‟s union (if a union worker)
 if the union representative is unavailable, have the employee choose another employee to
stand in for the union representative
 if the employee continues to refuse to work, call a representative of the health and safety
committee or a safety officer and have the committee representative or the safety officer
investigate the complaint
 take any further required corrective action
 if the employee still refused to work consider the employee insubordinate and take
appropriate disciplinary action
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 Workplace Conflict Resolution
Community governments must recognize the diversity of the workforce and be
committed to providing a workplace where all individuals are treated with fairness, dignity and
respect. Governments must be committed to providing a work environment where there is
respect among coworkers and to the provision of a flexible conflict resolution system that offers
effective solutions to workplace conflicts and the elimination of harassment. Harassment is
discrimination whether based on
o race
o creed
o colour
o sex (gender)
o marital status
o nationality
o ancestry
o place of origin
o age
o disability
o family status
o beliefs
o sexual preference
o religion
Community governments should develop a workplace conflict resolution policy. The policy
should apply to every employee in the community government, volunteers and contractors who
do business with the community government. The community government should make an effort
to ensure that all of the above parties are informed of the policy.

PERSONNEL POLICIES
DEFINITION OF PERSONNEL POLICIES
Policy-
1) Statement of predetermined guidelines
2) Policies in general, they are guidelines to help in the safe and efficient achievement of organizational
objectives

PERSONNEL POLICY-
1) A set of rules that define the manner in which an organization deals with a human resources or
personnel-related matter. A personnel policy should reflect good practice, be written down, be
communicated across the organization, and should adapt to changing circumstances.

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2) Personnel policy is an integrated function which encompasses many aspects of the personnel
management.
3) The written statement of an organization’s goal and intent concerning matters that effect the
personnel working in an organization.
4) Personnel policies are the statements of the accepted personnel principles and the resulting course of
administrative action by which a specific organization pattern determines the pattern of its employment
conditions.

IMPORTANCE:
1) To the employee it represents a guarantee of fair and equitable treatment.

individual worth.

t the needs of the organization better.

2) To the supervisor it is a safeguard in that it relieves her of the responsibility of making a personal
decision which may conflict with decisions given by other supervisors.

e as guides to action so that a great deal of time is saved by

administrational personnel in handling individual cases.

AIMS:
1) To ensure that its employees are informed of these items of policy and to secure their co-
operation for their attainment
2) To enable an organization to fulfill or carry out the main objectives which have been laid
down as the desirable minima of general employment policy
3) To provide such condition of employment and procedures as will enable all the employee to
develop a sincere sense of unity with the enterprise and to carry out their duties in the most
willing and effective manner
NEEDS FOR PERSONNEL POLICIES:
The objectives for formulating personnel policies are basically twofold:
One to have a formal statement on corporate thinking which will serve as a guideline for
action. Two, to establish consistency in the application of the policies over a period of time so
that each one in the organization gets a fair and just treatment,
Personnel policies need be specially created because of the following reasons:
1) The certainty of action is assured even though the top administration personnel may change
.The tenure of the office of any manager is finite and limited: but the organizations
continues, and along with it continue the policies, and this continuity of policy promotes
stability in organization.

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 2) Because they specify routes towards selected goals, policies serve as standard or measurable
yards for evaluating- performance the actual result can be compared with the policies to
determine how well the member of an organization have lived up to their professed
intentions.
3) The basic need and requirement both an organization and its employees require deep thought.
The administration is required to examine its basic convictions as well as give full
consideration to practices in the other organize.
4) Established policies ensure consistent treatment of all personnel throughout an organization.
Favoritisms and discrimination are thereby minimized.
5) Policies are “control guides for delegated decision-making” they seek to ensure consistency
and uniformity in decision on problem “that recur frequently and under similar, but not
identical, circumstances”.
6) Sound policies help to build employee enthusiasm and loyalty. This is specially true when
they reflect established principles of fair play and justice, and when they help people to grow
within an organization.
7) They set patterns of behavior and permits participants of plan with a greater degree of
confidence.
ESSENTIAL CHARACTERISTICS/TESTS OF A SOUND PERSONNEL POLICY
The main features of a good personnel policy are
1) It must be supplementary to the overall policy of an organization, for if departmental
policy is made such as to come into conflict and violate the company policy, it would be
tantamount to insubordination. Peter Drucker has observed. “The policies of an enterprise
have to be balanced with the kind of reputation an enterprise wants to build up with
special reference to the social and human needs, objectives and values’.
2) The statement of the any policies should be definite, positive, clear and easily understood
by everyone in the organization so that what it proposes to achieve is evident.
3) It should be written in order to preserve it against loss to stimulate careful consideration
before its formulation and to prevent the promulgation of numerous, differing and
temporary oral policies from multiple sources.
4) It should indicate that the administration knows that workers prefer to deal with the
administration on an individual basis.
5) It must be reasonably stable but not rigid, i.e., it should be periodically reviewed ,
evaluated , assessed and revised and should , therefore, be in tune with the challenge of
change in the environment and should have a but in resilience for adjustment from time
to time.
6) It must provide a two – way communication system between the administration and
employees to so that the later are kept informed of the latest development in the
organization and the employers are aware of the actions and reactions of the employees
on particular issues.
7) It should be formulated with due regarded for the interested of all the concerned parties –
the employees, the employers and the public community.
8) It should recognize the desire of many workers for recognition as groups in many of their
relationships.
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 9) It should be consistent with public policy, i.e., with the spirit rather than the letter of the
law, so that the intentions and settled course of an organization are appreciated in terms
of public opinion from the standpoint of national, economic and social justice for the
employees and for the community at large
10) It should be the result of a careful analysis of all the available facts.
11) It should be generally known to all interested parties.
12) It must have not only the support of the administration but the co-operations of
employees at the ship floor level and in the office.
13) It should have a sound base in appropriate theory and should be translatable into practice,
terms and peculiarities of every department of an enterprise
14) It should be uniform throughout the organization , though, in the light of local condition ,
slight variation may be permitted in specific policies relating to staffing , compensation ,
benefits and services
15) Before evolving such a policy , trade unions should be consulted in matter of industrial
relations; and the role of trade unions should be restricted only to this area
16) It should be progressive and enlightened, and must be consistent with professional
practice and philosophy.
17) It must make a measurable impact , which can be evaluated and qualified for the
guidance of all concerned , especially in the field of the three R’s of personnel
administration viz ., recruitment, retainment and retirement
ORIGIN AND SOURCES OF PERSONNEL POLICIES
Policies stem from a wide variety of places and peoples. They are not created in vacuum but are
based on a few principal sources which determine the content and meaning of policies. These
are.
1) The practices of an organization
2) State and national legislation
3) The prevailing practices among sister concerns in the neighborhood and throughout the
country in the same industry
4) The attitudes, ideals, and philosophy of the board of directors , top administration and
middle and lower and administration
5) The knowledge and experience gained from handling day–to –day personnel problems
6) Employees suggestions and complaints
7) Collective bargaining programmes
8) The extent of unionism
9) International forces ,such as may operate in times of wars
10) The attitudes and social values of labor
11) Change in the country’s economy
12) The culture of the plant and its technology, its business environment, its social and
political environment
13) The ethical points view or the social responsibility of the organization toward the public
,and
14) The goals of the organization

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OBJECTIVES:
1) To employ those persons best fitted by education, skill and experience to perform prescribed work.

2) Guarantee fairness in the maintenance of the discipline

3) Upgrade and promote existing staff wherever possible.

4) Take all practical steps to avoid excessive hours of work.

5) Ensure the greatest practicable degree of permanent and continuous employment.

6) Maintain standards of remuneration

7) Provide and maintain high level of physical working conditions.

8) Maintain effective methods of regular consultation between administration and employees.

9) Provide suitable means for the orientation, on the job training and evaluation of employees.

10) Encourage social and recreational facilities for employees.

11) Develop appropriate schemes for employees welfare.

FUNCTIONS AND TECHNIQUES

Employment Job analysis, job specifications, time schedules, works Schedules, manuals, agreed code of
regulations, assessment of personnel.
Remuneration Job evaluation
Health and safety Physical examination, safety training, accident analysis, sickness statistics.
Welfare Social and recreational programs, rest rooms, canteen, pension schemes, employers counseling
Training On the training, training for leadership.
TYPES OF POLICIES
a) Implied Policy:

 It is the policy which is not directly voiced or written but is established by pattern of decision.

 They may have either favourable or unfavorable effects

 It is the policy neither written nor expressed verbally have usually developed over time and
follow a presendent.

 If you have people who are accountable to you, you don‘t need to formally issue policy
statements to create policy.

 Parents, bosses, boards, government administrations, etc. are producing implied policy all of the
time.
 For Example: Imagine that an employee comes to the boss and asks, ―What should I do about
this?‖

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  If the boss responds by giving an instruction, that employee will assume that this is how to cope
with all similar situations. They will interpret the instruction in terms of the implied values or the
general policy that would result in the instruction.

b) Expressed Policy:

 These are delineated verbally or in writing.

 Oral policies are more flexible than written ones and can be easily adjusted to changing
circumstances.

 Most of the organization have many written policies that are readily available to all people and
promote consistency in action. It may include:
 Formal dress code
 Policy for sick leave or vacation time
 Disciplinary procedures

TYPES OF PERSONNEL POLICIES IN NURSING

1) General and Specific policies:
General policies are stated in broad terms which generalize a statement allowing freedom to
individual department and action
For example in nursing profession, there is a general policy which states that nurses should be
having the qualification of RN and RM to enter into practice to work as a general nurse. But in a
hospital there may be s special policy which restricts freedoms of entry into a particular area
such as “nurses who have worked in ICU for at least one year are eligible to work in recovery
room and ICU.
This helps you to understand that specific policies have a sort of limitation for decisions as well
as actions.
2) Expressed policies :
These are expressed either orally or in a written form
a) Oral policies are more flexible and lose authenticity
b) Written policies: policies which are written are explained as written policies and they are
better guides to take quick actions. Best example could be written manuals of nursing
practices and job descriptions of different jobs. The only disadvantage of written policies are
they are not flexible and are rigid too follow. But written documents are always like evidence
which reduce confusions.
3) Implied policies:
These are entirely opposite to written policies. The behavior and actions of superior are followed
by other. The actions implemented as precedence may be followed as policies. Written policies
are preferred to imply ones as they can act as definite guidelines and have an authenticity. They
offer a good reference for taking appropriate decision. Implied policies are sometimes
questionable due to their unethical nature.
4) Originated policies :
These policies are purposefully originated from the top managers to guide the subordinates. They
originate from the objectives and goals of the organization and they are broad from where the
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departmental policies could emerge. Top management’s broader policies are kept in mind by the
subordinates or followers to develop supplemental policies. These are also known as internal
policies.
Sometimes policies may be framed by the first line manager and passed to top managers for
approval
One of the examples could be that the ward in charge frame policies for their departments and
get the approval of chief nursing officer or director. A policy manual in writing is a good
example.
5) Appealed policies:
On request of subordinate, policies are written which help them to take appropriate decision.
For example, standing orders to act in a particular situation as and when needed can be
written as a policy or order. Sometimes these appealed policies are not clear and may be
incomplete. Some examples may be taken on which the decision are made the decision may
overlook later on repercussion. Some examples could be promotions or postings with some
appeals or some justifications which may create problem as “precedent” to the management.
6) Imposed policies:
Policies are imposed under the direction of other forces also known as external policies and
are thrust on the organization by external , such as government or labor union or associations.
Many times the policies are framed according to the direction or order of government,
council or association, in nursing, nursing services and education are influenced by the direction
of TNAI or INC or state government or central government .some time some actions are the
result of the decision of the professional union
Sometime force from external sources could be situations created by labor unions through
which policies emerge. Negotiations and collective bargaining help to frame imposed policies in
the process of conflict management
7) Organizational policies:
If the organizational policies are formulated by the top manager or head of the organization as
over all policies they are termed as organizational policies they are similar to originated policies
Timings or working schedules for all the employees specified, could be one example, suggesting
an overall policies
8) Departmental policies:
These are different from organizational policies and these are limited to departments and they
also called as functional policies. They are based on the directions of organizational policies but
limited to a particular department operational theatre policies apply to that department which
may not be applicable to other departments.
STEPS TO FORMULATING THE POLICY:
Policy formulation requires knowledge and skills such as judgment, imagination,
creativity and evaluative skills. There is a need to considerer some factors in policy formulation.
They are:
Factors consider:
i) objectives of organization
ii) The facilities and limitation to be taken care of for implementation of policies

211
 iii) The individual values , interest and abilities of those who are responsible for the external
i.e. the society
iv) The external forces affecting the policies e.g.goverment , religious norms etc
v) Past experiences with similar or related policy implementation
vi) Organizational behavior especially the attitudes and human relations.
1) Defining the policy area:
Based on the philosophy and objectives, the area needs to be needs to be well defined e. g.
working hours or working schedules, uniform of nurses; recruitment and selection of staff etc
2) Developing various policies considering the available resources , types of environment
influencing the work and efforts in the organization
3) Examination / evaluation of the policy alternatives (different policies) against the criteria of
achievement of objectives.
4) Choosing a right policy
Even though it is a tough job, this is the vital step in policy formulation. Right policy is that one
which merits all the principles and requisites of a “sound policy” which enable not only the
achievement of set objectives of the organization but also encourages co – ordination, co –
operation and smooth functioning among and between all the personnel
5) Intimation and interpretation of policy:
Proper communication is an essential factor in policy formulation. Policy should be written
clearly in such a way that it avoid misinterpretation and all the personnel should be made to
understand and interpret the policy correctly in order to implement the same with appropriate
decision making and action
Policies should be clearly written so that each and every one follows with uniformity
6) Policy revision :
7) Policy should be made relevant and up to date , keeping in the mind the changing situation ,
which needs periodic review
In nursing practice many procedures are modified according to the changing/ advancing
scientific knowledge. Similarly the policies imposed on nurses for registration/licensure are
reviewed and it is seen that there is almost a kind of uniformity in many states of India
Policy developed should become relevant to the needs of the organization, needs of society and
needs of the nation.
CHALLENGES OF THE PERSONNEL MANAGEMENT AND CHANGING
PERSONNEL POLICIES IN NURSING:
As it was explained earlier policies are dynamic in nature and are expected to face
frequent review based on the challenges faced by personnel management. The common
problems which challenge the management is.
1) Changing trends in workforce or employees
a) more female employees
b) increasing number of married females
c) different levels of educational background
d) increase in number of qualification
Nursing profession is also showing similar changing trends and many nurses are increasing their
level of education and more nurse are married in comparison to earlier days , demanding
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 changing strategies in the personnel management . The policies e.g maternity leave are
periodically revised by the institution based on needs of family and country.
2) Changing value of the personnel
People with different avenues opened for jobs look for different job for different increased
prospects. Changes in attitude due to changed values is causing increased turn over or migration
to other places . The personnel department is forced to impose some rules or disciplinary
measure in order to reduce the quick turn over rate.
For example, some hospitals do not issue an experience certificate to an employee if she / he
leave the institution before the specified period. Individual in spite of this rule deciding to; leave
for personal benefits, shows the changed values and interests.
3) Changing expectations of members:
Management has never been so confused as it is required to fulfill the highest expectation of the
lowest members to the same extent as that of higher member and there is a steep rise in the
expectation of members at all levels in every organization
4) Changing needs of employee and employers
PHILOSOPHY:
―The nursing service administration of…….. believes that its supreme objective ; the best possible
patient care, can be achieved only by the full cooperation of all who are privileged to take part in that
care‖.
―It seeks to establish a team dedicated to the protection of health and well being of the patient in an
environment that will enable every member of the team to obtain as well as give satisfaction in his or
her work‖.
ELEMENTS OF PERSONNEL POLICIES STATEMENT
Operating Procedures
The statement details the company's operating procedures, including how employees should
accomplish their assigned tasks; punctuality, work hours, and breaks; payment structure; personal
appearance and dress code; drug and alcohol policies; benefits; and other employee guidance and
responsibilities.
Employee Conduct
The statement defines the company's policies and guidelines about such matters as professional
conduct with other employees and clients.
Equipment Use Regulations
Employee use of office equipment is another key item. If personal or non-work-related use of
computers, telephones, other equipment, and office supplies is prohibited, this should be outlined.
Professionalism
With an employer personnel policies statement in effect, business owners, managers, and employees are
afforded a greater air of professionalism, according to the National Restaurant Association's guidelines
for writing an employee manual.
Employer Authority
One of the principal functions of an employee statement is that it offers the employer a point of
reference in the event that an employee is reprimanded or terminated, thereby protecting the employer
from wrongful termination lawsuits.
PROCESS OF DEVELOPMENT OF PERSONNEL POLICIES
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 Every organization should have a complete set of well developed personnel policies before it
begins to function. The existing ones also need to be revised. At times, the policies may be formulated
simultaneously from the top management as well as the lower division management. The stages and
sequences of events in the process of development of policy are:
1) Clarification by top management of philosophy and the objectives of the organization.

2) Analysis of personnel policy requires assessment of relevant facts. Job is delegated to the committee
who through interviews and conferences collect data from inside and outside the organization.

3) Consultation with staff representatives.

4) Writing the first draft of the policy statement.

5) Further discussion to get the final approval of policies from top management and staff
representatives.

6) Communication of policy statements by means of training session, discussion groups and staff hand
books.

7) Periodic re evaluation and follow up

SERVICE STAFFING POLICIES (HOSPITAL)

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 - recruitment rules,
qualification

tation To Different Shifts

- special duty/ hard duty

allowance, medical allowance. The nursing
personnel have demanded a uniform
allowance of Rs 3,000 per month and a
nursing allowance of Rs 1,600 per month.

POLICIES RELATED TO NURSING EDUCATION

Policies For College Of Nursing
STUDENTS STAFFS HOSTEL POLICIES

authorized visitors

iform

violation of rules

FACTORS INFLUENCING PERSONNEL POLICY

The following factors will influence determining of personnel policies of an organization:
i) Law of the country: The various laws and labor legislation govern the various aspects of personnel
matters. Policies should be in conformity with the laws of the country

ii) Social values and customs: there are codes of behavior of any community which should be taken in
account in framing policies.

215
iii) Management philosophy and values: Management cannot work together for any length of time
without clear broad philosophy and set of values which influence their actions on matters concerning the
work force.

iv) Stage of development: All changes such as size of operations, scale of technology, innovations,
fluctuations in the composition of workforce, decentralization of authority and change in financial
structure influence the adoption of personnel policies.

v) Financial position of the firm: The personnel policies cost money which will be reflected in the
price of the product. Because of this, prices set the absolute limit to organization‘s personnel policies.

vi) Type of work force: The assessment of characteristics of workforce and what is acceptable to them
is the responsibility of the effective personnel staff.
CHARACTERISTICS OF PERSONNEL POLICIES
• Specific Consistency, Permanency, Flexible with Purpose Recognize individual differences.
• Be formulated with regards for the interest of all parties, i.e. employer, employee (individual/
groups) public and clients.
• Confirm to the government regulations be written and formulated as a result of careful analysis
of all facts available.
• Be forward looking and forward planning for continuing development
• Recognize individual difference

ADVANTAGES

ization for which they work.

they want to remain in the organization.

ious situations to
meet the needs of the organization

TERMINATION:
Meaning:

People have different reasons for leaving an organization. Sometimes the termination is planned and
other times it is not. The organization should be ready for both planned and unplanned terminations.
When the organization is not prepared for terminations the consequences can have a major impact on the
business. Some of the consequences could include:

216
 A disruption in service and not being able to meet commitments. The result could be a loss of
business and a loss of credibility for the organization. There should always be a plan to deal
with terminating employees to ensure that the business operates smoothly and commitments are
met.
KINDS OF TERMINATION:

There are a number of different kinds of terminations from employment. The different types of
termination include:
 Rejection or Probation
 Lay offs
 Abandonment of position
 Medical Termination
 Resignation
 Retirement
 Death in service
MEMBERS INVOLVED IN TERMINATION

The supervisor and the employee should always be involved in the termination process. Sometimes
other people are involved:
 medical termination would include the employee’s physician
 death in service would include the employee’s next-of-kin

WHEN SHOULD TERMINATION OF EMPLOYMENT TAKE PLACE:

 REJECTION OR PROBATION :
The purpose of a probationary period is to:
-Provide the employing department with a reasonable period of time to decide if an
employee is suitable and competent in the duties of the position
-Provide an employee with the opportunity to adapt to the work environment
Rejection on probation is termination of employment while on probation. Rejection on probation
may be considered when:
-A probationary employee fails to maintain the required standard of conduct and
corrective action has not resulted in acceptable improvement in performance
-if it is determined the employee is not suitable for the position or does not have the
competency to perform the duties of the position at an acceptable level

The duration of a probationary period must be stated in the original job offer.
Probationary periods are usually six months. The probationary period can be twelve months for
more responsible positions. Employees that move to a position of higher responsibility within an
organization are usually placed on probation. Employees are usually rejected on probation for
unsuitability, incompetence or misconduct. There must be adequate documentation to support
the rejection on probation. The supporting documentation could include:
217
  performance appraisals
 records of disciplinary action
 attendance records
 letters of warning
It is very important for the supervisor to meet with the employee within the first week of
employment. During this meeting written expectations should be agreed on. Follow-up meetings
on a regular basis throughout the probationary period should be held. During these meetings:
 expectations should be reviewed and compared to the performance
 strengths and weakness of the employee should be discussed
 the employee must be made aware of any failure to reach an acceptable level of
performance and given an opportunity to improve the performance
 the employee must also be made aware that failure to reach an acceptable level of
performance may result in his/her being rejected on probation

If a probationary employee’s performance does not meet the required standard despite the
assistance provided and the reviews conducted, the supervisor may determine that the employee
should be rejected on probation. A supervisor may also recommend rejection on probation as a
result of misconduct. The recommendation to reject an employee on probation should be made to
the senior manager of the organization. The appropriate documentation should accompany the
recommendation.

The employee is informed in writing by the supervisor that rejection on probation is

being recommended. The employee is advised of the reasons for the rejection on probation and
given the opportunity to make a submission to refute the recommendation. If the employee
chooses to resign during the probationary period, the rejection on probation recommendation is
withdrawn and does not become a part of the individual’s employment record.

The senior manager reviews the recommendation and the submission made by the
employee. If it is determined that rejection on probation is appropriate, the senior manager
informs the employee of the rejection in writing. A copy of the letter of rejection is placed on the
employee’s personnel file.
 Layoffs
Layoff is the termination of employment because of lack of work or because of the
discontinuance of a function. “Layoff” does not include termination of employment because of
a transfer of the work or function to another employer where the employee is offered
employment with the new employer.
 All organizations should value their employees and the work they perform. It is important for all
the organization to be committed to the retention, retraining and department of staff. This
commitment provides stability to employees through the promotion of job security and career
development. It also allows the organization to maintain a skilled, stable and competent work
force.

218
Unfortunately, in some circumstances layoff is unavoidable and is the only viable option of the
employer and the employee. Where positions will be deleted because of a change in department
structure, responsibilities or functions, every reasonable effort should be made to retain employees by
placing them in vacant positions in the organization. They should either be qualified for the positions or
become qualified through retraining. When an organization determines that positions are to be deleted,
the senior manager identifies those employees who may be affected. The organization should develop a
strategy for retention of employees. The strategy should be designed to mitigate the impact of the
deleted positions. The strategy should:
-set out a plan to minimize as much as possible the need for layoff
-identify vacant positions and retraining opportunities within the organization
-identify transfer opportunities that may be available
-identify alternative employment and retraining needs and opportunities
-identify potential funding sources for retraining
Employees subject to layoff should be notified of:
-vacancies in the organization
-transfer opportunities
-alternative employment
-retraining opportunities
Layoff should never be used to terminate the employment of an employee for poor performance or
misconduct.
 As soon as it is determined that positions may be deleted, management should meet with the
employees who may have been affected. If employees are part of a bargaining unit, a
representative from the union is invited to participate. The employee(s) are advised of the time
frame in which the positions will be deleted or reorganized.
 Abandonment of position:
An employee has abandoned their position when they have failed to report for duty for a
period of one week and have not made arrangements to be absent. When an employee is absent
from duty without permission the supervisor should:
 make every reasonable effort to contact the employee to determine the reason for
absence and to establish the employee’s intent with respect to returning to duty
 Document all attempts to contact the employee. Attempts should include
telephoning the employee, contacting a spouse or relative, visiting the employee
at home and sending the employee a double registered requesting an immediate
response.

If the supervisor is successful in contacting the employee, the supervisor and the
employee should agree on a date for the employee to return to work. When the employee returns
to work the supervisor should determine if discipline is necessary.
If the employee does not return to work on the date specified or the supervisor has been
unsuccessful in contacting the employee, a request for declaration of abandonment of position is
prepared. The request should be sent to the senior manager of the organization. The request must
be accompanied by supporting documentation. The supporting documentation should include:
219
 -name of the employee
-position title and number
-attendance records showing the period of absence without leave
-a summary of the attempts made to contact the employee
The senior manager should advise the employee in writing that he or she is declared to have abandoned
his or her position. The employer should make every reasonable attempt to immediately hand deliver
this written notice. A copy of the letter is placed on the employee’s personnel file.
 Medical Termination
Medical termination is a non-disciplinary termination of employment. A medical
termination is considered when an employee is unable to do the job because of illness and it is
unlikely that the employee will sufficiently recover to return to duty in the near future.
A medical termination is appropriate in cases where an employee has been off duty due to
illness for an extended period of time. Usually the employee has been off for over a year and the
employee is unable to carry out the duties of the position. Medical terminations can be actioned
earlier if the prognosis shows that the employee is unlikely ever to return to duty. The basis of a
medical termination is a prognosis of the employee’s condition. The employer is expected to
accommodate absenteeism due to illness in most cases. A medication termination is appropriate
only where the absences are extensive and likely to be of long duration. Care needs to be taken in
all medical termination cases to ensure that there is no discrimination against an employee due to
disability.
When an employee requests an extended period of sick leave, either with or without pay, the
senior manager should write to the employee and request a prognosis. A prognosis is a physician’s
statement outlining the long-term expectations regarding an employee’s medical condition. The
prognosis does not state or describe the employee’s medical condition. It indicates if and when the
employee may be able to report for duty and what tasks the employee may be able to perform. If a
prognosis is not provided or is incomplete, the senior manager requests the prognosis a second time.
The senior manager advises the employee that refusal to provide the medical prognosis may be seen
as insubordination.
The prognosis is used to assist the organization in dealings with the employee.
 If the prognosis does not indicate a definite return to duty date or if it states that the employees
medical condition makes it impossible for the employee to return to the position in the near
future, medical termination may be considered
 If the prognosis states that the employee can return soon, every effort is made to accommodate
the employee
 if the prognosis indicates the employee can return but cannot do all the duties of the position,
efforts are made to accommodate the employee through a transfer, reduction in hours, special
office equipment, etc

Proceeding With Medical Termination:

The supervisor discusses the situation with the employee and advises the employee that
medical termination is being recommended and the employee is given the opportunity to
apply for disability insurance or Workers‟ Compensation benefits, if applicable
220
 the employee is advised to consider other options such as medical retirement
the employee’s supervisor recommends medical termination to the senior manager
the senior manager writes to the employee to advise of the recommendation for
termination
the employee is given the opportunity to present information to refute the
recommendation
The senior manager considers any information the employee provides. If medical
termination is determined to be appropriate, the senior manager advises the employee
that the medical termination is being actioned
a copy of the termination letter is placed on the employee’s personnel file
 Retirement:
Employees are considered to have retired from an organization when they are eligible for
company and/or Canada Pension benefits. Employees have the primary responsibility for
planning for their retirement. Employees can request pension information from their Human
Resource Officer. The Human Resource Officer directs the employee to other sources of
retirement benefits and information such as Canada Pension Plan and Old Age Security.
 Death in service :
An organization should make every effort to deal with terminations due to death as
quickly and compassionately as possible. When an employee dies, all advanced but unearned
leave should be forgiven. Payments for salary and benefits earned up to and including the date
of death should be made to the employee’s estate. Pension and insurance benefits should be
processed as outlined in the employee’s personnel file.
TOOLS AND RESOURCES:
There are a number of tools and resources that you can use to assist in the termination
process.
o This manual and samples: you can use this manual and samples each time you need
to conduct a termination session.

Employee retention refers to the various policies and practices which let the employees stick to
an organization for a longer period of time.

Every organization invests time and money to groom a new joined, make him a corporate ready
material and bring him at par with the existing employees. The organization is completely at loss when
the employees leave their job once they are fully trained. Employee retention takes into account the
various measures taken so that an individual stays in an organization for the maximum period of time.

EMPLOYEE’S PROBATION RATING FORM

Name ---------------------- date:---------------------------------

Confirmation due on ----------------
Designation:---------------------------- department:--------------------------
Please choose the rating which best describe the employee’s performance in each factor and tick your
choice
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Factor Description
Quality of work Generally careless, excessive errors -----
somewhat careless, occasional errors -----
quality meets requirement of the job -----
careful worker, good quality of work ----
Seldom makes error, excellent quality of work -----
Attendance, Has never been absent or tardy -----
punctuality, Seldom absent or tardy -----
Occasionally absent or tardy ------
Dependability Frequently absent or tardy -----
Unacceptable absence or tardiness ------
Quantity of work Exceptionally fast worker ----
Fast worker ----
Meets volume requirement of the job ------
Slow worker, occasionally falls behind in work ------
Very slow worker , often falls behind in work -----
Initiative Exceptional ability in initiating action , follow- up -----
Works well with minimum supervision and direction -----
Shows qualities of leadership and originality -----
Performs routine assignment needing some supervision -----
Does not take initiative
------
Ability to work with Very co –operative, seeks way to help ----
others, graciousness Actively co – operative ----
Good attitude , follow instructions willingly ----
Not readily co –operative ----
Antagonistic and or / trouble maker ----
Appearance Exceptionally well groomed, good taste in dress ----
Carefully groomed , appropriately attired for work -----
Meets grooming and dressing requirement for job ----
Some what careless, occational disregard for appearance -----
Generally careless in grooming , solvetly attired
------
Interpersonal relation With superior -------(very good/ good/so-so/bad)
With peers -------(very good/ good/so-so/bad)
With subordinates-------(very good/ good/so-so/bad)
With patients -------(very good/ good/so-so/bad)
With visitors -------(very good/ good/so-so/bad)

Department head’s comments, if any

Signature of the employee department head’s signature
222
SAMPLES: ORIENTATION PROGRAM CHECKLIST
Item Date
Completed

Provide employee with orientation folder including:

Organizational Information:
History of the community government Jan 10, „04
Structure of the community government including the Council or Jan 11 o4
Board structure (organizational chart)
Organizational vision, mission, mandate, principles, values, goals Jan 11, „04
and objectives
Rules of the organization Jan 10, „04
Programs and services provided by the organization Jan 10, „04
Job Related Information: Jan 11, „04
A current job description
Layout of physical facilities and equipment Jan 10, „04
Safety procedures and processes Jan 10, „04
General Employment Information related matters: Jan 11, „04
Pay scales
Probationary period Jan 10, „04
Disciplinary process Jan 11, „04
Training and development procedures Jan 11, „04
Performance appraisals procedures Jan 11, „04
Benefits information Jan 10, „04
Entitlements such as rest breaks, holidays (including process for Jan 10, „04
applying for holidays)
THE FOLLOWING PROCESS WILL BE USED TO ORIENT NEW STAFF TO THE
WORKPLACE
Item Date
completed
Introduce employee to co-workers and workplace

Make formal introductions to:

Senior Officer Jan 10, 04
Co-workers Jan 10, 04
Representatives from other governments and organizations Jan 12, 04
Vendors, contractors and other Jan 10, 04
Show employee around the office including:
Washrooms Jan 10, 04
Supply areas Jan 10, 04
Tools/equipment areas and storage Jan 10, 04
223
 Filing cabinet Jan 10, 04
Other
Go over important information with the employee including

Job description, performance appraisal and training needs assessment Jan 11, 04
process
Mission, mandate, goals and Jan 11, 04
objectives

Organizational structure Jan 11, 04

Organizational rules Jan 11, 04

Review safety rules and Jan 12, 04 Jan 12, 04

information

Other

Item Date
completed
Go over benefits and entitlement information

Ensure employee signed up on pay system Jan 11, 04

Review and sign up for benefits Jan 10, 04
Review entitlements Jan 11, 04
Review personnel policies and procedures Jan 11, 04
Vendors, contractors and other Jan 10, 04
Schedule follow up sessions:

Two-week follow-up meeting Jan 24, 04

One month follow up meeting Feb 10, 04

Six months follow-up meeting Jul 10, 04

including performance review
and training needs assessment

WORKBOOK
IN THE FOLLOWING CHART, DEVELOP YOUR OWN ORIENTATIONCHECKLIST.
(MAKE COPIES AS REQUIRED).
Item Date
completed

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ATTRACTING AND RETAINING CHECKLIST
item Date
completed
Placement into employment category
Outlined salary administration
Set up rates of pay
Overtime guidelines
Setting up pay periods

Establishing Northern allowance

Setting increments
Deductions
Establishing benefits
Establishing medical travel assistance
Staff Housing
Establishing hours or work
Leave
Employee recognition
Employee code of conduct
Workplace health and safety guidelines

CHAPTER- V Jaqulin mary

STAFF DEVELOPMENT PROGRAM

1. INTRODUCTION:

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Staff development program is a broad area of responsibility and is borne by many people in the
organization the needs of the adult learner are explored and the coaching as a staff development tool is
introduced. There is an emphasis on how organizations, leader – manager and staff development
department can best support evidence based practice. Last the need to build a cohesive team, including
the needs of a culturally divesrse workforce, is explored.

2. MEANING:

Staff development is the process directed towards the personal & professional growth of the nurses and
other personnel while they are employed by a health care agency. Personal and Professional
Development (PPD) is the new name for the Staff Development.

3. DEFINITION:

Staff development includes all training and education undertaken by an employer to improve the
occupational and personal knowledge, skills, and attitudes of employment.

-swanburg

Staff development refers to the processes, programs and activities through which every organization
develops, enhances and improves the skills, competencies and overall performance of its employees and
workers.

-Pallab dutta

A process consisting of orientation, in-service education and continuing education for the people of
promoting the development of personnel within any employment setting, consistent with the goals and
responsibilities of the employment. - (ANA)

4. NEEDS FOR STAFF DEVELOPMENT:

 Social change and scientific advancement cause rapid obselescene of nursing knowledge and
skill.
 Advancement in the field of science like medical science and technology increased the demand
of nursing services and improved nursing’s response capabilities.
 To provide the opportunity for nurses to continually acquire and implement the knowledge,
skills, attitudes, ideals and valued essentials for the maintenance of high quality of nursing care.
 As part of an individual & apposes long-term career growth.
 To add or improve skills needed in the short term
 Being necessary to fill gap in the past performance
 To change or correct long-held attitudes of employee
 To move ahead or keep up with change.
 Fast changing technologies
 Need to increase the productivity and quality of the work.
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  To motivate employees and to promote employee loyalty
 Fast growing organizations.

5. THE STAFF DEVELOPMENT PROCESS:

Philosophy Objectives organization personnel Advisory Budget

committees.

5.1 Philosophy of staff development program

The organization needs a statement of beliefs about how it will accomplish its staff development
program. The staff development philosophy should be related to the mission and philosophy of the
organization of which it is a part. The statement of philosophy should be written by a representative
group, not by an individual and be accepted by both staff and administration.

In writing a philosophy for staff development for the health care professionals, beliefs about the
following areas are addressed:

1. How learning take place s

2. Teaching models
3. Responsibilities of employees for their own learning
4. Organization’s responsibility for providing staff development
5. Client rights to health care

5.2 Objectives

 Assist each employee (nurse) to improve performance in his/her position.

 Assist each employee (nurse) to acquire personal and professional abilities that maximize the
possibility of career advancement

 To increase employee productivity.

 To ensure safe and effective patient care by nurses.
 To ensure satisfactory job performance by personnel.
 To orient the personnel to care objectives, job duties, personnel policies, and agency regulations.
 To help employees cope with new practice role.
 Help employees cope with new practice role.

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Help nurses to close the gap between present abilities and the scientific basis for nursing practice that is
broadening through research

5.3 Organization of staff development

A staff development program can function under many organization models depending on the
philosophy of the agency.

Centralized model

In centralized model there is an agency – wide staff development, and the educational staff may consist
of nurses are educator who are not nurses. In this model all department collaborate in determining and
planning job needs of their staff. The centralized model facilitates scheduling and use of equipment and
may prevent duplication of efforts. The main criticism of this model is separation from nursing staff and
perpetuation of the us- against – them attitude.

Decentralized model

In Decentralized model the nursing department has its own organized in – service or staff development
department. The nursing staff development department may then adopt a centralized or decentralized
model. The strength of the decentralized model is that the specific needs identified by an area can be
addressed. The major area of concerned in Decentralized

Are the use and scheduling of class rooms, duplication of efforts and the cost of providing multiple
small programs. There is a trend towards Decentralized of as many functions as possible in health care
organizations.

5.4 Staff development personnel:

Nursing service administrators are responsible for staff development in order to promote quality client
care. Among their responsibilities are the following.

 Providing financial and human resources

 Establishing policy for staff development
 Providing release time and / or finances for staff to attend continuing education
offerings.
 Motivating employees to assume responsibility for their own professional
development
 Providing mechanism to identify staff growth needs
 Evaluating the effects of staff participations in continuing education offerings on
quality of client care.

The staff development coordinator is an administrator and a teacher who is able to communicate and
establish trust, has knowledge and a skill in adult education, had knowledge of training resources and
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subject matter, and understands the program planning process. As an administrator, the coordinator
understands organization theory and has a skill in budgeting, personnel management and group process.
As a teacher, the coordinator has educational skills in diagnosing learning needs, developing learning
objectives and lesson plan and selecting and using appropriate teaching techniques.

The professional development staff is selected by the coordinator to work in the planning, implementing
and evaluation of staff development programs. The size of the staff depends on the size of the agency. In
small agencies the coordinator may be the only staff member. These personnel may be totally
decentralized to the unit level.

5.5 Advisory committees.

An Advisory committee can be useful for identifying needs and resources and for planning programme.
Members of the committee should represent fields of practice in the agency. Other members may
include people with needed expertise. Committee members may increase participation because they can
communicate the purpose of staff development or program directly to the people they represent.

5.6 Budget for the staff development

The amount of budget allocation for the staff development depends on the staff size, expected number of
new employees and existing resources. The staff development coordinator is responsible for developing
and implementing the development budget with input from the staff. The agency administration will
demonstrate a commitment to staff development by allocating adequate funds for salaries staff time for
training, periodicals books. Audiovisuals and outside educational resources

6. Standards of staff development programme (ANA)

Standard 1 – Organization and Administration• The nursing service department and the nursing staff
development unit philosophy, purpose and goals address the staff development needs of nursing
personnel.

Standard II – Human Resources• Qualified administrative, educational and support personnel are
provided to meet the learning and developmental needs by nursing services personnel.

Standards III – Learner• Nursing staff development educators assist nursing personnel in identifying
their learning needs and planning learning activities to meet those needs.

Standard IV – Program Planning• Provides the unit systematically, plans and evaluate the overall
nursing staff development program in response to health care needs.

Standard V – Educational Design• Educational offering and learning experience are designed through
the use of educational process and incorporate adult education and learning principles.

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Standard VI – Material Resources And Facilities• Material sources and facilities are adequate to achieve
the goals and implement the functions of the overall nursing staff development unit.

Standard VII – Records And Reports• The nursing staff development unit establishes and maintains a
record keeping and report system

Standard VIII – Evaluation• Evaluation is an integral ongoing and systematic process, which includes
measuring the impact on the learning

Standard IX – Consultation• Nursing staff development educators use the consultation process to
facilitate and enhance achievement of individual, departmental and organizational goals.

Standard X – Climate• Nursing staff development educators foster a climate which promotes open
communication, learning and professional growth.

Standard XI – Systematic Enquiring• Nursing staff development educators encourage systematic inquiry
and applications of the results into nursing practice.

7. Potential difficulties in staff development & training activities:-

• Lack of time

•Inadequate resources at disposal

• Under-funded training budgets

• Conflicting priorities

• Lack of Clarity about what should be done.

• Shortfall in training skill or experience

• Fear that trained employee will leave the organization or will be poached by competitor.

• Cynical attitude to Staff development- Not directly measurable.

8. STAFF DEVELOPMENT MODEL FOR GOAL ACHIVEMENT OF THE HEALTH CARE

AGENCY, THE NURSE AND THE NURSING PROFESSION

Staff development model is based on the aforementioned philosophical statement, that the
activities within a health care agency are directed towards achieving a high quality care through the
mutual goal oriented efforts of the health care agency, nursing profession and its practitioners. This
model has three main components.

Education
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 Experience

Socio-economics

Educational component includes:

The educational component assumes that the nurse is motivated to continue learning through
involvement in educational activities endorse by a health care agency and the nursing profession. It may
take the form of continuing education – in service education and extramural education or post basic
nursing education. Staff nurse is self-motivated for learning. She may accept any type of staff
developmental activity, comes under local agency or outside agency.

-service education is referred to an agency based educational activity. It begins with orientation to
the health care agency and to a particular position and continues in the form of specific skill training
related to nursing or more generalized skill training related to patient care within the context of the
health care team.

group learning, as well as programmed learning and correspondence courses.

Post basic education refers to formal study at degree-granting institution. It involves full time
commitment to an academic programme leading to university diploma, certificate, baccalaureate degree,
master‘s degree or doctorate degree etc.

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Staff Experience:

Nursing practice and experience in daily life are integral parts of staff development. Planned approach to
the daily assignment of nursing responsibilities is both a benefit to the development of the nurse
practitioner and prerequisites to high quality patient care. For quality care – experiences may be planned
or unplanned. Experiences are curricular and co-curricular and self.

Socio-economic component:

It involves health care agency, the nurse and nursing association in management, planning, counseling
and employee – employer relations.

standards set by the nursing profession and the job commitment made between the health care agency
and the nurse.

Counseling includes career planning as well as performance evaluation for the benefit of both the
health care agency and the nurse.

-employer relations are reflected in the personal practices, form the basics of policies
underlying staff development in any agency.

The interrelationship of the components provides the framework for purposeful staff development
structured to meet the needs of both a health care agency and the nurse.

9. TYPES OF STAFF DEVELOPMENT:

Staff development includes formal and informal group and individual training and education. Staff
development activities include the following:

 Induction training
 Job orientation
 Continuing education
 In service education

9.1. INDUCTION TRAINING

a) Definition:

Induction is concerned with the introduction of a new employee to the organization. In other words
induction is the process of receiving and welcoming employee when they first join a company and
giving them the basic information they need to settle down quickly and happily and start work.

-Gurupptee

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Induction is the process of introducing new employees to an organization and to their work
responsibilities in that organization.

Induction, the first phase of indoctrination, takes place after the employee has been selected but before
performing the job role. The induction process includes all activities that educate the new employee
about the organization and employment and personnel policies and procedures.

Induction activities are often performed during the placement and pre-employment functions of
staffing or may be included with oriented activities. However, induction and oriented are often separate
entities, and new employees suffer if content from either program is omitted. The most important factors
are to provide the employee with adequate information.

Employee handbooks, an important part of induction, are usually developed by the personnel
department.

Managers, however, should know what information the employee handbooks contain and should have
input into their development. Most employee handbooks contain a form that must be signed by the
employee, verifying that he or she has received and read it. The signed form is then placed in the
employee’s personnel file.

Objectives:

The generic objectives of the induction programme include

6) To develop realistic job expectation, positive attitudes and satisfaction

7) To reduced anxiety and employee turnover
8) To reduce time of supervision of the supervisor
9) To develop a sense of belonging and
10) To adopt oneself according to the culture of the organization.

Induction by human resource department

This should be cover

 A brief history of the institution

 Its aims and objectives
 The terms and condition of the appointment letter
 Personnel policies
 An explanation of services available to the employee in the employee in the
hospital, such as bank , canteen, fair – price shop , library ,social club, etc
 The attitudes expected of him with regard to patient and visitors
 Promotion policy
 The name of the key officials
 A tour of the hospital
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  Fire precaution and safety regulation
 General discussion

Induction by department head

This should cover

 An introduction to the department

 The location of the changing room, rest room , toilet etc.
 The use of lifts , telephones
 An explanation of the job description of others
 An explanation of his own job description
 An introduction to all the supervisors in the department
 A tour of the department
 General discussion

Types of inductions

Basically there are two types of inductions, Formal induction and Informal induction.

1. Formal induction is a planned attempt to introduce new employees to the organization, job and
the working environment. This induction type may consume more time of the superiors to learn
and deliver the new employees needs at the beginning. But this may create new employees less
number of errors at the working period and good coordination among all the parties.

At this type of program, new employee may get know, who are the most experienced person to have the
solution of the particular problem new employee might has. At the very beginning new employees are
having lots of questions as same as kids at small ages. That is full normal thing and common thing,
because the new employee needs to get know all the things, he may actually needs or not.

CEO, GM, Section/Department Heads, Senior Managers, and Line Managers may involve in to the
formal induction program. (From top management to bottom line). This will deliver fundamental things
that new employees need to know.

 Advantage:

Organization will have the better chance to win the new employees’ loyalty at the very beginning.

New employee will have the chance to carry his/her works clearly, with less numbers of errors.

Also, new employee will fit to the organizational culture and the work group easily, and strongly.

2. Informal induction is not planned and is ad hock. New employees learn through trial and error
method. They get familiar with the work and work environment by themselves.
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Disadvantages:

This induction type will make the stress on new employee at the very beginning, because of his/her not
knowing things at the operations. So in that case, new employee may leave the organization at the
beginning and then the organization may need to follow all the process of recruiting and new employee
to the organization. Also this method will create a large number of errors making by new employee and
then it may create big losses to the organization. Those are the of informal induction program.

Advantage:

If the new employee survived, then he/she may know the process by his/her experience, and the later on
errors may minimize. But at the beginning the vice versa thing of above advantage may create loses, if
the new employee unable to survive at the organization. At the movements which employees couldn’t
survive, there could be see they are leaving organization at the beginning they have joined to it. So this
will creates high labor turn over too.

Techniques of induction:

The following techniques may be adopted to orient new employees:

a) The general orientation letter. In those hospitals where the number of new employees
is more than ten per month, it is advisable to hold a group orientation session. It
should be compulsory for all new employees to attend this session. Such a meeting
should be held in a comfortable room. Devices such as charts, slides, handbooks, etc.
should be used to make it interesting

ii) General tour: a tour of the hospital can prove very informative for new employees. It should be
arranged to show to the new employee

h) How patient , arrive

i) Where patients are cared for
j) How patients are fed
k) Where different tests are conducted
l) Where patient linen is washed
m) Where the hospital’s payroll is made and
n) Any other place of major interest

iii) Employee hand book: a well – prepared employee handbook is an important document. It can set
out a wide range of useful information for new employees. It can be read at leisure. It is prepared for the
use of employees but is also read by his friends and family members as well. This booklet should cover
a brief history of the hospital, its aim and objectives, condition of employment, employee’s health
programme, grievance procedure, safety precaution. Etc.
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iv) Buddy system. Under this plan, the new employee is introduced to an old employee- a specially
chosen buddy. This buddy assumes the responsibility of sharing the general information about the
department and hospital such as locker, uniform, toilet , daily routine duties , canteen , leave procedure ,
bus routes etc. the buddy should be carefully selected , lets the new employee receives wrong
information. If possible, some training should be given to some good employees in each department so
that their services may be utilized under this buddy system. Thus a new employee will not fall into the
wrong hands and not collect false information about the hospital in general and the department in
particular.

Advantages of induction

For employees

 A chance to get a clearer picture of the organization with a comprehensive introduction to its
philosophy, objectives, culture, policies etc.
 Introduction to relevant people, which makes easier for new employees to approach them at
the time of need in future.
 Time to settle into a new environment with new people
 A valuable opportunity to gather all sort of information according to one’s needs, likes and
taste

For the organization

 A chance to watch closely new employees in order to know them better

 Helps the new employees to shape up according to the requirement of the organization
 A system that ensures new employees are well settled
 An opportunity to inject fresh blood into the DNA of an organization

9.2. ORIENTATION

Orientation activities are more specific for the position. Organization may use wide variety of
orientation program. For example, a first –day orientation could be conducted by the hospitals personnel
department, which could include a tour of the hospital. The next phase of the orientation program could
take place in the staff development department where aspect of concern to all employees, such as fire
safety, accident prevention, and health promotion would be presented. The third phase would be the
individual orientation for each department. At this point, specific departments, such as dietary,
pharmacy and nursing would each be responsible for developing their own program.

Importance of orientation program:

 Orientations programs can help to reduce turnover by making employees feel more at
home in the workplace in a shorter period of time
 Establishing an orientation program will help to alleviate “new job stress”

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  Orientation programs also allow employees to become more productive in a shorter
period of time
 Orientation is also important because it introduces the employee to the rules and culture
of the organization

Members involved in orientation program

 The senior manager to welcome the person on behalf of the organization and provide
information about the organization, workplace rules and so on
 The supervisor to provide information about the workplace, introduce the person to staff
and provide information about the job
 The human resources specialist to provide information about pay and benefits, leave
entitlements, pensions and so on
 A member of the Board, Association or Council to welcome the new employee

Time of orientation program

An orientation program should start the day that the new employee accepts the position.

 As part of the orientation program the new employee should be provided with some basic
information about the organization such as the organization structure, organizational
rules and information about the job and the pay and benefits
 The orientation should include introductions to staff, showing the employee around the
office and providing the employee with time to meet with the Senior Manager and the
supervisor

Uses of orientation program

The primary purpose of an orientation program is introducing the new employee to the job and the
workplace and to make him/her comfortable.

Other important purposes include:

 Reducing employee turnover –most employee turnover occurs within the first six months
of work
 Reducing errors – employees who are familiar with the work environment and the job
make fewer mistakes
 Saving time – employees who have been given an orientation spend less time trying to
figure out how things work and more time being productive
 Develop clear job and organizational expectations – employees are less likely to end up
doing the wrong thing and/or doing the right thing in the wrong way
 Introduce the employee to the culture of the workplace –it is important for new
employees to have an understanding of both the culture of the workplace and the cultures
of the people that work there
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Tools and resource:

There are a number of tools and resources that can use to assist in the staffing process. These tools and
resources include:

 Manual and workbook: you can use the manual and workbook to develop your own
orientation program
 Current job descriptions – current job descriptions should be included in the orientation
program

Guide for the orientation program

Orientation programs consist of essential information that employee needs to be comfortable and
productive in the workplace.

 Not all information should be provided at once, as it will result in information overload
 All important information should be provided to the employee in a booklet or handbook
 Orientation programs should include information on the following topics:

- Organizational matters: the employee should be introduced to the purpose and structure
of the organization
- Job related matters: the employee should be provided with specific information about
his/her job
- Employment related matters: the employee should be introduced to matters related to
employment
- General introductions: it is important to introduce new employees to others in the
workplace so they feel at home as soon as possible

Steps in orientation program:

It is important to have the information the employee will need in a simple format that the employee can
review at his/her leisure. Information to put in the folder includes organizational, job related and general
employment information

1. Organizational Information:

- history and structure of the community government (include an organizational chart)

- organizational vision, mission, mandate, principles, values, goals and objectives
- rules of the organization
- programs and services provided by the organization

2. Job Related Information:

- A current job description

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 - Relationship to other jobs
- Supervisory positions
- Layout of physical facilities and equipment
- Important processes and procedures (i.e. How and where to get tools, supplies, etc.)
- Safety procedures and processes

3. General Employment Information related matters

- pay scales
- probationary period
- disciplinary process
- training and development procedures
- performance appraisals procedures
- rules of the organization
- benefits including pensions, insurances and so on
- entitlements such as rest breaks, holidays (including process for applying for holidays)

4. Introduce the employee to others

Even though the new employee is likely to know most, if not all of the other employees, he/she should
be taken around to let everyone know he/she has started and to help build a sense of team.

 At the same time it is important to let the employee know where things are such as
washrooms, supplies, filing cabinets and other materials and resources that he/she will
need as part of the job
 The employee should also be formally introduced to others that he/she will be working
with on a regular basis such as Regional MACA Staff, contractors and suppliers, other
government officials and so on

5. Go over the important information:

Before the new employee starts the job, the supervisor should sit down with him/her to go over
important aspects of the job.

 this includes a review of the job description, providing the employee with a performance
evaluation form and training needs assessment form and going over the rules of the office
 the senior manager should also spend some time with the supervisor and the employee to
go over the mission, mandate, goals and objectives of the organization.

6. Sign up for the benefit and entitlements:

An important part of the orientation process is to ensure the employee is set up on the pay and benefits
systems and that he/she signs all the necessary benefits paperwork.

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  this should be done with the supervisor and the person responsible for administrating pay
and benefits

7. Follow up sessions:

Follow-up orientation sessions should be scheduled with the employee after one to two weeks, one
month and after six months.

 This will provide the employee with a scheduled time to ask any questions they have and
to clarify policies and procedures
 At the six-month orientation session you may want to complete a performance appraisal
and training needs assessment form

9.3. CONTINUING NURSING EDUCATION

DEFINITION

Continuing education is all the learning activities that occurs after an individual has completed his basic
education-

--- COPPER

That education which builds on previous education

-----SHANNON

An educational activity primary designed to keep the registered nurses abreast of their field of interest
and do not lead to any formal advances standing in the profession

-----NURSING THE SARUS OF INTERNATIONAL NURSING INDEX

Continuing education is an arrangement which provides for opportunities to people of all ages to learn
any course of their choice, at convenient time and place and progress at one’s own speed to suit the
individual capacity and capability

Experience after initial training which helps the health care personal to maintain and improve existing
and acquire new competency relevant to the performance of their responsibilities. Appropriate
continuing education should reflect continuing needs to planned improvements in the health of the
community.

Planned activity directed towards meeting the learning needs of the nurse following basic nursing
education exclusive of full time formal post basic education

“Continuing education” means an approved or accredited planned learning activity that builds upon a
prelicensure or precertification education program and enables a licensee or certificate holder to acquire
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or improve knowledge or skills that promote professional or technical development to enhance the
licensee’s or certificate holder’s contribution to quality health care and pursuit of professional career
goals.

“Faculty-directed continuing education activity” means a continuing education activity in which faculty
facilitate the pace and content of the activity, and the activity is one for which contact hours may be
awarded in accordance with this chapter. The activity may occur in settings such as, but not limited to, a
classroom, on-line, or via teleconference provided that one or more individuals is facilitating the pace of
the activity.

DEVELOPMENT OF CONTINUING EDUCATION

Continuing education is the link from basic preparation to advancement in one’s career. Continuing
education not only upgrades professional information but it can be great source of rejuvenation and
inspiration. In 1960’s the United State saw a movement towards continuing education in health
professions, that had the nursing world debating whether continuing education was really necessary and
if it was should be mandatory for relicensure. Now it has made mandatory to undergo continuing
education in their specialty areas in U.S and many other countries.

In India government institution have made it mandatory, the staff should undergo regular staff
development programs which include orientation, in-service education and continuing education. Now
central government implements the scheme Nurse Training

PHILOSOPHY OF COTINUING EDUCATION

Philosophy is thought of relating to basic beliefs. Actions are guided by one’s belief about learning and
education. The educator has to think through his personal values and belief.

Philosophy of education is always an emerging one, rather than static one. Nursing is based on
knowledge on the physical and psychological functioning of man within his environment, expanding the
knowledge related to man and his dynamic, proliferating field of operation is of concern. It includes

 To sharpen the judgment and an increased understanding of ideas and values as they shape
personal and social goals
 To maintain worth, dignity of the individual, compassion, care and nurture in his professional
roles
 To shape personal and social goals by acquiring more knowledge understanding of ideas and
values
 To develop basic nursing abilities, and new dimensions of adjustment to a changing society,
provides liberation of the individual for maximum personal growth

FUNCTONS OF CONTINUING EDUCATION

 To meet the health needs and public expectations.

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  To develop the practicing abilities of the nurse
 Recruiting function
 Recognize gaps in their knowledge
 To test ability to do final academic study
 To improve the communication between the participants, faculty, community and health sector
 To test the participants ability to do formal academic study
 To shape or support university educational policies and practices
 To ensure the quality of education
 To grant budget for extension studies
 To maintain academic standards
 To meet educational requirement

OBJECTIVES OF CONTINUING EDUCATION

 To assist the nurse in identifying and meeting current learning needs and those needs
generated by changing professional practice
 To promote the development of leadership potential of nurse
 To disseminate new information
 To assist the nursing educator in increasing effectiveness
 To facilitate a return to practice

PRINCIPLES OF CONTINUING EDUCATION

o Provision for school and nursing faculty involvement in planning and teaching and
teaching the continuing nursing education courses tends to maintain high educational
standards for the programme
o An adequate staff is essential to planning, implementation and evaluating a programme
which is based on learning needs
o Responsibilities of direction of continuing nursing education are
 Determination of learning needs of the nurse population

 Development & implementation of a programme to meet these needs

 Evaluation of results
o Staff services are required with sufficient talents and numbers to implement the planned
programme they should be in

 Advisory committee
 Secretarial committee
 Administrative committee
 Supportive committee

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 o The community may serve as a liaison between school off nursing and the health
community
o Continuing nursing education may be centralized or decentralized

ELEMENTS OF CONTINUING EDUCATION

1. Learner

As a person, as a nurse, as a citizen philosophy of education recognizes all 3 aspects

 Diversity is a part of learning process and contributes to the development of

individual so the teacher has to make the learner to involve in nursing and non-
nursing
 The learner in his life plays many different roles e.g. Adult, learner, friend etc.

2. Teacher or nurse educator

 He has to accept the concept of life – long learning and responsibility to

encourage nurse
 Must be aware of sources of information
 To help the students how to learn and to approach
 To act as a role model

 Be a dispenser of wisdom and knowledge guide in learning process

 Able to instill his students a sense of own adequacy, feeling of confidence
 To show interest and concern for every member of the class

FORMS OF EDUCATION PROGRAMMES

1. Formal
2. Informal
3. In-service
4. Mandatory

1. Formal education

Includes undergoing organizational staff development programmes, short term courses related to
the professional area. Recognized forms of Post-secondary learning activities within the domain include
degree credit courses by non- traditional students, non – degree career training workforce training,
formal personal enrichment courses.

2. Informal education

Includes self- learning subscribing of journals.

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 3. In-service education

Definition

In-service education is planned learning experience provided by the employing agency for employees

Aims

 Improvement of client through upgrading the services rendered with scientific principles
 To keep in face in changing society to their needs.

 Acquisition of new knowledge.

 Improvement of performance.
 To develop specific skills required for practice.
 Improves the staff members’ chances for promotion.
 To develop right concept of client care.
 To maintain high standards of nursing.
 To observe and bring change in staff behavior.
 It ensures thinking on the job, reduces mechanical action to a minimum and
 Promotes economy, safety and efficiency of personnel in their work situation.
 It reduces turnover, absenteeism.
 Effective production will be observed (in work performance)
 To discover potentialities, to alert personnel in working environment.

Components

 Orientation skill training programme.

 Continuing education programme.
 Leadership training and management skill.
 Staff development programmes

Orientation skill training programme

Orientation training programmes introduces a new employee to these basic aspects of her job. In
hospitals field, if any new nurses are appointed, first the supervisor has to discuss with them the job
charts, polices of institution. If she well- oriented to her working situation, she will be getting adjusted
to the new environment very easily and do the work effectively.

Orientation skill training has to be given for development of the knowledge and skills (cognitive, co
native, affective domains).

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In community field orientation training camps will be organized to school teachers, village leaders and
MPAW by the health personnel about the concept of health and illness, etiological factors for disease ,
identification of case, prevention and treatment in order to reach health for all (HFA) by 2000 AD.

Continuing education types

Centralized in service training

Decentralized in service training

Combined or coordinated training

Management skill and leadership training

For the administrators and the senior personnel , for the purpose who possess higher qualification , who
is having the chances for promotion and the supervisors the authorities will give in service training to
obtain management and leadership skills in order to supervise the institution to achieve the targets by
reaching goals and preparing the person to solve their problems.

Staff development programme

To meet the educational needs of nursing students, there must be provision for regular staff development
programmes

Methods of delivering in-service education

Forum, ward teaching, discussion, conferences, seminar, workshops, fieldtrip

A successful continuing education programme is the result of careful and detailed planning.

4. Mandatory education

It is implemented in U.S and foreign countries. The nurse should undergo continuing education
in a specific area of nursing for getting relicensure

DIFFERENT BETWEEN THE IN-SERVICE EDUCATION AND CONTINUING EDUCATION:

In-service education Continuing education

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 Planned learning program given by Is developed by nurses and conducted with
employing agency in nursing department

On job training Training conducted by university or

recognized institution

Professional role altered improves career

Improves staff members and changes for development
promotion

CONTINUING EDUCATION UNIT:

The goal of the CEU is to maintain competency in nursing practice. It comprises of continuing
education courses, seminars, workshops, and in service education programs.

SEMINAR:

Seminar is program of collective thinking on various problems of education by educationist’s experts

and teachers. A number of seminars can be held on various problems of education. The entire course of
discussion is covered in a seminar on the principal of mutual understanding and co-operation. The topic
of a seminar generally chosen by organizers. A paper on that topic is prepared by beforehand and is
circulated among the participants.

WORKSHOP

A workshop is conducted to think over the practical problems related to various problems of education.
In workshops great stress is laid on practical work. Every participant is given sufficient time and
opportunity for individual work and study. Thus practical suggestions to solve the problem. The themes
taken up in the workshop are generally of great significance, such as curriculum construction, new
technique in nursing etc.

AGENCIES:

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 1. Sponsoring agencies:

Continuing education is offered by the health care organizations, government agencies, community
service organizations, professional organizations, colleges and university. E.g. ANA, NLN.

2. Employing agencies:

It is the responsible of providing opportunities for individual nurse to participate in continued

learning process. In service educational and staff development program in hospital and nursing homes to
meet ultimate goal

PLANNING

A successful continuing education programme is the result of careful and detailed planning.

Planning for continuing education begins with an identification of needs followed by setting objectives,
educational activities, and evaluation.

The following points must be considered when planning continuing education

 Most individual are motivated to continue their learning beyond their professional education
 Participation in continuing education is strongly influenced by individual’s past experiences
 Continuing education should support health professionals natural desire to learn
 Health professionals should be encouraged to accept the personal responsibility for learning
 Continuing educations must be planned according to adult learning principles

PREPARATION OF CONTENT

The most challenging aspect of continuing education is the need to foster innovative and creative
approaches to nursing practice to improve the patient care. At the other side of coin, it brings out the
potentials of the staff and helps in deciding which persons are able to assume more responsibility in
their respective jobs according to the levels at which they function. The content may be developed on
the basis of

 Contents on the clinical areas like community health nursing, mental health nursing, medical
surgical nursing, maternal and child health nursing, forensic nursing etc.
 Level of group of nurses like under graduates, post graduates etc
 Designations like staff nurses, clinical instructor, tutors lecturers

STEPS IN CONTINUING EDUCATION DEVELOPMENT

In order to increase the probability, continuing education programs have an impact on professional
competence the following steps are helpful:

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 Identify problems that focus on health care
Analyze needs or problems to determine if there is a potential educational solution
Identify potential facilitators of and barriers to learning process
Select educational needs bared on a priority system
State educational goals and objectives for the selected needs
Select or design a learning experience to meet the goals and objectives
Implement the learning experience
Evaluate the extent to which learners achieved objectives determine the extent to which
the original problem has been reduced
Identify any additional tasks necessary to meet the need based on evaluation

PLANNING PROCESS

1. Establishing goals with the purpose or philosophy of the organization

Purpose gives direction in planning

It identifies the reason for existence

Purposes are based in the learning needs and social needs so it has to be reviewed from time to time
and restated as appropriate

The planning formula

It provides framework for programme planning

A.What is to be done?

Understand clearly what your unit is accepted to do in relation to the work assigned to it

Break the unit work into separate jobs in terms of manpower, money, and material you have at your
disposal

Think each job through

B.Why is it necessary?

Alternate methods which are necessary to meet the goals

C.How is to be done?

Look for better ways of doing it in terms of the utilization of manpower, money and material

D.Where is it to be done?

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Study the flow of work, availability of material and equipment best suited to do the job

E. When is it to be done?

Time schedule for the maximum utilization of time, money material

F. Who should do the job?

Determine what skills are needed to do the job successfully, select or train the man best suited for the
job

2. Establishing goals and objectives

Planning moves toward goals which are significant and realistic, which can be attained? Goals serve to
stimulate and direct action and should be reachable.

An objective is specific, it is a desired and or accomplishment to be sought.

Objectives

To assist the nurse in identifying and meeting current learning needs and these needs
generated by changing professional practice
To promote the development of leadership potential of the nurse
To encourage the nurse to identify and influence societal changes which have implications fir
nursing and to modify practice accordingly
To identify nursing problems and in seeking solution to them
To develop varied teaching methods for extending nursing knowledge and competency
To disseminate new information from varied channels
To assist the nursing educator in increasing teaching effectiveness
To facilitate a return to practice
To assess the health needs of nurses, hospitals and community to plan, implement and
evaluate educational programs in hospitals and health facilities
To seek opportunity for and collaborate with other health disciplines to effect improvement
in the delivery of healthcare system

3. Determining needs and priorities (if the action required meeting the specific objective course)

Assessment of needs will be done by survey through

 Mailed questionnaires
 Interview
 Formal and informal discussion with participant (feedback)
 Checklist

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 After assessing the needs, prioritization to be carried out

4. Assess the available resources for establishing the programme

Careful assessment of ways and means to meet the established programme goals

Faculty, finances and facilities may be seen as the major resources required for a continuing
nursing education

A broad survey of the major resources are necessary to the total continuing nursing education
programme and a more detailed assessment for any specific courses or activity.

Planning involves deciding upon the resources necessary to the activity and then determines the
availability

Adequate financial support appropriate faculty, facilities with easy accessibility space and
necessary equipment required to conduct offering

5. Plan the budget appropriate for the programme

Separate budget is required for each specific activity and each individual offering is
accepted to be self-supporting .Budget requires ascertaining all the anticipated costs of the offering.The
fee is set on the basis of the cost involved and the expected enrollment Sometimes budget for in-service
training or continuing education programmes will be sanctioned by government, university grants or fee
collected from participants.

Also getting sponsorship from NGO or voluntary organization

The co coordinators have to write the proposal after the problem has been identified and the
substantiating data collected, guidelines studied, guidelines has to be followed in writing the proposal

Writing the proposal

The proposal should be written with carefulness clear, concise familiar terms which
include enough detail so that reviewers have a thorough understanding of what the project intends to
accomplish

Formats for proposal preparation

1. Cover sheet includes

Name of project

Summary of project (optional, one paragraph)

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 Name of funding source to which proposal is directed

Name and address of institution submitting project

Name of principal initiator and others involved in proposal preparation

Date of submission

2. Proposal abstract (optional)

3. Proposal narrative

Statement of objectives

Describe the nature of problem

Document existence of problem with appropriate data

Describe the existing efforts to solve problem or create opportunity

Define target groups

State goals of project

Procedure

Describe phases or sequences o procedure

Describe work performed at each stage and duration

Show how work will be organized

Personnel handling each component of work

Facilities requires

Resources that will be tapped

Evaluation procedure

4. Budget narrative

Explain each budgetary item

Criteria and data used to make estimates

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 Breakdown of budgetary material

5. Appendices

Statement outlining qualification of institution requesting funds

Vitae of personnel involved

Supporting statement from proposed clientele

Supporting statement from cooperating individuals or agencies

ORGANIZATION

Programming of professional courses in nursing is a joint responsibility of a director of

continuing nursing education and a dean of nursing institution. The nursing faculty make possible to
explore the needs of continuing nursing education, to set priorities, to plan course and to teach them.

University faculty may be assigned to continuing education in nursing as a part of the regular
teaching lead or extra compensation basis

Methods of delivery

The methods of delivery of continuing education can include traditional types of

classroom lectures and laboratories. however, much continuing education makes heavy use of distance
learning, which not only includes independent study which can include videotaped or CD ROM
material, broadcast programming and online or internet delivery.

In addition to independent study, which can include study network as well as different types of seminars
or workshop, can be used to facilitate learning.

A combination of traditional, distance and conference type study may be used for a particular continuing
education course or program

EVALUATION

Evaluation is needed to assess the effectiveness of the programme or the progress, in order to
find out to what extent pre-set goals have been achieved, evaluations should be along at different stages
of the programme.

Purpose of evaluation

o To identify the areas which require greater attention in terms of participation of trainees,
academic activities and management (at planning stage)

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 o To identify bottlenecks in various activities carried out during the operation of the
programme( implementation stage)
o To assess the applicability of training in field or actual situation
o Qualitative improvement in instruction promotes better learning, determines future
changes and needs
o For quality control or qualitative improvement

What to evaluate

Evaluation should cover

o The growth and satisfaction of participants

o The outcome course and the whole programmed activity
o Effectiveness of faculty members
o Transfer of knowledge
o Effect on the system

Procedure for evaluation

o Pretest and post test

o Aptitude test
o Observation of skills
o Questionnaire
o Audio or video tapes

Evaluation design

o Focus of evaluation
o What do you want to find out
o Devise the instrument
o Collection of information
o Organize the information coding, organizing strong and retrieving
o Analyze the information
o Report the findings, reassessing the goals
o Updating, modifying the plan periodically based on the need
o Evaluate the design for validity, reliability, credibility, timelines and pervasiveness

Evaluating activities

Continuing education programs are evaluated by the providing units.

The issues related to continuing education evaluation are:

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 1. Is there logical relationship between the planned educational project and the identified needs
of participant in relation to their practice responsibilities?

2. What evidence is there that the program actually attended to the learning needs of participants?

3. What evidence are there the clients perceived the intended relationship between the project and their
learning needs?

4. Are the project’s goals and objectives stated appropriately?

5. What evidence s there that the goals and objectives of the project have been achieved?

6. Are the selection orientation and motivation of the faculty effective?

7. Did the faculty demonstrate appropriate instructional and interpersonal skills in conducting the
activities?

8. Did the practice who attended the project have the background and experience that was anticipated
wen the project was planned?

9. Did any side effect occur as a result of the project?

10. Are the planned activities based on the logic and on the principles ad generalizations of management
and educational psychology?

11. Does the intended instructional activity operate as planned?

12. What evidence is there the rationale for designing and implementing the project was appropriate?

13. Are the planned physical facilities appropriate?

14. Do the instructional material meet accepted criteria and standards of the art and science of the
instructional martial development?

15. Were the instructional material was used as planned?

16. What was the impact of the evaluation?

17. Is the project cost- effective?.

10. ROLES AND FUNCTIONS OF ADMINISTRATOR/MANAGER IN STAFF

DEVELOPMENT:

Roles:

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  Applies adult learning principles when helping employees learn new skills or information.
 Coaches employees readily regarding knowledge and skill deficits.
 Actively seeks out teaching opportunities.
 Uses teaching techniques that empower staff.
 Is sensitive to the learning deficits of the staff and creatively minimises these deficits.
 Frequently assess learning needs of the unit.

Functions:

 Works with reduction department to delineate shared individual responsibility for staff
development.
 Assumes responsibility for quality and fiscal control of staff development activity.
 Makes appropriate decisions regarding educational resource allocation in periods of fiscal
constraints.
 Ensures that all staff are competent for roles assigned.
 Provides input in formulating staff development policies.

11. CAREER DEVELOPMENT:

Career development is the planning and implementation of career plan. This can be accomplished
through assessment,jop analysis ,education ,training,jop search and acquisition and work experience.

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256
11.1Components of career development:

 Career planning
 Career management

Career planning:

It is the subset of career development that represents individual responsibility.

Career planning is an on-going process, has steps as follows:

 Self-assess interests, skills, strengths, weakness and values.

 Determine goals.
 Assess the organization for opportunities.
 Assess opportunities outside the organization.
 Develop strategies.
 Implement plans.
 Reassess and make new plans as necessary at least biannually.

11.2 Career management:

It focuses on the responsibilities of the organization for career development.

Organizational responsibility in career management:

 Integrate individual employee needs with organizational needs.

 Establish, design, communicate and implement career path.
 Disseminate career information.
 Post and communicate all job openings.
 Assess employees.
 Provide work experience for development.
 Give support and encouragement
 Develop new personnel policies as necessary
 Provide training and education.

11.3 Manager roles and responsibilities in career development:

 Is self-aware of values influencing personal career development.

 Encourages employees to take responsibility for their oun career planning.

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  Identifies and develops future leaders.
 Shows a genuine interest in the career planning for career paths within the organization.
 Supports employees personal career decisions based on each employees needs and values.
 Develops fair and well communicated policies on promotions and transfers.
 Uses organizational transfers appropriately.
 Uses planned system of long term coaching for career development.

12. TRAINING METHODS AND TECHNIQUES:

The choice of any methods will depend upon cost, time available, number of persons to be trained, depth
of knowledge required, background of the trainees and many other factors.

Various methods of training:

 On the job method

 Vestibule training
 Class room method
 Apprentices training
 Induction training

12.1 On the job method

This is considered to be the most effective method of training the operative personnel. That is why vast
majority of training programs organized are of on the job variety. Under this method the worker is
trained on the job and at his work place.

Effectiveness of on the job training depends primarily upon qualified trainers. Another important on the
job method is ‘‘under study” whereby a senior and experienced employee teaches a new employee as his
understudy. But this method takes a long time and the trainee loses his motivation because of
uncertainty in his promotion position.

“Rotation” is another method of training on the job. Its main objective is to broaden the background of
trainee in various positions of jobs. The trainee is periodically rotated from job to job instead of sticking
to one job and hence acquires a general background.

On the job training techniques are most appropriate for teaching knowledge and skill that can be learnt
in a relatively short time and where only one or a few employees must be trained at the same time for
the same job.

Advantage:

It has the chief advantage of strongly motivating the trainee to learn.

It is not located in an artificial situation, either physically or psychologically.

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It permits the trainee to learn at the actual environment of the job.

It is cheaper and less time consuming.

Production does not suffer.

Laws in learning:

 The law of readiness.

 The law of exercise.
 The law of effect.

When the person is confronted with a job which he is potentially able to do and is interested in learning
how to do a job in order to hold it: the law of readiness is definitely satisfied. Such a situation presents
as good an incentive for learning as would ever be found.

The second law of learning is that of exercise and it is satisfied when a person is trained on the job
because he has the chance to immediately apply for what he has been trained to understand and to do.

The law of effect is likewise satisfied through on the job training. If the training is good and new
employees are intelligently dealt with by his supervisor, he will get satisfaction out of his work and feel
secured in his job and he will be better satisfied than he would have been left to learn by trial and error
method.

12.2 Vestibule training:

The term vestibule training is used to impart training in a classroom for semi-skilled jobs in the plant
and the office.it is more suitable where a large number of employees need to be trained at the same time
for the same kind of work.

Where this method is used there should be well qualified instructor incharge of training program. There
the emphasis tends to be on learning rather than production.

The staffs of the vestibule consist of experts and specialist instructors.

Vestibule training has certain demerits also. The artificial training atmosphere may create the adjustment
problem for the trainees when they return to the place of job.

The vestibule training is relatively expensive because there is duplication of material, equipment and
conditions found in a real work place.

12.3 Classroom training:

Classroom instructions are most useful where concepts, attitudes, theories and problem solving abilities
are to be taught.
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Orientation about organization and safety training can be accomplished most effectively in the
classroom.

The standard instructional method suitable for operational employees is a formal lecture by an instructor
to the trainees.

The lecture method can be used for very large groups. Thus the cost per trainee is low; however it has
certain limitations also.

The learner also passive. It violates the principle of learning and constitutes one way communication.
But students nay be permitted to ask questions which will provide feedback from the students to lecturer
and can easily be combined with other techniques. Thus a teacher may conduct a class by the combined
lecture discussion method.

12.4 Apprentices training:

The governments of various countries have passed law which makes it obligatory on every employer to
provide apprenticeship training to young people.

The advantages of apprenticeship training to the trainees are that they receive wedge while learning and
they acquire a valuable skill which help them to secure a job. In India also there are so many who
earning when they learn.

It is very much prevalent in printing trades building construction, welders.

12.5 Induction training:

After a candidate is finally selected he is issued the appointment letter and requested to join the
organization up to some specified period.

Aims:

To bring an agreement between the organization goals and the personal goals of the person employed.

To build the new employee’s confidence in the organization and in himself so that he may not form false
impression regarding the new place of work.

To give the new employees information and knowledge about the organization its structure, products,
rules and regulation.

To give the new entrant the information that he needs such as locations of locker rooms, cafeteria and
other facilities, time to break off, leave rules.

To foster a close relationship between the new workers and old worker and supervisors.

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To create a sense of security for the worker in his job by assuring him the idea that fairness to the
worker is the inherent policy in the organization.

To avoid cost of replacing workers who separate during the early impressionable period because of lack
of accurate information.

The range of information that can be covered in such a course may be as follows:

History of organization:

A brief description of the early history and growth of the organization.

Product and service of the organization:

A brief story of the original products, service and its evolution to meet competition and consumer needs.

Structure of organization:

A brief description of the organization structure, relation of new employees department with other
departments and so on.

Location of department:

Location and layout of the company’s plants, stores, departments, canteens.

Personnel policies:

Polices of the company regarding compensation, training, promotion, retirement, and insurance.

Employee’s activities:

Statements of the available programs and activities carried on by workers, such as recreation mutual
benefit association, credit union.

Rules and regulation:

Description of rules and regulations of the company regarding attendance, working hours, pay advances,
sick leave.

Safety:

Safety measures taken by the company for the protection of the workers and their use by the workers.

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Standing orders:

Grievance and disciplinary procedure and suggestion system in the company.

Counselling service:

Information about the counselling service provide by the company.

Job routine:

Requirements of the particular job to which personally assigned as well as the job to which this may
lead in the chain of promotions.

Special training:

Information about the training programs carried out by the company to help the employees learn new
skills in doing their job.

13. Procedure for training:

Any training program if systematically developed and introduced brings a desirable change in
behaviour.

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14. Responsibility for training:

Managers normally assume that problems such as accidents, turnover, more errors, wastage and low
productivity relate to inadequate training . But even after the training most of the problems continue to
exist and only then the management realises that training efforts were premature.

The analysis of any training problem begins with training needs statements.

A need or performance deficiency is the difference between actual performance and desired
performance. The actual performance of an individual can be illustrated as PC+P

Where PC = present capacities of the individual

P=potential of the individual

The desired performance of the same individual can be analysed in training and illustrated as P1 C1+p1.

Performance deficiency = (P1C1 +P1)-(PC+P).

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If the performance deficiency is zero, then no training is required.

The training analysis is concerned with identifying the causes of performance deficiencies. Decision
whether to train or not to train can be based on the extent acquisition or execution.

Where the individual has the prerequisite skills to perform the job properly and still does not signify that
execution type of problem exists and there is no need to train the individual. The ideal training situation
is one in which the individual has training situation is one in which the individual has the skill and will
to work and the job environment reinforces his performance.

Soon after it has been decided that training is essential the immediate starting point becomes the
designing of an effective training program.
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The two essential elements in preparing programmes are:

 Determination of training objectives.

 Construction of performance measures.

The essential features of training design is to provide control points for measuring training design is to
provide control points for measuring training effectiveness. The performance before training and after
training can be compared and if discrepancies exist between the two, the existing training objectives are
achieved. Next phase is the development phase. The training analyst is concerned with facilitating the
desired, change in the learners behaviours so that terminal objectives of the design phase are fulfilled.

15. Planning training program:

Training approach developed during World War 2 consists of the following steps:

 Preparing the worker

 Presenting the task
 Trying the performance
 Following up on his job.

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Trainin gcycle:
Revise the
program
Report the Determine
results to the need
management

Evaluate the Analyze the

result job

Administer a Appraise
training system the tranees

Design a
Organize
training
training system
program

Gain Prepare
acceptance budget
training Determine
cost benefits

Essentials of training:

The requirements of any training program may be conveniently grouped into following heads which
may be considered essential.

 Knowledge
 Attitude
 Continuous participations
 Timing of training
 Conformity with objectives
 Fulfilling certain needs of employees
 Stimulus
 Response
 Motivation
 Reward and incentives

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Role of training:

At present there is no systemic standardization of the different training programs in India. Each
organization has developed its own methods of training both the workers and supervisors. However
management must consider a systematic training program to improve the efficiency and morale of
employees. A systemic training program will help the management to standardise the job performance
as well as in selection and placement program.

Requirements of effective training:

Training is a vital tool of management capable of making important contribution to the goals of the
organization.

The effectiveness of an organization training program depends firstly upon the extent to which
management is committed to support it. Top management must therefore provide a climate which is
conducive to continued learning and growth.

Evaluation of training program:

Evaluation is an essential feature of all programs for the training of employees. The concept of
evaluation is most commonly interpreted in determining the effectiveness of a program in relation to its
objectives.

Evaluation can be done for various purposes. The evaluator should be clear about why he has been
asked to evaluate training. Evaluation of training program may be done:

 To increase effectiveness of the training programs while it is going on.

 To increase the effectiveness of the programs to be held next time.
 To help participants to get feedback for their improvement and efficiency.
 To find out to what extent the training objectives are achieved.

In evaluating the effectiveness of any program whatever may be the method used, the following criteria
should always be kept in mind.

 Objectives
 Cost benefit analysis
 Flexibility
 Results obtained
 Staff required
 Improvement possible

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Watson Wilson said: “If you dig deep into any problem you will get to people.” Any activity is
predominantly people oriented. Industries in fact wrongly combine science with people, technology with
humanity, with the result following are a few problems:

 Many people leaving the organization at frequent intervals.

 Lack of cohesiveness or team spirit.
 Feeling of detachment rather than attachment among employees.
 Go slow inadequate contributions.
 Poor quality of work
 Lack of enthusiasm and the spirit of meeting challenges.
 Increased absenteeism
 Too many grievances
 Lack of communication
 Low morale
 Poor job satisfaction

The trainee needs to be aware of such problem situations either through his own investigations or
making arrangements whereby these are brought to his notice as soon as they are discovered by others.
This discovery helps us in analysing problem viz. “what is that requires change” also known as context
evaluation one of the important phases of evaluation.

Input evaluation:

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After completing the “context evaluation” the trainer now turns to the next phase. He has to decide the
techniques and procedures to be adopted for bringing about the desired change. Whatever the conditions
be he will have a set of alternatives to choose from.

Outcome evaluation:

The purpose of the evaluation is to find out whether objectives of the training program have been met or
not.

Careful planning with regard to the following will have to be done right from beginning of the program.

 Clear definition of the training objectives.

 Designing the means of measuring these objectives.
 Carrying out measurements at appropriate intervals.
 Interpreting the results of measurement and their use for improvement for later program.

17. Organizing the training:

In small organizations training is generally on the job variety and it is given by the line supervisor. Even
in such organizations where the personnel department exists the planning and responsibilities of the
personnel manager.

The staff training section generally performs the following functions:

 Determination of training needs.

 Development of training objectives.
 Development of training programs in consultation with line executives.
 Administration and instruction for various courses.
 Preparation of training instructions.
 Evaluation of the effectiveness of a training program.

18. Concept of hard technology in training:

The continuous upgrading of the profession lies in hard technologies applied to its responsibilities. The
technologies are more sophisticated than in the past.

The focus on behaviour rather than personality:

Supervisor training often deal with making people trustworthy, loyal, helpful, rather than making them
productive, creative and skilled.

Designing training for result and not for process alone:

In many training programs of the past the process is the only thing of interest to the trainer.
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This distinction between process and result is the major difference between the sensitivity training and
new and more useful forms of organization development.

Relate training to its context:

The behaviour change in order to persist must be supported by the environment. The
organizational culture the managerial climate to which the trainee returns should have some supporting
characteristics. If the organization cannot support the behaviour which training presents then the training
will fail.

Not all management problems are behavioural problems:

Feeling that education is a solution to all problems has often carried over, with some unfortunate
effect, into the industrial and administrative training. One of the best things for trainers to learn is to say
no which patently not a training problem. Trainers and behaviour change experts also need the top
management of the unit to be changed.

A training objective should have criteria:

Before training begins the objectives of the training should be prepared and approved. It helps team of
instructors to match their efforts towards a common purpose. It also comprises the best yardstick for the
evaluation of training after completion of the training.

In designing training think of simulation first:

A single important breakthrough in training is a means of changing relevant behaviour. While designing
training simulation would rank on top. The trainer who persists in unrealistic simulations is not clever
but lazy.it takes more work to prepare training which simulates reality.

Break the total training objectives down into successive stage:

Job breakdown helps the trainers at every step. Modem adaptations of that approach are sometimes
known as personalised system of instruction. The major advantage of task breakdown prior to
conducting the training lies in the ability of the trainers.

It is required that the learner should show some action during training:

Passive behaviour by the learner may produce some learning, but the training which relies on such
learning is engaged in a blind form of management of the training efforts. Simulation is one in which
situational facts resemble but do not fully duplicate the features of reality. However the simulation in a
way that resembles relating to the real world.

Trainees should receive feedback for their actions:

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Important aspects of hard technology training is that people in training should get feedback of the effects
on their action is going on. Some guidelines to successful feedback training:

 Fast feedback is more effective than slow feedback.

 The feedback to the behaviour explicitly increases the learning effect of the feedback.
 Favourable or pleasant feedback will have better effect than punishing or negative feedback.

18. Audio visual aids in training:

Audio visual aids enliven teaching and increase interest, comprehension and retention which are based
on the hypothesis that more abstract the content the more difficult is becomes for the learner to
comprehend it. Dale’s well known “cone of experience”

19. Classification of training aids:

Therefore, it is essential that these A.V aids should be carefully chosen and worked into the instructions
in learning i.e. perception and hearing.

The following factors can be considered to choose the kind of aid:

 Objective to use such aid.

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  Number and experience of trainees.
 Physical location of the class.
 Time and finance available for training.

There are several types of aids but the most popularly used are:

 Materials to produce written instructional material, charts and graphs.

 Display board materials.
 Magnetic board materials
 Chart display board.
 Panel board materials.
 Bulletin and journal materials.

Audio equipment and materials:

 Radio receivers.
 Record and player.
 Tape materials and equipment’s.

Projected teaching materials:

 Camera
 Films
 Mounting materials
 Slide projector
 Motion film projector 16mm
 8mm and loop film projector
 Transparency preparation materials
 Epedoscope
 Overhead projector
 Opaque projector
 Model making machines and materials
 Printing press and printing materials
 Sound film projector

Selection and preparation of software for a particular situation is the real problem of a trainer.\

CHAPTER-VI Mrs.V.JenniferMary

ROLES AND FUNCTIONS, MOTIVATION ,CREATING A MOTIVATIONAL CLIMATE,

MOTIVATIONAL THEORIES

DIRECTING
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 Directing is the process through which a manager communicates with and influences other members of
the organization in the pursuit of company objectives.

Directing/Direction is a function of management performed by top level management in order to achieve

organizational goals. It is very important and necessary function of management. Directing is said to be
a process in which the managers instruct, guide and oversee the performance of the workers to achieve
predetermined goals. Directing is said to be the heart of management process. Regardless of the
nomenclature this is the “doing phase” of the management, requiring the leadership and management
skills necessary to accomplish the goals of the organization. Managers direct the work of their
subordinates during this phase. Planning, organizing, staffing has got no importance if direction function
does not take place.

Directing initiates action and it is from here actual work starts. Direction is said to be consisting
of human factors. In simple words, it can be described as providing guidance to workers is doing work.
In field of management, direction is said to be all those activities which are designed to encourage the
subordinates to work effectively and efficiently. Therefore, Directing is the function of guiding,
inspiring, overseeing and instructing people towards accomplishment of organizational goals.

The managerial function of directing is like the activities of a teacher in a classroom. In order to teach, a
teacher has to guide his students, maintain discipline, inspire them and lead them to the desired goal. It
is a very important function in the management of any enterprise. It helps the managers in ensuring
quality performance of jobs by the employees and achievement of organizational goals.

 DEFINITION OF DIRECTION

“Directing consists of process or technique by which instruction can be issued and operations
can be carried out as originally planned” - Human
“ Directing involve determining the course, giving order and instruction and providing dynamic
leadership”. – Marshall

Importance of Directing

Plans remain mere plans unless they are put into action. In the absence ofdirection, subordinates will
have no idea as to what to do. They will probably notbe inspired to complete the job satisfactorily.
Implementation of plans is, thus,largely the concern of directing function. As a function of management,
directingis useful in many ways.

 FUNCTIONS OF DIRECTING
1) It guides and helps the subordinates to complete the given task properly and as per schedule.
2) It provides the necessary motivation to subordinates to complete the work satisfactorily and
strive to do the best.
3) It helps in maintaining discipline and rewarding those who do well.
4) Directing involves supervision, which is essential to make sure that work is performed
according to the orders and instructions.
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 5) Different people perform different activities in the organization. All the activities are
interrelated.
6) It help to initiate plan and implementation in all organization
7) It integrates employees action
8) Help to maximize the out put
9) Facilitates changes in organization
Provides stability in organization
10) Help to achieve the goals
11) Reduce the reluctance to changes
12) In order to co-ordinate the activities carried out in different parts and to ensure that they are
performed well, directing is important. It thus, helps to integrate the various activities and so also
the individual goals with organizational goals.
13) Directing involves leadership that essentially helps in creating appropriate work environment
and build up team spirit.
 CHARACTERISTICS OF DIRECTING

1. Pervasive Function - Directing is required at all levels of organization. Every manager provides
guidance and inspiration to his subordinates.

2. Continuous Activity - Direction is a continuous activity as it continuous throughout the life of

organization.

3. Human Factor - Directing function is related to subordinates and therefore it is related to human
factor. Since human factor is complex and behavior is unpredictable, direction function becomes
important.

4. Creative Activity - Direction function helps in converting plans into performance. Without this
function, people become inactive and physical resources are meaningless.

5. Executive Function - Direction function is carried out by all managers and executives at all levels
throughout the working of an enterprise; a subordinate receives instructions from his superior only.

6. Delegate Function - Direction is supposed to be a function dealing with human beings. Human
behavior is unpredictable by nature and conditioning the people’s behavior towards the goals of the
enterprise is what the executive does in this function. Therefore, it is termed as having delicacy in it to
tackle human behavior.

 ELEMENTS OF DIRECTION

Supervision Communication

ELEMENTS
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OF
DIRECTION
 Motivation Leadership

 MOTIVATION
“MOTIVATION IS THE CORE OF MANAGEMENT”
(Resins Likert)

Survival and growth of an organization dependsconsiderably on the performance of its employees

which depends on their ability to work and will to work. Motivation is a management technique to
improve human behavior and attitude towards work, which enables him to work. A motive stimulates an
individual to behave in a particular way. Motivation of the health personnel is a difficult thing to achieve
as that is essential and also relevant for all categories of health personnel. Motivation comes from
withinthe person, managers cannotdirectly motivate subordinate.The humanistic manager can,
however, create anenvironment that maximizes the development of human potential. Management
support, collegial influence, and the interaction of personalities in the work group can have a
synergistic effect on motivation. The leader-manager must identify those components and strengthen
them in hopes of maximizing motivationat the unit level. All human beings have needs that motivate
them. The leader focuses on the needs and wants of individual workers and uses motivational
strategies appropriate for each person and situation.

MOTIVATION

MEANING OF MOTIVATION

The term motivation has been derived from the word motive. Motive is anything that initiates or
sustains activity. It is inner state that energizes, activates or moves and that directs or channels behavior
towards goals.

 DEFINITIONS
 “ Motivation is a general inspirational process which gets the members of the team to pull their
weights effectively, to give their loyalty to the group, to carry out properly the task that they
have accepted and generally to play an effective part in the job that the group has undertaken”
(E.F.L. Brech.)
 Motivation is the process of steering a person’s inner and action towards certain goals and
committing his energies to achieve these goals.
 Motivation may be defined as the work a manager performs in order to induce sub ordinates to
act in the desired manner by satisfying their needs and desires. Thus motivation is concerned
with how behavior gets started, is energized, sustained and directed.
 CHARACTERISTICS OF MOTIVATION

Various characteristics of motivation are

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 1) Individuals differ in their motivation as per their motives.

2) Motivation is highly situational. A person may work well in one organization and poorly in
another.

3) Motivation of each individual changes from time to time.

4) Different people react differently to their unfulfilled needs

5) Sometimes the individual himself may not be aware of his motive

6) Motivation is complex process.

7) Motivation is a continuous process.

8) Motivation can be either positive or negative.

9) Motivation is different from job satisfaction.

 IMPORTANCE OF MOTIVATION

Human Relation.
Higher Efficiency.

Facilitates Change Low Absenteeism And Turn Over.

Corporate Image.

 FACTORS AFFECTING MOTIVATION

The motivation of employees in an organization is determined by the following factors.

 External factors-Which are outside the organization, such as customs, norms, social values in
society, the family problems, expectations and needs of the employee.
 Individual factors- Such as aim and objectives, needs, values of the employee.
 Organizational factors-Structure, functioning, physical facilities, work culture, work norms,
organizational policies and procedures related to performance appraisal, recruitment and selection,
human resource planning, reward system, transfer, punishment and control mechanism, training, and
development, career planning and development.

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  The factors related to the job-The employees are more motivated if they are able to define and
take the tasks they like most, and their tasks are important and linked with that of to others, and
where they can influence others and have their own personal growth as well. The jobs with optimum
number, variety and duration of tasks are more motivating to the employee

Types Of Motivation

INTRINSIC MOTIVATION

Intrinsic motivation comes from within the person, driving him or her to be productive. To be
intrinsically motivated at work, the worker must value job performance and productivity. The intrinsic
motivation to achieve is directly related to a person's level of aspiration.

Intrinsic motivation comes from rewards inherent to a task or activity itself - the enjoyment of a puzzle or
the love of playing. Students are likely to be intrinsically motivated if they:

 attribute their educational results to internal factors that they can control (e.g. the amount of
effort they put in),

 believe they can be effective agents in reaching desired goals (i.e. the results are not determined
by luck),

 Are interested in mastering a topic, rather than just rote-learning to achieve good grades.

Parents and peers play major roles in shaping a person's values about what he or she wants to do and be.
Parents who set high but attainable expectations for their children, and who constantly encourage them
in a non authoritative environment, tend to impart strong achievement drives in their children. Cultural
background also has an impact on intrinsic motivation; some cultures value career mobility, job success,
and recognition more than others.

 EXTRINSIC MOTIVATION

Extrinsic motivation comes from outside of the performer. Money is the most obvious example, but
coercion and threat of punishment are also common extrinsic motivations.

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In sports, the crowd may cheer the performer on, and this motivates him or her to do well.
Trophies are also extrinsic incentives. Competition is often extrinsic because it encourages the
performer to win and beat others, not to enjoy the intrinsic rewards of the activity.

Social psychological research has indicated that extrinsic rewards can lead to over justification and
subsequent reduction in intrinsic motivation.

Extrinsic incentives sometimes can weaken the motivation as well. In one classic study done by Green
& Leper, children who were lavishly rewarded for drawing with felt-tip pens later showed little interest
in playing with the pens again.

Rewards resulting from extrinsic motivation(which is motivation that is enhanced by the work
environment) occur after the work has been completed. Although all people are intrinsically motivated
to some degree, it is unrealistic for the organization to assume that all workers have adequate levels of
intrinsic motivation to meet organizational goals. Thus, the organization must provide a climate that
stimulates both extrinsic and intrinsic drives.Extrinsic motivation is motivation enhanced by the job
environment or external rewards.

 INDICATORS FOR MOTIVATED EMPLOYEES IN THE ORGANIZATION

 Employee work willingly.
 Often give their best at work.
 Have a sense of belonging to the organization.
 Take pride in being member of the organization.
 High productivity and output.
 INDICATORS FOR DE-MOTIVATED EMPLOYEES IN AN ORGANIZATION
 Increasing absenteeism.
 Increased turnover.
 Low output and productivity.
 Increased rank discipline.
 Arguments with superiors.
 Frustration.
 Unrest.
 Non-cooperation.
 Strike .
 VARIOUS DEMOTIVATORS AT WORK PLACE.

 Under assignment-Skilled person given unskilled work.

 Over assignment- Over loading of the work.
 Buck mastership-Supervisors avoid doing hard work and pass the same to their subordinates and
find fault with them.
 Making promises not full filling them.
 INTERVENTIONS IN THE ORGANIZATION FOR EMPLOYEE MOTIVATION

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  Well defined humanistic personal policies where employees are regarded as most valuable asset
and care is taken to develop it.
 Fairness in recruitment and selection.
 Placement of right person with right skills at right place.
 Fair promotions and transfers.
 Well defined training and development programme for all types of manpower.
 Fair wages and salary administration.
 Rewarding good performance.
 Objective performance appraisal system.
 Prompt handling of workers grievances.
 Fairness in disciplinary action.
 Participatory and consultative style of management
 INDIVIDUAL RELATED INTERVENTIONS
1. Financial incentives for doing job well.
2. Praise from supervisor.
3. Admiration by peer group.
4. Better working conditions.
5. Taking responsibility for educational & health needs of employees and their family
members.
6. Transportation facilities, accommodation & other perks.
 CREATING A MOTIVATING CLIMATE:

In planning and organizing, managers attempt to establish an environment that is conducive to

getting work done. In directing, the manager sets those plans into action. Creating a motivating
climate as a critical element in meeting employee and organizational goals. The amount and
quality of work accomplished by managers directly reflect their motivation and that of their
subordinates. Because the organization has such an impact on extrinsic motivation, it is important to
examine organizational climates or attitudes that directly influence worker morale and motivation. For
example, organizations frequently overtly or covertly reinforce the image that each employee is
expendable and that individual recognition is in some way detrimental to the employee and his or her
productivity within the organization. Just the opposite is true, because employees are an organization's
most valuable asset.

McConnell (2005) maintains that employees want achievement, recognition and feedback,
interesting work, the opportunity to assume responsibility, a chance for advancement, fairness, good
leadership, job security and acceptance, and adequate monetary compensation. All of these things create
a motivating climate and lead to satisfaction in the workplace. Nurses who experience satisfaction stay
where they are, contributing to an organization's retention.

Managers also must be cognizant of an employee's individual values and attempt to reward each
worker accordingly. McConnell (2005) states that people vary considerably in how they respond to
needs. So, the manager must assess individual employee values and needs as well as organization values
and then use his or her authority to bring these values together. The abilityto recognize each worker as a

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unique person who is motivated differently and then to act upon those differences is a leadership skill.
Besides the climate created by the organization's beliefs and attitudes, the unit supervisor or unit
manager also has a tremendous impact on motivation at the unit level. McConnell (2005) states that "at
the level of the first-line manager, it should be evident that employees want recognition and feedback,
two need-fulfilling activities over which the manager has a great deal of control"

The manager can use to create a motivating climate is positive reinforcement. Connell an (2003)
refers to such reinforcement as positive feedback and calls it energizing because it validates workers'
effort. On the other hand, negative feedback makes workers feel as if they are being punished for trying,
and if negative feedback is consistently provided, the person will give up trying. Connellan identified
the following simple approaches for an effective reward-feedback system that uses positive
reinforcement

• Positive reinforcement must be specific or relevant to a particular performance. The manager should
praise an employee for a specific task accomplished or goal met. This praise should not be general. For
example, saying "Your nursing care is good" has less meaning and reward than "The communication
skills you showed today as an advocate for Mr. Jones were excellent. I think you made a significant
difference in his care."

• Positive reinforcement must occur as close to the event as possible.

• Reinforce any improvement, not just excellence. Both large and small achievements should be
recognized or rewarded in some way.

• Rewards should be intermittent.

• Reinforcement of new behaviors should be continuous.

If positive reinforcement and rewards are to be used as motivational strategies, then rewards must
represent a genuine accomplishment on the part of the person and should be somewhat individual in
nature. For example, many managers erroneously consider annual merit pay increases as rewards that
motivate employees. Most employees, however, recognize annual merit pay increases as a universal
"given"; thus, this reward has little meaning and little power to motivate

 CHARACTERISTICS OF HEALTHY AND MOTIVATING ENVIRONMENT

o People feel part of a team.
o There is ongoing clear communication up and down the organization hierarchy.
o Everyone is aware of and works towards defined goals.
o Good behavior is valued and reinforced.
o Staff development is ongoing.
o Employees have the authority to complete their work.
o The work and the people are respected.
o The staff feels generally positive about the other staff.

 CHARACTERISTICS OF AN UNHEALTHY ENVIRONMENT

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  Divisiveness is apparent among the staff, as in a dysfunctional family(we versus they)
 People complain continually or do not communicate at all.
 People do not want to come to work.
 New members may feel isolated.
 Top down communication is rare nonexistent.
 An open door policy is espoused but in reality rarely practiced.
 There are continually identified problems without attempts at resolution.

 STRATEGIES FOR CREATING A MOTIVATING CLIMATE

In addition to providing a climate that promotes joy in people's work, the leader-manager can do
many other things that create an environment that is motivating. Sometimes, fostering a
subordinate's motivation is as simple as establishing a supportive and encouraging environment. The
cost of this strategy is only the manager's time and energy.

Strategies to Create a Motivating Climate

1. Have clear expectations for workers, and communicate these expectations effectively
2. Be fair and consistent when dealing with all employees.
3. Be a firm decision maker using an appropriate decision-making style.
4. Develop the concept of teamwork. Develop group goals and projects that will build a team
spirit.
5. Integrate the staff’s needs and wants with the organization’s interests and purpose.
6. Know the uniqueness of each employee. Let each know that you understand his or her
uniqueness.
7. Remove traditional blocks between the employee and the work to be done.
8. Provide experiences that challenge or "stretch" the employee and allow opportunities for
growth.
9. When appropriate, request participation and input from all subordinates in decision making.
10. Whenever possible, give subordinates recognition and credit.
11. Be certain that employees understand the reason behind decisions and actions.
12. Reward desirable behavior; be consistent in how you handle undesirable behavior.
13. Let employees exercise individual judgment as much as possible.
14. Create a trustful and helping relationship with employees.
15. Let employees exercise as much control as possible over their work environment.
16. Be a role model for employees

 MOTIVATIONAL THEORIES

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MASLOW’S THEORY:

Maslow (1970) believed that people are motivated to satisfy certain needs, ranging from basic
survival to complex psychological needs, and that people seek a higher need only when the
lower needs have been predominantly met..
Although Maslow's work helps to explain personal motivation, his early work,
unfortunately, was not applied to motivation in the workplace. His later work, however, offers
much insight into motivation and worker dissatisfaction. In the workplace, Maslow's work
contributed to the recognition that people are motivated by many needs other than economic
security

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Maslow’s Hierarchy of needs.

1) Physiological: These are essential to survival, e.g food, drink, sleep etc.
2) Security or safety: These refer to the needs to be free from danger & to live in a stable, non-
hostile environment.
3) Social: As social beings, people need company of other humans.
4) Esteem: These include self – respect & value in the opinion of others.
5) Self – actualization: These are the needs at the highest level, which are satisfied by
opportunities to develop talents & to achieve personal goals.

Because of Maslow's work, managers began to realize that people are complex beings, not solely
economic animals, and that they have many needs motivating them at any one time.

Motivation is internalized and that if productivity is to increase, management must help employees
meet lower-level needs. The shifting focus on what motivates employees has tremendously affected how
organizations value workers today.

SKINNER’S THEORY

B. F. Skinner was another theorist in this era who contributed to the understanding of motivation,
dissatisfaction, and productivity. Skinner's (1953) research on operant conditioning and behavior
modificationdemonstrated that people could be conditioned to behave in a certain way based on a
consistent reward or punishment system. Behavior that is rewarded will be repeated, and behavior that is
punished or goes unrewarded is extinguished. Skinner's work continues to be reflected today in the way
many managers view and use discipline and rewards in the work setting.

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HERZBERG’S THEORY

Frederick Herzberg (1977) believed that employees can be motivated by the work itself and that there is
an internal or personal need to meet organizational goals. He believed that separating personal
motivators from job dissatisfiers was possible. This distinction between hygiene or maintenance factors
and motivator factors was called the Motivation-Hygiene theory or Two Factor theory.

Herzberg maintained that motivators or job satisfiers are present in work itself; they give people the
desire to work and to do that work well. Hygiene or maintenance factors keep employees from being
dissatisfied or demotivated but do not act as real motivators. It is important to remember that the
opposite of dissatisfaction may not be satisfaction. When hygiene factors are met, there is a lack of
dissatisfaction, not an existence of satisfaction. Likewise, the absence of motivators does not necessarily
cause dissatisfaction

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For example, salary is a hygiene factor. Although it does not motivate in itself, when used with other
motivators such as recognition or advancement, it can be a powerful motivator. If, however, salary is
deficient, employee dissatisfaction can result. Some argue that money can truly be a motivator, as
evidenced by people who work insufferable hours at jobs they truly do not enjoy. Some theorists would
argue that money in this case might be taking the place of some other unconscious need.

Herzberg's work suggests that although the organization must build on hygiene or maintenance factors,
the motivating climate must actively include the employee. The worker must be given greater
responsibilities, challenges, and recognition for work well done. The reward system must meet both
motivation and hygiene needs, and the emphasis given by the manager should vary with the situation
and employee involved. Although hygiene factors in themselves do not motivate, they are needed to
create an environment that encourages the worker to move on to higher-level needs. Hygiene factors

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also combat employee dissatisfaction and are useful in recruiting an adequate personnel pool. Vaughn's
(2003) study showed that among the numerous retention factors suggested by Herzberg's Two Factor
theory, nurses most desired a sense of recognition and achievement.

VROOMS’ THEORY

Victor Vroom (1964), another motivational theorist in the human relations era, developed an expectancy

VROOM’S EXPECTANCY MODEL

model, which looks at motivation in terms of the person's valence, or preferences based on social
values. In contrast to operant conditioning, which focuses on observable behaviors, the expectancy
model says that a person's expectations about his or her environment or a certain event will influence
behavior. In other words, people look at all actions as having a cause and effect; the effect may be
immediate or delayed, but a reward inherent in the behavior exists to motivate risk taking. In Vroom's
expectancy model, people make conscious decisions in anticipation of reward; in operant conditioning,
people react in a stimulus-response mode. Managers using the expectancy model must become
personally involved with their employees to understand better the employees' values, reward systems,
strengths, and willingness to take risks.

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Mc CLELLAND’S THEORY

David McClelland (1971) examined what motives guide a person to action, stating that people are
motivated by three basic needs: achievement, affiliation, and power. Achievement-oriented people
actively focus on improving what is; they transform ideas into action, judiciously and wisely, taking
risks when necessary. In contrast, affiliation-oriented people focus their energies on families and
friends; their overt productivity is less because they view their contribution to society in a different light
from those who are achievement oriented. Research shows that women generally have greater affiliation
needs than men and that nurses generally have high affiliation needs. Power-orientedpeopleare
motivated by the power that can be gained as a result of a specific action. They want to command
attention, get recognition, and control others. McClelland theorizes that managers can identify
achievement, affiliation, or power needs of their employees and develop appropriate motivational
strategies to meet those needs.

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GELLERMAN’S THEORY

Saul Gellerman (1968), another humanistic motivational theorist, has identified several methods to
motivate people positively. One such method, stretching, involves assigning tasks that are more difficult
than what the person is used to doing. Stretching should not, however, be a routine or daily activity
but an activity used to help the employee to grow.

Mc GREGOR’S THEORY

Douglas McGregor (1960) examined the importance of a manager's assumptions about workers on the
intrinsic motivation of the workers. These assumptions, which McGregor labeled Theory X and Theory
Y led to the realization in management science that how the manager views, and thus treats, the worker
will have an impact on how well the organization functions.

THEORY X
People dislike work.
People must be directed to work
People want to avoid responsibility
People believe that achievement is irrelevant
People are dull and uncreative
Money is the reason for working
People lack desire to improve quality.
THEORY Y
Work is natural
People will exercise self control
People enjoy responsibility
People value achievement
People have potential, imagination, and creativity.
Money is the only reason for working
People want to improve quality.

McGregor did not consider Theory X and Theory Y as opposite points on the spectrum but rather as
two points on a continuum extending through all perspectives of people. McGregor believed that people
should not be artificially classified as always having Theory X or Theory Y assumptions about others;
instead, most people belong on some point on the continuum. Likewise, McGregor did not promote
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either Theory X or Theory Y as being the one superior management style, although many managers
have interpreted Theory Y as being the ultimate management model. No one style is effective in all
situations, at all times, and with all people. McGregor, without making value judgments, simply stated
that in any situation, the manager's assumptions about people, whether grounded in fact or not, affect
motivation and productivity.

EQUITY THEORY [Jo Stacy Adams]

Equity theory says that employee’s fairness by considering their input and their
psychological, social, & their financial rewards in comparison with those of others. Perceived inequity
causes tension. The amount of tension to be proportional to their magnitude of the perceived inequity.
Tension motivates people to reduce its cause. Accordingly, the strength of the motivation to reduce the
perceived inequity is proportional to the cognitive dissonance. To reduce the inequity, people may alter
input or output; change the basis for comparison or leave. If people feel overworked and underpaid, they
are likely to decrease their productivity. Less often, employees feel over rewarded & strive to improve
their performance. People do not leave the organization unless there is extreme inequity. If the
comparison is equal, people feel that they are treated fairly. If not they are motivated to take corrective
action.

A person compares his or her input \ output with and perceives relation to a reference person.

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 OP = ORP } EQUITY

IP < IRP

OP< ORP } INEQUITY

IP > IRP

IP > IRP } INEQUITY

IP = INPUT OF THE PERSON

OP = OUTPUT OF THE PERSON

IRP = INPUT OF THE REFERENCED PERSON

IRP = INPUT OF THE REFERENCED PERSON

TAYLOR’S MONISTIC THEORY

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 He believe that if energetic people with high productivity learn that they earn no more than a lazy
worker who does as little as possible, they will lose interest in giving optimal performance . Taylor
argued that an incentive is needed to prevent this loss. It should be possible to earn more by
producing more, so that they pay would depend on productivity. Incentives such as merit increases,
bonus systems, profit sharing, savings sharing, and piece rates are examples of monistic methods. This
system can place considerable pressure on the worker and create tensions that lead to undesirable
behavior. Payment by piece rate almost certainly guarantees that some workers will be paid more
than others. A large paycheck may increase one’s self- esteem and even serve as a status symbol
as well as help to meet physiological needs by being able to purchase food, ,clothing, and shelter

Chapter- VI Karol

Communication:Meaning,Process,PrinciplesAndTechniques,Types,Confidentiality,Channels,
Barriers,Strategies, Interpersonal And Public Relation, Delegation; Common Delegation
Errors, Managing Conflict
INTRODUCTION:
Nurse Managers are required to be aware of the techniques that can help them ensure
effective management of educational/service unit. Communication is one of the most
important activities in the nursing management. It is the foundation upon which the manager
achieves organizational objectives.
DEFINITION OF COMMUNICATION:
Communication is a process in which a message is transferred from one person to
other person through a suitable media and the intended message is received and understood
by the receiver.
IMPORTANCE OF COMMUNICATION:
Promotes motivation:
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 Communication promotes motivation by informing and clarifying the employees about
the task to be done, the manner they are performing the task, and how to improve their
performance if it is not up to the mark.
Source of information:
Communication is a source of information to the organizational members for decision-
making process as it helps identifying and assessing alternative course of actions.
Altering individual’s attitudes:
Communication also plays a crucial role in altering individual’s attitudes, i.e., a well
informed individual will have better attitude than a less-informed individual. Organizational
magazines, journals, meetings and various other forms of oral and written communication
help in moulding employee’s attitudes.
Helps in socializing:
Communication also helps in socializing. In today’s life the only presence of another
individual fosters communication. It is also said that one cannot survive without
communication.
Controlling process:
Communication also assists in controlling process. It helps controlling organizational
member’s behavior in various ways. There are various levels of hierarchy and certain
principles and guidelines that employees must follow in an organization. They must comply
with organizational policies, perform their job role efficiently and communicate any work
problem and grievance to their superiors. Thus, communication helps in controlling function
of management.
ELEMENTS:
There are seven elements of communication: Source idea Message Encoding Channel
Receiver Decoding Feedback
Source idea:
The Source idea is the process by which one formulates an idea to communicate to
another party. This process can be influenced by external stimuli such as books or radio, or it
can come about internally by thinking about a particular subject. The source idea is the basis
for the communication.
Message:
The Message is what will be communicated to another party. It is based on the source
idea, but the message is crafted to meet the needs of the audience. For example, if the
message is between two friends, the message will take a different form than if
communicating with a superior.
Encoding:
Encoding is how the message is transmitted to another party. The message is converted
into a suitable form for transmission. The medium of transmission will
determine the form of the communication. For example, the message will take a different
form if the communication will be spoken or written.
Channel:
The Channel is the medium of the communication. The channel must be able to
transmit the message from one party to another without changing the content of the message.
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The channel can be a piece of paper, a communications medium such as radio, or it can be an
email. The channel is the path of the communication from sender to receiver. An email can
use the Internet as a channel.
Receiver:
The Receiver is the party receiving the communication. The party uses the channel to
get the communication from the transmitter. A receiver can be a television set, a computer, or
a piece of paper depending on the channel used for the communication.
Decoding:
Decoding is the process where the message is interpreted for its content. It also means
the receiver thinks about the message's content and internalizes the message. This step of the
process is where the receiver compares the message to prior experiences or external stimuli.
Feedback:
Feedback is the final step in the communications process. This step conveys to the
transmitter that the message is understood by the receiver. The receiver formats an
appropriate reply to the first communication based on the channel and sends it to the
transmitter of the original message.
CHARACTERISTICS OF COMMUNICATION:
1. Clarity:
* One of the most essential characteristics of an impressive communication is "Clarity".
* Use Simple and Sound words, so that listeners can grab it easily.
* Be clear in your thoughts, jumbled and confused mind cannot deliver a good and clear
saying. * Avoid using any technical terms, try to explain in laymen language.
* Use Examples to explain & support complex scenarios.
* Work a little bit on your accent and pronunciation.
2. Aim or Goal:
* At every stage of your talk/communication, don't forget your "Aim or Goal".
* Try to deduce an acceptable stuff by judging Pros & Cons impartially.
* Communicate with a broad and practical mind.
3. Precision:
* Be precise & exact in your approach. Neither be too deep nor be too short.
* Include some good facts acknowledging your topic.
4. Avoid Repeatability, unless required so.
5. Linkage :
* Try to maintain a logic link between your sayings.
* Don't put two opposite faces of coin at a same time.
* Deliver in a structured & planned way.
6. Globalization and Localization:
* Try to explain the broader aspects but not on the cost of local values.
* Aggregation of local values should result into global and broader aspects.
7. Style of Expressing:
* Control various speech parameters like pitch, tone, intensity etc. according to the
environment. * Don't be too fast or too slow.
* Light Humor at the right time is always accepted.
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* Look straight & forward. Keep a light smile on your face.
* Avoid using words that show arrogance.
* Feel what you say.
* Avoid being too formal, be natural and practical.
8. Know and Analyze the audiences.
9. Do a good Homework.
10. Dress properly:
* 25% confidence and 25% Respect from audiences comes automatically, if you have
dressed up well.
* Be neat, clean, ironed and polished irrespective of the fact that you have dressed up
formally or informally.
* Do a good hair styling; avoid any casual or unethical looks.
PROCESS OF COMMUNICATION:
All of the manager’s functions involve communication. The communication process
involves six steps.

Ideation encoding transmission receiving decoding response

Response decoding receiving transmission encoding

Ideation:
The first step, ideation, begins when the sender decides to share the content of her
message with someone, senses a need to communicate, develops an idea or selects
information to share. The purpose of communication may be inform, persuade, command,
inquire or entertain.
Encoding:
Encoding is the second step, involves putting meaning into symbolic forms. Speaking,
writing or non verbal behavior. One’s personal, cultural and professional biases affect the
goals and encoding process. Use of clearly understood symbols and communication of all the
receiver needs to know are important.
Transmission:
The third step, transmission of the message, must overcome interference such as garbled
speech, unintelligible use of words, long complex sentences, distortion from recording
devices, noise and illegible handwriting.
Receiving:
The receiver’s senses of seeing and hearing are activated as the transmitted message is
received. People tend to have selective attention (hear the message of interest to them but not
others) and selective perception (hear the parts of the message that conform with what they
want to hear) that cause incomplete and distorted interpretation of the communication.
Sometimes people tune out the message because they anticipate the content and think they
know what is going to be said. The receiver may preoccupied with other activities and
consequently not be ready to listen.
Decoding:
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 Decoding of the message by the receiver is the critical fifth step. Written messages
allow more time for decoding, as the receiver assesses the explicit meaning and implications
of the message based on what the symbols mean to her. The communication process is
depend on the receiver’s understanding of the information.
Response or feedback:
It is the final step. It is important for the manager or sender to know that the message
has been received and accurately interpreted.
PRINCIPLES OF COMMUNICATION:

and individuality of the communication.

munication should be familiar.

TECHNIQUES TO IMPROVE THE COMMUNICATION:

Listening:
An active process of receiving information. The complete attention of the nurse is
required and their should be no preoccupation with oneself. Listening is a sign of respect for
the person who is talking and a powerful reinforce of relationships. It allows the patients to
talk more, without which the relationship cannot progress.
Broad openings:
These encourage the patient to select topics for discussion, and indicate that nurse is
there, listening to him and following him. For e.g. questions such as what shall we discuss
today? “can you tell me more about that”? “And then what happened?” from the part of the
nurse encourages the patient to talk.
Restating:
The nurse repeats to the patient the main thought he has expressed. it indicates that the
nurses is listening. It also brings attention to something important.
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Clarification:
The person’s verbalization, especially when he is disturbed or feeling deeply, is not
always clear. The patients remarks may be confused, incomplete or disordered due to their
illness. So, the nurses need to clarify the feelings and ideas expressed by the patients. The
nurses need to provide correlation between the patient’s feeling and action. For example “I
am not sure what you mean “? “ could you tell me once again?” clarifies the unintelligible
ideas of the patients.
Reflection:
This means directing back to the patient his ideas, feeling questions and content.
Reflection of content is also called validation. Reflection of feeling consists of responses to
the patient’s feeling about the content.
Focusing:
It means expanding the discussion on a topic of importance. It helps the patient to
become more specific, move from vagueness to clarity and focus on reality.
Sharing perceptions:
These are the techniques of asking the patient to verify the nurse understands of what
he is thinking or feeling. For e.g. the nurse could ask the patient, as “you are smiling, but I
sense that you are really very angry with me”.
Theme identification:
This involves identifying the underlying issues or problem experienced by the patient
that emerges repeatedly during the course of the nurse-patient interaction. Once we identify
the basis themes, it becomes easy to decide which of the patient’s feeling and thoughts to
respond to and pursue.
Silence:
This is lack of verbal communication for a therapeutic reason. Then the nurse’s
silence prompts patient to talk. For e.g. just sitting with a patient without talking, non
verbally communicates our interest in the patient better.
Humor:
This is the discharge of energy through the comic enjoyment of the imperfect. It is a
socially acceptable form of sublimation. It is a part of nurse client relationship. It is
constructive coping behavior, and by learning to express humor, a patient learns to express
how others feel.
Informing:
This is the skill of giving information. The nurse shares simple facts with the
patient.
Suggesting:
This is the presentation of alternative ideas related to problem solving. It is the
most useful communication technique when the patient has analyzed his problem area, and is
ready to explore alternative coping mechanisms. At that time suggesting technique increase
the patient’s choices.
TYPES OF COMMUNICATION:
Communication

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

Formal informal vertical horizontal verbal non

verbal

Downward upward oral written.

ONE-WAY V/S TWO WAY COMMUNICATION:
One-way communication:
The flow of communication is one way from the communicator to the audience.
Example receive method.
Drawbacks are:

Two way communication:

In this both the communicators and the audience take place. The process of
communication is active and democratic. It is more likely to influence behavior than one way
communication.
FORMAL V/S INFORMAL COMMUNICATION:
Communication has been classified into formal (follows lines of authority) and
informal (group line) communication.
Formal communication:
It is officially organized channels of communication and it is delayed communication. It
is generally used for all practices purposes. This authoritative, specific, accurate and reaches
everybody. The medium of formal communication may be department meeting, conferences,
telephone calls, interviews, circular etc.
Informal network:
Gossip circles such as friends internet group, like minded people and casual groups.
Communication is very faster here. The informal channels may be more active. It follows
grape wine route. It may be a fact but more in native of rumor. It does not reach every one
informal communications are quite fast and spontaneous.
Physiological communication:
It is a stimulus received by the body immediately the brain receives the information and
transmits to the respective organs through the nervous, where it has to be passed.
Psychic communication:

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 Extra sensory perception occurs, i.e something which will occur in future. The person
pertains and predicts that in advance is called psychic communication.
Serial communication:
Person to person the message will be passed line a chain. Sender passes the message to
one person, then that receiver passes information to other and so on.
Symbolic communication:
Good communication requires awareness of symbolic communication, the verbal and
nonverbal symbolism used by others to convey meaning.
Visual communication:
The visual forma of communication comprise charts and graphs, pictograms, tables,
maps, posters etc.
VERBAL V/S NONVERBAL COMMUNICATION:
The traditional way of communication has been by word of mouth language is the
chief vehicle of communication. Through it, one can interact with other can be passes
through. Direct verbal communication by word of mouth may be loaded with hidden
meanings. The important aspects if verbal communication are as follows.
Vocabulary:
Communication is unsuccessful if senders and receivers cannot translate each others
word and phrases when a nurses cases for a client who speaks another language an interpret
may be necessary.
Denotative and connotative meaning:
A single word has several meaning. Individuals who use a common language share
the denotative meaning, baseball has the same meaning for everyone who speaks English, but
code denotes cardiac arrest primarily to health care providers.
The connotative meaning is the shade or interpretation of a word’s meaning
influences by the thoughts, feelings or ideas people have about the word.
Pacing:
Conversation is more successful at an appropriate speed or pace nurse should speak
slowly enough to enunciate clearly. Pacing is improved by thinking before.
Adoptability:
Spoken messages need to be altered a according with behavioral due from the
receiver.
Intonation:
Tone of voice dramatically affects a meaning. The nurse must be aware of voice line
to avoid sending unintended messages.
Clarity and brevity:
Effective communication is simple, brief and direct. Clarity is achieved by speaking
slowly, enunciating clearly and using, repeating important parts of a message also clarifies
communication.
Brevity is achieved by using short sentences and words that expresses an idea
simply and directly.
Credibility:
Credibility means worthiness of belief, trustworthiness and reliability.
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Time and relevance:
Timing is critical in communication. Even though message is clear, poor timing
can prevent it from being effective. Often the best time for interaction is when a client
express an interest in communication. If message are relevant of important to the situation at
hand, they are more effective.
Oral communication:
Oral communication is a transmitting message orally either by meeting the person
through artificial media of communication such as telephone and intercom systems.
Written communication:
It is transmitting message in writing. Written communication can be followed when a
record of communication is necessary.
NON VERBAL COMMUNICATION:
Communication can occur even without word. Non-verbal communication is message
transmission through body language without using words. It includes bodily movements,
positive, facial expression. Silence is non verbal communication. It can speak louder than
words.
Personal appearance:
Nurse learn to develop a general impression of clients health and emotion status
through appearance and clients develop a general expression of the nurse’s professionalism
and caring in the same way personal appearance includes physical characteristics, facial
expression, manner of dress and grooming first impressions are largely based on appearance.
Poster and gait:
Poster and gait are forms of self expressions. The way people sit, stand and more
reflect attitudes, emotion and self concept and health status.
Facial expression:
The face is the most expressive part of the body. Facial expression convey emotion
such as surprise, fear, anger, happiness and sadness. People can be unaware of the messages
their expression convey doing procedure and the client may interpret. This is anger or
disapproval.
Eye contact:
Maintaining eye contact during conversation shows respect and willingness to listen,
lack of eye contact may indicate anxiety, discomfort or lack of confidence in communicating.
Hand movements and gestures:
Hands also communicate by touch, slapping or caring another’s head communicates
obvious feelings.
MECHANICAL COMMUNICATION:
By using mechanical devices the communication will be sent. For e.g. internet, radio,
T.V. etc.
ADVANTAGES OF COMMUNICATION:
Oral communication:

-operative spirit.
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 ick.

Written communication:

DISADVANTAGES OF COMMUNICATION:
Oral communication:

unication.

Written communication:

is no opportunity for the subordinates to ask questions and exchange ideas.

STRATEGIES OF COMMUNICATION:
Think before you speak:
Think about the purpose of your communication. What do you hope to accomplish
with your words or actions? Are your comments about something you are responsible for
doing, such as parenting or managing someone or about an activity you are doing together
with the other person? Or, is it an opinion about something that is not your business, maybe
even something that the other person has already asked you to stop discussing?
"Before you speak, ask yourself: Is it kind? Is it necessary? Is it true? Does it improve on the
silence?" . Also, think about the structure of your communication.
Listening:
The most effective leaders know when to stop talking and start listening. This is especially
important in three particular situations: when emotions are high, in team situations and when
employees are sharing ideas.
First, listening is crucial when emotions are high. Extreme emotions, such as anger,
resentment and excitement, warrant attention from a personal and a business standpoint. On a
personal level, people feel acknowledged when others validate their feelings. Managers who
ignore feelings can create distance between themselves and their employees, eroding the
relationship and ultimately affecting the working environment.
Questioning:
Many leaders need information but aren't sure how to get it. Similarly, their employees may
have information but don't know how to impart it. Managers can open the lines of
communication by asking good questions. Note that different kinds of questions yield
different kinds of results. Here is a short primer on questioning:
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* Closed questions are those that elicit yes/no answers. These are beneficial when a manager
simply needs to check the status of an issue. Has the report been completed? Do you know
what to do? Can you get that to me by Friday? These are examples of closed questions that
are perfectly appropriate in the right situations.
* Open questions are those that elicit longer responses. They are useful almost anytime a
manager wants more than a yes/no answer--for instance, when seeking input from others,
looking for information about a particular topic or exploring a problem. What do you think
would be the best way to go about this? How are you doing on that project? What went
wrong? These kinds of questions give others the chance to give all of the information they
have and to avoid the innumerable consequences that can come when leaders make
assumptions without becoming well-informed.
* Personal questions have a special role in leadership. Inappropriate personal questions can
alienate employees. Asking direct reports if they are dating anyone or why they haven't
bought a house can be perceived as prying, even if the questions are well intended.
Appropriate personal questions, however, can create a sense of camaraderie between
employee and boss.
Asking whether employees had a nice weekend, inquiring about their families or following
up on common interests all help people connect on a personal level. That relationship leads
to a greater commitment as well as a more pleasant environment.
Using Discretion:
Knowing when not to speak as a leader is just as important as speaking. Managers must
understand that the moment they don a new title, they become a leader--one whom others
look to for guidance, direction and even protection. Good leaders adopt a policy of
discretion, if not confidentiality, with their employees. Only then can they develop the trust
that is so vital to productivity.
Confidential situations may arise in a number of areas, personal and professional. Here are
some topics that may warrant discretion:
* An employee is having a direct conflict with another employee.
* An employee is concerned about another employee's conduct.
* An employee's performance has dropped substantially.
* An employee has a health issue or personal problem.
* An employee wants genuine advice on how to excel but doesn't want to be seen as cozying
up to the boss.
Directing
Notice that directing comes last on the list of communication strategies. It may not be the
least important, but it is definitely one to use less often. Many managers direct their
employees because they believe it's the only way to get things done. It is not.
But directing has its place. Directing means giving directions clearly and unequivocally, such
that people know exactly what to do and when. It is best used in times of confusion, or when
efficiency is the most important goal. Although it can be effective, directing also
can lead to complacency on the part of employees who may adopt an "I just do what they tell
me" attitude. Use it sparingly
CHANNELS OF MANAGERIAL COMMUNICATION:
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 There are four levels of managerial communication:
Downward communication.
Upward communication.
Lateral communication.
Diagonal communication.
Downward communication:
This is the traditional and most used communication, where the management gives
orders to the subordinates at the bottom level to carry out the orders as per the organizational
hierarchy.

Management

Subordinates subordinates
All the written and oral communication which are carried out from the top
management to the employees by various means in order that the employees carry out their
duties in the organization in achieving its goals.
Upward communication:
Upward communication in the management levels from staff, lower and middle
management personnel and continuous up to the organizational hierarchy. It provides a
means for motivating satisfying personnel by encouraging employees input.
Management

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

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

Medical department Nursing department

Medical unit surgical unit pathology medical surgical

pediatrics

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 Laboratory x-ray laundry
CSSD
Common means are: unit in-charge ordering diet for the patient, X-ray department informs
appointments given to patients in a particular unit, etc.
BARRIERS OF COMMUNICATION:
Communication barriers create problem of misunderstanding and conflict between men
who live together in the same community, who work together on the same job and even
between men living in the distinct parts of the world who have never seen one another.
Following are the main barriers to overcome:
1.Due to organization structure:
The breakdown or distribution in communication sometimes arises due to:
1. Several layers of management;
2. Long lines of communication;
3. Special distance of subordinates from top management;
4. Lack of instructions for passing information to the subordinates;
5. Heavy pressures of work at certain levels of authority.
2.due to status and position:
1. the attitude exhibited by the supervisor are sometimes a hurdle in two way
communication. One common illustration is non listening habit. A supervisor may guard
information for:
a. consideration of prestige, ego and strategy.
b. underrating the understanding and intelligence of subordinates.
2. prejudice among the supervisors and subordinates may stand in the way of a free flow
of information and understanding.
3. the supervisors particularly at the middle level may sometimes like to be in good books
of top management by:
a. not seeking clarification on instructions which are subject to different interpretations;
and
b. acting as screen for passing only such information which may please the boss.
3. semantic barriers:
Semantic is the science of meaning. Words seldom mean same thing to two person.
Symbols or Words usually have a variety of meaning arid the sender and the receiver have to
choose one meaning from among many. If both of them choose the same meaning,
communication will be perfect. But this is not so always because of differences in formal
education and specific situations of the people.
Strictly one cannot convey meaning, only one can do it to convey words. But the same
words may suggest quite different meaning to different people, e.g. „profits‟ may mean to
management efficiency and growth, whereas to employees it may suggest excess funds piled
up through paying inadequate wages.
4. Tendency to evaluate:
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 A major barrier to the communication is the natural tendency to judge the statement of
the person or other group. Every one tries to evaluate others from his own point of view or
experience. Communication requires an open mind and willingness to see things through the
eyes of others. Some intelligent brains even complimented him on his excellent style of
imagination.
Heightened emotions:
Barriers may also arise but in specific situations, e.g. emotional reactions, physical
conditions like noise or insufficient light, past experience, etc. when emotions are strong, it is
most difficult to know the frame of mind of the other person or group.
Lack of ability to communicate:
All persons do not have the skill to communicate. Skill in communication may come
naturally to some, but an average man may need some sort of training and practice by way of
interviewing and public speaking, etc.
Inattention:
The simple failure to read bulletins, notices, minutes and reports is a common
feature. With regard to failure to listen to oral communications, it has been seen that non
listeners are often turned off while they are preoccupied with other affairs, like their family
problems.
Unclarified assumptions:
This can be clarified by an illustration. A customer send a message that he will visit
a vendor’s plant at particular time on some particular date. Then he may assume that vendor
will receive him and arrange for his lunch, etc. whereas vendor may assume that the
customer was arriving in the city to attend some personal work and would make a routine
call at the plant. This is an unclarified assumption with possible loss of goodwill.
Resistance to change:
It is the general tendency of human-being to maintain status quo. When new ideas
are being communicated, the listening apparatus may act as a filter in rejecting new ideas.
Thus, resistance to change is an important obstacle to effective communication.
Sometimes, organizations announce changes which seriously affect the
employees, e.g. shifts in timings, place and order of work, installation of new plant, etc.
changes affect people in different ways and it may take sometime to think through the full
meaning of the message. Hence, it is important for the management not to force changes
before people are in a position to adjust to their implications.
Closed minds:
Certain people who think that they know everything about a particular subject
also create obstacles in the way of effective communication.
THEORIES OF COMMUNICATION:
Related to management:

The decibal theory:

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 It argues that the best way to get the message across is to state one’s point loudly and
frequently. its effectiveness over a period of time is nil, but many of us still need to be
reminded that shouting only makes poor communication louder.
The sell theory:
It lays down that the total burden of communication is on the communicator while the
receiver is passive and pliable. One of the problem created by this approach is that it tends to
increase the barriers between the individuals and thus reduces the chances of hearing each
other.
The minimet theory:
It assumes that the receiver probably is not much interested in what is being
communicated. By telling an individual what he needs to know, he will have little to object
and little to question.

PUBLIC RELATIONS
INTRODUCTION:
Public relation is an essential and integrated component of public policy or
service. The professional public relation activity will ensure the benefit to the citizens, for
whom the policies or services are meant for. An effective public relations can create and
build up the image of an individual or an organization or a nation. At the time of adverse
publicity or when the organization is under crisis an effective public relations can remove the
"misunderstanding" and can create mutual understanding between the organization and the
public.
TERMINOLOGIES:
(1) Fortitude: Happening by chance.
(2) Composite: Made up of different part or material.
(3) Humility: Quality of being humble
(4) Persuasive: Able to give good reason for doing something.
DEFINITION OF PUBLIC RELATION:
According to John Millet,
“Public relation are knowing what the public expects and explaining how
administration is meeting these desires….”.
According to J.L MeCamy,
“Public relation in Government is the composit of all the primary and
secondary contacts between the bureaucracy and citizens and all the interactions of
influences and attitudes established in these contracts”.
According to W.T. Parry‟
“Public relation means the development of cordial, equitable and therefore
mutually profitable relations between a business industry organization and the public it
serves”.
According to Rex Harlow,
“Public relations are the process whereby an organization analyses the needs
and desires of all interested parties in order to conduct itself more responsively towards
them”.
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 NEED OF PUBLIC RELATION:
Not many years ago, management decisions took no consideration of public
attitudes but today management cannot ignore the views of employees, and the community in
making – policy decisions. It has been estimated that eighty per cent of the problems
confronting management have public relations implications. Management has to foresee the
impact of policy decisions on the opinion of the public.
There is normally four distinct reasons for ever increasing necessity of public relations:
(1) Increased governmental activities.
(2) Population explosion creating communication problems.
(3) Increased educational standards resulting in rise in expectations.
(4) Progress in communication techniques.
Well-executed public relations will

the hospital’s image.

levies and bonds.

Boost employee morale.

Functions of public relation:

public).

eption & attitude, identifies the organization policy with public

interest and then executes the programmes for communication with the public.
ELEMENTS OF PUBLIC RELATIONS:
A planned effort or management function.
The relationship between an organization and its publics.
Evaluation of public attitudes and opinions.
An organization’s policies, procedures and actions as they relate to said organization’s publics.
Steps taken to ensure that said policies, procedures and actions are in the public interest and
socially responsible.
Execution of an action and or communication programme.
Development of rapport, goodwill, understanding and acceptance as the chief end result sought
by public relations activities.
FORMS OF PUBLIC RELATION:
Public relation is a general term that may include many other “relations” with
different audiences, strategies and tactics. For example:
Employee relations:
It is a function of public relations that includes responding to employee concerns and
informing and motivating staff. Some tactics used for employee relations may include new
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 employee education, employee award programs and recognitions, new-hire press releases
and newsletters to name a few.
Community relations:
It is the function of actively planning and participating with and within a community
for the benefit of the community and the hospital. Tactics within this category include
community events, volunteer activities and co-sponsorship opportunities with other
community organizations. Community relations may also include fundraising and
development activities.
Government relations:
It is a function of relating to government officials and agencies about issues that
impact the hospital and its audiences. Hill climb events in Olympia, letter writing campaigns,
and op-ed placements in the newspaper are often part of government relations.
Media relations:
It is often considered synonymous with public relations, is the function of working
with the media to communicate news. Media relations can be active – seeking positive
publicity for a newsworthy topic at the hospital – or reactive – responding to a news inquiry
about a positive or negative story of interest to the media and its readers or viewers.
PUBLIC RELATION PLAN FOR A HOSPITAL:
Every hospital should have a current public relations plan that outlines goals and
desired outcomes for a period of three to five years. Once a general PR plan is in place,
periodic planning and updating is critical. The plan and its updates will not only help guide
employees responsible for public relations work, but will result in an effective tool to
communicate with the board and other staff. Following are the key elements of an effective
PR plan:
Goals:
Public relations goals help direct the strategies and tactics in future public relations
endeavors. The goals should clearly support hospital mission statement. While a mission
statement may include what the hospital wants to accomplish, a public relations goal should
be focused on what you want the public to think and know about the hospital
Examples:

health care for the people of Carter, Key and Kangley counties.

safe environment for people in the Highland Valley region.

health care service provider in the state.

Objectives:
Objectives help determine specific outcomes from your public relations efforts.
Objectives should be clear and concise, and include timing.
Examples:
medical advances used at the hospital within
Evergreen County over the next six months.

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community that provides health care services, jobs and community leadership.

next two years.

Target Audiences:
Detail the groups of people that are important to inform or influence, and why.
Examples:
purchase health care services and generate revenue for the hospital.

where patients go for care in the hospital or outside of the community.

e both positive and negative stories about the hospital, its staff and services.
They have considerable influence and access to all of the hospital’s target audiences.
Other audiences to consider may include employees, board members, community leaders,
local government officials, state legislators, vendors and suppliers.
Tactics:
It’s easy for busy hospital professionals to think about tactics first, but it is critical to
have a solid strategy in place. Only pursue the tactics that will help achieve the goals. Here
are some “best uses” for specific tactics.
Brochure/Collateral – To inform patients and community members about programs and
services provided at the hospital for promotional use only. It may be provided to media for
background, but not to be used instead of effective media tools, such as press releases or fact
sheets.
Direct mail – To help create awareness for programs or services with target audiences.
Message is controlled.
Letters – Good for personal or business communication. Adjustable length (1-2 pages).
Postcards – Good for event invitations or welcome cards. Inexpensive postage.
Direct mail packages – Good for inclusion in new neighbor welcome packages or community
coupon envelopes. Consider including brochures or inserts. Costs are typically part of an
advertising or sponsorship package. Production of materials likely not included.
Specialty mailings – Good for awareness efforts, such as a child safety campaign sponsored
by the hospital. Mailing may include a magnet with safety tips and local emergency contact
information.
Distribution Methods:
How you distribute materials is often as important as what the organization send. It is
a good idea to know which methods the target audiences, especially reporters, prefer.
Mail – Good to use when timing is less sensitive (one to three days). Good for newsletter
mailings, new neighbor welcome packets, media kits, and other materials that are difficult to fax
or e-mail. Mail can also be certified to verify receipt or insured to avoid loss.
Fax – Good for timely communication (faster than mail). Good for press releases, event
reminders, and some forms of newsletters (such as weekly news notices). Less effective for
documents with images or graphics.

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 E-mail – Good for timely and direct communication with an individual. Good for press
releases, media reminders, media personnel questions, and pitch letters. Access to e-mail and
electronic document size can be limitations.
Face-to-face meetings – Best way to make a personal connection. It allows for detailed
explanation of a point-of view or complicated subject. Best way to demonstrate excitement,
concern, tolerance, empathy, etc.
Phone conference call – Allows for personal contact when face-to-face is not possible. Good
for back-and-forth communication. Inexpensive method for communicating with large groups in
different locations (cities/states).
Web site – Web pages allow interested parties to pull information thereby facilitating
distribution. Directing people to a web site may be done through mailings, publicity or other
notices.
Newsletter – To regularly update a variety of target audiences about the happenings at the
hospital. Good way to establish and maintain community support for the hospital and services.
Public service announcement (PSA) – To create awareness of a problem or issue through
radio or television.
Press release – To distribute straightforward news to the media.
Press kit – To provide extensive information about a topic. It may precede an event or new
program launch.
Press conference – To disseminate time sensitive and critical news to multiple media
contacts at once. It should be rarely used.
Special event – To make a personal connection with target audiences in a positive
environment. It is good way to recognize people for good work or launch new programs of
facilities.
Speaking engagement – To reach a target audience, establish the speaker as an expert and
build credibility for the speaker and the hospital.
Video – To communicate messages with emotion through visuals. It is good for town
meetings, new employee education, fundraising projects, special events, etc.
Web site – To provide 24-hour access to information about the hospital. It may include health
information or links to health information depending on site design. It is good for general
information about the hospital, its services and staff.
Budgets:
Public relations budgets may come in a variety of ways. It may be pre-determined and
passed down from the overall hospital budget. It may include general guidelines but is open
to the tactics decided upon. It may be non-existent, in which case the tactics will need to rely
on investments in staff time, instead of materials. All of these factors will determine where
budgeting fits into the overall public relations planning. Regardless of where budgeting fits
into the plan, consider the following:
Nothing is free------- Consider all of the direct and indirect costs. Even a press release, one of
the least expensive tactics, has a price tag, the time spent writing and editing the release, the
paper it is printed on and the postage it’s mailed with at a minimum.
Don’t underestimate time investments-------- Every public relations activity has time
investments and opportunity costs and don’t just consider the time investments for the PR staff.
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Administrative oversight and involvement, interview source preparation and even volunteer
efforts all play into the opportunity costs of public relations. When planning and prioritizing
projects, consider all necessary staff time and what else they would be doing with their time if
not promoting the hospital.
Shop around--------- When producing brochures or printed materials; be sure to get more than
one estimate. Printing shops with more capacity at certain times may discount their rates.
Evaluate options--------- Another way to save money when producing materials is to consider
design options. For example, two-color brochures are far less expensive than their four color
counterparts. Specialty work, such as die-cuts for holding business cards or layered stair-steps
for handouts, are nice features, but may carry a hefty price tag. Designers and printers can be
allies in determining options. Just be sure to have your budget in mind.
Be prepared for the unexpected opportunities-------- Reserve 10 to 15 percent of the
overall public relations budget for unexpected activities. There may be some great opportunities
to do events, community outreach activities or other projects that you didn’t anticipate.

METHOD OF IMPROVING PUBLIC RELATION IN HOSPITAL:

There are certain other aspects which need careful consideration which are
described in brief as under.
General:
High quality patient care by the hospital is the theme of any public relation programme.
No amount of smile, cheers and propaganda will compensate for bad administration and poor
professional care in the hospital.
Physical facilities:
Well planned hospital with sufficient waiting area for the patient and its relation in the
hospital, optimum floor space for each department of t e hospital, logical layout of the
department and work areas, provision of adequate facilities like toilets, public utility services
like canteen, drinking water facility and so on go a long way in improving the image of the
hospital.
Staff:
In a hospital the staff consists of variety individuals drawn from different status of the
society with different levels of education and background. Imbibing a team spirit in all these
groups of people for the patient care will lead to a general satisfaction foe the patients in the
hospital.
Name Labels and Uniform:
All functionaries should wear uniforms and name labels. This creates initial good
impression on patients and reflects good administration. It also infuses among the employees
a pride and sense of belonging to the institutions. These also help in identifying the staff by
name and their status. These are particularly useful in OPD and ancillary departments.
Importance of Color:
Color affects many of our moods and emotions. Proper choice of color can transform
depressing and monotonous atmosphere into pleasing and exciting one. It stimulates
employee‟s productivity. Hospital is one area where color can be used with measured
success not only in appearance but for the psychological uplifting which it brings to patients.
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Operating facility:
The operating efficiency in an organization like, hospital is the outcome of its soundness
of objectives, policies, procedures, programmes and standing orders. The clear cut policy and
procedure in writing and their periodic promulgation to the staff specially, clear order
regarding organizational structure, defining their duties, authorities and accountability of the
staff.
The speciality clinics:
The speciality clinics if located proximally are one of the concentrated areas of the OPD
services. It will facilitate mutual interaction of the functionaries and effective protocol among
the various specialities and will in turn save great deal of effort for the patient to move
around for multiple consultations, as and when necessary.
Waiting time:
The waiting time in the OPD is invariably the sore point of public grievances.
Introduction of appointment system, staggering of OPD timings for the registration, punctual
attendance by doctors are some of the remedies which can be introduced to reduce waiting
time and have successfully been implemented in many hospitals.
Delay in Admission:
Anxiety and distress is the result of delays in admission due to long waiting list. In
allotting priorities for admission, hospitals consider the physical state of the patients but
forget the social background and as a result, social emergencies have to wait. Adequate
facilities in efficient use of present resources can resolve this problem to some extent.
Ward Reception:
Patients are generally vulnerable to anxiety and fear on arrival in the ward. The
reception they get tends to leave a deep impression. Prompt reception improves the morale of
the patients.
Privacy:
It is normally observed that majority of the patients are dissatisfied with the type of
privacy provided in the ward. Provision of screens around each bed would afford greater
privacy. To have the privacy and at the same time provide the advantage of companionship
of other patients in the ward would go a long way in creating a feeling of warmth and
understanding.
Food:
Good food, well prepared and attractively served to patients, makes a very favorable
impression. Presence of dietician or a nurse at the time of service creates good impact on the
patients.
Cleanliness:
Cleanliness is much a desired thing in a hospital. It not only enhances the image of the
hospital but also helps in controlling hospital infection. Frequent cleaning and liberal use of
detergents and deodorants eliminates the stink which is most dissatisfying.
Information about Illness:
The most important thing to a patient is to know as to what is wrong with him and how
long will it take to recover. Information in this respect will always be associated with fear,
anxiety and thus, will help in building patients confidence. A doctor or a nurse should be
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 available in the ward during visiting hours to furnish information regarding illness of the
patients to their relatives.
Visitors:
Relatives and friends come rushing to the hospital the moment they learn about the
illness of their near and dear one. This is to show their loyalty, affection and strength of ties.
It also satisfies emotional needs of the patient. The relatives etc. are allowed to visit their
patients for a short while. The visiting hour policy should be more liberal for the visitors to
the serious patients and relatives coming from distant places. Too rigid visiting policy makes
the public critical of the hospital.
Complaints and Suggestions:
The best way to deal with complaints is to do everything possible to avoid getting
them by anticipating the problems. In spite of the best intentions of everyone and as it
happens everywhere
else, sometimes things go wrong. Any complaint and suggestions should receive prompt
attention and wherever possible remedial actions be taken. Equally important is that whatever
action is taken, the same is communicated to the complaint.
Mortuary and Chaplain Facility:
The disposal of the dead is influenced by religion, social and cultural beliefs and
practices. It is necessary to provide within the hospital or its premises a place to which a dead
body can be moved quietly so that other patients do not get upset. Disposal of dead has a
great bearing on public relations of the hospital. This is a sensitive area for the relatives and
friends. Even unintentional neglect or delay may carry unpleasant impression about the
hospital. Utmost care is needed by all members of the staff to ensure that prompt and proper
disposal of the dead is arranged.
NEED FOR PUBLIC RELATION IN THE COMMUNITY:

-up
of two-way communication.
community with the concept of what a hospital and a health centre are.

munity to assess their needs.

the top level management.

hospital through effective staff performance.

building. The right sort of relationships where there is good public relations, the hospital and
health care are functioning at its best and contribute maximum to which it serves.

METHODS OF MAINTAINING PUBLIC RELATION IN THE COMMUNITY:

There are mainly two methods:
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 Operative methods:
These methods are essentially connected with every aspect of community operation
including those are carried out by such workmen as health personnel, office personnel,
enquiry, media personnel etc. The fundamental ingredients of community operation are:
i. Cheerful and courteous behavior.
ii. Prompt and efficient treatment.
iii. Clear surroundings and well appearance of the workers.

Some operations of improving operation of primary health care in the community level are:
i. A high quality patient care is the key of good public relation
ii. Adequate physical facility with good functional layout. Waiting room with benches or chairs,
water, refreshment facility in the outpatient department.
iii. To make others happy one must be happy himself. Good morale of workers not only
increases efficiency, but workers with high morale interact in a positive manner with one another
and also with the patients in the community.
iv. Operating efficiency with effective coordination among all clinical departments and other
supportive services stem from good administration, organization structure, policies, procedures
and authority and accountability should be clearly understood by each staff.
Communicative methods:
These methods employ means of communication in all possible forms to enable the
primary health centre to convey its message to the public. Some of these are also intermixed
in a way with intra-mutual functions of the hospital or health centers and the operative
methods may be used in the following ways:
a. Making the available appropriate information to the patients, their relatives and visitors.
b. A provision to listen to verbal complains instead of insisting on written one.
c. Prompt reply to questions.
d. Provision of suggestion box at appropriate place.
e. Visual communication, film shows, exhibitions and hospital Boucher are to be displayed.
f. Hospital tours can be conducted by the school teachers, students, housewives and members of
women‟s organization and religious leaders.
g. Holding an annual hospital day or open day house where public can be shown every aspect of
the hospital operation including some of the highly technical functions.
h. Using mass media would be helpful to improve public relation.
Qualities of public relation staff:
Warm and friendly with good common sense.
Good organizing ability.
Good judgment, creativity and then critical ability.
Imagination and appreciate others.
Calm and not excitable person.
Ability to take pains.
Lively and inquisitive minds.
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 Willingness to work long and in constraint atmosphere, whenever necessary especially in pulse
polio campaigns.
Resilient and a sense of humor.
Flexibility and ability to deal with many problems.
Ability to communicate in any languages.
Capable of correcting and subediting others communication.
Loyalty to the organization.
Indicators for assessing public relation in the community:
-satisfaction surveys.

in clinics and health centers.

nd prevalence rate of the communicable diseases in the community.

PUBLIC RELATION IN AN EDUCATIONAL INSTITUTION
PUBLIC IMAGE:
An idea or mental picture about the organization by the public.
STEPS FOLLOWED IN PUBLIC RELATION IN EDUCATIONAL INSTITUTION:
The followings are the steps followed in public relation campaign in an educational
institution.
i. Listing and prioritizing of information is to be disseminated:
May wish to inform the public:
a) The new policy of the Government or organization.
b) The change in the existing policy.
c) The new scheme promoted.
d) The change in the existing scheme.
Public Relations activity starts with identifying the message to be disseminated and
prioritized.

ii. Ascertaining the existing knowledge level or understanding the perceptions of the
public:
The organization can check a quick survey among the target group of the public to
ascertain the knowledge level of the issue for which the organization is planning to initiate
Public Relations process and in case of the image it is essential to know whether the image is
positive, neutral or negative in terms of the assessment or in terms of the organization or
both.
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iii. Communication objectives and prioritize:
Based on the knowledge level or image factor, a communication objective is to be
established which is possible to evaluate and the top management approval is required. For
example, communication objective instead of using the term increasing awareness level
about the scheme, it should be specific "By 2005, in the number of families where of the
scheme be at least one lakh" so that we can evaluate the impact.

iv. Message and Media:

After choosing the objective, the content of the message need to be developed. While
developing the message we should keep in mind the media in which we are going to use for
disseminating that message. TV/Visual media may be effective for showing the
demonstrating awareness. Training media may be effective whether the recipient may wish to
keep the gap or further reference.
v. Implementation of message and media:
Based on the expected reaching level and target group, the budget is to be prepared and
message is transmitted. through the appropriate media.
vi. Impact assessment:
After release of the message, it is essential to study the impact at interval by interacting
with the target group.
vii. Message redesigned:
In case, the interaction of the target group reveals the message did not reach as
expected the modification in message or media need to be done and the revised message
should be disseminated.
TYPES OF PUBLIC RELATION:
Advertising:
The main forms of advertising are------

-mail messages

Publicity:
Publicity is the spreading of information to gain public awareness for a product, person,
service, cause or organization, and can be seen as a result of effective PR planning.
Propaganda:
Propaganda is a form of communication that is aimed at influencing the attitude of a
community toward some cause or position. Propaganda, in its most basic sense, presents
information primarily to influence an audience and change in their attitude.
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Public diplomacy:
Public diplomacy, broadly speaking, is the communication with foreign publics to
establish a dialogue designed to inform and influence. It is practiced through a variety of
instruments and methods ranging from personal contact and media interviews to the Internet
and educational exchanges.
Campaign:
Effective public relations require a knowledge, based on analysis and understanding,
of all the factors that influence public attitudes toward the organization. While a specific
public relations project or campaign may be undertaken proactively or reactively to manage
some sort of image crisis.
Promotion:
Commercialization of publicity.
Annual reports:
They are ripe with information if they include an overview of your year's activities,
accomplishments, challenges and financial status.
Collaboration or strategic restructuring:
If you're organization is undertaking these activities, celebrate it publicly.
Presentations:
Find ways to give even short presentations, for example, at local seminars, conventions,
seminars, etc. It's amazing that one can send out 500 brochures and be lucky to get 5 people
who
respond. Yet, you can give a presentation to 30 people and 15 of them will be very interested
in staying in touch with you.

QUALITIES OF A PUBLIC RELATION OFFICER IN THE EDUCATIONAL

INSTITUTION:

ty to write and speak English correctly.

ialization.

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 ROLE OF DEAN:
Deans are expected to support and promote the highest quality educational
programs, research, public service, and economic development activities of their respective
colleges and schools. Each dean must be an effective advocate for his/her college, both
within the University and externally. Deans have ultimate accountability for their colleges‟
sound management of resources: fiscal, facilities, and human. They are responsible for
collegiate planning, including alignment of plans for educational, research, and other
activities in their colleges. The Deans have direct responsibility for:
Faculty:
The academic dean is responsible for the hiring of most department chairs and faculty
selection. She often acts as a bridge between the academic and bureaucratic sides of
education. Often the dean will delegate responsibility to trusted department heads but still
oversee all the activity within each department.
Finance:
The academic dean may also be responsible for fund-raising and financial decisions
made in regard to the school. Because of the complexities of the financial responsibilities of
the dean, the job strongly resembles that of the chief executive officer of a mid-sized
business or enterprise.
Course Scheduling and Public Relations:
The academic dean is responsible for overseeing course scheduling and the
introduction of new courses into the curriculum of the school. She also plays an integral role
in maintaining good relationship with alumni and the general public and garnering financial
support for the institution. An academic dean must have excellent social skills, as he is called
upon to interact with the public as a representative of the college or university.
Campus Upkeep and Student Affairs:
The academic dean may also be responsible for much of the decision making in
regards to campus upkeep and the regular care of campus grounds. He delegates the
responsibility for care and upkeep of the grounds, but makes the financial decisions
regarding upkeep and general funding allotted to the physical appeal of the university or
college.
Faculty Communication:
Because all faculty report directly to the academic dean, she is often looked to for
problem-solving and conflict resolution. For this reason he must have an active interest in
and knowledge of the academic side of this jurisdiction, as well as a basic understanding of
all areas of education. She must likewise be persuasive, an effectual listener, and
collaborative. The authority of the academic dean is consistently being challenged, and thus
she must possess humility, patience, and fortitude.
Fee Accounts:

–
keeping in view merit and other criteria that demand concession.
the fee dues of students and educate parents in clearing the same within the time
stipulated.
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 Public relation with parents:

already studying in your zone.

your zone.
onal students for feedback on the performance of respective campuses
in academic and administrative areas.

staff for improvement.

Sick room:
The health of a student is important since it also reflects on the academic
performance. A student in good health can perform up to potential, whereas a student who is
ill cannot. Besides, the welfare of a student studying on residential campus is of primary
concern to the organization. It is
for this reason that every residential campus has a Doctor attending to sick students with
special rooms to keep them in, and under the care of Sick-in-charges.

against
common ailments.

wards.
CONFLICT MANAGEMENT
INTRODUCTION
Conflict is generally defined as the internal or external discord that results from differences
in ideas, values, or feelings between two or more people. Because managers have
interpersonal relationships with people having a variety of different values, beliefs,
backgrounds, and goals, conflict is an expected outcome. Conflict is also created when there
are differences in economic and professional values and when there is competition among
professionals.
Any organization in which people interact has a potential for conflict. Health care institutions
include many interacting groups: staff with staff, staff with patients, staff with families and
visitors, staff with physicians, and so on. These interactions frequently lead to conflicts.
Conflict relates to human feelings, including feelings of neglect, of being taken for granted,
of being treated like a servant, of not being appreciated, of being ignored, and of being
overloaded.
I. TERMINOLOGIES
1. Conflict: is the dissension that occurs when two or more individual with different values,
interests, goals or needs view things from different perspectives.
2. Intrapersonal conflict: conflict that occurs within the individual.
3. Interpersonal conflict: conflict that occurs between two or more people.
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4. Organizational conflict: conflict that occurs between two or more people in an organization
setting.

THE HISTORY OF CONFLICT MANAGEMENT

Early in the 20th century, conflict was considered to be an indication of poor
organizational management, was deemed destructive, and was avoided at all costs. When
conflict occurred, it was ignored, denied, or dealt with immediately and harshly. The
theorists of this era believed that conflict could be avoided if employees were taught the one
right way to do things and if expressed employee classification was met swiftly with
disapproval.
In the mid 20th century, when organizations recognized that worker satisfaction and
feedback were important, conflict was accepted passively and perceived as normal and
expected. Attention cantered on teaching managers how to resolve conflict rather than how to
prevent it. Although conflict considered to be primarily dysfunctional, it was believed that
conflict and cooperation could happen simultaneously.
The interactionist theories of the 1970s, however, recognized conflict as a
necessity and actively encouraged organizations to promote conflict as a means of producing
growth. Some level of conflict in an organization appears desirable, although the optimum
level for a specific person or unit at a given time is difficult to determine. Too little conflict
results in organizational stasis, whereas too much conflict reduces the organization’s
effectiveness and eventually immobilizes its employees. With few formal instruments to
assess whether the level of conflict in an organization is too high or too low, the
responsibility for determining and creating an appropriate level of conflict on the individual
unit often falls to the manger.
Conflict also has a qualitative nature. A person may be totally overwhelmed in
one conflict situation, yet be able to handle several simultaneous conflicts at a later time. The
difference is in the quality or significance of that conflict to the person experiencing it.
Although quantitative and qualitative conflicts produce distress at the time they
occur, they can lead to growth, energy, and creativity by generating new ideas and solutions.
If handled inappropriately, quantitative and qualitative conflicts can lead to demoralization,
decreased motivation, and lowered productivity.

MEANING & DEFINITION OF CONFLICT

expressed struggle between at least two interdependent
parties, who perceive that incompatible goals, scarce resources, or interference from others are
preventing them from achieving their goals (Wilmot & Hocker, 2001).

granted, of being treated like a servant, of not being appreciated, of being ignored, of being
overloaded, and other instances of perceived unfairness.

organizing to resolve conflict where it does happen, as rapidly and smoothly as possible.

TYPES OF CONFLICTS
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 Conflict has been described and studied from the standpoint of its context, or where it
occurs. 3 types of conflicts are
Intrapersonal conflict: an intrapersonal conflict occurs within an individual in situations in
which he or she must choose between two alternatives. Choosing one alternative means that
he or she cannot have the other; they are mutually exclusive. E.g. we might internally debate
whether to complete an assignment that is due the next day or watch a favourite television
programme.
Interpersonal conflict: is conflict between two or more individuals. It occurs because of
differing values, goals, action, or perceptions. For e.g. when you want to go to a science
fiction movie, but your partner may prefer to attend an opera. Interpersonal conflict becomes
more difficult when we are involved in issues relating to racial, ethnic and life style values
and norms.
Organizational conflicts: conflict also occurs in organization because of differing
perceptions or goals. Organizational conflicts may be intrapersonal or interpersonal, but they
originate in the structure and function of the organization. Typically, aspects of the
organizations style of management, rules, policies and procedures give rise to conflict.
When a conflict occurs within an organization, it is important that the conflict be resolved in
a constructive way in order to maintain the team’s motivation. The leader’s role takes on
special significance.
Two areas responsible for conflict in organizations are role ambiguity and role conflict.
Role ambiguity occurs when employees do not know what to do, how to do it, or what the
outcomes must be. This frequently occurs when policies and rules are ambiguous and unclear.
Role conflict occurs when two or more individuals in different positions within the
organization believe that certain actions or responsibilities belong exclusively to them. The
conflict could relate to competition. E.g. In some hospitals, conflict have existed between the
nurse and the social workers about the responsibility for providing discharge planning. Both
groups see discharge planning as an important aspect of their own care of the patients.

COMMON CAUSES OF CONFLICT

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

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 CHARACTERISTICS OF CONFLICT
The characteristics of a conflict situation are:
1) At least two parties (individuals or groups) are involved in some kind of interaction.
2) Mutually exclusive goals and mutually exclusive values exist, either in fact or as perceived by
the patients involved.
3) Interaction is characterized by behavior destined to defeat, reduce, or suppress the opponent or
to gain a mutually designated victory.
4) The parties face each other with mutually opposing actions and counteractions.
5) Each party attempts to create an imbalance or relatively favored position of power vis-a-vis
the other.
THE CONFLICT PROCESS
Before managers can or should attempt to intervene in conflict, they must be able to assess its
five stages accurately
1. Latent conflict (also called antecedent conditions).
2. Perceived conflict
3. Felt conflict
4. Manifest conflict
5. Conflict resolution
6. Conflict aftermath.

Latent conflict (also called antecedent conditions)

Felt conflict
Perceived conflict

Manifest conflict

Conflict resolution or conflict management

Conflict aftermath
Latent conflict
The first stage in the conflict process, latent conflict, implies the existence of antecedent
conditions such as short staffing and rapid change. In this stage, conditions are ripe for
conflict, although no conflict has actually occurred and none may ever occur. Much
unnecessary conflicts could be prevented or reduced if managers examined the organization
more closely for antecedent conditions.
Perceived conflict

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 If the conflict progresses, it may develop into the second stage: perceived conflict. Perceived
or substantive conflict is intellectualized and often involves issues and roles. The person
recognizes it logically and impersonally as occurring. Sometimes, conflict can be resolved at
this stage before it is internalized or felt.
Felt conflict
The third stage, felt conflict, occurs when the conflict is emotionalized. Felt emotions include
hostility, fear, mistrust, and anger. It is also referred to as affective conflict. It is possible to
perceive conflict and not feel it. A person also can feel the conflict but not perceive the
problem.
Manifest conflict
It is also called as overt conflict, action is taken. The action may be to withdraw, compete,
debate, or seek conflict resolution. People often learn pattern of dealing with manifest
conflict early in their lives, and family background and experiences often directly affect how
conflict is dealt with in adulthood.
Gender also may play a role in how we respond to conflict. Men are socialized to respond
more aggressively to conflict, while women are more apt to try to avoid conflicts or to pacify
them. Power also plays a role in conflict resolution. Therefore, the action an individual takes
to resolve conflict is often influenced by culture, gender, age, power position and upbringing.
Conflict aftermath
The final stage in the conflict process is conflict aftermath. There is always conflict
aftermath- positive or negative. If the conflict is managed well, people involved in the
conflict will believe that there position was given a fair hearing. If the conflict is managed
poorly the conflict issues frequently remain and may return later to cause more conflict.
Outcomes of conflict
We often hear people hear about conflict situation resulting in win-win, win-lose and
lose-lose. Filley (1975) identified these 3 different positions or outcomes of conflict.
Win-lose outcome: occurs when one person obtains his or her desired ends in the situation and
the other individual fails to obtain what is desired. Often winning occurs because of power and
authority within the organization or situation.
Lose-lose outcome: in lose-lose situation, there is no winner. The resolution of the conflict is
unsatisfactory to both parties.
Win- win outcome: are of course the most desirable. In these situations, both parties walk away
from the conflict having achieved all or most of their goals or desires.
EFFECTS OF CONFLICT IN ORGANIZATIONS
• Stress
• Absenteeism
• Staff turnover
• De-motivation
• Non-productivity
SIGNS OF CONFLICT BETWEEN INDIVIDUALS
1. Colleagues not speaking to each other or ignoring each other
2. Contradicting and bad-mouthing one another
3. Deliberately undermining or not co-operating with each other, to the downfall of the team
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 CONFLICT MANAGEMENT
The optimal goal in resolving conflict is creating a win- win solution for all involved. This
outcome is not possible in every situation, and often the manager’s goal is to manage the
conflict in a way that lessens the perceptual differences that exist between the involved
parties. A leader recognizes which conflict management strategy is most appropriate for each
situation. The choice of most appropriate strategy depends on many variables, such as the
situation itself, the urgency of the decision, the power and status of the players, the
importance of the issue, and the maturity of the people involved in the conflict.
1. Discipline
2. Consider Life Stages
3. Communication
4. Active Listening
5. Assertiveness Training
6. Assessing the Dimensions of the Conflict

Discipline: In using discipline to manage or prevent conflict, the nurse manager must know
and understand the organization’s rules and regulations on discipline. If they are not clear,
the nurse manager should seek help to clarify them. The following rules will help in
managing discipline:
1. Discipline should be progressive.
2. The punishment should fit the offense, be reasonable, and increase in severity for violation of
the same rule.
3. Assistance should be offered to resolve on-the-job problems.
4. Tact should be used in administering discipline.
5. The best approach for each employee should be determined. Managers should be consistent
and should not show favoritism.
6. The individual should be confronted and not the group. Disciplining a group for a member‟s
violation of rules and regulations makes the other members angry and defensive, increasing
conflict.
7. Discipline should be clear and specific.
8. It should be objective, sticking to facts.
9. It should be firm, sticking to the decision.
10. Discipline produces varied reactions. If emotions are running too high, a second meeting
should be scheduled.
11. The nurse manager performing the discipline should consult with the supervisor. One should
expect to be overruled sometimes. Knowing the boundaries of authority and the supervisor will
avoid most overrules.
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12. A nurse manager should build respect, trust, and confidence in his or her ability to handle
discipline.

Consider Life Stages: Most organizations will have nurses at all life stages in their employ.
Conflict can be managed by supporting individual nurses in attaining goals that pertain to
their life stages. Three developmental stages are as follow.”
1. In general, in the young adult stage, nurses are establishing careers. Nurses at this stage may
be pursuing knowledge, skills, and upward mobility. Conflict may be prevented or managed by
facilitating career advancement.
2. In general, during middle age, nurses become reconciled with achievement of their life goals.
These nurses often help develop the careers of younger nurses.
3. In general, after age 55 years, nurses think in terms of completing their work and retiring.
Egos and ideals are integrated with accomplishments.

Communication: Communication is an art that is essential to maintaining a therapeutic

environment. It is necessary in accomplishing work and resolving emotional and social
issues. Supervisors prevent conflict with effective communication and should make it a way
of life. To promote communication that prevents conflict, do the following.
1. Teach nursing staff members their role in effective communication.
2. Provide factual information to everyone: be inclusive, not exclusive.
3. Consider all the aspects of situations: emotions, environmental considerations, and verbal and
nonverbal messages.
4. Develop these basic skills;
a. Reality orientation, by direct involvement and acceptance of responsibility in resolving
conflict.
b. Physical and emotional composure.
c. Positive expectations that generate positive responses.
d. Active listening.
e. Giving and receiving information.

Active Listening: Active or assertive listening is essential to managing conflict. In order to

be sure that their perceptions are correct, nurse managers can paraphrase what the angry or
defiant employee is saying. Paraphrasing clarifies the message for both. Paraphrasing can
help cool off the situation because it gives the employee time and the opportunity to hear the
supervisor‟s perceptions of the emotions expressed.
Active assertive listening is sometimes called stress listening. Powell suggest these
techniques for stress listening.
1. Do not share anger; it adds to the problem. Remain calm and matter-of-fact.
2. Respond constructively in both verbal and nonverbal language. Be cheerful but sober.
Maintain eye contact. Prevent interruptions. Bring problems into the open. Make the employee
comfortable. Act serous. Always be courteous and respectful.
3. Ask questions and listen to the answers. Determine the reasons for the anger.
4. Separate fact from opinion, including your own.
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5. Do not respond hastily. Plan a response.
6. Consider the employee’s perspective first.
7. Help the employee find the solution. Ask questions and listen t responses. Do not be
paternalistic.

Assertiveness Training: Assertive nurse, including managers, will stand up for their rights
while recognizing the rights of others. They are straightforward and know that they are
responsible for their thoughts, feelings, and actions. Assertive nurses also know their
strengths and limitations. Rather than attack or defend, assertive nurses assess, collaborate,
support, and remain neutral and nonthreatening. They can accept challenges and prevent
conflict by helping others deal with their own anger.
Assertiveness can be taught through staff development programs. In these programs nurses
are taught to make learned, thoughtful responses and to know when to say no, even to boss.
They learn to hold people to a standard and to know when to accept responsibility rather than
to blame others. When they are dissatisfied, they do something to
increase their satisfaction. Most assertive behaviors can be learned with the use of case
studies, role playing, and group discussion.
When they finish their training, assertive nurses will use positive comments to reinforce
expectations that others do their jobs. They will use praise and consideration to promote
wellness and positive individual behaviour. Nurse Managers learn that direct communication
of support to staff members increases staff job satisfaction.
Assertive nurses focus on data and issues when offering constructive cretinism to the boss or
constructive feedback to the staff, which encourages dialogue and produces solutions to
problems rather than conflict. They ask for assistance or delay when it needed.
People generally respond positively to assertion and negatively to aggression; however, some
people respond negatively to assertion.
Assessing the dimensions of the conflict
Greenhalgh has developed a system for assessing the dimensions of conflict. His
view is that conflict may be considered to be managed when it does not interfere with
ongoing functional relationships. Participants in a conflict have to be persuaded to rethink
their views. A third party must understand the situation empathetically from the participants‟
view points. The conflict may be the result of a deeply rooted antagonistic relationship.
Greenhalgh‟s Conflict Diagnostic Model has seven dimensions, each with a continuum from
“difficult to resolve” to “easy to resolve.” Once the dimensions of the conflict have been
assessed, those should be shifted to the easy-to-resolve domain.

The issue in question

It has already been stated that values, beliefs, and goals are difficult issues to bring to a
reasonable compromise. Principles fall into the same category, since they involve integrity
and ethical imperatives. The third party must persuade the conflicting parties to acknowledge
each other’s legitimate point of view. How can principles be maintained and the organization
and employees be saved?
The size of the stakes
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 The size of the stakes can make conflict hard to manage. If change threatens somebody‟s job
or income, the stakes are high. The third party must try to keep egos from being hunt,
postponing action if necessary. What will the parties settle for? Precedents create potential
for future conflicts: If I give in now, what will I have to give up in the future?
Interdependence of the parities
People must view resources in terms of interdependence. If one group sees no benefits from
the distribution of resources, they will be antagonistic. A positive-sum interdependence of
mutual gain is needed.
Continuity of interaction
Long-term relationships reduce conflict. Managers should opt for continuous, not episodic,
interaction.
Structure of the parties
Strong leaders who unify constituents to accept and implement agreements reduce conflict.
When informal coalitions occur, involve their representatives to find and implement
agreements.
Involvement of third parties

Conflicts are difficult to resolve when participants are highly emotional and resort to
distorting non rational arguments, unreasonable stances, impaired communication, or
personal attacks. Such conflicts can be solved with a prestigious, powerful, trusted, and
neutral third mediator, or arbitrator. The inside manager who acts as judge or arbitrator
polarizes; inviting a third party makes it public. Third parties have to be involved when the
nurse manager, as party to a conflict, cannot resolve it

Viewpoint Continuum

Dimension

Difficult to Resolve Easy to Resolve

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 Issue in question Matter of principle Divisible issue
Size of stakes large Small
Interdependence of Zero sum Positive sum
the parties
Continuity of Single transaction Long-term
interaction Amorphous or relationship
Structure of the fractionalized, with Cohesive, with
parties weak leadership strong leadership
No neutral third party
available Trusted, powerful,
Involvement of third Unbalanced: One party prestigious, and
parties feeling the more neutral
Perceived progress harmed Parties having done
of the conflict equal harm to each
other

TECHNIQUES OR SKILLS FOR MANAGING CONFLICT

Aims: The manager should work on a compromise to stimulate the interaction and
involvement of the parties, another aim of conflict management. Other aims include better
decisions and commitment to decisions that have been made.
Strategies:
There are 5 strategies from conflict management theory for managing stressful situation.
1. Avoidance
2. Accommodation
3. Competition
4. Compromise
5. Collaboration

Avoidance/Avoiding (no winners/no losers):

This isn't the right time or place to address this issue. In the avoiding approach, the
parties involved are aware of a conflict but choose not to acknowledge it or attempt to
resolve it. Avoidance may be indicated in trivial disagreements, when the cost of dealing
with the conflict exceeds the benefits of solving it, when the problem should be solved by
people other than you, when one party is more powerful than the other, or when the problem
will solve itself. The great problem in using avoidance is that the conflict remains, often only
to re-emerge at a later time in an even more exaggerated fashion.

Accommodation/Accommodating (lose/win):
Working toward a common purpose is more important than any of the peripheral
concerns; the trauma of confronting differences may damage fragile relationships.

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 Cooperating is the opposite of competing. In the cooperating approach, one party
sacrifices his or her beliefs and allows the other party to win. The actual problem is usually
not solved in this win-lose situation. Accommodating is another term that may be used for
this strategy. The person cooperating or accommodating often collects IOUs from the other
party that can be used at a later date. Cooperating and accommodating are appropriate
political strategies if the item in conflict is not of high value to the person doing the
accommodating.

Competition/Competing (win/lose):
Associates "winning" a conflict with competition.
The competing approach is used when one party pursues what it wants at the expense
of the others. Because only one party wins, the competing party seeks to win regardless of
the cost to others. Win-lose conflict resolution strategies leave the loser angry, frustrated, and
wanting to get even in the future.
Managers may use competing when a quick or unpopular decision needs to be made.
It is also appropriately used when one party has more information or knowledge about a
situation than the other. Competing in the form of resistance is also appropriate when an
individual needs to resist unsafe patient care policies or procedures, unfair treatment, abuse
of power, or ethical concerns.

Compromise/Compromising (win some/lose some):

Winning something while losing a little is OK. In compromising, each party gives up
something it wants for compromising not to result in a lose-lose situation, both parties must
be willing to give up something of equal value. It is important that parties in conflict do not
adopt compromise prematurely if collaboration is both possible and feasible.

Collaboration/Collaborating (win/win): Teamwork and cooperation help everyone achieve

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

MANAGE AND RESOLVE CONFLICT SITUATIONS

1. Collective bargaining
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 Especially in workplace situations, it is necessary to have agreed mechanisms in
place for groups of people who may be antagonistic (e.g. management and workers) to
collectively discuss and resolve issues. This process is often called "collective bargaining",
because representatives of each group come together with a mandate to work out a solution
collectively.

2. Conciliation
he dictionary defines conciliation as "the act of procuring good will or inducing a
friendly feeling". It is the synonymous terms that refer to the activity of a third party to help
disputants reach an agreement.
3. Negotiation:

This is the process where mandated representatives of groups in a conflict situation meet
together in order to resolve their differences and to reach agreement. It is a deliberate
process, conducted by representatives of groups, designed to reconcile differences and to
reach agreements by consensus. The outcome is often dependent on the power relationship
between the groups.

4. Mediation:

When negotiations fail or get stuck, parties often call in and independent mediator. This
person or group will try to facilitate settlement of the conflict. The mediator plays an active
part in the process, advises both or all groups, acts as intermediary and suggests possible
solution.

5. Arbitration:

Means the appointment of an independent person to act as an adjudicator (or judge) in a

dispute, to decide on the terms of a settlement. Both parties in a conflict have to agree about
who the arbitrator should be, and that the decision of the arbitrator will be binding on them
all.

CHAPTER-VI Nandha kumar

COLLECTIVE BARGAINING & HEALTH AND SAFETY

1: INTRODUCTION

Labor unions, negotiations, collective bargaining strike are common language in

today’s health scene, especially in relation to hospitals. These new terms can note
positive or negative meanings to different people, depending upon one’s status and role
in the organizational structure. Few persons, however, have a neutral attitude regarding the implications
of these terms.

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 Labor relation is the management’s method of dealing with the organizational aspects of their personnel
who are covered by a collective bargaining agreement. It also includes working with unions who are
attempting to organize personnel. These activities and functions are regulated by labor laws at the state,
federal, local government levels. The labor laws and regulations have forced improved by policies,
procedures and standards.

Factors that have an impact on the directing aspects o management are collective bargaining,
unionization, and health care labor laws. It is possible to make these factors positive rather than negative
influences on management effectiveness. To accomplish this, task managers must first understand the
interrelationship of unionization, the proliferation of legislation regarding employment practices, and the
impact of both on the health care industry.

Managers must be able to see the collective bargaining and employment legislation from four
perspectives: the organization, the worker, general and historical and societal and personal. Gordon
(2004) states that “collective bargaining in most industrialized countries is well established and rarely
challenged.”

Collective bargaining can have a positive influences in the management union climate if, in achieving
demands, the union can increases productivity and reduce cost for the hospital. Union that wish to grow
with the future cannot forces the economy to remain in a constant state of suspended inflation just
because the union membership has had it so good for so long. Business and industries learned a big
lesson from the depression in the early part of the century; they developed sound and practical methods
for dealing with their work-forces and other business practices. Hopefully, organized labor will learn a
proper lesson from prosperity, or it may find that those who do not change with the time must suffer the
consequences of prolonged unemployment as a result of a recession or a depression. Some authorities
believe that labor has many problems that were will be a decline in the union growth rate. Also it
appears unions are having organizational problems, and therefore, may find it difficult to gain more
power or even maintain their present stature. Collective bargaining in hospitals is highly controversial.
There appears at the present time to be little uniformity of official opinion among hospital administrator,
boards of trustees, and hospital association in regard to unionism.

Those persons opposed to unions believe that collective bargaining can have a stifling effect on the
skilled and unskilled hospitals employees, there by endangering patient care. They contend unionism
may have deleterious effect on the quality and quantity of employees work. Some basically fear unions
because of the strength and power they could exert. There are individuals who believe legislation is
needed to curb the monopoly power of the larger union. The long-term inflationary spiral presently
occurring in our country is attributing by some to the union and its demands. Hospitals have an
obligation to furnish equitable terms and conditions of employment for their employees. Hospital
employee practices should conform to all standards established by competent public authority.
Remuneration and benefits furnished to employees should compare favorably with those that prevail for
the community for comparable occupations. Hospital should adopt and observe standards of enlightened
personnel practices. Hospitals have the right to expect that the unit of representation is appropriate for
representation.

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2: TERMINOLOGIES

2:1 COLLECTIVE BARGAINING

Collective bargaining is, negotiation about working conditions and terms of employment between an
employer and a group of employees or one or more employee, organization with a view to reaching an
agreement wherein the terms serve as a code of defining the rights and obligations of each party in their
employment relations with one another.

2:2 NEGOTIATIONS.

Negotiation is a tool, strategy, or technique useful for avoiding head-on competition or a win- lose
conflict outcome. Negotiation employs communication, interpersonal skills, persuasion, the ability to
articulate a point of view, and the acknowledgement of the other person’s position.

2:3CONFLICT

Conflict is generally defined as the internal or external discord that result from differences in ideas,
values, or feelings between two or more Conflict is generally defined as the internal or external
discord that people.

2:4CONSENSUS

Consensus means that negotiating parties reach an agreement that all parties can support, even it does
not represent everyone’s priorities.

2:5COMMUNICATION

Communication is the transmission and receiving of information, 'feelings and / or attitudes with the
overall purposes of having understood, producing a response.

2:6 UNION

A trade union is an organization of employees formed on a continuous basis for the purpose of securing
diverse range of benefits. It is a continuous association of wage earners for the purpose of maintaining
and improving the conditions of their working lives.

2:7 PROFESSIONAL ORGANIZATIONS

It is a non-profit organization seeking to a particular profession, the interest of the individuals engaged
in the profession, and the public interest.

2:8 LAWS: A rule that is supported by the power of government, and that controls the behavior of the
members of the society.

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3: COLLECTIVE BARGAINING

3:1 DEFINITION OF COLLECTIVE BARGAINING

 Collective bargaining is process of joint decision making and basically represents a democratic
way of life in industry. It is the process of negotiation between firm’s and workers’
representatives for the purpose of establishing mutually agreeable conditions of employment. It
is a technique adopted by two parties to reach an understanding acceptable to both through the
process of discussion and negotiation.
 Collective bargaining is, negotiation about working conditions and terms of employment
between an employer and a group of employees or one or more employee, organization with a
view to reaching an agreement wherein the terms serve as a code of defining the rights and
obligations of each party in their employment/ relations with one another.
 Collective bargaining involves discussions and negotiations between two groups as to the terms
and conditions of employment. It is called ‘collective’ because both the employer and the
employee act as a group rather than as individuals. It is known as ‘bargaining’ because the
method of reaching an agreement involves proposals and counter proposals, offers and counter
offers and other negotiations.
Thus collective bargaining:
 Is a collective process in which representatives of both the management and employees
participation.
 Is a continuous process which aims at establishing stable relationships between the parties
involved.
 Not only involves the bargaining agreement, but also involves the implementation of such an
agreement.
 attempts in achieving discipline in the industry
 Is a flexible approach, as the parties involved have to adopt a flexible attitude towards
negotiations.

3:2OBJECTIVES OF COLLECTIVE BARGAINING

The objectives of the collective bargaining are:

 To protection the economic position and personal welfare of the worker.

 Protect the union’s integrity as growing institution.
 Recognize the outer limits imposed on collective bargaining outcomes.

3:3 SCOPE OF COLLECTIVE BARGAINING

Collective bargaining enables both the parties to:

 Increase their economic strength.

 Establish uniform conditions of employment with a view to avoiding organizational disputes and
maintaining stable place in the industry.
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  Secure a prompt and fair redressal of grievances.
 Avoid interruptions in work which follow strikes, go-slow tactics and similar coercive activities.
 Lay down fair rates of wages and norms of working conditions.
 Achieve an efficient operation of the organization
 Promote the stability and the prosperity of the organization.
 It provides a method for the regulation of the conditions o employment of those who are
directly concerned about them.
 It provides a solution to the problem of sickness in the organization, of old age persons benefits
and other fringe benefits.

3:4 FUNCTIONS OF COLLECTIVE BARGAINING

 It is a rule making or legislative process in the sense that it formulates terms and conditions under
which labor and management will cooperate and work together over a certain stated period.
 It is also a judicial process for in every collective agreement there is a provision or clause
regarding the interpretation of the agreement and how any difference of opinion about the
intention or scope o a particular clause is to be resolved.
 It is also an executive process, for both management and the trade unions undertake to implement
the agreement signed. Each accepts a series of obligations under the agreement.

3 :5 PRINCIPLES OF COLLECTIVE BARGAINING

The University’s principles and goals for collective bargaining will support our mission as a
comprehensive higher education system serving Alaska through instruction, research, and public
service. In all our collective bargaining relationships, we will focus on achieving our mission by
emphasizing the importance of quality, individual and institutional accountability, efficiency, flexibility,
unity and diversity, and our work environments. We recognize that all our collective bargaining
activities must occur within the constraints of our fiscal resources.

Quality

Expand the University’s expertise in a broad range of academic disciplines, while concentrating on
research and public service in academic areas related to our geographic location, demographic and
cultural characteristics, and major economic sectors.

Enhance the University’s organizations ability to recruit and retain the highest quality faculty and staff
by providing competitive compensation packages that provide for merit and that reflect appropriate
labor markets for different faculty and staff groups.

Accountability

Ensure that appropriate standards and measures are used to continuously improve all educational
activities, including instruction, research, and public service.

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Expect all faculty and staff groups to work together toward achieving the University’s & organization’s
goals and insuring the long term success of our community within our fiscal constraints.

Account for and assign all costs incurred in contract negotiation and administration.

Efficiency

Improve access and graduation rates through higher instructional productivity, improved teaching and
learning, enhanced academic support activities, and appropriate administrative structures. Pursue
opportunities for improving academic quality through more productive, efficient, and cost effective
delivery of educational services.

Flexibility

Strengthen the University’s & organization’s ability to respond to the changing educational goals, needs,
conditions, and opportunities of Alaskans. Structure courses, academic programs, and administration to
maximize the appropriate use of instructional technologies, distance education, and self-paced studies.
Expand collaboration among the campuses of the University and with other institutions for richer and
more efficient program offerings.

Unity/Diversity

Enhance the University’s special mission in community and vocational education. Improve integration
of our baccalaureate and graduate programs while supporting appropriate specialization on particular
campuses.

Work Environment

Pursue opportunities for maximum possible collaboration with faculty and staff groups. Foster work
environments that support professional development and mutual respect.

3:6 IMPORTANCE OF COLLECTIVE BARGAINING

Collective bargaining includes not only negotiations between the employers and unions but also
includes the process of resolving labor-management conflicts. Thus, collective bargaining is, essentially,
a recognized way of creating a system of industrial jurisprudence. It acts as a method of introducing
civil rights in the industry, that is, the management should be conducted by rules rather than arbitrary
decision making. It establishes rules which define and restrict the traditional authority exercised by the
management.

Importance to employees

•Collective bargaining develops a sense of self respect and responsibility among the employees.

•It increases the strength of the workforce, thereby, increasing their bargaining capacity as a group.
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•Collective bargaining increases the morale and productivity of employees.

•It restricts management’s freedom for arbitrary action against the employees. Moreover, unilateral
actions by the employer are also discouraged.

•Effective collective bargaining machinery strengthens the trade unions movement.

•The workers feel motivated as they can approach the management on various matters and bargain for
higher benefits.

•It helps in securing a prompt and fair settlement of grievances. It provides a flexible means for the
adjustment of wages and employment conditions to economic and technological changes in the industry,
as a result of which the chances for conflicts are reduced.

Importance to employers

1.It becomes easier for the management to resolve issues at the bargaining level rather than taking up
complaints of individual workers.

2.Collective bargaining tends to promote a sense of job security among employees and thereby tends to
reduce the cost of labor turnover to management.

3.Collective bargaining opens up the channel of communication between the workers and the
management and increases worker participation in decision making.

4.Collective bargaining plays a vital role in settling and preventing industrial disputes.

Importance to society

1. Collective bargaining leads to industrial peace in the country

2. It results in establishment of a harmonious industrial climate which supports which helps the pace of
a nation’s efforts towards economic and social development since the obstacles to such a development
can be reduced considerably.

3. The discrimination and exploitation of workers is constantly being checked.

4. It provides a method or the regulation of the conditions of employment of those who are directly
concerned about them.

3:7CHARACTERISTICS OF COLLECTIVE BARGAINING

 It is a group process, wherein one group, representing the employers, and the other, representing the
employees, sit together to negotiate terms of employment.

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•Negotiations form an important aspect of the process of collective bargaining i.e., there is considerable
scope for discussion, compromise or mutual give and take in collective bargaining.

•Collective bargaining is a formalized process by which employers and independent trade unions
negotiate terms and conditions of employment and the ways in which certain employment-related issues
are to be regulated at national, organizational and workplace levels.

•Collective bargaining is a process in the sense that it consists of a number of steps. It begins with the
presentation of the charter of demands and ends with reaching an agreement, which would serve as the
basic law governing labor management relations over a period of time in an enterprise. Moreover, it is
flexible process and not fixed or static. Mutual trust and understanding serve as the by products of
harmonious relations between the two parties.

•It a bipartite process. This means there are always two parties involved in the process of collective
bargaining. The negotiations generally take place between the employees and the management. It is a
form of participation.

•Collective bargaining is a complementary process i.e. each party needs something that the other party
has; labor can increase productivity and management can pay better for their efforts.

•Collective bargaining tends to improve the relations between workers and the union on the one hand
and the employer on the other

•Collective Bargaining is continuous process. It enables industrial democracy to be effective. It uses

cooperation and consensus for settling disputes rather than conflict and confrontation.

•Collective bargaining takes into account day to day changes, policies, potentialities, capacities and
interests.

It is a political activity frequently undertaken by professional negotiators.

3:8PROCESS OF COLLECTIVE BARGAINING

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

This will normally include procedures in respect of individual grievances, disputes and discipline.
Frequently, procedural agreements are put into the company rule book which provides information on

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the overall terms and conditions of employment and codes of behavior. A substantive agreement deals
with specific issues, such as basic pay, overtime premiums, bonus arrangements, holiday entitlements,
hours of work, etc. In many companies, agreements have a fixed time scale and a collective bargaining
process will review the procedural agreement when negotiations take place on pay and conditions of
employment.

The collective bargaining process comprises of five core steps:

1. Prepare: This phase involves composition of a negotiation team. The negotiation team should
consist of representatives of both the parties with adequate knowledge and skills for negotiation. In
this phase both the employer’s representatives and the union examine their own situation in order to
develop the issues that they believe will be most important. The first thing to be done is to
determine whether there is actually any reason to negotiate at all. A correct understanding of the
main issues to be covered and intimate knowledge of operations, working conditions, production
norms and other relevant conditions is required.

2.Discuss: Here, the parties decide the ground rules that will guide the negotiations. A process well
begun is half done and this is no less true in case of collective bargaining. An environment of mutual
trust and understanding is also created so that the collective bargaining agreement would be reached.

3.Propose: This phase involves the initial opening statements and the possible options that exist to
resolve them. In a word, this phase could be described as ‘brainstorming’. The exchange of messages
takes place and opinion of both the parties is sought.

4.Bargain: negotiations are easy if a problem solving attitude is adopted. This stage comprises the time
when ‘what ifs’ and ‘supposals’ are set forth and the drafting of agreements take place.

5.Settlement: Once the parties are through with the bargaining process, a consensual agreement is
reached upon wherein both the parties agree to a common decision regarding the problem or the issue.
This stage is described as consisting of effective joint implementation of the agreement through shared
visions, strategic planning and negotiated change.

PROCESS OF COLLECTIVE BARGAINING

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3:9LEVELS OF COLLECTIVE BARGAINING

Collective bargaining operates at three levels:

1. National level
2. Sect oral Industry level
3. Company/ Enterprise level

Economy-wide (national) bargaining is a bipartite or tripartite form of negotiation between union

confederations, central employer associations and government agencies. It aims at providing a floor for
lower-level bargaining on the terms of employment, often taking into account macroeconomic goals.

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

Company/enterprise level

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

3:10TYPES OF COLLECTIVE BARGAINING ACTIVITIES

A collective bargaining process generally consists of four types of activities- distributive bargaining,
integrative bargaining, attitudinal restructuring and intra-organizational bargaining. Distributive
bargaining: It involves haggling over the distribution of surplus.

Under it, the economic issues like wages, salaries and bonus are discussed. In distributive bargaining,
one party’s gain is another party’s loss. This is most commonly explained in terms of a pie. Disputants
can work together to make the pie bigger, so there is enough for both of them to have as much as they
want, or they can focus on cutting the pie up, trying to get as much as they can for themselves. In
general, distributive bargaining tends to be more competitive. This type of bargaining is also known as
conjunctive bargaining.

Integrative bargaining:

This involves negotiation of an issue on which both the parties may gain, or at least neither party loses.
For example, representatives of employer and employee sides may bargain over the better training
programme or a better job evaluation method. Here, both the parties are trying to make more of
something. In general, it tends to be more cooperative than distributive bargaining. This type of
bargaining is also known as cooperative bargaining.

Attitudinal restructuring:

This involves shaping and reshaping some attitudes like trust or distrust, friendliness or hostility
between labor and management. When there is a backlog of bitterness between both the parties,
attitudinal restructuring is required to maintain smooth and harmonious industrial relations. It develops a
bargaining environment and creates trust and cooperation among the parties.

Intra-organizational bargaining:
It generally aims at resolving internal conflicts. This is a type of maneuvering to achieve consensus with
the workers and management. Even within the union, there may be differences between groups.

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For example, skilled workers may feel that they are neglected or women workers may feel that
their interests are not looked after properly. Within the management also, there may be
differences. Trade unions maneuver to achieve consensus among the conflicting groups

3:11FACTORS AFFECTING COLLECTIVE BARGAINING

Educati
on

3:11PREREQUISITIES OF COLLECTIVE BARGAINING

 An organized trade union

movement
 Absence of external pressure
 A measure of parity of strength
or bargaining power.

3:12 ROLE OF NURSE MANAGER IN COLLECTIVE BARGAINING

LEADERSHIP ROLES.

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  Creates unit and organizational climate that values nurses.
 Guides nurses in conflict resolution strategies.
 Creates a vision of professionalism and collectivity.
 Inspires professional autonomous behavior
 Communicates relevant work-related information
 Leads others to value and respect the work of nurses
 Advocates for nurses value and needs
 Inspire trust and respect and pushes and envelope

MANAGEMENT FUNCTIONS

 Plan career growth opportunities

 Structures the work environment for professional autonomy
 Manages work related conflicts
 Organizes the flow of work- related communication
 Acquires specific state and federal collective bargaining rules, regulations, and communication
 Administers the collective bargaining contract fairly and equitably
 Ensures that managements rights and employees right are respected
 Coma act as a role model team builder, mentor

3: UNION

3:1DEFINITION OF TRADE UNION

 A trade union is an organization of employees formed on a continuous basis for the purpose of
securing diverse range of benefits. It is a continuous association of wage earners for the purpose
of maintaining and improving the conditions of their working lives.
 The Trade Union Act 1926 defines a trade union as a combination, whether temporary or
permanent, formed primarily for the purpose of regulating the relations between workmen and
employers or between workmen and workmen, or between employers and employers, or for
imposing restrictive condition on the conduct of any trade or business, and includes any
federation of two or more trade unions.
 This definition is very exhaustive as it includes associations of both the workers and employers
and the federations of their associations. Here, the relationships that have been talked about are
both temporary and permanent. This means it applies to temporary workers (or contractual

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 employees) as well. Then this definition, primarily, talks about three relationships. They are the
relationships between the:

• Workmen and workmen,

• Workmen and employers, and

• Employers and employers.

Thus, a trade union can be seen as a group of employees in a particular sector, whose aim is to negotiate
with employers over pay, job security, working hours, etc, using the collective power of its members. In
general, a union is there to represent the interests of its members, and may even engage in political
activity where legislation affects their members. Trade unions are voluntary associations formed for the
pursuit of protecting the common interests of its members and also promote welfare. They protect the
economic, political and social interests of their members.

3:2FEATURES OF TRADE UNION

1.It is an association either of employers or employees or of independent workers. They may consist of:-

 Employers’ association (egg. Employer’s Federation of India, Indian paper mill association,
etc.)
 General labor unions
 Friendly societies
 Unions of intellectual labor (egg, All India Teachers Association)

2.It is formed on a continuous basis. It is a permanent body and not a casual or temporary one. They
persist throughout the year.

3.It is formed to protect and promote all kinds of interests –economic, political and social-of its
members. The dominant interest with which a union is concerned is, however, economic.

4.It achieves its objectives through collective action and group effort. Negotiations and collective
bargaining are the tools for accomplishing objectives.

5.Trade unions have shown remarkable progress since their inception; moreover, the character of trade
unions has also been changing. In spite of only focusing on the economic benefits of workers, the trade
unions are also working towards raising the status of labors as a part of industry.

3:3FUNCTIONS OF TRADE UNION

Trade unions perform a number of functions in order to achieve the objectives. These functions can be
broadly classified into three categories:

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(I) Militant functions,

(ii) Fraternal functions

1. Militant Functions

One set of activities performed by trade unions leads to the betterment of the position of their members
in relation to their employment. The aim of such activities is to ensure adequate wages secure better
conditions of work and employment get better treatment from employers, etc. When the unions fail to
accomplish these aims by the method of

Collective bargaining and negotiations, they adopt an approach and put up a fight with the management
in the form of go-slow tactics, strike, boycott, gherao, etc. Hence, these functions of the trade unions are
known as militant or fighting functions. Thus, the militant functions of trade unions can be summed up
as:

• To achieve higher wages and better working conditions

• To raise the status of workers as a part of industry

• To protect labors against victimization and injustice

2. Fraternal Functions

Another set of activities performed by trade unions aims at rendering help to its members in times of
need, and improving their efficiency. Trade unions try to foster a spirit of cooperation and promote
friendly industrial relations and diffuse education and culture among their members. They take up
welfare measures for improving the morale of workers and generate self confidence among them. They
also arrange for legal assistance to its members, if necessary. Besides, these, they undertake many
welfare measures for their members, e.g., school for the education of children, library, reading-rooms,
in-door and out-door games, and other recreational facilities. Some trade unions even undertake
publication of some magazine or journal. These activities, which may be called fraternal functions,
depend on the availability of funds, which the unions raise by subscription from members and donations
from outsiders, and also on their competent and enlightened leadership. Thus, the fraternal functions of
trade unions can be summed up as:

• To take up welfare measures for improving the morale of workers

• To generate self confidence among workers

• To encourage sincerity and discipline among workers

• To provide opportunities for promotion and growth

• To protect women workers against discrimination

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The existence of a strong and recognized trade union is a pre-requisite to industrial peace. Decisions
taken through the process of collective bargaining and negotiations between employer and unions are
more influential. Trade unions play an important role and are helpful in effective communication
between the workers and the management. They provide the advice and support to ensure that the
differences of opinion do not turn into major conflicts. The central function of a trade union is to
represent people at work. But they also have a wider role in protecting their interests. They also play an
important educational role, organizing courses for their members on a wide range of matters. Seeking a
healthy and safe working environment is also prominent feature of union activity.

Trade unions help in accelerated pace of economic development in many ways as follows:

• helping in the recruitment and selection of workers.

•inculcating discipline among the workforce

•enabling settlement of industrial disputes in a rational manner

• helping social adjustments. Workers have to adjust themselves to the new working conditions, the new
rules and policies. Workers coming from different backgrounds may become disorganized, unsatisfied
and frustrated. Unions help them in such adjustment.

Trade unions are a part of society and as such, have to take into consideration the national integration as
well. Some important social responsibilities of trade unions include:

•promoting and maintaining national integration by reducing the number of industrial disputes

•incorporating a sense of corporate social responsibility in workers

•achieving industrial peace

3:4REASONS FOR JOINING IN TRADE UNION

The important forces that make the employees join a union are as follows:

1. Greater Bargaining Power

The individual employee possesses very little bargaining power as compared to that of his employer. If
he is not satisfied with the wage and other conditions of employment, he can leave the job. It is not
practicable to continually resign from one job after another when he is dissatisfied. This imposes a great
financial and emotional burden upon the worker. The better course for him is to join a union that can
take concerted action against the employer. The threat or actuality of a strike by a union is a powerful
tool that often causes the employer to accept the demands of the workers for better conditions of
employment.

2. Minimize Discrimination
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The decisions regarding pay, work, transfer, promotion, etc. are highly subjective in nature. The
personal relationships existing between the supervisor and each of his subordinates may influence the
management. Thus, there are chances of favoritisms and discriminations. A trade union can compel the
management to formulate personnel policies that press for equality of treatment to the workers. All the
labor decisions of the management are under close scrutiny of the labor union. This has the effect of
minimizing favoritism and discrimination.

3. Sense of Security

The employees may join the unions because of their belief that it is an effective way to secure adequate
protection from various types of hazards and income insecurity such as accident, injury, illness,
unemployment, etc. The trade union secure retirement benefits of the workers and compel the
management to invest in welfare services for the benefit of the workers.

4. Sense of Participation

The employees can participate in management of matters affecting their interests only if they join trade
unions. They can influence the decisions that are taken as a result of collective bargaining between the
union and the management.

5. Sense of Belongingness

Many employees join a union because their co-workers are the members of the union. At times, an
employee joins a union under group pressure; if he does not, he often has a very difficult time at work.
On the other hand, those who are members of a union feel that they gain respect in the eyes of their
fellow workers. They can also discuss their problem with’ the trade union leaders.

6. Platform for self expression

The desire for self-expression is a fundamental human drive for most people. All of us wish to share our
feelings, ideas and opinions with others. Similarly the workers also want the management to listen to
them. A trade union provides such a forum where the feelings, ideas and opinions of the workers could
be discussed. It can also transmit the feelings, ideas, opinions and complaints of the workers to the
management. The collective voice of the workers is heard by the management and give due
consideration while taking policy decisions by the management.

7. Betterment of relationships

Another reason for employees joining unions is that employees feel that unions can fulfill the important
need for adequate machinery for proper maintenance of employer-employee relations. Unions help in
betterment of industrial relations among management and workers by solving the problems peaceful.

3:5REASONS WHY NURSES DO NOT WANT TO JOIN IN UNIONS

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 1. A belief that unions promote the welfare state and oppose the American system of free
enterprise.
2. A need to demonstrate individualism and promote social status.
3. A belief that professionals should not unionize.
4. Identification with management’s viewpoint.
5. Fear of employee reprisal.
6. Fear of lost income associated with a strike or walkout.

3:6UNIONS AND COLLECTIVE BARGAINING

Collective bargaining involves activities occurring between organized labor management that concern
employee relations .Such activities include negotiation of formal labor agreement and day to day
interactions between unions and management. Huston (2006) points that the heart of the debate about
collective bargaining and nursing is whether nursing, long recognized as a caring profession, should be a
part of bargaining efforts to improve the working conditions. Although this may seem to dichotomy, it is
also true that unions and collective bargaining are a very much a part many nurses lived experience.

First and middle – level managers usually have a little to d with negotiating the labor contract, they
are greatly involved with the contract’s daily implementation. The middle manager has the greatest
impact on the quality o the relationship that develops between labor and management.

3:7UNION ORGANIZING STRATEGIES (Haugh 2006)

 Meetings ( both group & one – on –one)

 Leaflets & brochures
 Pressure on the hospital corporation through media & community contacts.
 Corporate campaign strategies
 Activism o the local employees
 Using lawsuits
 Bringing pressure from the financiers
 Technology

3:8MANAGER’S ROLE IN DURING UNION ORGANIZING

 Know and care about your employees.

 Establish fair and well communicated personnel policies.
 Use an effective upward and downward system of communication.
 Ensure that all managers are well trained and effective.
 Establish a well developed formal procedure for handling employee grievances.
 Establish a competitive compensation program of wages and benefits
 Use an effective performance appraisal system in place.
 Use fair and well communicated system for promotions and transfers.
 Use organizational actions to indicate that job security is based on job performance, adherence to
rules and regulations, & availability of work.
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 Maintain an administrative policy on unionization

3:9 ROLE OF NURSE MANAGER IN UNIONIZATION

 Understand the specific laws and its applicable regulation

 Unfair representation in the union
 Understand the human behavior
 Use effective leadership skill
 Maintain productive communication
 Proper collaboration and co-ordination with the other disciplines
 To achieve higher wages and better working conditions
 To raise the status of workers as a part of industry
 To protect labors against victimization and injustice
 To take up welfare measures for improving the morale of workers
 To generate self confidence among workers
 To encourage sincerity and discipline among workers
 To provide opportunities for promotion and growth
 To protect women workers against discrimination

3:10 DEVELOPMENT OF TRADE UNION IN INDIA

The trade unionism in India developed quite slowly as compared to the western nations. Indian trade
union movement can be divided into three phases.

The first phase (1850 to1900)

During this phase the inception of trade unions took place. During this period, the working and living
conditions of the labor were poor and their working hours were long. Capitalists were only interested in
their productivity and profitability. In addition, the wages were also low and general economic
conditions were poor in industries. In order to regulate the working hours and other service conditions of
the Indian textile laborers, the Indian Factories Act was enacted in 1881. As a result, employment of
child labor was prohibited.

The growth of trade union movement was slow in this phase and later on the Indian Factory Act of 1881
was amended in 1891. Many strikes took place in the two decades following 1880 in all industrial cities.
These strikes taught workers to understand the power of united action even though there was no union in
real terms. Small associations like Bombay Mill-Hands Association came up by this time.

The second phase (1900 to 1946)

This phase was characterized by the development of organized trade unions and political movements of
the working class. Between 1918 and 1923, many unions came into existence in the country. At
Ahmedabad, under the guidance of Mahatma Gandhi, occupational unions like spinners’ unions and
weavers’ unions were formed. A strike was launched by these unions under the leadership of Mahatma
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Gandhi who turned it into a satyagrah. These unions federated into industrial union known as Textile
Labor Association in 1920.In 1920, the First National Trade union organization (The All India Trade
Union Congress (AITUC)) was established. Many of the leaders of this organization were leaders of the
national Movement. In 1926, Trade union law came up with the efforts of Mr. N N Joshi that became
operative from 1927. During 1928, All India Trade Union Federation (AITUF) was formed.

The third phase began with the emergence of independent India (in 1947). The partition of country
affected the trade union movement particularly Bengal and Punjab. By 1949, four central trade union
organizations were functioning in the country:

1. The All India Trade Union Congress,

2. The Indian National Trade Union Congress,

3. The Hindu Mazdoor Sangh, and

4. The United Trade Union Congress

The working class movement was also politicized along the lines of political parties. For instance Indian
national trade Union Congress (INTUC) is the trade union arm of the Congress Party. The AITUC is the
trade union arm of the Communist Party of India. Besides workers, white-collar employees, supervisors
and managers are also organized by the trade unions, as for example in the Banking, Insurance and
Petroleum industries.

3:11TRADE UNIONS IN INDIA

The Indian workforce consists of 430 million workers, growing 2% annually. The Indian labor markets
consist of three sectors:

1. The rural workers, who constitute about 60 per cent of the workforce.

2. Organized sector, which employs 8 per cent of workforce, and

3. The urban informal sector (which includes the growing software industry and other services, not
included in the formal sector) which constitutes the rest 32 per cent of the workforce.

At present there are twelve Central Trade Union Organizations in India:

1. All India Trade Union Congress (AITUC)

2. Bharatiya Mazdoor Sangh (BMS)

3. Centre of Indian Trade Unions (CITU)

4. Hind Mazdoor Kisan Panchayat (HMKP)

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5. Hind Mazdoor Sabha (HMS)

6. Indian Federation of Free Trade Unions (IFFTU)

7. Indian National Trade Union Congress (INTUC)

8. National Front of Indian Trade Unions (NFITU)

9. National Labor Organization (NLO)

10. Trade Unions Co-ordination Centre (TUCC)

11. United Trade Union Congress (UTUC)

PROFESSIONAL ORGANIZATION

ICN

The International Council of Nurses (ICN) is a federation of more than 120 national nurses associations.
It was founded in 1899 and was the first international organization for health care professionals. It is
headquartered in Geneva, Switzerland.

GOAL

The organization's goals are to bring nurses' organizations together in a worldwide body, to advance the
socio-economic status of nurses and the profession of nursing worldwide, and to influence global and
domestic health policy.

MEMBERSHIP

Membership is limited to one nursing organization per nation. In most cases, this is the national nurses'
association (such as the American Nurses Association, the Slovak Chamber of Nurses and Midwives or
the Nursing Association of Nepal). [1] In 2001, the ICN permitted its members to adopt alliance or
collaborative structures to be more inclusive of other domestic nursing groups. [2] However, few
member organizations have adopted the new structures.

ICN's Mission:

To represent nursing worldwide, advancing the profession

and influencing health policy.

The International Council of Nurses is a federation of national nurses’ associations (NNAs),

representing nurses in more than 128 countries. Founded in 1899, ICN is the world’s first and widest
reaching international organization for health professionals. Operated by nurses for nurses, ICN works
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to ensure quality nursing care for all, sound health policies globally, the advancement of nursing
knowledge, and the presence worldwide of a respected nursing profession and a competent and satisfied
nursing workforce.

ICN Goals and Values

Three goals and five core values guide and motivate all ICN activities.

The three goals are:

• To bring nursing together worldwide;

• To advance nurses and nursing worldwide;

• To influence health policy.

The five core values are:

• Visionary Leadership

• Inclusiveness

• Flexibility

• Partnership

• Achievement.

The ICN Code for Nurses is the foundation for ethical nursing practice throughout the world. ICN
standards, guidelines and policies for nursing practice, education, management, research and socio-
economic welfare are accepted globally as the basis of nursing policy.

ICN advances nursing, nurses and health through its policies, partnerships, advocacy, leadership
development, networks, congresses, special projects, and by its work in the arenas of professional
practice, regulation and socio-economic welfare. ICN is particularly active in:

Professional Nursing Practice

• International classification for nursing practice - ICNP®

• Advanced nursing practice

• Entrepreneurship

• HIV/AIDS, TB and malaria

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• Women’s health

• Primary health care

• Family health

• Safe water

Nursing Regulation

• Regulation and Credentialing

• Code of ethics, standards and competencies

• Continuing education

Socio-economic Welfare for Nurses

• Occupational health and safety

• Human resources planning and policy

• Remuneration

• Career development

• International trade in professional services

Our partnerships and strategic alliances with governmental and non-governmental agencies,
foundations, regional groups, national associations, and individuals, assist ICN in advancing nursing
worldwide.

ICN is headquartered in Geneva, Switzerland..

TNAI

The Trained Nurses Association of India is the national body of practitioners of Nursing at various
levels. The main idea behind the establishment of the Association was to uphold in every way the
dignity and honor of the Nursing profession and to promote team spirit, apart from enabling the
members to represent their grievances and express their point of view to concerned quarters in events of
problematic situations. While the stress is on orientating the members to the real needs of the profession,
the regular activities of the Association are organized in such a way that those associated with them
have a sense of participation in all the programmers of direct professional relevance along with treating
the Association as a major source of inspiration and provider of title delights of life occasionally.

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 ACTIVITIES OF TNAI

RAPPORT WITH GOVERNMENT OF INDIA

1 (I). Government Recognition as Service Association: The Association is considered to be on a par

with other service organizations. A copy of the letter from the Ministry of Health, Government of India
to all the State Governments communicating recognition of the TNAI as a Service Association on par
with other Associations is given.

1 (ii). Issue of Railway Concessions: In 1991 Railways granted concession to TNAI members and the
Association was authorized to issue certificates to members for getting concession. Previously, the
concession was available in all classes of railway compartments. In the 1980s the Government reduced
the extent of concession and its rate for all categories. For Nurses it was reduced from 50 per cent to 25
per cent and it is now available in second class only. This in a way is serving as a financial relief to
many Nurses. Students are given 50 per cent concession for educational trips.

2. Affiliation with Government Committees and Councils

The Government of India has all along appreciated the importance of TNAI as the National Association
of Nurses and following the formal recognition in 1950; it was involved in all governmental endeavours
in the field of Nursing and given the opportunity to put across its point of view on all matters of
consequence. This was largely due to the great interest of Rajkumari Amrit Kaur in nursing, the first
Minister for Health in independent India.

The committee and investigative bodies launched by the Central Council of Health to study problems
and prospects of the profession consult the Association on various matters and give weightage to its
viewpoint. The contribution of TNAI to the findings of Bhore Committee and Mudaliar Committee as
well as to other similar bodies has been considerable. Its views have been considered as the most
authentic for the nursing profession in processing the findings of such official committees.

TNAI played an important role in the High Power Committee on Nursing and Nursing Profession
(Report: 1987). The Central Council of Health (CCH) has also been drawing on TNAl's experience for
its recommendations on various aspects of the profession. It can derive ample satisfaction from its role
in setting of norms and professional standards in our field of activity in cooperation with the CCH.

The Indian Nursing Council (INC) which was actually mooted by the TNAI has been doing work in the
field of nursing education and establishment of professional norms at different levels. The TNAI is
associated in most of its activities and its links with the INC have given rise to a number of endeavours
for the promotion of Nursing education and other aspects of the profession.

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3. Affiliation with Other Organisations

The activities of the Association cannot be of proper use to the society unless it takes an interest and
participates in the work of other agencies concerned with the total welfare of the community.The TNAI,
therefore, keeps itself informed of developments that take place in many areas of health activity. It is an
associate member of many other associations and societies doing welfare activities in their own fields.
These societies are: Indian Red Cross Society, Indian Public Health Association, Association for Social
Health, Indian Hospital Association, Federation of Delhi hospital Welfare Societies, Tuberculosis
Assocation of India, Indian Leprosy Association and National Institute of Public Cooperation and Child
Development. These associations and institutions too involve themselves in the activities of TNAI on a
reciprocal basis.

The TNAI takes part in the activities of important social organisations devoted to the welfare of women,
especially National Council of Women in India, National Federation of Indian Women and All-India
Women's Conference. The Association is invited to all important deliberations of such bodies and effort
is made by the TNAI representatives to keep these organisations informed of the problems of practicing
nurses.

In 1936 Nurses' Auxiliary of the Christian Medical Association (CMA), known as Christian Nurses'
League (CNL) since 1954, was affiliated to TNAI. Another organization with which TNAI is associated
or affiliated is : Catholic Nurse's Guild of India.

4. Affiliation with International Council of Nurses (ICN)

A Landmark was TNAI's affiliation with International Council of Nurses (ICN) in 1912. Both ANSI and
TNAI united for this purpose. TNAI was among the first eight National Nurses' Associations (NNAs)
which joined ICN and was represented first time at its Congress at Cologne. Miss Dora Chadwick
(President, TNAI: 1933- 41) was appointed to ICN's Education Committee in 1930. The first Indian
Nurse delegate who attended ICN Congress in Rome (1933) was Miss B.J. Singh.

In 1957 for the first time the President and Secretary attended the ICN Congress in Rome as official
delegates. In 1973 for the first time four Indian students attended ICN Congress in Mexico. Affiliation
with ICN offered many opportunities for broadening the professional horizon and bringing forth newer
ideas. The 'Nursing Abroad' programme of ICN assisted Indian Nurses in their work and study abroad.
In recent years the ICN sponsored a Socio- Economic Welfare Project (1989-91) through which about
300 Nurses from different parts of the country received Training in Leadership Development and
Management Skills.

Mrs. Rita Sarkar was appointed Coordinator of the project. Mrs. Narender Nagpal, the Secretary-
General, TNAI, attended during 1990-91 ICN workshops in Seoul and Tokyo on Nursing Regulations.
Her participation in these international workshops has been useful in bringing about amendments in
Indian Nursing Council and State Nursing Councils acts to follow up workshops for the Council
Registrars in collaboration with INC. This was in pursuance of the Association's objective of raising the
standard of Nursing education and practice through necessary regulations.
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In these long years of affiliation TNAI representatives often got elected to the ICN Board of Directors as
Area Members from time to time and also as Vice- President. Some ICN officers visited TNAI
Headquarters and also some of them attended TNAI Conferences: Barbara Fawkes, Executive Director
(1977), Miss Constance Holleran, Executive Director (1985, 1986), Miss Martha Quivey, Vice-
President (1991). Their visits provided for mutual sharing. However, there has been a set back in the
continuity of TNAI affiliation with ICN in recent years due to financial constraints. Since May 1995
TNAI stands disaffiliated from the ICN.

5. Affiliation with Commonwealth Nurses Federation

Around 1974 the TNAI became a member of the Commonwealth Nurses Federation (CNF). The
association with CNF has been fruitful in many ways. Presently Mrs. Reena Bose is the President of
CNF. She is the first Indian Nurse who has been elected to the post of President of CNF. Dr. (Mrs) S.
Krishnan, Mr. C.P.B. Kurup, Sr. Francesca Vazhapillyand Mrs. Narender Nagpal have served as Vice-
President and/or Area Member on the Federation.

6. Affiliation with Scholarship Funds

One of the ways in which the TNAI carries out its educational objectives and serves the cause of
nursing, is by being the Trustee for various scholarships. These are listed below and the rules and
regulations regarding application and contractual agreements connected with them appear in this
section.

6 (i). Kapadia Memorial Scholarship Fund: This fund was created in 1946 by the School of Nursing
Administration, Bara Hindu Rao, Delhi in memory of 'Pestonjee Nowroji' and 'Roshan Postonjee' with
an initial donation of Rs. 500 by Miss G. Kapadia in March, 1946. The Fund was entrusted for the
purpose of administration to the Trained Nurses Association of India. It was to be built up gradually
through collections from the school, and it was proposed that when the income from its interest would
become sufficient, a scholarship could be awarded to any deserving nurse for higher studies in India in
nursing administration.

6 (ii). Margaret Jehan Scholarship Fund: This fund was created with an initial donation of Rs. 12,000
and subsequent donations made by Dr. G. Stapleton, W.M.S., in 1944. The objective of the fund was to
provide a scholarship for nine months every year to enable a nurse, preferably from Hospital for Women
and Children in India, to take the Sister Tutor's Course at the Delhi Postgraduate School of Nursing.

6 (iii). Ajmer Minto Sister's Scholarship Fund: This fund was created with an initial donation of Rs.
25,300 made by the Rajputana Branch of the Lady Minto Nursing Association in 1946. The fund was
named "AJMER MINTO SISTERS' SCHOLARSHIP". Out of the income from interest, scholarship of
the value of Rs. 900 per year is awarded to a candidate for four years for doing B.Sc. (Hons.) Degree
Course is Nursing in the College of Nursing, New Delhi. The selection of the candidate is made by the
College of Nursing and recommended to TNAI for award of the scholarship.

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6 (iv). Lady Linlithgow Scholarship Fund: This fund was created in October 1943 through a generous
gift of Rs. 23,400 made by H.E. Lady Linlithgow on the eve of her departure from India. This
scholarship is given for the training of nurses for administrative and teaching posts in hospitals and
schools of nursing in India.

6 (v). Rajkumari Amrit Kaur & Miss Adranvala Scholarship Fund: This fund was created with the
donation of Rs. 4,214.50 in 1954, Rs. 2,189.50 in 1955, and Rs. 833.62 in 1956 totalling Rs. 7,237.62
made by various institutions in India for awarding scholarship in the name of the former Union Minister
of Health. T.N.A.I. contributed Rs. 1,000 per year from 1960 to 1963 and Rs. 500 per year from 1964 to
1966. The original intention was to establish a scholarship for Public Health Nursing, but now a grant
out of the income from interest of this fund is to be awarded to a nurse for research, in any aspect of
nursing.

6 (vi). Tata Memorial Scholarship Fund: This fund was created in 1947 with an initial donation of Rs.
15,000 received from the trustee of Sir Dorabji Tata Trust as Tata Memorial Scholarship Fund. Out of
the income from interest a scholarship is to be awarded to a nurse for post-basic or post-graduate studies
in College of Nursing, New Delhi.

6 (vii). Lady Minto Nursing Scholarship Fund: This fund was created from India's share of the funds of
the Lady Minto Nursing Association with an initial donation of Rs. 1,65,848 in 1949 with a second
instalment of Rs. 11,529 received in 1950.

6 (viii). Military Nursing Service Scholarship Fund: This fund was created in 1943 with the donations
and collections made by the Military Nursing Service reserve mess account, for awarding scholarship
(out of the income from interest) for higher studies in Nursing to any nurse of the Military Nursing
Service.

6 (ix). Florence Nightingale Fund for Research in Nursing: This fund was entrusted some time in 1942-
43, to the Trained Nurses Association of India by the Indian Red Cross Society. In the early years the
income was utilised for scholarships for study in U.K. but in view of the high costs for the courses to be
undertaken in U.K., it was decided to use the income for research in Nursing.

6 (x). Rules for Scholarship in India:

(a) Courses of Study: Teaching and Administration, B.Sc. (N) Post-Basic and M.N. degree programmes.

Public Health Nursing or any other post-certificate course given in an institution recognised by the
Indian Nursing Council.

(b) General education : The candidate should meet the requirements of the institutionl, but ordinarily, it
would be Ten Plus Two or an equivalent examination.

(c). Professional education Registration as a general nurse and midwife. In case of men nurses, evidence
of having training in a special subject instead of midwifery.
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(d) Professional experience: A minimum of two years bedside nursing experience in an institution for
Ward Administration course; three years experience for a Tutor's course, and five years for a course in
Nursing Administration. In all cases the requirements of the institution should be met.

(e) Applications Applications will be invited through The Nursing Journal of India in December/January
every year.

(f) Selection Selection will be made by the Committee appointed for this purpose as per the information
obtained from the application form and confidential reports.

(g) Scholarship The student will receive the scholarship through the head of the institution to which
she/he is admitted for study.

(h) Agreement An undertaking to continue in service for two years within three months of completion of
the course or to refund the amount paid to her/him in case of default will have to be executed by the
student on the prescribed form.

(i) General The candidate should be a member of the TNAI for at least three years, preferably a Life-
Member. The candidate will have to seek admission directly in the institution she/he proposes to join
and a!so make her/his own arrangement for getting leave from the institution in which she/he is
employed.

The information of the award will be communicated to the candidate by the Secretary of the Scholarship
Committee to whom the Selection Committee will give report. The Secretary of the Scholarship
Committee will request the Hony. Treasurer, TNAI, to make payment to the institution after the student
has joined it.

The Secretary, Scholarship Committee, will submit an annual statement on whether the Students who
had secured the scholarship continue to hold posts in institutions for the period required in the
agreement. A report on their work will also be called, for from the institution in which they are empl

About us : An Introduction

TNAI > Establishment and Formation - Constitution - Executive Committee - Council Members -
Activities

Membership Statement: TNAI/HVL/ANM

SNA > Introduction - Membership Statement - SNA Biennial Conference 2009 - Activities

STUDENT NURSES ASSOCIATION

The Student Nurses Association (SNA) is a nation-wide organisation. It was established in 1929 at the
time of the Annual Conference of the Trained Nurses’ Association of India (TNAI). The Nursing

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Superintendent of the Government General Hospital, Madras, Miss L.N. Jeans, was the first Honorary
Organising Secretary of this Association. The pioneer unit of SNA was established at the General
Hospital, Madras, followed by Christian Rainy Hospital, Madras and the Presidency General Hospital,
Calcutta.

It is remarkable that the growth of SNA Units has been persistent ever since its inception. In the year
1954, the SNA celebrated its Silver Jubilee and there was significant increase in the number of units by
then. The number rose to 117 and the membership to 4,259. The S.N.A. celebrated its Diamond Jubilee
with almost three fold increase in the number of units and seven times increase in membership, i.e., 355
units and 29,233 members. By September 30,1998, the number of SNA units were 518 and the total
membership of SNA was 45,171. The present number of SNA units, till August 2001 is 506 and the
membership is 43,453.

The SNA and TNAI used to have combined Annual Conference, but due to the increase in number of
delegates it was felt in 1960 to hold separate Conferences for the student Nurses. Since 1961 the student
Nurses are having separate Biennial Conferences. These are held alternately with TNAI Conferences.

The students are being given more and more responsibility to manage their affairs both at the State and
national levels. In 1975 it was agreed by the TNAI Council that one student representative be included
in the State Branch Executive Committee on trial basis before the students are included in the TNAI
Council as representatives of SNA.

As work of the Association increased, the need for a full time Secretary for the SNA was felt and in
1947 Miss I. Dorabji was appointed as SNA Secretary . Miss M. Philip succeeded Miss Dorabji in 1964,
when Miss Dorabji joined TNAI as Secretary. Miss Philip continued as SNA Secretary till 1967. In
1970 with the reorganisation of TNAI the designation of the SNA Secretary was changed to SNA
Advisor.

Mrs. Narender Nagpal was appointed first SNA Advisor in 1973 and she served in this capacity upto
1978. Miss D.K. Singh succeeded Mrs. Nagpal after the latter’s appointment as Secretary, TNAI. Mr. T.
Stephens succeeded Miss Singh in 1981. On Mr. T. Stephens’ retirement in 1983 Miss Jaiwanti P.
Dhaulta took over as SNA Advisor. On appointment of Miss Dhaulta as Secretary-General, TNAI, in
1996, Lt.Col. (Miss) M. David took over as SNA Advisor. On her retirement in March 1998, Mrs.
Sujana Chakravarty became the SNA Advisor.

5: HEALTH CARE LABOR LAWS

LAW: A rule that is supported by the power of government and that controls the behavior of members
of the society.

5:1EMPLOYMENT AND LABOR LAWS

TITLE OF LEGISLATION REGULATION

Fair labor standards act ( 1938) Sets minimum wage & maximum hour that should
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 be worked before overtime is paid
Civil Rights Act of 1964 Sets equal employment practices
Executive order 11246(1965) and executive Sets affirmative action guidelines.
order 11375( 1967)
Age discrimination act (1967) and 1978 Protect against forced retirement.
amendment
Rehabilitation act (1973) Protect the disabled.
Vietnam veterans act (1973-1974) Provides reemployment rights

5:2 FIVE CATEGORIES OF EMPLOYMENT LAWS

 LABOR STANDARDS: These laws establish minimum standards for working conditions
regardless of the presence or absence of a union contract. Included in this set are minimum wage,
health and safety, equal pay laws.
 LABOR RELATIONS : These laws relate to the rights and duties of unions and employers
and their relationship with each other.
 EQUAL EMPLOYMENT : The laws that deal with employment discrimination.
 CIVIL AND CRIMINAL LAWS : These are statutory and judicial laws that proscribe certain
kinds of conduct and establish penalties.
 OTHER LEGISLATION : Nursing managers have some legal responsibilities that do not
generally apply to industrial managers. For instance , licensed personnel are required to have a
current, valid license from the state in which they practice. Confidentiality laws also have a
significant impact on health care organization.

5:3OCCUPATIONAL HEALTH AND SAFETY ACT (OHSA)

The objects of the Occupational Health and Safety Act 2000 are to:

 secure and promote the health, safety and welfare of people at work
 protect people against workplace health and safety risks
 provide for consultation and cooperation between employers and workers in achieving the
objects of the Act
 ensure that risks are identified, assessed and eliminated or controlled,
 develop and promote community awareness of occupational health and safety issues,
 provide a legislative framework that allows for progressively higher standards of occupational
health and safety to take account of new technologies and work practices protect people against
risks arising from the use of plant (ie. machinery, equipment or appliances )

5:4 LAWS APPLICABLE TO HOSPITALS

The laws applicable to hospitals directly and specifically are the various “ Hospitals and Nursing
Home Acts” passed by the States and UNION Territories legislatures and which have received the

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assent of the Heads of States \ Union. The various Public Health Acts also regulate the functioning of
the hospitals. The laws applicable to hospitals.

 The Consumer Protection Act, 1986.

 The Indian Medical Council Act, 1956.
 The Indian Nursing Council Act, 1947.
 The Pharmacy Act, 1948.
 Medical Termination of Pregnancy Act, 1971.
 The Drugs and Cosmetics Act, 1940.
 Transplantation of Human Organs Act, 1994
 The Drugs Control Act, 1950
 The Poisons Act , 1919

The above acts are applicable to Medical and Health Institutions. There are other Acts which are
applicable to Institutions and organizations in general. They include

 Payment of Wages Act 1936

 Minimum Wages Act , 1984
 Maternity Benefit Act, 1961
 Employment Exchange ( compulsory notification of vaccines) Act, 1959
 Payment of Gratuity Act, 1972
 Employees Provident Fund ( and miscellaneous provisions ) Act, 1952
 The Indian Medicine Central Council Act, 1970

HOSPITALS AND NURSING HOMES ACTS

Governments have the duty and responsibility to ensure the health of the people. Hospitals from an
important component of the health care system. Hospitals function at different levels and provide
varying levels of care.

The standards of care are based on what is desirable and what is feasible under the given
circumstances- location( rural or urban) size ( large , medium, small) , services provided ( primary ,
secondary, and tertiary ) and the economic and social situation of the region . Government should set
appropriate standards and the hospitals must follow the standards set for each group. This will ensure
the quality of health care and health outcome.

CONSUMER PROTECTION ACT

Consumer protection act was passed by the Government in 1986 with a view to provide the better
protection of the interest of the consumers. It provides for the establishment of Consumer Councils to
educate the public and creation of authorities for the settlement of consumer disputes and for matters
connected therewith. The act is designed to provide a for a quicker and cheaper remedy when there is
deficiency in service and claims for damages are made arising from such deficiency in service.

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  According to section 2(1) (d) (ii) of the Act , Consumer means any person who hires or avails
of any services for a consideration which has been paid or promised or partly paid and partly
promised or under any system of deferred payment.
 Section 2 ( 1) (0) of the Act defines” Service.” According to it ,” Service “ means service of
any description which is made available to potential users.
 Health care services will be a service, within the meaning of section 2(1) (0) of the act, if
such services are obtained for consideration.

………… the activity of providing medical assistance for payment carried on by hospitals and
members of the medical profession falls within the scope of the expression service as defined in section
2(1) (0) of the Act , and that in the event of any deficiency in the performance of such service the
aggrieved party can invoke the remedies provided under the act by filling a complaint before the
consumer forum having justification.

5 :5 The Emergency Medical Treatment and Active Labor Act ( EMTALA) is a United States Act
of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act. It requires
hospitals and ambulance services to provide care to anyone needing emergency healthcare treatment
regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. As a
result of the act, patients needing emergency treatment can be discharged only under their own informed
consent or when their condition requires transfer to a hospital better equipped to administer the
treatment.

EMTALA applies to "participating hospitals", i.e., those that accept payment from the Department of
Health and Human Services, Centers for Medicare and Medicaid Services (CMS) under the Medicare
program. However, in practical terms, EMTALA applies to virtually all hospitals in the U.S., with the
exception of the Shriners Hospitals for Children, Indian Health Service hospitals, and Veterans Affairs
hospitals. The combined payments of Medicare and Medicaid, $602 billion in 2004, or roughly 44% of
all medical expenditures in the U.S., make not participating in EMTALA impractical for nearly all
hospitals. EMTALA's provisions apply to all patients, and not just to Medicare patients

The cost of emergency care required by EMTALA is not directly covered by the federal government.
Because of this, the law has been criticized by some as an unfunded mandate. Similarly, it has attracted
controversy for its impacts on hospitals, and in particular, for its possible contributions to an emergency
medical system that is "overburdened, underfunded and highly fragmented."More than half of all
emergency room care in the U.S. now goes uncompensated. Hospitals write off such care as charity or
bad debt for tax purposes. Increasing financial pressures on hospitals in the period since EMTALA's
passage have caused consolidations and closures, so the number of emergency rooms is decreasing
despite increasing demand for emergency care. There is also debate about the extent to which EMTALA
has led to cost-shifting and higher rates for insured or paying hospital patients, thereby contributing to
the high overall rate of medical inflation in the U.S.

6: LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS ASSOCIATED WITH

UNIONIZATION, HEALTH CARE LABOR LAWS.

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LEADERSHIP ROLES

Be self aware regarding personal attitudes and values regarding collective bargaining& health
care labor laws.
Recognizes and accepts reasons why people seek unionization.
Crates a working environment that eliminates the need for unionization to meet employees
needs.
Maintains an accommodating or cooperative approach when dealing with unions and
employment legislation.
Act as a role model.
Be nondiscriminatory in al personal and professional actions.
Examines the work environment periodically to ensure that it is supportive for all members
regardless of gender ,race, age , disability etc.

MANAGEMENT FUNCTIONS

Understands and appropriately implements union contracts.

Administrates personal policies fairly and consistently.
Works cooperatively with the personnel department and top –level administration when dealing
with union activity.
Understands & follows the labor and employment laws that relate to the manager’s sphere of
influence.
Ensure that the work environment is safe.
Be alert for discriminatory employment practices in the workplace.
Follows through on investigating any employee reports f discrimination.
Ensures that the unit or department meets state licensing regulations.
Immediately and fully investigates all complaints regarding violations of the collective
bargaining contract and take appropriate action.

8: INTRODUCTION

Health and safety are important aspects of an organization’s smooth and effective functioning. Good
health and safety performance ensures an accident-free industrial environment.

Awareness of Occupational Health and Safety (OH&S) has improved in India considerably.
Organizations have started attaching the same importance to achieve high OH&S performance as they
do to other key aspects of their business activities. This demands adoption of a structured approach for
the identification of hazards, their evaluation and control of risks.

Successful occupational health and safety practice requires the collaboration and participation of both
employers and workers in health and safety programms, and involves the consideration of issues relating
to occupational medicine, industrial hygiene, toxicology, education, engineering safety, ergonomics,
psychology, etc.

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Occupational health issues are often given less attention than occupational safety issues because the
former are generally more difficult to confront. However, when health is addressed, so is safety, because
a healthy workplace is by definition also a safe workplace. The converse, though, may not be true - a so-
called safe workplace is not necessarily also a healthy workplace. The important point is that issues of
both health and safety must be addressed in every workplace. By and large, the definition of
occupational health and safety given above encompasses both health and safety in their broadest
contexts.

9: TERMINOLOGIES

 A hazard is something that can cause harm if not controlled.

 Occupational Health is the promotion and maintenance of the highest degree of physical,
mental and social well-being of workers in all occupations by preventing departures from health,
controlling risks and the adaptation of work to people, and people to their jobs.

(ILO / WHO 1950)

 Safety is the condition of being safe; freedom from danger, risk, or injury.

 Occupational safety and health is a cross-disciplinary area concerned with protecting the
safety, health and welfare of people engaged in work or employment.

10: OCCUPATIONAL HEALTH AND SAFETY

10:1DEFINITION OF OCCUPATIONAL HEALTH AND SAFETY

Since 1950, the International Labor Organization (ILO) and the World Health Organization (WHO)
have shared a common definition of occupational health. It was adopted by the Joint ILO/WHO
Committee on Occupational Health at its first session in 1950 and revised at its twelfth session in 1995.

"Occupational health should aim at: the promotion and maintenance of the highest degree of
physical, mental and social well-being of workers in all occupations; the prevention amongst
workers of departures from health caused by their working conditions; the protection of workers
in their employment from risks resulting from factors adverse to health; the placing and
maintenance of the worker in an occupational environment adapted to his physiological and
psychological capabilities; and, to summarize, the adaptation of work to man and of each man to
his job."

10:2 AIMS OF OCCUPATIONAL HEALTH AND SAFETY

Occupational health and safety is a discipline with a broad scope involving many specialized fields. In
its broadest sense, it should aim at:

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  the promotion and maintenance of the highest degree of physical, mental and social well-being
of workers in all occupations;
 the prevention among workers of adverse effects on health caused by their working conditions;
 the protection of workers in their employment from risks resulting from factors adverse to
health;
 the placing and maintenance of workers in an occupational environment adapted to physical and
mental needs;
 The adaptation of work to humans.

In other words, occupational health and safety encompasses the social, mental and physical well-being
of workers that is the “whole person”.

10:3IMPRTANCE OF OCCUPATIONAL HEALTH AND SAFETY

Work plays a central role in people's lives, since most workers spend at least eight hours a day in the
workplace, whether it is on a plantation, in an office, factory, etc. Therefore, work environments should
be safe and healthy. Yet this is not the case for many workers. Every day workers all over the world are
faced with a multitude of health hazards, such as:

 Physical hazards
 Chemical hazards
 Biological hazards
 Psychological hazards

Unfortunately some employers assume little responsibility for the protection of workers' health and
safety. In fact, some employers do not even know that they have the moral and often legal responsibility
to protect workers. As a result of the hazards and a lack of attention given to health and safety, work-
related accidents and diseases are common in all parts of the world.

10:4 FACTORS AFFECTING OCCUPATONAL HEALTH AND SAFETY

Poor working conditions affect worker health and safety

• Poor working conditions of any type have the potential to affect a worker's health and safety.

• Unhealthy or unsafe working conditions are not limited to factories — they can be found
anywhere, whether the workplace is indoors or outdoors. For many workers, such as agricultural
workers or miners, the workplace is “outdoors” and can pose many health and safety hazards.

• Poor working conditions can also affect the environment workers live in, since the working and
living environments are the same for many workers... Workers can be exposed to toxic chemicals in a
number of ways when spraying pesticides: they can inhale the chemicals during and after spraying, the

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chemicals can be absorbed through the skin, and the workers can ingest the chemicals if they eat, drink,
or smoke without first washing their hands, or if drinking water has become contaminated with the
chemicals.

 Negligence of the worker,

 Lack of knowledge of the worker about occupational hazards and safety.
 Improper handling of the equipments.
 Improper sterilization of the articles.
 Improper disposal of the contaminated articles.
 Improper usage of the protecting devices. e.g. lead shield

10:5REASONS FOR OCCUPATIONAL HEALTH AND SAFETY

The reasons for establishing good occupational safety and health standards are frequently identified as:

• Moral - An employee should not have to risk injury or death at work, nor should others
associated with the work environment.

• Economic - many governments realize that poor occupational safety and health performance
results in cost to the State (e.g. through social security payments to the incapacitated, costs for medical
treatment, and the loss of the "employability" of the worker). Employing organizations also sustain costs
in the event of an incident at work (such as legal fees, fines, compensatory damages, investigation time,
lost production, lost goodwill from the workforce, from customers and from the wider community).

• Legal - Occupational safety and health requirements may be reinforced in civil law and/or
criminal law; it is accepted that without the extra "encouragement" of potential regulatory action or
litigation, many organizations would not act upon their implied moral obligations.

11: OCCUPATIONAL HEALTH HAZARDS

11:1 Physical Hazards

Radiation Exposure

There is a wide range of radiation hazards related to medical imaging (X rays, nuclear scans utilizing
radioactive isotopes) and radiation oncology which utilizes ionizing radiation from a variety of sources
to treat a range of malignant tumors. These sources include (me) sealed sources containing radioactive
material such as isotopes of radium, cobalt and strontium, and (ii) linear accelerators emitting short
wave length gamma waves.

PREVENTION

(i) Appropriate training, certification and credentialing of users

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 (ii) Demonstrated implementation of safety precautions related to storage, use and shielding of
non target personnel
(iii) Regular inspection, maintenance and certification of equipment Ongoing monitoring of
radiation exposure of staff using the equipment.

Back Injury

Hospital staff and particularly nurses are prone to back injury from the need to lift and roll immobilized
or disabled patients for toilet, washing, dressing and pressure care.

 Hospitals are now required to give training on back care to all new staff.
 The training, combined with the use of wards persons to assist nurses and the use of hydraulic
lifting devices, has decreased the risk of back injury considerably.
 Maintain proper body mechanisms during procedures.

Burns due to Steam Sterilizing

Larger hospitals now have Central Sterilizing Departments utilizing appropriately trained, dedicated
staff that are familiar with and follow set policy and procedure. This type of specialized set up
minimizes risk of physical injury from hot equipment. However, smaller peripheral steam sterilizers are
still required in some departments such as the Operating Theatres.

Where possible many smaller satellite hospitals now use the Central Sterilizing Department of their
larger referral Base Hospital for their sterilization needs.

Laser Burns

Lasers are now frequently used in Operating Theatres and appropriate protective equipment must be
used, especially eye protection to prevent retinal burns. The use of this equipment is covered by set
protocols.

Electrical Defibrillators

Use of this equipment is restricted to those staff who have undergone competency based training and
certification.

Personal Violence

Risk of injury from personal violence is an important hazard in Emergency Departments who at times
deal with mad, bad or intoxicated patients. Similarly, Psychiatric Units who have to look after the
psychotically disturbed are also at risk.

 Staff education and set policy and procedure needs to be in place for dealing with aggressive
patients.

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  Personal security alarms, a system for rapidly mobilizing ancillary staff, and a set approach to
safely restraining, immobilizing and sedating violent patients are all important components.

11:2CHEMICAL HAZARDS

Toxic chemicals in use in hospitals include:-

•Industrial cleaners used by contracted cleaning staff.

•Chemical sterilizers, in particular gluteraldehyde used for the sterilization of endoscopes and other
equipment that cannot be steam sterilized.

•Tissue preservatives such as formaldehyde used to store and preserve body tissue prior to
histopathology.

•Chemical reagents used in the hospital Pathology Laboratory.

•Cytotoxic drugs requiring preparation prior to parenteral administration to cancer patients.

•Processing chemicals for X-ray film development.

•Anesthetic gases in the Operating Theatre.

The hierarchy of principles for controlling chemical hazards is well documented and utilized
within hospitals:-

•Elimination (use an alternative process or strategy egg. disposables).

•Substitution (use the least toxic chemical that will do the job).

•Isolation (keep the relevant chemical in one isolated area if possible).

•Enclosure (e.g. gluteraldehyde fume cupboard, preparation enclosure for cytotoxics, closed circuit
anesthetic machines with scavenging of exhaust gases).

•Ventilation (X-ray processors).

•Personal protection (gloves, goggles, plastic gowns etc. where appropriate).

•Personal hygiene (hand washing after use).

•General cleanliness (clean up spills, appropriate storage, etc.).

Relevant staff must have appropriate training and education in the use of any of these chemicals, and
must be informed of any dangers including those of low risk.
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11:3BIOLOGICAL HAZARDS

Management of biological hazards should be comprehensively covered in the hospital’s Infection

Control Manual, with the policies and procedures developed and monitored by an Infection Control
Committee chaired by an Infection Control Nurse. This manual should be based on expert publications
such as the National Health and Medical Research Council’s “Infection Control in the Health Care
Setting” 1996.

There are 3 important modes of disease transmission from patients to staff:

1. Airborne and droplet aerosol exposure - includes viral upper respiratory tract infections,
measles and TB.

 Preventative measures include (i) keeping distance (>1m) from frontal coughing as much
as possible (ii) wash hands after every patient contact and especially avoid rubbing eyes
before washing (iii) high filtration face masks (where applicable - generally not practical
in the outpatient setting) (iv) isolate inpatients in a negative air pressure room.

2. Skin contact exposure - includes Staphylococcus aurous and Vermicelli.

 Prevention requires protective gown and gloves.

3. Exposure to infectious fluids via broken skin, eyes, mucous membranes, and parenteral
exposure - includes hepatitis B, hepatitis C, and HIV from all body fluids except sweat, as
well as gastroenteritis and hepatitis A from fecal fluid.

 Preventative measures include universal precautions (gloves, gown, goggles and mask), and
appropriate management of sharps, spills, and contaminated waste.

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If acute exposure to a biological hazard does occur, staff members need to be aware of relevant
policies and procedures for appropriate management of the exposure. This will include:

 Appropriate washing for mouth, eyes or skin exposure

 First aid for penetrating sharps injury
 Prophylaxis for high risk exposure
 Vaccination
 Barrier nursing technique
 Universal precaution
 Testing of the source if possible
 Testing and follow up of exposed staff
 Incident reporting.

2008 Study of Nurses’ Views on Workplace Safety and Needle stick Injuries

The 2008 Study of Nurses’ Views on Workplace Safety and Needle stick Injuries seeks to capture
opinions, concerns, and experiences about workplace climate of nurse safety and needle stick injuries.
The survey of more than 700 U.S. nurses, sponsored independently by the American Nurses Association
(ANA) and Inviro Medical Devices, reveals NSIs and blood borne infections remain major concerns for
nearly two-thirds (64%) of nurses. The research also highlights that concerns about nurse safety
influences the decisions made by the vast majority of nurses (87%) about the type of nursing they do,
and that nearly two-thirds of nurses (64%) have been accidentally stuck by a needle while working.

When Needle stick Injuries Occur

. The three principal causes account for two-thirds (66%) of needle stick injuries:

While giving an injection

Before activating the safety feature

During disposal of non-safety device

After sharp was left on surface by co-worker

In response to action of co-worker

Workplace Climate of Nurse Safety

The majority of nurses nationwide (55%) say the safety climate of their workplace negatively impacts
their personal safety. 59% of nurses say when pressure mounts, they feel the need to work faster. Nurses
reveal the issues impacting the workplace climate of nurse safety:

Increasing workloads
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 Workplace stress levels

Emphasis on productivity

Emphasis on patient-acuity levels

Work shifts of 12 hours or longer

Needle stick Injuries

74% of nurses say they would not consider working for an employer that does not provide a staff
member, doctor, or a nurse with safety syringes. Nearly two-thirds (64%) report being accidentally stuck
by a needle while working, and a staggering 74% report being stuck by a contaminated needle. Over the
course of their career, nurses have experienced contaminated needle sticks:

Nurses nationwide express a strong interest in using a safety syringe with environmental benefits. This
includes a safety syringe that:

Creates less medical waste

Uses less paper in packaging and shipping containers

Manufactured by a company with an environmentally friendly program

Uses recyclable components

Reporting Needle stick Injuries

While the vast majority (86%) of nurses nationwide say their department strongly encourages and
supports reporting of needle stick injuries (NSIs), nearly three-quarters (74%) of nurses say NSIs still
are underreported. Nurses believe the reasons for underreporting include:

Within one to two hours

Not evaluated or treated at all

Within four hours

Next day

Within eight hours

Longer than 24 hours afterwards

Regulation of needle stick injuries

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 Food and Drug Administration (FDA) – A 2005 document issued by the FDA analyzes key sharps
injury performance indicators as well as characteristics of a well-made safety product. The InviroSNAP!
Safety Syringe is compared to the criteria.

Occupational Safety and Health Administration (OSHA) – Due to a high level of needlestick injuries,
Congress was spurred into action, leading to the creation of the Needlestick Safety and Prevention Act
of 2000. OSHA issued a list of criteria to help reduce needlestick incidents.

National Institute for Occupational Safety and Health (NIOSH) – The InviroSNAP! Safety Syringe is
compared to NIOSH’s preferred characteristics for safety devices.

The Joint Commission – Hospital safety is of the utmost importance, and establishing a needlestick
prevention program encourages staff to be aware of potential contaminants as well to adhere to
medication labeling procedures.

Safety Syringe Designs & Criteria

The Needle stick Safety and Prevention Act and subsequent revisions in OSHA’s enforcement
procedures have led to a dramatic increase in the use of safety needle products and syringes. In acute
care settings, the use of medical safety devices and syringes has grown from an estimated 46 percent in
2002 to 79 percent in 2005. At alternate healthcare sites, usage has increased from an estimated 35
percent in 2002 to 45 percent in 2005.1 Since the law was enacted, studies have shown that syringes
with a safety needle and other safety features significantly reduce the frequency of needle stick injuries.

However, medical safety devices do not completely eliminate the risk of needle stick injuries and
reasons may include:

Clinician fails to activate the safety feature

Clinician bypasses the safety needle feature

Safety needle feature fails

Needle sticks Can Lead to Serious Infections

Healthcare professionals can experience serious blood borne pathogen exposure due to needle sticks ,
including:

Hepatitis C transmission, the most frequent infection from needle sticks

Hepatitis B

Human Immunodeficiency Virus (HIV) disease

Hepatitis C Transmission
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Of healthcare workers who become infected from an accidental needle stick injury, approximately 85%
become chronic carriers of hepatitis C. The transmission rate of hepatitis C from an accidental needle
stick is 1 to 10 percent.1

It is possible that thousands of nurses and other clinicians have occupationally acquired hepatitis C
through blood borne pathogen exposure and remain unaware of their disease. Hepatitis C carriers have
the potential to spread the disease to others including their partners and close family members, thereby
making widespread hepatitis C transmission a serious societal consequence of needle stick injuries.

Hepatitis C can lead to liver failure, liver transplants and liver cancer. There is no cure for Hepatitis C,
but drugs to slow the progression of hepatitis C are available, but can cost thousands of dollars each
month.

Hepatitis B

Hepatitis B is one of few blood borne diseases that is now preventable thanks to the vaccine that must be
offered to healthcare workers. For a susceptible person, the risk from a single needle stick injury or cut
exposure to HBV-infected blood is 6 - 30 percent.2

HIV

Human Immunodeficiency Virus (HIV) is the virus that causes AIDS. The average risk of HIV infection
after a needles tick injury or cut exposure to HIV-infected blood is 0.3 percent.

Immunization Safety

Inviro Medical Devices flagship, patented InviroSNAP! Safety Syringes offer the ultimate in
immunization safety. As a leader in immunization safety research and products, Inviro Medical plays a
vital role in assuring that every vaccination needle used is safe for both the administrator and the patient.

Making the Vaccination Needle Safer

Created to address the growing concerns about needle safety and the severe economic, medical and
psychological consequences of accidental needle stick injuries, InviroSNAP! Safety Syringes are
designed to offer cutting-edge performance and premium immunization safety. InviroSNAP! Safety
Syringes look and function like a traditional vaccination needle and require minimal training and no
change in clinical technique. Integrated in the design of each syringe is a unique safety feature that
enables clinicians to administer immunizations via vaccine needles as usual and disable the device by
simply snapping the plunger off when finished. The user’s hands remain out of harm’s way, behind the
needle of our retractable safety syringes, during activation of the safety feature.

Management of needle stick injuries.

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Needle stick safety should always be a priority. The following suggested steps regarding how to handle
a needle stick injury were first published in the American Journal of Nursing.1

Step one – Clean the Wound

the first thing you should do is clean the wound with soap and water. Don't pinch or squeeze blood out
of the wound or apply bleach. If the injury is sustained in the OR while assisting with a procedure,
cleanse the site with either povidone iodine or isopropyl alcohol.

Step Two – Testing

It is critical that you get tested for HIV, hepatitis B and hepatitis C as soon as possible.

Step Three – Report the Incident

In order to maintain needle stick safety, always report the needle stick – even a "clean stick" – via an
incident report according to protocol.

Step Four – Retesting

You should be retested for hepatitis C six weeks after the needle stick and again at four to six months for
HCV antibodies and elevated liver enzymes. After HIV exposure, get tested at six weeks and again at
three, six and twelve months for antibodies to HIV. The frequency will depend on the risk of
transmission.

11:4PSYCHOLOGICAL HAZARDS

Hospitals are stressful places for sick and injured patients and their families. However they can also be
stressful for staff due to such factors as:

• Shift work, on call duty, fatigue and “burn out”.

• High workload and demand.

• High or unrealistic patient expectations.

• Verbal abuse or threats from disgruntled or intoxicated patients.

• High or unrealistic expectations from supervisors and management.

• Problematic interpersonal work relationships.

• Frustrations due to limited resources, especially staffing levels.

• Poor organizational climate with low staff morale.

MEASURES FOR HEALTH PROTECTION OF WORKERS

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Hospitals are part of a high demand, high expectation service industry and are heavily reliant on staff for
the friendly, safe, effective and efficient delivery of services.

 To optimize productivity and attitude of staff, senior management must be committed to

ensuring a conducive organizational climate with high staff morale.
 Clear priorities and direction, realistic performance goals and workloads, commitment to
continuing education and quality assurance, reception to staff feedback, and support with
counseling services for stressed staff are all important components.
 Individual workers must be encouraged to report any relevant incidents to their supervisors on
the appropriate incident report form which are then forwarded to the hospital’s WHS Officer for
collating and analysis, and, if appropriate, investigation and action.

12: PREVENTION OF OCCUPATIONAL DISEASES.

MEDICAL MEASURES

 . Preplacement examination
 . Periodic examination
 . Medical and health care services
 Notification
 . Supervision of working environment
 . Maintenance and analysis of record
 .Health education & counseling

PREPLACEMENT EXAMINATION

It is the foundation of the effective occupational health service. It is done at the time of employment
and includes worker’s medical, family, occupational and social history; a through physical
examination. The purpose of the examination is to place the right man in the right job, so the worker
can perform his duties efficiently without detriment to his health. It will also serve as a useful bench –
mark for future comparison.

PERIODIC EXAMINATION

Many diseases of occupational origin require months or even years for their development. Their slow
development, very often, leads t their non-recognition in the early stages and this is harmful to the
worker. This is the reason why a periodical medical check-up of workers is very necessary when they
handle toxic or poisonous substances.

MEDICAL AND HEALTH CARE SERVICES.

It is the basic function of an occupational health service. In India Employee State Insurance Health
Act provides medical care to the worker as well as to his family members. Immunization is another

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accepted function of an occupational health service. Provide protective devices to the worker. E.g. Lead
shield for x-ray technician.

NOTIFICATION

National laws and regulations require the notification of cases and suspected cases of occupational
disease.

SUPERVISION OF WORKING ENVIRONMENT

Periodic examination of the working environment provides information of primary importance in

the prevention of occupational disabilities.

MAINTENCE OF HEALTH RECORDS

Proper records are essential for the planning, development and efficient operation of an
occupational health service.

HEALTH EDUCATION AND COUNSELLING

All the risks involved in the industry in which he is employed and the measures to be taken for
personal protection should be explained to him. The correct use of protective devices like masks and
gloves should also be explained. Simple rules of hygiene – hand washing, paring the nails, etc should be
instructed o the worker.

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 Nosocomial Infection Control

Minimizing adverse outcomes of health care for inpatients is of prime importance to hospitals and a
major focus of Quality Assurance activities. A very significant indicator of quality care is the
nosocomial infection rate.

The hospital’s Infection Control Nurse and Infection Control Committee are concerned with the
prevention, surveillance and control of nosocomial infections. The Infection Control Program should be
documented in the hospital’s Infection Control Manual, which outlines the principles, strategies, policy
and procedures for infection control in the hospital. All staff needs to be familiar with its contents.
Regular feedback on surveillance of nosocomial infection rates will help motivate staff to remain
vigilant.

Environmental Protection

In an increasingly cost conscious world concerned with the long term environmental effects of pollution
there is an increasing expectation that producers of hazardous products should be responsible for them
“from cradle to grave”, that is from their production to their safe disposal.

Waste disposal is governed by the Queensland Environmental Protection Act 1994, the Environmental
Protection (Interim Waste) Regulation 1996, and various Local Government Authority by-laws. The
Environmental Protection Act is administered by the Environmental Protection Agency and is binding
on all persons including the Crown.

Clinical (biomedical) waste disposal gives rise to some special issues in relation to infectious material,
hazardous chemicals and drugs, and body parts. A standardized systems approach is adopted by most
Public Hospitals and is generally documented in the hospital’s Infection Control Manual. It is based on a
number of key policies and guidelines including (i) Health guidelines for the management of clinical
and related waste (ii) National Health and Medical Research Council guidelines (iii) National Clinical
Waste Management Industry Group code of practice (iv).

The major components of such a waste management system include:-

 Waste segregation at the source - sharp containers, biohazard bins, general waste bins, and
cytotoxic bins - all standardized and color-coded.
 Waste streams - general, contaminated, cytotoxic / pharmaceutical, body parts.
 Storage and transport - cold storage for contaminated waste and body parts; transport in safe,
leak proof containers.
 Waste treatment - sterilization of contaminated waste (steam autoclave); incineration of
cytotoxics, pharmaceuticals and body parts in an incinerator meeting all relevant standards and
statutes.
 Proper waste disposal.
 .Communicable disease control
 .Environmental sanitation
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Water supply, food, toilet, general plant cleanliness, sufficient space, lighting, ventilation,

Spill management/Housekeeping

1) Spills of body substances should be cleaned up promptly. Workers should wear gloves and use
other protective equipment if there is risk of splash. Encapsulator products may be used to
solidify liquid waste or pickup. Area should then be disinfected with hospital grade
disinfectant/detergent.
2) Broken glass will be handled safe
3) Areas not routinely cleaned by Environmental Services personnel shall be cleaned by department
personnel.

a) Work surfaces shall be cleaned and decontaminated after contact with blood or other potentially
infectious materials.
b) Contaminated surfaces shall be cleaned and decontaminated with an appropriate disinfectant
after the completion of procedures; whenever feasible if the surface work area becomes overtly
contaminated; or at the end of the workshift. A tuberculocidal disinfectant is required to clean
spills of blood or other potentially infectious materials.

 Additional cleaning is required for certain precautions (Special Organism Precautions).

 gainst hazards.

STERILIZATION OF THE ARTICLES

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  Sterilize the contaminated articles used for the patient.
 Heat sterilizing instrument after every patient.
 Monitor the sterilization technique to guarantee the effectiveness.
 Follow barrier nursing techniques during sterilization.

RESEARCH

Conduct research in the various aspects of occupational health and safety.

Administrative. level

a)Workers should receive health and safety training.

b) Vaccination for rubella, measles, mumps, and influenza is recommended, especially for women of
child-bearing age.
c) Work-related stressors, such as inadequate work space, unreasonable work load, lack of readily
available resources, inadequate and unsafe equipment, should be considered.
d) Appropriate emergency equipment (i.e., fire extinguishers, showers, eye wash) should be readily
available.
e) Perform periodic environmental sampling when indicated.
f) Replace hazardous substances with less hazardous substances whenever possible (i.e., plastic for
glass, small packets of chemicals, pre-poured formalin containers). Provide appropriate containers for
disposal of sharps, hazardous waste, and personal protective equipment.
g) Provide conveniently located and supplied hand washing facilities.
h) Document and retain inventories of radioactive materials. Only authorized personnel should have
access to storage areas.

MaintenanceSchedules.

a. Hospital-grade electrical equipment including anesthesia machines, portable x-ray machines and laser
systems, biological safety cabinets, and exhaust ventilation systems should have a preventive
maintenance schedule. Testing intervals of electric equipment shall be set by the institution.
b. A specific person should have the responsibility for assuring proper maintenance of the portable x-
ray machines..
c. The anesthesia machine should be inspected and maintained at least every four months. This should
be done by factory service representatives or other qualified personnel. Leakage of gas should be less
than 100 ml/min during normal operation.

d. The entire laser system should be properly maintained and serviced according to the manufacturer's
instructions. Only qualified personnel from the manufacturer or in-house shall maintain the system.
Maintenance may only be done according to written standard operating procedures.

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e. A written log is recommended for any detected leak and any service done on an ethylene oxide
chamber. Sterilizer/aerator door gaskets, valves, and fittings must be replaced when necessary.

c. Training.

a. All hospital staff members should have training on electrical and fire safety, hazard
communication, and infection control by qualified personnel. Some educators recommend hands on
training with pre- and post-tests.

b. In the hospital, specific training regarding hazardous substances should be given. Only qualified
personnel may handle the hazardous substances or operate the specified machines.

D.WarningSigns.

a. Specific requirements regarding the warning signs to be used on electrical equipment are outlined in
UL No. 544. This should include a Hospital Grade warning. Warning signs should be placed in areas
where exposure to ribavirin, antineoplastic agent spills, ethylene oxide, or lasers is likely to occur.

b. Contract employees should not endanger hospital employees and can be controlled sometimes
through use of privileges contracts.

A. WORK PRACTICES.
 Hands should be washed frequently and thoroughly. Workers should wash immediately after
direct contact with any chemical, drug, blood, or other body fluid.
 No eating, drinking, smoking or application of cosmetics should take place in the lab.
 Needles and other sharp objects should be disposed of promptly in impervious containers.
Needles should not be clipped or recapped by hand. .
 There should be immediate and proper disposal of biohazardous waste.
 Mouth pipetting is to be prohibited.
 Care should be taken not to create aerosols.
 Appropriate personal dosimetry devices should be worn when working with radioactive
materials.
 Electrical equipment that appears to be damaged or in poor repair should not be used. Any
shocks from electrical equipment should be reported promptly to the maintenance department.
 Cylinders of compressed gases should be kept secured. They should never be dropped or allowed
to strike each other with force.
 Large pieces of broken glass should be removed with brooms and disposed of in a separate
container. Small pieces can be removed with tongs. Glass should never be removed with fingers.
 Vaporizers of anesthesia machines should be turned off when not in use. Also, proper face
masks, sufficiently inflated endotracheal tubes, and prevention of anesthetic spills will decrease
the amount of waste anesthetic gases in the operating room.

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  Antineoplastic drug contact requires the use of an isotonic wash to the body or eyes.Eating,
drinking, smoking, applying cosmetics and lip balm and handling contact lenses in any work
areas where there is a reasonable likelihood of occupational exposure is prohibited, e.g.
specimens are, at times, temporarily left at a nurse's station. Prior to the consumption of food or
drink, after handling potentially infectious materials, employees will remove potentially
contaminated PPE, wash hands, and exit the work area.
 Food and drink will not be kept in freezers, refrigerators, counter tops, shelves, and cabinets
where blood or other potentially infectious materials are stored or handled.
 Procedures which could potentially generate aerosols or other inhalation hazards shall be
performed in a manner that will minimize pathogen transmission.

B. PERSONAL PROTECTIVE EQUIPMENT.

1)Lab coats should be worn in the laboratory area and removed before leaving.Plastic or rubber aprons
should be worn when there is a potential for splashing.

2 )Goves should be worn when performing tasks such as handling hazardouschemicals,

specimens, or hot materials. The type of glove should be selected according to the task being performed,
as follows:

 Latex or vinyl type gloves should be changed frequently and inspected for
punctures before putting them on.
 Double gloving to decrease the risk of exposure by penetration is
recommended if it does not interfere with the task.
 Less permeable surgical latex gloves are recommended over polyvinyl
gloves.
 Lead-lined gloves are to be worn in the direct x-ray field.

3)Rubber-soled shoes should be worn to prevent slips and falls. Rubber-lined shoe coverings may also
be used to protect against spills or dropped objects. Fluid-proof shoes must be worn if there is a
possibility of leakage to the skin.

4)Protective eyewear or shields should be used if splashes of a hazardous substance are likely to occur.
Goggles that are tight-fitting may prevent irritation of the eyes if aerosolized chemicals are present.
Goggles that protect the cornea, conjunctive and other ocular tissue are required for all personnel in the
operating room during laser surgery. The wavelength of the laser output is the most important factor in
determining the type of eye protection to be used. Opaque goggles are to be worn if in the direct x-ray
field.

5) Impervious or low permeability gowns should be worn when in contact with antineoplastic drugs,
ribavirin and blood/body fluids. These gowns should be properly stored in the area of use if
contaminated. Soiled gowns should be washed or discarded. Lead-lined aprons are to be worn if in the
x-ray field.

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 6) Respirators may be required in case of emergencies, such as accidental spills and/or exposure to
specific chemicals, e.g., formaldehyde and ethylene oxide. Check for a respirator progra

PREVENTION OF OCCUPATIONAL HAZARDS IN WORKPLACE

STANDARD PRECAUTIONS FOR HEALTH CARE WORKERS

Standard Precautions represents a system of barrier precautions to be used by all personnel for contact
with blood, all body fluids, secretions, excretions, non intact skin, and mucous membranes of ALL
patients, regardless of the patient's diagnosis. These precautions are the "standard of care." This system
embodies the concepts of "Universal Precautions" and "Body Substance Isolation".

PURPOSE OF STANDARD PRECAUTIONS

A. The purpose is to reduce transmission of infectious agents between patients, caregivers, and others in
the medical center environment, and to reduce the incidence of nosocomial infections among
patients.
B. Hospital departments and clinics will incorporate Standard Precautions into departmental policies
and procedures to be reviewed at least every two years by that department and the Infection Control
Committee.
C. Ongoing education concerning Standard Precautions principles will be given to newly hired
employees involved directly or indirectly in patient care. Review classes will be provided as needed
for dissemination of new information or for reinforcement upon request of the department manager.
Documentation of training will be maintained by the individual departments.
D. Standard Precautions will be followed by all personnel and will be based on the degree of
anticipated exposure to body substances. It is the responsibility of the individual to comply with all
isolation precautions. Standard Precautions focuses on reducing the risk of transmission of
microorganisms. The use of barriers is determined by the care provider's "interaction" with the
patient and the level of potential contact with body substances.

HAND HYGIENE

Nosocomial infections are most frequently spread by contact and the most common form of contact is
hand contact, hand washing is the most important and most effective means of preventing nosocomial
transmission of organisms.

Employees have a responsibility for maintaining hand hygiene by adhering to specific infection control
practices. manicured and should not extend past the fingertips.. This includes, but is not limited to
artificial nails, tips, wraps, appliqués, acrylics, gels, and any additional items applied to the nail surface.

A. Indications for Handwashing and Hand Antisepsis include:

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 1) Before having direct contact with patients.
2) Before donning gloves and performing an invasive procedure.
3) After removing gloves or other personal protective equipment.
4) After contact with body substances or articles/surfaces contaminated with body substances.
5) After contact with patient's intact skin (e.g. taking a pulse, blood pressure or lifting a patient).
6) Before preparing or eating food (do not use alcohol gel).
7) After personal contact that may contaminate hands (e.g. covering sneeze, blowing nose, using
bathroom - do not use alcohol gel).

C. Hand Hygiene Products

1) In patient care areas, alcohol gel, liquid or foam soap will be used for hand hygiene.
2) Alcohol gel hand rub is recommended as the primary hand hygiene product if hands are not
visibly dirty, soiled with proteinaceous material or visibly soiled with blood or body fluids.
3) Antimicrobial agents, including alcohol gel or soap, are recommended for use prior to invasive
procedures, in critical care units, and for patients on special organism precautions.
4) Staff with skin sensitivities should consult with Employee Health regarding the use of alternative
hand hygiene products (preferably in dispenser form).

D. Handwashing Procedure with Liquid or Foam Soap

1) Wet hands first with water.

2) Apply an amount sufficient for lather to cover all surfaces of hands and wrists.
3) Rub hands together will covering all surfaces of the hands and fingers with special attention to areas
around nails and between fingers for a minimum of 15 seconds
4) Rinse well with running water.
5) Dry thoroughly with paper towel.
6) Use paper towel to turn off faucet.
7) Avoid using hot water as repeated exposure to hot water may increase risk of dermatits.

E. Hand Antisepsis Procedure Utilizing Alcohol Gel

1) Apply to dry hands that are not visibly soiled.

2) Rub hands vigorously to apply gel to all surfaces of hands, fingers and fingernails, until hands
are dry. If hands feel dry after rubbing hands together for 10 - 15 seconds, insufficient volume of
product was applied.

F. Skin Care

Healthcare workers should use hospital approved hand lotion to minimize the occurrence of irritant
contact dermatitis associated with hand antisepsis or hand washing.

PERSONAL PROTECTIVE EQUIPMENT (PPE)

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A. Gloves

Disposable (single use) gloves shall be readily available in patient careand specimen handling areas.

1. Gloves must be worn for:

a) Anticipated contact with moist body substances, mucous membranes, tissue, and non-intact skin
of all patients;
b) Contact with surfaces and articles visibly soiled/contaminated by body substances;
c) Performing venipuncture or other vascular access procedures (iv starts, phlebotomy, in-line
blood draws);
d) Handling specimens when contamination of hands is anticipated.

2. Don gloves at bedside, immediately prior to task.

3. Replace torn, punctured or otherwise damaged gloves as soon as patient safety permits.
4. Remove and discard gloves after each individual task involving body substance contact, before
leaving the bedside.
5. Gloves should not be worn:

Away from the bedside or lab bench at the nursing station to handle charts, clean linen, clean equipment
or patient care supplies in hallways or elevators.

6. Perform handwashing or hand antisepsis (per aboveindications) as soon as possible after glove
removal, or removalof other protective equipment. Gloves are not to be washed or decontaminated
for reuse (exception: utility gloves)
7. Caution: Gloves do not provide protection from needlesticks or other puncture wounds caused
bysharp objects. Use extreme caution when handling needles, scalpels, etc.

B. Masks, Eye Protection and Face Shields

Wear masks in combination with eye protection devices (goggles or glasses with side shields) or chin-
length face shields during procedures that are likely to generate droplets, spray, or splash of body
substances to prevent exposure to mucous membranes of the mouth, nose and eyes. Masks are also worn
to protect personnel from the transmission of infectious droplets during close contact with the
symptomatic patient.

Situations which may increase risk of splash/splatter include the following:

a. Trauma care
b. Surgery or delivery of newborn
c. Intubation/suctioning/extubation (including code situations)
d. Bronchoscopy/endoscopy
e. Emptying bedpans/suction canisters into hopper/toilet
f. Code blue
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 g. Patient care of coughing patient with suspected infectious etiology

C. Aprons, Gowns, and Other Protective Body Clothing

The appropriate type of garment shall be based on the task and the degree of exposure anticipated.
Gowns are worn to prevent contamination of clothing and protect the skin of personnel from blood/body
fluid exposure.

1) Wear plastic aprons or gowns during patient care procedures that are likely to soil clothing with
body substances.
2) Wear lab coats in laboratory settings.
3) Remove protective body clothing before leaving the immediate work area.
4) In surgical or autopsy areas, additional protective attire may include surgical caps or hoods and
shoe covers or boots..

D. Soiled Linen Handling

1) Wear gloves to handle moist or visibly soiled linen.

2) Place soiled linen in plastic laundry bags.
3) Securely close laundry bag when bag is three-fourths full and place in storage area.
4) Laundry workers must always wear gloves.

Standard Precautions: Key Components

Handwashing (or using an antiseptic handrub)

 After touching blood, body fluids, secretions, excretions and contaminated items
 Immediately after removing gloves
 Between patient contact

Gloves

 For contact with blood, body fluids, secretions and contaminated items
 For contact with mucous membranes and non intact skin

Masks, goggles, face masks

 Protect mucous membranes of eyes, nose and mouth when contact with blood and body fluids is
likely

Gowns

 Protect skin from blood or body fluid contact.

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  Prevent soiling of clothing during procedures that may involve contact with blood or body fluids.

Linen

 Handle soiled linen to prevent touching skin or mucous membranes

 Do not pre-rinse soiled linens in patient care areas

Patient care equipment

 Handle soiled equipment in a manner to prevent contact with skin or mucous membranes and to
prevent contamination of clothing or the environment
 Clean reusable equipment prior to reuse

Environmental cleaning

 Routinely care, clean and disinfect equipment and furnishings in patient care areas

Sharps

 Avoid recapping used needles

 Avoid removing used needles from disposable syringes
 Avoid bending, breaking or manipulating used needles by hand
 Place used sharps in puncture-resistant containers

A) HANDLING AND DISPOSAL OF SHARPS

 Sharps disposal is the responsibility of the user of the sharp. Sharps disposal may be delegated
only to a person currently present in the room (i.e., never left for another person to dispose of
later). The only exception to the delegation policy would be in the surgical suite.
 Puncture-resistant sharps containers shall be readily available in areas where sharps waste
(needle, all syringes, scalpels, glass slides or pipettes, etc.) may be generated.

1) DO NOT place sharps in the regular trash.

2) Dispose of sharps as close as possible to the point of use.

 Contaminated needles shall not be recapped or removed from syringes UNLESS the employee
can demonstrate that no alternative is feasible or patient safety is threatened.

1. If recapping is required, then it shall be performed by mechanical means or by a one-handed

technique.
2. If needle removal is required, use needle removal device on sharps container or an
instrument such as a plastic clamp to distance the hand from the needle. Disposable clamps
are available on supply carts.

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 3. When not piercing the skin of the patient, use needleless systems (for example, when
accessing an IV line).

 Needle clippers and other devices which shear, bend, or break contaminated needles are
prohibited from use.

C) DO NOT OVERFILL sharps containers.

1) Look closely at the sharps container before placing a used sharp inside to assure that nothing
is protruding from the container or that the container is not overfilled.
2) When sharps container is 2/3 full (to "full" line), close securely remove and discard as
biohazardous waste, and replace with empty sharps container.

 DO NOT place needles, introducers, or other sharps on food trays or patient bed. DO NOT stick
needles into the mattress after use or while performing a procedure.
 Surgical instruments with sharp edges (e.g. scalpel) should not be passed hand-to-hand but
should be placed on a neutral surface (e.g. tray or basin).

D) Reusable Sharps:

1) Reusable sharps will be placed in puncture-resistant containers for transport.

2) Reusable sharps that are contaminated with blood or other potentially infectious materials
will not be stored or processed in a manner that requires an employee to reach by hand into
the container where these sharps have been placed.
3) Containers for reusable sharps will be decontaminated before reuse.
4) Each department that handles reusable sharps will have written procedures for appropriate
use. Each department that decontaminates containers will have written procedures in
compliance with the policies and procedures of Section 6.

E) Sharps Container Safety

1) All sharps containers are marked with the BIOHAZARD SYMBOL.

2) Whenever possible, have sharps container at point of use i.e., patient area, treatment room.
Avoid walking to container with a used sharp.
3) An open, in-use sharps container should never be on the floor, located under a sink or any
other poorly visible area.

F) Sharps Container Placement

1) Mount and/or secure box whenever possible. Use wire racks, counter holders and other
mountings to prevent a loose container from falling over.
2) Mounting of box with holder should be at a level such that the user can easily see into the
opening where sharps are to be placed.

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 3) Sharps containers should be kept out of public areas when at all possible. Public area
placement should be limited to only those required for personnel safety and mounted/placed
with public safety consideration. Children, must be supervised by the adult accompanying
them to prevent an accident.

2) Broken glassware which may be contaminated will not be directly handled with a gloved or bare
hand. It will be handled by mechanical means (tongs, dust pan and broom). Contaminated
broken glass will be placed in a puncture-resistant container and disposed of as biohazardous
waste.
3) Teeth or bone fragments extracted during surgery that are to be disposed of will be considered as
sharps and handled as such. Disposal of such teeth or bone fragments will be into a sharps
container. Larger bone pieces will be handled in a manner to minimize accidental cutting and
will be placed in a biohazard box lined with a red bag.

G) SPECIMEN HANDLING and TRANSPORT

A. Standard Precautions will be used to obtain, transport, and handle ALL specimens. It is not
necessary to label specimens as biohazardous. Packaging of specimens to be transported outside of
the Medical Center will be handled as described in "D" below.
B. Specimens of blood or other potentially infectious materials will be placed in a well sealed primary
container and a secondary plastic bag (ziplock) to prevent leakage during handling, processing,
storage, transport or shipping. During transport, gloves are not required because the specimen is
already in a secondary plastic bag.

Exception: Within each building, blood specimens in vacationer tubes may be transported in the
phlebotomist's tray without a secondary container, provided that the exterior of the tube is not visibly
contaminated with blood. If the exterior is visibly soiled, then it will be wiped clean.

C. Specimens in syringes should be capped off (needle removed) before transporting to the laboratory.
The exception to this is a fine-needle aspirate.
D. Specimen containers for transport or shipping outside of the immediate Medical Center will be
labeled with the universal biohazard symbol or color-coded prior to transport.

H) EQUIPMENT CLEANING, TRANSPORTING AND SERVICING

A. Used equipment will be enclosed in containers or bags to prevent in advertent exposure to

patients or personnel.
B. Equipment which is contaminated with body substances will be cleaned/decontaminated if
possible prior to transport. If this is not possible, place equipment in containers or bags and label.
C. If equipment cannot be cleaned/decontaminated, the receiving department or individual will be
notified of that contamination so that adequate precautions can be taken.

13 ) LEGISLATION OF OCCUPATIONAL HEALTH

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 The occupational health and safety services provided by an employer are influenced by specific
legislation at federal and state levels. The Mini Safety and HEALTH Act of 1968 was the first
legislation that specifically required certain prevention programmers for the workers. This was followed
by the Occupational Safety and Health Act of 1970, which established two agencies, the occupational
Safety and Health Administration & The National Institute for Occupational Safety and Health ,
each with discrete functions to carry out the act’s purpose of ensuring “ safe and healthful working
conditions for working men and women.

6:1Functions of OSHA (OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION)

 Determines and sets standards and permissible exposure limits for hazardous exposures in the
workplace.
 Enforces the occupational health standards.
 Educates the employees and employers about occupational health and safety.
 Develops and maintains a database of work- related injuries, illness and deaths.
 Monitors compliance with occupational health and safety standards.

13:2 NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH (NIOSH)

 Conducts research and reviews findings to recommend exposure limits for occupational hazards
to OSHA.
 Identifies and researches occupational health and safety hazards.
 Educates occupational health and safety professionals.
 Distributes research findings relevant to occupational health and safety.

13:3 OCCUPATIONAL HEALTH AND SAFETY ACT

Occupational health and safety act, OSHA, a federal agency within the U.S. department of labor, was
created to develop and enforce workplace safety and health standards and regulations that regulate
workers exposure to potentially toxic substances, enforcing these at federal and state levels. Specific
standards and information about compliance can be obtained from federal, regional, and states OSHA
offices, which can be found on the OSHA website. The national institute for occupational safety and
health (NIOSH) was established by the occupational safety and health act of 1970 and is part of the
centers for disease control and prevention (CDC). In 1996 NIOSH and its partners unveiled the national
occupational research agenda (NORA), a frame work to guide occupational safety and health research
into the following decade. The NIOSH agency identifies, monitors, and educates about the incidence,
prevalence, and prevention of work-related illnesses and injuries and examines potential hazards of new
work technologies and practices (USDHHS, NIOSH, 2002). NORA identifies targeted research areas
with the highest likelihood of reducing the still significant toll of workplace illness and injury.

DISEASE AND INJURY

 Allergy and irritant dermatitis

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  Asthma and chronic obstructive pulmonary disease
 Fertility and pregnancy abnormalities
 Hearing losses
 Infectious diseases
 Low back disorders
 Musculoskeletal disorders of the upper extremities
 Traumatic injuries

WORK ENVIRONMENT AND WORKFORCE

 Emerging technologies
 Indoor environment
 Mixed exposures
 Organization of work
 Special population at risk.

RESEARCH TOOLS AND APPROACHES

 Cancer research methods

 Control technology and personal protective equipment.
 Exposures assessment methods.
 Health service research.
 Intervention effectiveness research.
 Risk assessment methods.

Many standards have been established by OSHA to protect worker health. One example is Hazard
Communication Standard. The hazard communication standard, which was first established in 1983,
requires that all worksites with hazardous substances inventory their toxic agents, label them, and
provides information sheets, called material safety data sheets (MSDS’s), for each agent. In addition, the
employer must have in place a hazard communication program that provides workers with education
about these agents. Numerous standards have been established by OSHA for specific chemicals and
programs. E.g. Blood borne pathogen standard.

The objects of the Occupational Health and Safety Act 2000 are to:

•secure and promote the health, safety and welfare of people at work

•protect people against workplace health and safety risks

•provide for consultation and cooperation between employers and workers in achieving the objects of
the Act

•ensure that risks are identified, assessed and eliminated or controlled,

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•develop and promote community awareness of occupational health and safety issues,

•provide a legislative framework that allows for progressively higher standards of occupational health
and safety to take account of new technologies and work practices

•protect people against risks arising from the use of plant (ie. machinery, equipment or appliances

13:4WORKER’S COMPENSATION ACT

Worker’s compensation act are important state laws that govern financial compensation to employees
who suffer work-related health problems. These acts vary by state and each state sets rules for the
reimbursement of employees with occupational health problems for medical expenses and lost work
time associated with illness or injury.

13:5 EMPLOYEE STATE INSURANCE ACT.( ESI ACT , 1948)

The act provides the following benefits.

 Medical benefit
 Sickness benefit.
 Maternity benefit.
 Disablement benefit.
 Dependent’s benefit.
 Funeral benefit.
 Rehabilitation benefit

14: OCCUPATIONAL HEALTH AND SAFETY PROGRAMMES

14:1OBJECTIVES OF THE PROGRAMME

•Workplace hazards are controlled - at the source whenever possible;

•Records of any exposure are maintained for many years;

•Both workers and employers are informed about health and safety risks in the workplace;

•There is an active and effective health and safety committee that includes both workers and
management;

•Worker health and safety efforts are ongoing.

Effective workplace health and safety programmers can help to save the lives of workers by reducing
hazards and their consequences. Health and safety programmers also have positive effects on both
worker morale and productivity, which are important benefits. At the same time, effective programmers
can save employers a great deal of money.
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14:2 SCOPE OF SERVICES PROVIDED THROUGH AN OCCUPATIONAL HEALTH AND
SAFETY PROGRAM

 Health\ medical surveillance

 Workplace monitoring \ surveillance.
 Health assessments

 Replacement
 Periodic\ mandatory, voluntary

 Health promotion.
 Health screening.
 Employee assistance programs.
 Case management.
 Primary health care for workers and dependents.
 Worker safety and health education related to occupational hazards.
 Job task analysis and design.
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  Worker’s compensation management.
 Risk management.
 Emergency preparedness
 Counseling.
 Integrated health benefits programs.

Points to remember

1.Occupational health and safety encompasses the social, mental and physical well-being of workers in
all occupations.

2.Poor working conditions have the potential to affect a worker's health and safety.

3.Unhealthy or unsafe working conditions can be found anywhere, whether the workplace is indoors or
outdoors.

4.Poor working conditions can affect the environment workers live in. This means those workers, their
families, other people in the community, and the physical environment around the workplace, can all be
at risk from exposure to workplace hazards.

5.Employers have a moral and often legal responsibility to protect workers.

6.Work-related accidents and diseases are common in all parts of the world and often have many direct
and indirect negative consequences for workers and their families. A single accident or illness can mean
enormous financial loss to both workers and employers.

7.Effective workplace health and safety programmers can help to save the lives of workers by reducing
hazards and their consequences. Effective programmers can also have positive effects on both worker
morale and productivity, and can save employers a great deal of money.

14: 3 HEALTHY PEOPLE 2010 RELATED TO OCCUPATIONAL HEALTH

As a part of the Healthy people 2010 document, occupational health and safety objectives are identified
to promote good health and well-being among workers, including the elimination of and reduction of
elements in occupational environments that cause death, injury, disease or disability.

Objectives focusing on occupational health

 Reduce death related to occupational health.

 Reduce work related injuries.
 Reduce work related assault.
 Reduce occupational needle stick injuries among health care workers.

15: OCCUPATIONAL HEALTH NURSE

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15:1 MEANING OF OCCUPATIONAL HEALTH NURSE

Occupational health nursing means the specialty practice that focuses on the promotion, prevention, and
restoration of health within the context of a safe and healthy environment. (American Association of
Occupational Health Nurses (aaohn.1999)

The occupational health nurse is a registered nurse with additional knowledge and skill in:

•Environmental and health assessment

•Identification and primary treatment of workplace injury and illness

•Case management, worker rehabilitation and return to work programs

•Health and Safety education

•Interpretation of and compliance with legislation pertaining to the workplace.

15:2 SCOPE OF OCCUPATIONAL HEALTH NURSING

 It involves the prevention of adverse health effects from occupational and environmental hazards.
 It provides for and delivers occupational and environmental health and safety services to workers,
worker populations, and community groups.
 It is an autonomous specialty, and nurses make independent nursing judgments in providing
health care.
 Their scope and practice is broad and includes worker, workplace assessment and surveillance,
primary care, case4 management, counseling, health promotion, protection, administration and
management, research, legal , ethical monitoring.

15:3RESPONSIBILIIES OF OCCUPATIONAL HEALTH NURSE

The Occupational Health Nurse is responsible for the following:

•Participates in the Employee Assistance Program (EAP) as a contact person, making appropriate
referrals and also is a member of the Committee, involved in program planning and implementation for
CUPE, staff/faculty on campus.

•Participates in the Joint Health and Safety Committee as a resource member and is part of the
laboratory safety audit team with special expertise in infection control.

•Works cooperatively with the Safety Office to develop and manage Occupational Health maintenance
programs such as screening and monitoring of health conditions (i.e. needle stick injuries, chemical
exposure) and to minimize the risks associated with potential workplace hazards

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•Develops and presents programs promoting employee health/wellness in the workplace

•Collaborates with Office for Persons with Disabilities and Parking services to provide confidential
assessment and facilitation of special needs parking on campus for CUPE, staff/faculty who have
medical requirements

•Works with Human Resources in the management of sick leave and safe return to work programs.

•Works with Human Rights and Conflict Management in resolution of workplace stress resulting in
health related issues

•Works co-operatively with the Union, Staff and Faculty Associations when appropriate

•Works with one/all departments across campus for health promotion, increased awareness regarding
workplace hygiene, and education regarding specific health topics relevant to the workplace group.

15:4SPECIAL RESPONSIBLITIES

•Assists the Coordinator with evaluation of medical requirements for workplace accommodations

•Creates and maintains a confidential and accurate data base, for example sick leave management,
health monitoring.

•develops Occupational Health Policies and Procedures such as Food Safety for Student Vendors,
protocol for management of needle stick injuries

•Maintains occupational health website, creates pamphlets and media releases to keep employees
informed about services.

•Disseminates health education information through written and verbal presentations in response to on
campus employee health issues (for example: West Nile Virus, SARS)

•Produces reports as required

•Coordinates training and deployment of Automatic External Defibrillators (AED)

•Is a Member of the Critical Incident Stress Debriefing Team (CISD?)

•Assists the various Departments on campus with resources in order to comply with occupational health
legislation for specific roles (for example: health assessment and certification for Diving Program,
audiometric testing for noisy environments, visual testing for laser use, pulmonary function testing for
smokers and asthmatics)

•Resource person for Food Safety on campus

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•First Aid Training for Summer Camp Counselors

•First Aid Training for TA’s and new lab assistants

•Supervises Workplace Wellness Student for EAP events

•Performs other duties as requested

Specialized/Unique Occupational Health Tasks

1. Workplace Surveillance and Health Risk Identification:

The Occupational Health Nurse in collaboration with the members of the Safety Office conducts
workplace surveillance, a term used to describe activities which determine whether groups of workers
may be suffering actual or potential work related injury or illness. Occupational Health Nurse conducts
workplace surveillance utilizing methods to detect, appraise, identify and manage health hazards and
exposures to physical and chemical hazards at work.

•Comprehensive interventions or programs to control all actual and potential health risks to employees
and provide the worker with education of potential health risks and strategies to prevent injury and
illness

•Intervention measures designed to prevent occurrences, monitor exposure and eliminate the problems

•Early detection of workplace hazards

•Health education for employees to reduce the likelihood of injury/illness

•Documentation of health and safety potential risks for each job activity

•Utilize statistics to indicate trends and target health risks

2. Health Surveillance:

As part of health surveillance, the Occupational Health Nurse conducts activities which determine
whether groups of workers may be suffering an occupational illness as a result of exposure to a
particular hazard or group of hazards. Health surveillance is always based on environmental
assessments with exposures evaluated and documented. Examples of health risk assessment and medical
surveillance include immunization for employees who are exposed to infectious biological agents. This
includes those who come into contact with: animals, human blood or body fluids, certain bacteria and
viruses used in research, communicable diseases etc

•Reduction of workplace injuries/illnesses due to early detection of workplace hazards

•Reduction of financial costs associated with exposure to workplace hazards

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•Increased knowledge of the workplace environment by the worker and employer

•Develop statistics to identify significant trends in occupational illness or injuries

3. Health Promotion and Protection:

The Occupational Health nurse is responsible for employee health promotion and protection. This
programming focuses on the prevention of illness/injury by promotion of health and well-being using
strategies directed towards modifying the behavior of individuals/groups and encouraging them to
accept responsibility, in matters which affect their health and over which they have control, towards
achieving a healthy lifestyle. Anticipatory interventions include strategies for protection from agents
causing disease and /or hazards in the work environment and /or university community.

•Enhancement of employee well-being by gaining knowledge of risk factors in the workplace

•Movement toward a state of optimal health by obtaining management commitment and policies to
support development and provision of individual employee and work group programs

•Reduction of health risks by programs targeted to meet goals determined by needs assessment of
individual workplace.

•Familiarity with community resources and skill in utilizing community resources such as posters,
pamphlets, brochures, fact sheets, newsletters, health programs where applicable

•Individual knowledge of risk factors and preventative measures as a foundation for development and
provision of health building programs such as smoking cessation, nutrition, hypertension, fitness, which
in turn will provide a reduction of financial costs to both the employer and the health care system

•Reduction of financial, psychological cost to the individual by timely referrals to the Employee
Assistance Program when applicable.

4. Primary Care:

Primary care is the set of nursing actions that are provided to manage illness or functional challenges in
the workplace. The goal is to prevent complications, promote recovery and facilitate rehabilitation of
both occupational and non-occupational illness and injury. Primary care is based on the nursing
process, on a theoretical base consistent with occupational health nursing practice, on knowledge of the
health/illness continuum and on norms and deviations of the continuum.

•Appropriate treatment, referral and follow-up so that an early return to work process, where indicated,
can be initiated

Reporting and recording: confidentiality ensured by utilizing the nursing process

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•After obtaining an informed consent, investigating and addressing factors which influence progress to
optimal functioning

•Promoting worker responsibility for self care which includes: health education in treatment (where
appropriate), collaboration with other health disciplines (where indicated), maintain competence in
emergency/primary care.

5. Counseling:

Counseling is the process of helping employees to clarify problems and make informed decisions and
choices while giving positive reinforcement. It provides strategic interventions and appropriate referrals
to deal with a crisis situation and time for the employee to reflect on impending decisions and evaluate
actions taken. Counseling is a broad area that ranges from simple encouragement of clients who are
motivated to make positive changes to health behavior to providing direct care for clients in a crisis
situation. The type of counseling offered is determined by the level of additional preparation and
expertise of the nurse.

•Safety of client and others in the situation is ensured

•Confidentiality is ensured

•Legal obligation to report criminal or dangerous situations (e.g. child abuse, harm to self or others)

•Client returns to optimal functioning

•Appropriate referral and follow-up are made

•Collaborate with internal and external resources

•Use contracting and mutual goal setting to promote client’s responsibility for self care

•Pursue continuous improvement of counseling ability through education

6. Rehabilitation/Case Management:

Rehabilitation/Case Management is the process/provision of services necessary to restore an individual

to the fullest physical, mental, emotional, social, vocational and economical independence of which they
are capable. Rehabilitation cases may be either work or non-work related. Rehabilitation includes
preventative processes whereby the Occupational Health Nurse implements knowledge gained from
research studies/epidemiological studies within the workplace and work culture.

•Return of individual to maximum ability to function in physical, mental, emotional, social, vocational
and economical areas by utilizing community resources, referral agencies

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•Increased individual self-esteem and morale, especially with the modified return to work program when
applicable

•Participates in facilitated meetings following the RTW Principles when workplace stress/issues are
prime reason for absence.

•Reduced WSIB assessments and insurance premiums

•WSIB penalty avoidance

•Improved corporate culture and morale (good corporate citizens)

•Well established modified work programs by co-ordinating the return to work to the pre-illness level of
the individual through positive communication with all parties involved

•Maintain/document statistics to support programs

15:5 STANDARDS OF OCCUPATIONAL AND ENVIRONMENTAL HEALTH NURSING

PRACTICE

STANDARDS OF CLINICAL NURSING PRACTICE

1. ASSESSMENT: Systematically assess the health status of the individual, population, and the
environment.
2. DIAGNOSIS: Analyzes the assessed data to formulate the diagnoses.
3. OUTCOME INDENTIFICATION: Identifies the outcome specific to the client.
4. PLANNING: Develops a goal directed plan that is a comprehensive and formulate
interventions to attain expected outcomes.
5. IMPLEMENTATION: Implements interventions to attain the desired outcomes identified in the
plan.
6. EVALUATION : Systematically and continuously evaluates responses to interventions and
progress toward the achievement of desired outcomes.
7. RESOURCE MANAGEMENT: The occupational and environmental health nurse secures and
manages the resource that supports an occupational health and safety program.
8. PROFESSIONAL DEVELOPMENT: The occupational and environmental health nurse
assumes responsibilities for professional development enhance professional growth and maintain
competency
9. COLLABRATION: The occupational and environmental health nurse collaborates with
employees, management, other health care providers, professionals and community
representatives.
10. RESEARCH: The occupational and environmental health nurse uses research findings in
practices and contributes to the scientific base in occupational and environmental health nursing
to improve practices and advance the profession

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16:GENERAL SAFETY RULES IN HOSPITAL

The following are some of the basic safety rules and principles which everyone should bear in mind and
observe.

 The only correct way to do a job in the hospital is the safe way. Urgency is a poor excuse or
neglecting safety.
 Know your job thoroughly. Do not indulge in any guess. It there is any doubt, ask the supervisor.
 Do not handle or operate machinery, tools and equipment without authorization.
 Be alert and observe keenly. Report immediately any faulty equipment, unsafe conditions or acts,
and defective or broken equipment. Do not try amateur repairs.
 Stay physically and emotionally fit for your work by maintaining good health and a proper diet.
Abstain from alcoholic drinks. Take sufficient rest and practise cleanliness.
 Personal hygiene is important. Wash your hands often. In many areas of the hospital, this is
absolutely necessary.
 Prevent the spread of infection and contagious diseases. Cooperate with the hospital infection
control committee by observing the established procedures. When you are ill with an infectious
disease, report to the doctor immediately and stay at home.
 Wear proper uniform or clothing for your job: neither too tight nor too loose. Tight clothing does not
permit freedom of movement, while loose one runs the risk of getting entangled. Jewellery and high
heel footwear may be hazardous.
 Walk, not run, particularly when you are carrying delicate, breakable articles or instruments. Be
extra cautious at the corridor intersections, in front of swinging doors (particularly when they do not
have view panels), at blind corners and in congested areas.

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 If you see some foreign material, loose wire, oil spill, etc. on the floor which may cause an accident,
make sure it is removed at once.
 Never indulge in horseplay or practical jokes involving fire, acid, water, compressed air and other
potentially dangerous things.
 Pay attention to all warning boards. These signs caution you about dangers and hazards that may
cause injury or harm. For example, smoking in an area where oxygen cylinders are stored.
 Be familiar with your work procedure. All departments have written work procedures which include
safety practices at work and for handling equipment.
 Always remember to use handrails on stairways or ramps. They are there to ensure your safety and
are meant to be used by all, not just the sick and the old.

When you want to reach overhead objects, always use a good ladder. Do not climb on chairs or boxes.
Apart from these general safety rules, there are other rules relating to particular areas like fire

Chapter- VII prishanthini anto

“MATERIAL MANAGEMENT – CONCEPTS, PRINCIPLES, PLANNING AND

PROCUREMENT PROCEDURES”

1. DEFINITIONS OF MATERIAL MANAGEMENT:

It is defined as the aspect of management functions which is primarily concerned with the acquisition
control and use of material needed and flow of good and services connected with production process
having some predetermined objectives in view. - A.K. Datts

Material management is the integrated functioning of purchasing and allied activities, so as to achieve
the maximum coordination and optimum expenditure in the area of materials. - N.K. Napir

Material management is defined as “planning, organizing and controlling aspects involved in ensuring
availability of necessary materials, supplies, drugs and equipment as and when required” -
TNAI

2. CONCEPTS OF MATERIAL MANAGEMENT:

According to the APICS Dictionary, Materials management means “the grouping of management
functions supporting the complete cycle of material flow, from the purchase and internal control of
production materials to the planning and control of work in process to the warehousing, shipping, and
distribution of the finished product”.

The core of this concept is “materials flow”. This material flow has three phases: upstream physical
supply from the purchase, internal flow planning and controlling work in process, and downstream flow,
the distribution of the finished product.

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 Put together the three phases of material flow plus the supplier, the manufacturer and the customer, we
may establish the supply production and distribution system, which is actually the basic supply chain.

No wonder that Tony and Stephen claim that materials management is a coordinating function. This
may help us touch something behind the concept of materials management: it is introduced in an attempt
to resolve the conflicting objectives among marketing, production and finance by closely coordinating
the supply, production and distribution so as to minimize the total costs involved and maximize
customer service consistent with the goals of the organization. To put it simply, one department should
be responsible for supply, production and distribution instead of allowing those three functions to spread
among marketing, production and distribution. This integrated approach may help eliminate or mitigate
the awkward position faced by the materials department in some manufacturing companies.

Traditionally, various activities related to managing materials were looked after by various departments.
While purchases were generally arranged by top management with the assistance of a Purchase Agent or
Purchase Officer, store keeping and stock control was the responsibility of the production head with the
assistance of a store keeper or Stores Officer. Apart from these two main activities, distribution of
materials (mostly finished goods) was the responsibility of marketing.

After realizing the profitability potential of Materials Management function, when attempts were made
to exploit this potential, it was realized that there were many problems in achieving the objectives due to
inherent conflicts amongst various departmental objectives. When purchasing personnel wants to
purchase in bulk to get price discounts, inventory of the stores personnel becomes high. Similarly desire
of marketing personnel to have adequate stocks of finished goods in order not to loose any opportunity
of sale resorts in high inventory.

 The conclusion is that in the traditional set up one person could not be held responsible for all
the functions of materials management to achieve overall economy. Therefore necessity of
placing all the functions related to materials management e.g. purchasing, stocking, inventory
control and distribution under one department headed by an executive of status at par with other
departmental heads, was felt.
 Thus evolved the concept of integrated materials management which can be defined as the
function which is responsible for the coordination of planning, selecting sources, purchasing,
moving, storing and controlling materials in an optimum manner so as to provide a pre-decided
service to the customer at a minimum cost.

3. OBJECTIVES OF MATERIAL MANAGEMENT:

Primary objectives:

The primary objectives of materials management are:

(i) Low purchase price (low cost): this is the most important aspect of material management, that is, to
obtain correct quality of material at the lowest possible price to the hospital.
(ii) High inventory turn over: use the material along with the incoming flow so that minimum capital is
blocked on inventories.
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(iii) Low storage cost: if materials are purchased, handled and stored in an effective and efficient
manner, the carrying cost and cost of ordering will be reduced considerably.
(iv) Maintaining continuous supply: uninterrupted supply of material is the essential requirement of any
organization. Whenever continuity of the supply is interrupted, it affects the quality of care and
services, which brings dissatisfaction.
(v) Maintaining quality of purchases: consistency of quality is aimed at ensuring proper purchase of
standard specifications.
(vi) Cordial relations with suppliers: cordial relations with suppliers or vendors are also important as
they may directly contribute to the success of any organization. Good supplier relations also help in
obtaining the supplies on time in case of emergency requirements.
(vii) Low pay roll cost: the lowest the pay rolls, the higher the profits, all other factors being equal.
(viii) Development of vendors: the materials department should also develop a number of vendors from
time to time to ensure more sources of supply as well as to reduce purchase cost of materials.
(ix) Good records: records and paper work contribute directly to the materials department’s contribution
to profits.

Secondary objectives:

The secondary objectives of material management are:

- Favorable reciprocal relations

- New materials and products
- Economic make and buy
- Standardization
- Product improvement
- Inter departmental harmony
- Economic forecasts.

The objectives of material management as such should be supported in every way by:

(i) Maintaining continuity of service operations by ensuring a uniform flow of materials.

(ii) Reducing materials cost by systematic use of scientific – techniques.
(iii) Releasing working capital for productive purpose by ensuring right quality at the right price,
especially in foreign markets.
(iv) Increasing the competitiveness of end products by ensuring right quality at the right price, especially
in foreign markets.
(v) Saving foreign exchange through economic use of foreign purchases and import substitution.
(vi) Establishing good buyer – seller – relations.
(vii) Ensuring low departmental costs and high efficiency.
(viii) Setting high ethical standards. In this way it is clear that material management covers all aspects of
materials, including, flow of materials, cost, quality, supply, conservation and utilization.

4. IMPORTANCE OF MATERIAL MANAGEMENT:

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 The importance of material management in nursing cannot be over emphasized.
For any nursing technique or procedure from very simple to complex and invasive nursing
procedures, materials are required; be it administration of an oral medication, an intra muscular
injection or performance of a dressing, materials are essential.
It can be seen that no nursing procedure can be undertaken without appropriate and adequate
materials - Whether these are performed in institutional or community settings.
The objectives not only vary in relative importance from industry to industry and even among
companies within an industry, but objectives can vary within the same hospital.
When services are expanding the material manager may concentrate on continuity of supply and
consistency of quality.
The manager is less interested in inventory turn over or low prices since the economic expansion
should bring both higher sales and high prices and these objectives may be achieved
automatically.
In a young hospital which is growing rapidly cash is perpetually short, all earnings and all
borrowings are ploughed back into plant and equipment. In these situation materials manager is
under considerable pressure to get along with as little stock as possible in order to make cash
available for other purposes.
If an organization does not identify its material management objective and develop a program to
achieve them, it may be giving undue attention to some objectives and neglecting others. The
efforts to achieve one primary objective almost necessarily involve relaxation of efforts to
achieve some other objective. The material manager who concentrates on inventory turn over
pays higher prices and has higher costs of acquisition because he must buy more frequently in
smaller quantities.
Material management objective should be balanced and responsibility for achievement should be
delegated to a material manager who has authority to do the job. The materials manager should
always reevaluate the objective when business condition change.

5. POLICIES OF MATERIAL MANAGEMENT:

Some of the policies of material management are discussed below,

The regulatory process must be timely, efficient, and predictable, to the maximum extent practicable.

Advanced material management planning must be conducted on a port or regional scale by a partnership
that includes the Federal government, the port authorities, state and local governments, natural resource
agencies, public interest groups, the maritime industry, and private citizens.

To be effective, this planning must be done prior to individual Federal or non-Federal project
proponents seeking individual project approval.

Material managers must become more involved in planning of materials to emphasize the importance of
material management.

Other policies are,

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─ Guidelines and responsibilities
─ Stocking Level and Inventory Turns
─ MRP explosion and order frequency
─ Service Level agreement
─ Surplus and Excess definition
─ Non-Stocking and Slow-Moving items definition
─ Storage and Handling
─ Stock physical count and adjustments

6. BASIC PRINCIPLES OF MATERIAL MANAGEMENT:

 Planning
 Organizing
 Staffing
 Directing
 Controlling
 Reporting
 Budgeting
 Sound purchasing methods
 Skillful and hard poised negotiations
 Effective purchase system
 Should be simple
 Must not increase other costs
 Simple inventory control programme

7. GOLDEN RULES OF MATERIALS MANAGEMENT:

There are certain cardinal rules that every material manager should know and practice.

Rule one successful material management is built upon an effective management system and good
supervision.

Rule two purchase order is often called the umbilical cord of the purchasing process. For internal control
and smooth flow of goods, the receiving store, the accounts and the requesting department should
receive copies of the purchase order. The original goes to the vendor and a copy of it to the purchasing
file. The procedure and document should be simple. Initiation of every purchase order costs money. It
should therefore be cost effective. Consider this: if the cost of initiating a purchase order is Rs. 50 or 75,
and the cost of the ordered commodities is Rs. 100, it will not be economical.

Rule three centralize the purchasing system. Decentralized purchasing is contrary to all the underlying
principles of good material management. Centralized purchasing eliminates uncontrolled purchases by
departments, secures a reduction in prices through improved purchasing methods and quantity buying
and shipping, results in improved allocation of space, and reduces inventory costs and staff. It saves
staff time.
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Rule four negotiation is the key to sound purchasing. Every purchase officer should learn the art of hard
nosed but ethical negotiation. Here are some tips for good and successful negotiation.

Never purchase at list purchase.

Negotiate for bulk price or price for the quantity the hospital would need for the whole year,
and then get the price for any quantity you want to purchase.
Regardless of how much you buy, always ask for a discount.
Always get a price protection on the agreed price. Start negotiating price protection for two
years. Even if you end up with the short period, it is worth while.
Try to get at least a month’s time to pay the invoice. Which ever way you look at it, it is a
positive gain.
Remember, even at a good bargain price, the supplier makes a profit. So, don’t feel sorry for
him.
Always keep in mind that there are tougher negotiators than you. They may be getting a better
price than you do.
Remember, it is the quality and determination of the negotiator which always get a good price
in buying and not merely the reputation and size of the hospital.

Rule five there should be an effective receiving programme with responsibility, accountability, and
internal control built into the system. The fundamental rule is that the three functions of purchasing,
receiving and paying of invoices should be handles by three different persons. Receiving is one of the
most important functions of material management which should be carried out professionally and
ethically.

Rule six establish an optimum level of inventory, and a simple but effective inventory control
programme. The inventory should be so large that you can replenish it only with the aid of the computer.
Remember the dictum: the secret to managing an inventory is to control it, not count it.

Rule seven establish effective and result oriented requisition and distribution systems. The goal of the
distribution system is: the right item to the right place at the right time in the right quantity and at the
least total cost.

Rule eight establish written policies and procedures. Internal control in material management starts with
them.

Rule nine if you want to buy the right supply in the right quantity at the right place and time, and
simultaneously effect cost containment, standardization, and evaluation of all products and services is a
good place to start with

Rule ten where ever possible, go for contract purchasing through prime wonders i.e., buy the entire
categories of supplies from single source on negotiated terms of quantity, quality, price and time. By
being innovative in their purchasing approaches, hospitals can create a buyer’s market instead of
competing with each other in a seller’s market. Since contract purchase encompasses all supplies of a
certain category, hospitals can get the best deal in fraction of time and effort they spend on traditional
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purchase. A host of items, from medical – surgical to dietary items, can be purchased through prime
vendors.

8. INTEGRATED MATERIAL MANAGEMENT:

 Integrated materials management is a close coordination of all the departments which are
concerned with specification and utilization of materials.
 Various functions served by materials management include materials planning,
purchasing, receiving, stores, inventory control, and scrap and surplus disposal.
 If some of the functions are to be separately handled, normally a conflict of interest
occurs and there is bound to be an increase in the material costs.
 The need is to balance the conflicting objectives from a total organization viewpoint so as
to achieve optimum results for the organization as a whole.
 In an integrated set up, the materials manager who is responsible for all such interrelated
functions is in a position to exercise control and coordinate with a view to ensuring
proper balance of the conflicting objectives of the individual functions.

Integrated Material Management Model:

The Material Management Model spans the MES (material execution system) and PCS (process control
system) as diagramed in the following:

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MES LAYER:

Campaign and Batch Manager

This component provides the mechanism to create campaigns and their associated batches. It has a link
to the Batch Executive to start a recipe in the PCS.

Materials Manager

The Materials Manager contains the definition of the materials required to produce a given product:
material name and required quantity.

Container Manager

The Container Manager contains the mechanism to track Intermediate Batch Container (IBC) use,
location, and status (e.g. clean, dirty, etc.). Each IBC is labeled with a barcode to identify the container.

Manufacturing Procedure Executive

Manufacturing procedures automate manual manufacturing activities. They enforce compliance to

standard operating procedures and can ensure the person executing the procedure has the appropriate
privileges. This component executes the manufacturing procedures and interfaces with the operator
through handheld Personal Data Terminals (PDT) with barcode readers.

In the context of this model, the manufacturing procedures are Weigh and Dispense and Material
Charging. The Weigh and Dispense procedure ensures that the operator fills IBCs with material to be
consumed by a batch. The Material Charging procedure ensures that the operator charges the correct
material to a recipe controlled batch unit.

Integrated Records Database

The Integrated Records Database is a storage location for records created by the MES components of the
Material Management and Campaign Management Model. The key link in the database is the campaign
ID. All material information related to a campaign is tied together by the campaign ID.

Batch Report Manager

Batch Report Manager contains the Electronic Batch Report definition for format and content. It has
links to the Integration Records Database and to the Batch Historian in the PCS layer of the model.

These links allow a single electronic batch report to be created that consolidates records from the MES
and the PCS.

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PCS LAYER

Batch Executive

The Batch Executive component contains the mechanisms to create, edit and control recipes. It is
typically a standard offering in a PCS.

Batch Historian

The Batch Historian component is a storage location for historical data associated with an executed
batch. It is typically a standard offering in a PCS.

Advantages:

Better Accountability

Through centralization of authority and responsibility for all aspects of materials functions, a clear-cut
accountability is established.

Better Coordination

When a central materials manager is responsible for all functions, the departments under the materials
manager create an identity which is common. This results in better support and cooperation in the
accomplishment of the material function.

Better Performance

As all the interrelated functions are integrated organizationally, a greater speed and accuracy results in
communication and performance is improved.

Adaptability to Electronic Data Processing (EDP)

All information with regard to materials function is centralized under the integrated materials
management function. This has facilitated the collection and analysis of data, leading to better decisions.
Advanced and efficient electronic data processing systems can be economically introduced under an
integrated set up.

Miscellaneous Advantages

Team spirit is inculcated under a central materials manager, resulting in better morale and cooperation.
The opportunities of growth and development are better in an integrated set up.

9. ELEMENTS OF MATERIAL MANAGEMENT SYSTEM:

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The elements of materials management can be grouped as following:

• Materials planning and programming

• Purchasing
• Receiving and warehousing
• Store keeping
• Inventory control
• Value analysis and standardization
• Production control
• Transportation
• Material handling
• Disposal of scrap and surplus.

All these elements are very much applicable to hospital situation. In relation to a modern hospital,

Housley (1978) described the following areas in the materials management:

 Writing and adhering to product specifications

 Procuring all supplies and services through centralized purchasing
 Receiving and accounting for all supplies
 Stocking supplies for “Adequate” period of time only
 Studying and reviewing utilization of the material
 Developing and adhering to policies and procedures for product utilization
 Standardizing and evaluating all products and services
 Processing and reprocessing reusable supplies and material
 Distributing ail goods and services
 Controlling 'Unofficial' inventories
 Assuming accountability for capital equipment
 Reviewing and servicing patient care equipment
 Controlling printing and all printed matter, including xerography
 Reviewing and evaluating patient charges
 Efficiently disposing the waste products of the goods and services purchased.

Materials management can best be described as a concept or philosophy that is religiously applied to the
materials process on a consistent basis. It is a continuum along which many important supply functions
take place under the disciplined supervision of the materials manager.

The continuum of supply functions supervised by the materials manager is shown. If developed and
implemented properly, the idea of total materials management represents control of 'anything that moves
and is not alive’ (Housley, 1978).

408
 Supplies
Equipme
nts
Pharmac
y
Acquisition

Inventory Linen
control Dietary
C.P.D

Printing
Purchasing
Inventory
management
Production

Soiled
materi
al
Materials
management

Retrieval
Waste

Committees
Prod.
evaluat
ion Make / buy
evaluation
Transportati
Prod. on
standard Dept.
s plan

Materials
Techniques /
managemen Material Patient
procedures
t reseaech

Unit Mail
Bulk

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The continuum of supply functions supervised by the material manager

 Supply and equipment specification

 Purchase process
 Receiving
 DISTRIBUTION
 Storage
 Inventory control
 Requisition by consumer units
 Supply
 Process
 DISTRIBUTION
 Utilization of supplies
 Initiation of patient charges
 Standardization
 Value analysis
 Cost analysis
 Forecasting
 Disposition
 DISTRIBUTION

10. MATERIAL IDENTIFICATION, CODIFICATION AND STANDARDIZATION:

Materials Identification:

Identification of stores is a necessity; it is also needed for proper placement of items in appropriate bins
and for proper accounting. Since a large number of items are generally held in the stores, if proper
management is not made for their identification, there may be confusion in locating them.

Codification:

Codification is a process of representing each item by a number, the digits of which indicate the group,
the sub-groups, the type and the dimension of the item. Many organizations have their own system of
codification and hospitals are not an exception to them. The first two digits normally represent the major
groups, such as injections, capsules, tables, etc. The next two digits indicate the sub-groups such as
antibiotics, analgesics, etc., and the last three digits indicate the number allotted to the item.

Two fundamental systems are described as following:

Kodak System

This system consists of ten digits of numerical code. This system is based on sources of supply. AH
materials are divided into 100 basic classifications. Each class is divided into further 10 sub-classes.
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Brisch System

This system consists of seven digits and is applied in three phases:

• The materials to be codified are grouped together so as to form a major group. The grouping should
be accurate, uniform, and should not overlap.
• The materials are further divided according to their nature, use, characteristics, class, etc. so as to
describe the materials in greater detail with less use of numbers.
• In the last phase, the numbers are allotted. Generally seven digits are given to an item for symbolizing
the classified description of the item so that the item may be clearly understood with the help of codes
allotted. As per requirements, digits can be increased or decreased.

Advantages of codification:

- Reduction in the number of items and avoiding duplication

- Systemic grouping of similar items and avoid confusion
- Serves as starting point of simplification and standardization
- Easy recognition of an item in stores

Standardization:

Standardization is the process of setting up standard. A standard is defined as a model or general

agreement of a rule established by authority, consensus or custom with which to measure quantities,
value, dimension, or quality.

Standardization is required not only for ensuring procurement of the right quality of incoming
material but also for cost reductions. The objectives of standardization are listed below:

- To provide a mechanism to ensure an improved level of patient care through product evaluation,
with emphasis on the quality of care and the containment of costs
- To evaluate the voluminous and continuous flow of new and improved products
- To reduce the expenses on educating and training personnel to many and varied products and
techniques through standardization.
- To keep administration and department heads informed and abreast of changes in equipment and
products.
- To assist department heads in understanding mutual problems in reference to supplies and
equipment.
- To minimize the quantities of inventory by reducing the variety of products

Benefits of standardization:

The important benefits of standardization are as follows:

 Standardization helps reduce inventory items.

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  It helps in evolving better means of communication about an item in the company.
 It forms a base for further inventory analysis.
 The specifications of items can be more clearly spelt out, making quality control firm.

Housley (1978) has advocated the establishment of a committee known as ‘product standardization
committee’ for hospitals. This committee should have multi disciplinary representations and it should
set standards of product acceptability and should meet periodically. The purpose of this committee is to
reduce the purchasing of different brands of item essentially to standardize items.

12. MATERIAL MANAGEMENT ORGANIZATION:

A separate department for materials management is essential to carry out the functions like purchasing,
store keeping, inventory control etc. to facilitate smooth functioning for the organization. In such a case,
the relationship of material management with other functional areas like finance, marketing, personnel
etc. becomes vital.

Following is the organizational structure in which the material management under integrated set up is
shown:

M.D

Quality circle Materials Finance Personnel

Purchase manager
manager manager manager

Purchasin Central Stores Inventory

g recieving control

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In the above structure, the materials management department occupies vital position at par with other
functional areas and is responsible for all the functions relating to materials.

12.1 Material management organization based on commodities:

Under this system the items are classified according to their nature such as capital, medicines, imported
items, and so on and they are assigned to individuals. For the commodity group, the work load will vary
between the groups and this forms the basis for determining the stock in each commodity group.

Organization chart for commodity grouping

Materials manager

Inventory control
& information
Stores manager Purchase manager manager

Purchase
manager

Buyer Buyer civil

Buyer house Buyer Buyer
material engineering
keeping capital items medicines
equipments materials

In the above system there is no wasteful duplication of efforts as each commodity is separately handled.
The group is intimately in touch with its respective commodity marketing and hence it becomes
specialized bulk buying and standardizations are facilitated in each commodity group.

12.2 Organization based on location:

When an organization has several plants located in the different parts of the country, there are two
alternatives. One is to have a centralized organization located at the head quarters. The other is to have a
decentralized material management set up in each location. The decentralized system can be followed
when distances from the plants are significant and the hospitals have different service lines. Each
hospital may require many unique materials and material management department located at a plant will
be in a much better coordination with the service, finance and marketing departments.
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Centralized materials management organization:

M.D

Marketing Finance Personnel Service

The material management organization may also be group based on its function. Activities like
purchasing, receiving store keeping, inventory control etc. have been created and each section in charge
has to report to the central office.

13. PURCHASING

13.1. Definition:

Purchasing is a managerial activity, that goes beyond a routine act of buying and includes the planning
and policy activities, covering a wide range of related activities, like proper selection of materials,
selection of the appropriate supplier, inspection of incoming materials and development of proper
procedure and policies to enable the purchase department to carryout its functions effectively.

13.2. Objectives of purchasing:

i. To avail the materials, medicines and equipments at the minimum possible costs.

The saving in purchasing the items at low cost largely helps in increasing the productivity and
profitability of the organization.

ii. To ensure the continuous flow of service.

All the items required for service like medicines components and consumable stores and supplies and
the items required for maintenance (spares, tools etc) must be made available at the right time to achieve
uninterrupted flow of service. This minimizes stock out situations and will stride to earn reputation in
the minds of customer.

iii. To increase the asset turnover:

The investments in fixed assets in inventories must be kept minimum in order to increase the turnover of
the assets and achieve greater profitability.

iv. To develop alternate sources of supply:

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 The purchase department is constantly in touch with the market and thereby updating the list of
suppliers. This will largely help in evaluating a large number of suppliers based on their finance
strength, reliability in supply, consistency in quality etc. So that ultimately the cost of purchases is
largely reduced.

v. To establish and maintain good relations with the suppliers:

Maintenance of good relations with the supplier helps in evolving a favorable image in business circles,
Further the buyer can get the benefits of better credit facilities, discount, and reliability in super
uniformity in quality etc.

vi. To achieve maximum integration with the other departments of the hospital:

The purchase department has to co-ordinate with the service departments in order to get the information
regarding the material specifications, quantity, the time at which the materials are required etc.

vii. To train and develop the personnel:

The purchase section must have to build, an imaginative work force through training and development
and the employees must be provided with the opportunity to fulfill their aspirations for promotions in
the organization.

viii. Efficient record-keeping and management reporting:

Paper processing in purchase department has to standardize to facilitate efficient record keeping. The
purchase department has to report to the top management about the purchase activities periodically so
that the volume and value of the purchases, analysis of work performed in the purchase department,
information about the cash discount and quantity discount, the about the price changes in the near future,
new sources of supply etc. can be made aware of, which help the management to frame policies.

13.3. Types of purchasing:

Purchasing is primarily a buying activity and therefore types of purchasing vary with the purpose of
buying. Therefore four types of buyers:

1. Industrial buyers
2. Buyers of wholesalers
3. Buyers of merchandise for retail stores
4. Ultimate consumers buying from the retail stores.

As such purchasing fundamentally is aimed at resale and consumption for conversion. Above
four types will fall in one or both of these categories viz industrial buyers, and consumers (buying from
retail stores) will purchase for consumption or conversion whereas Buyers for wholesalers and
merchandise for retail stores aim at distribution or resale. As for the purpose it is evident that buyers of

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type (2) and (3) above are opportunist and mainly concern with the market conditions. Ultimate
consumers, a large percentage has to go by a purchasing in terms in technique or scientific management
rests with industrial buyers.

‘Industrial Purchasing’ is defined by D. Watte as “the procurement by purchase of the proper materials,
machinery, equipments and supplies or store used in the manufacture of a product adopted to the
marketing in the proper quantity and quality at the proper time and at the lowest price consistent with
quality desired”.

In most organizations normally the consumption of materials ranges between 60% to 70% of the cost of
services

13.4. Purchase principles:

The basic objective of purchasing is to ensure continuous supply of materials, components, medicines
etc., so that the service is carried out without any interruptions. At the same time it also to be seen that
the items purchased is kept minimum. From the following parameters, one can judge with which a
purchase department is operating.

(i) Right Quality:

Right Quality does not mean the best quality. It implies right specifications and dimensions of the
materials, which a supplier has to meet. It is the duty of purchase department to make the right quality
materials available in the hands of the service units to reduce wastages and rejections.

(ii) Right Quantity:

The hospital has to ascertain EOQ and place order of EOQ, unless otherwise warranted. The inventory
models have to be constructed to determine the level of stock, the organization could hold and to
determine the right quantity to order.

(iii) Right Price:

While selecting the supplier, the lowest bidder, is not necessarily selected. The lowest responsible
bidder is the one, who has to be selected and orders, will be placed. The hospital has to apply the
principle of learning curve in case in case of materials with high amount content. Further the hospital
has to negotiate with the supplier or better terms & conditions of purchase.

iv) Right Time:

The purchase department has to ascertain the lead time for all materials procured from outside. This
helps it in fixing re-order point (Lead time consumption + Minimum stock) which is the right time at
which the order is placed with the supplier.

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v) Right transportation:

The buying firm has to make a comparative analysis of the cost of transportation by taking into
consideration the costs of owning fleet of vehicles and availing the services of the transport agencies. A
decision has to be then made to ascertain the right mode of transportation, which provides efficient
service at reduced costs.

vi) Right Contracts:

While entering into the contract with the supplier, the hospital must take into account the various legal
enactments that affect the performance of contracts. For (e.g) Indian Contract Act, Sale of goods Act,
I.S.I Act, Essential Commodities Act etc. For instance, under sale of goods Act, the supplier has to ring
the material to the deliverable state and the buyer has to apply for delivery.

vii) Right Source:

The buying hospital has to make an objective evaluation of the suppliers or (vendor rating) based on
various criteria like financial strength, continuity in supply, uniformity in quality etc., before selecting a
supplier. Further the company has to be constantly in search for the cheaper substitutes and update list of
suppliers.

(viii) Right place of delivery:

The hospital has to communicate clearly the place at which the materials are to be delivered. Hospital
has to appoint the place and intimate the same to the supplier.

(ix) Right material:

The material to be purchased has to be evaluated based on the functions performed by it.

Value = Functions

Cost

The procurement is to be made only for standardized materials components to minimize rejections and
ensure uniformity in quality.

(x) Right Attitude:

Taking into consideration the parameters mentioned above, the hospital to make a SWOT analysis
(Strength, Weakness, Opportunity, Threat) in order to make the right kind of materials available at the
right time, at the right price and in the right quantities. It has to be constantly in touch with the market,
so that the innovations and inventions can brought to the notice of organization, which is largely helpful
in adopting the latest technology at reduced cost.

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13.5. Purchasing procedures:

Purchasing procedures refers to the way in which a purchase transaction is carried through from its
inception to its conclusion. Purchasing policies outline the broad objectives to the accomplished and
guidelines within which the procedures must accomplish the desired results. Procedures outline in detail
the functions to be performed by the people involved in the purchasing operations

Basic steps of purchasing procedures recognition of the need:

 Any purchase transaction starts with the recognition of the need for an item by someone in the
hospital.
 The need may often be satisfied by a transfer of materials from another department or store
room; however the storeroom must also replenish its supplies of the item.
 For many items a well run purchasing department, will anticipate the needs of the using
department, anticipating advance needs is one of the consideration that determines the size of the
order for an item.
 In such cases purchase officer buys a quantity sufficient to reduce the likelihood of such orders
in case of sudden increases in the rate of consumption of item.
 A purchase officer has to develop alternate source of supply and potential alternative materials.

Description of the need:

Once the need has been recognized it must be so accurately described that all parties will know exactly
what is wanted.

Selection of the source:

The next is the selection of the source for requisitioned items. For branded or patented items there may
be a single source but in most cases there will be number of alternative suppliers. For regular purchase
consideration goodwill, price, company's policies etc. are considered for selection of source.

The process consists of selecting the desired number of suppliers, in accordance with established
guidelines from whom quotations will be requested. For non-routine purchases, the procedure involves a
careful survey of potential sources of supply.

Ascertaining the price:

Purchase department must ascertain price information on the item being purchased. Price will be one of
the important factor on which the final choice is made.

Placing order:

All orders should be in writing and should be on the buyers purchase order to avoid the possibility level
of difficulties.

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Follow up of the order:

It should not be supposed that once an order has been placed, the purchasing department has no further
responsibilities. Every purchasing department has the responsibilities for following up orders that it
places.

Checking invoices:

Invoices checking are a part of purchase function since receipt of invoice constitutes the usual
notification that the suppliers have made shipment.

Maintenance of records and files:

Purchase orders are legal contracts and as such should be preserved for as long as they have legal
significance.

Maintenance of vendor relations:

Good relations are based on mutual trust and confidence, these grow out of the dealing between buyers
and sellers over a period of time. The purchasing department effectiveness measured by the amount of
goodwill with suppliers.

13.6. Different types of purchase system:

1. Forward Buying

It simply means buying in excess of the normal requirements. Depending upon the availability of the
item, the financial policies, the EOQ, the discounts delivery etc., the future commitment is decided. The
forward buying is resorted to when the purchase section anticipates any scarcity in supply of materials in
the near future or the price may increase very soon. Forward buying however results in increased
storage cost as huge amount of money is locked-up in. inventories and there by considerable amount of
interest on investment is lost

2. Blanket orders:

The blanket order is the most popular alternative to the single item, fixed price order. A blanket order
may be an agreement to provide a designated quantity of specified items for a period of time at an
agreed price. A second type of blanket order is an agreement to furnish all of the buyers needs for
particular items for designated period time. Under this type of blanket order the quantity in not fixed
until the time period has elapsed.

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3. Stockless purchasing:

Under this system the hospital has no financial responsibility for inventory of the good being purchased.
The inventory is owned by the supplier. The goods may be located either at the supplier's or buyer's
location.

4. Tendor stock purchasing:

In big organizations, while making bulk purchase may resort to tender system of buying. This may be
classified into

(i) Open Tender:

Under this system buying organization after assessing its requirements gives a tender notice indicating
the type of materials required their specifications & quantities and other terms & conditions in some
leading newspapers. The suppliers who could meet the terms & conditions send their quotation to the
buyer. The buyer in turn makes evaluation of the terms of each supplier and the one, who quoted the
optimum price, is selected and order for materials is placed with him.

(ii) Limited Tender:

Under this system the buyer has a list of suppliers, usually 5 or 6 to whom the tender notice is sent and
among the suppliers, the supplier who quotes the lowest price is selected & purchase order is placed.

(iii) Single Tender:

The buying organization follows single tender of buying in case of proprietary items. There is no
possibility of making systematic vendor rating, while going for the purchase of proprietary items.

13.7. Selection of sources of supply:

As selection is the essence of the purchasing process, it is imperative that final authority rest with the
purchasing department. In some hospitals improper selection causing inferior goods and services has
resulted in authority being shared with the user department.

Procedure:

The procedure of source selection involves the preparation of an extensive test of prospective suppliers
and the successive elimination from the list on various grounds until the number has been reduced to
one or few to be favored with the business. The procedure is therefore one of searching for all likely
suppliers and then sorting for one or ones with whom to do business. Some of the important factors
responsible for selection of the prospective suppliers are: Experience; Catalogs; Trade directories; Trade
Journals Associates; Trade shows and conventions;

Requests for quotations:

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When a new item is under consideration, a buyer should therefore, first of all inquire whether any of this
present or past suppliers are likely prospects. Most purchasing departments maintain vendor files which
contain the names and addresses of vendors with whom the company has dealt throughout its history as
well as notation of classes of goods that have been purchased from each vendor. Frequently the files are
set up to include additional data on such things as the reliability of the supplier in meeting commitment
dates, willingness to handle emergency and rush orders, and defect or reject ratios on shipment received
in the past.

Catalogs:

For standard service such catalogs frequently are one of the most effective and efficient sources of
potential suppliers. All buyers make some use of their catalogs and a substantial percentage of buyers
use them extensively.

Trade directories:

A trade directory is a publication that list and classifies suppliers according to the services they
provided. Frequently it also gives a minimum amount of information on such matters as the financial
status of the companies, their method or distribution and location of their offices.

Trade journals:

Trade Journals or business magazines are other very fruitful sources of supplier names. There are
thousands of such publications, and no purchasing department can subscribe to more than a small
fraction of total number.

Trade shows and conventions:

Another source of information about suppliers that is available to all buyers is the trade show or
convention. At the trade show the members of an industry display their wares in an attempt to attract
buyers, build up their wares in an attempt to attract buyers, build up their interest, and, if possible, make
sales.

Requests for quotations:

Finally information on prospective suppliers can be secured through a request for quotation form. Such
requests contain a blue print or written specifications including quality requirements and estimated
usage. The procedures are usually used annually on all significant parts and services that are being
purchased. Bids are solicited from three potential suppliers, there by providing an opportunity for
equitable comparisons amount competitors.

Vendor rating:

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The objective assessment of vendors demands a systematic analysis of their past performance. But
reassessment at regular intervals is a time consuming process and thus did not receive adequate
attention. The systematic assessment of suppliers ability to meet the quality, delivery schedules, product
price and service giving an appropriate weightage to each ; factor can help us in designing Vendor
Rating system. The overall Vendor rating could be prepared to evaluate the vendors. Following are the
three methods normally used for rating vendors.

(i)

The Categorical method

(ii) The weighted method

(iii) The cost-ratio method

(i) The categorical method:

This is a functional method giving emphasis on the cost of value analysis. In this method the functional
utility is given more importance in vendor selection. We can device a system with three levels based on
the value viz High value; Middle value; Low value. In each of these value system a list of factors is
made for the purpose of evaluation, for example delivery; price and quality are given high value.

(ii) The weighted Point Method:

In this method the number of factors such as the objectives of the organization, its products and
economic conditions of the organization are included. The relative worth of these factors as compared to
each other will give a composite performance index. The relative worth's of these factors vary from
products to product, organization to organization. The following are the maximum but average points
for the best performance.

iii) Cost Ratio Method:

The Object of this method is to evaluate the suppliers on the basis of proceeding considerations which
may not be practical considerations. The small difference in the point score among various suppliers
may not be of a great significance to justify their reactive merits.

Factor Average points

(a) quality 35
(b) price 30
(c) delivery 20
(d) service 15

Percentage of price performance = lowest price bid

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Actual price

Percentage of lead time performance =

Shortest lead time (any vendor on comparable item)

Actual time

13.8. Capital equipment purchasing:

Capital equipment:

Capital equipment refers to those items of machinery and equipments whose long life and high value
require that they be carried in balance sheet and depreciated over a period of time.

Procedure for purchasing capital equipment:

 Evaluation of need:

The recognition of the need originates with the using department and the evaluation of this need requires
the study of alternative methods, a cost analysis of alternative methods, a search for equipment that will
do the job, and a second cost study to determine the savings made possible by the use of the proposed
equipment.

 Specification:

Once the need has been established and the type of equipment determined, the next step is to draw up
specifications. The manufacturer's representatives are also consulted in designing the specifications.

 Negotiations:

The materials management department, which has so far arranged the contacts with Vendors, determines
which vendors to solicit for quotations. The specifications are provided to selected vendors and they are
invited either to quote or to send a representative to survey the job before quoting.

 Ordering:

After deciding the supplier, it is necessary for the purchasing department to work out with that vendor
all details of the purchase order. An experienced buyer knows that, although he may be reimbursed for
any damages incurred he can save himself much trouble, cost and work by taking precautions before
placing the order.

 Follow - up:

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Because the purchase of capital equipment usually covers an extended period of time, follow up of the
order is an important responsibility of the purchasing department. The follow - up of an order should be
performed by the executive who placed the order.

13.9. Economic analysis:

Approaches to Capital Equipment:

The hospital considering the purchase of new equipments makes a careful cost analysis to compare the
operation of the proposed equipment with its present equipment. Because of the large size of capital
equipment expenditures, most hospitals use detailed economic analysis procedures to calculate the
expected return from the purchase against the expected cost.

Payback Period:

Payback period is calculated by relating the cost of the equipment to the profit it earns and then
estimating the number of years it takes for the equipment to pay for itself. The basic objective is to
purchase the equipment with fastest payback period. Payback period is simply the time it takes to cover
the cost of the equipment and is expressed in the formula P= C/R where P = the payback Period; C =
Cost and R = the cash return from the investment, or the present value of the further return. This simple
approach assumes the return each year to be constant, does not allow for depreciation or taxes, and
ignores returns after the original investment is recovered.

Discounted cash Flow:

According to this approach the management assumes that a minimum return must be made on their
capital, and an investment is not made if this standard is not met. For example, a lot of companies
assume that they must earn a 20 percent return after tax on new investment in hospital and equipment
they then discount the value of future cash flows will equate their sum to the supply price of the assets.
It is given in the formula.

C = Rs = R1 + R2 +…..+ Rn + S

1+r (1+r)n (1+r)n (1+r)n

Where,

r = discounted rate of return

R1, R2 = cash flow after taxes in years 1, 2…4.

N = life of association

S = salvage value

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After the discounted rate of return on the investment has been calculated it is compared with the cost of
the capital to be invested. If the return is greater than the cost, the purchase is economically sound,
because the discounted return is greater than the return that could be obtained from the invested capital
in alternative use.

Present Value:

Any investment calculations involve two things; the expected pay off; or savings, which extends over
many years, and the cost of the capital invested. Because capital equipment will usually produce savings
over a long period of time, it is necessary to determine the worth of the future savings today. The
present value of anticipated savings can be obtained by several means, the simplest of which is

V = R1 + R2 +…..+ Rn + S

1+i (1+i)2 (1+i)n (1+i)n

Where,

V = present value

I = the interest rate on capital

R1, R2, R3… Rn = cash flow after taxes in years 1, 2, 3…n

N = life of assets

S = salvage value in year n.

If the present value of the investment, V, exceeds the cost of the equipment, the purchase is
economically sound. The determination of the present value of estimated future savings is an integral
part of any capital equipment economic analysis.

Return on Assets:

The approach relates the cash savings anticipated to result from the purchase to the amount of money
invested.

Return of assests = present value * 100

Savings rupee investment

This approach is subject to all conceptual difficulties already mentioned viz. estimated if of equipment;
estimated future returns etc.
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Therefore variety of economic analysis techniques is great, and they often involve quite detailed and
complicated procedures. It is a new machine has a greatest output or a faster of operation, one might
assume this to be a greater value. But this is not necessarily true if there is no need for the faster or
greater output.

14. NURSES’ ROLE IN MATERIAL MANAGEMENT:

A ward is often referred to as a Nursing unit. This implies that a ward is actually under the control of the
nurse in charge for its maintenance and for running its day-to-day patient care activities. Material
management consequently is an onus that lies on the Nurse in charge as well on all members of the
Nursing team. The Nursing responsibilities in relation to material management are listed below:

i) Ensuring regular and adequate flow of supply of necessary equipment, supplies, drugs and solutions.

ii) Monitoring and sustaining the quality and safety of the materials used including drugs and solutions.
Issuing of items on the basis of “First in First out” and regular checking of expiry dates of drugs
contribute towards safety.

iii) Indenting, receiving, storing, checking and timely replenishing of all necessary equipment, supplies,
drugs and solutions.

iv) Maintaining of emergency and buffer stocks

v) Arranging for preventive maintenance wherever necessary.

vi) Maintaining inventory and stock of all items and supplies

vii) Arranging for condemnation of articles in accordance with the laid down policies of the
organization and maintaining of a dead stock register.

viii) Arranging and assisting in audit of materials

ix) Participation in policy making for material management.

x) Participation in tender / procurement sub-committees.

xi) Orienting Nursing personnel on material management policies from time to time.

xii) Evaluating the efficacy of the material management system followed in particular Nursing unit.

15. Principles of Administration applicable in Material Management are:

i) Discipline – involves observance of norms, rules regulations and established procedures.

ii) Unity of command – Refers to having on e superior to give commands.

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iii)Unity of Direction - Refers to having a single superior in control and for giving directions.

iv) Orders- concerned with systematic and orderly arrangement of materials, supplies and equipment
according to requirements of specific departments.

Nurses involved in material management are required to abide by these principles.

Chapter VII prishanthini anto

INVENTORY CONTROL (ABC ANALYSIS, VED ANALYSIS), CONDEMNATION

1. INTRODUCTION:

It means stocking adequate number and kinds of stores so that the materials are available whenever and
where ever is required. This has to be done at the optimum outlay of financial and human resources. In
health care system, material management is concerned with providing the drugs, supplies and equipment
needed by health personnel to deliver health services.

The right drugs, supplies and equipment must be at the right place, at the right time, and in the right
quantity in order that health personnel deliver health services.

Inventory control it is an important aspect of material management. Inventory control is a scientific

system which indicates as to what to order, when to order, and how much to order, and how much to
stock so that purchasing costs and storing costs are kept as low as possible.

2. Definitions of inventory control:

Inventory is the sum total of all supplies, official and non official, wherever they may be stored, that
have not yet been used.

It may be defined as planning, ordering and scheduling of materials used in the service process.

3. Objectives of inventory management:

Normally hospitals invest large amounts in inventories. Inadequate inventories will disrupt services.

(i) To make sure that materials are available for use in services as and when required.
(ii) To reduce the investment in inventories.
(iii) To ascertain the finished goods are available for delivery to customers.
(iv) To protect inventories against deterioration of obsolescence and unauthorized use.

Hospitals hold inventories for following three reasons:

(i) Transaction motive: it is the need to maintain inventories to facilitate the service activities.

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 (ii) Precautionary motive: it is the need to hold inventories in order to safe guard against
predictable changes in demand and supply forces.
(iii) Speculative motive: to take decisions in order to increase or decrease inventory levels that
arise due to price fluctuations.

4. Factors influencing inventory management and control:

Several factors influence inventory management and control, the principle effects of these factors are
reflected most strongly in the levels of inventory and the degree of control in the inventory control
system. The main factors are:

 Type of service & expected number of patients

 If the materials used in the service have high unit value when purchased, close control over
inventory is necessary.

Other important factors include:

1. The objectives of the hospital as they relate to inventories.

2. Qualifications of staff that design and coordinate the implementation of the system.
3. The nature and size of inventories and their relationship to the other functions of the
organizations.
4. The current or potential availability of data that can be used for controlling inventory and for
making inventory decisions.
5. The potential savings that might be anticipated from improved control of inventories.

5. Classification of inventory
Official inventories:

Official inventory is one that is brought into a storage space or unit, counted and controlled until it is
dispensed to a using department, for example,

a. central stores

 Medical and surgical items

 Dressings
 Linens
 X – ray supplies
 Laboratory supplies
 House keeping items
 All process of sterile supplies.

b. Pharmaceuticals

 All drugs, fluids

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 c. Dietary

 Cereals, pulses, etc.

unofficial inventories:

Unofficial inventories are those supplies that have been expended and dispensed to the various
departments and units where they are stored until used. Most hospitals never count or rarely control this
stock. Unofficial inventory exists in all supply consumer departments, such as:

• Nursing units
• Laboratories
• Casts rooms
• Anesthesia
• Surgery
• Emergency rooms
• Radiology
• Disaster storage
• Maintenance
• Administrative offices
• Physician offices
• Recovery rooms
• Special care unit.

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 other types of inventory:

 Raw material or manufacturing inventory:

There are five types of manufacturing inventory

 Production inventory:

Items going to final product such as raw materials, sub assemblies purchased from outside are called
production inventory.

 Work in progress inventory:

The items in the form of semi finished or products at different stage of production process are
known as Work in progress inventory

 M.R.O inventory

Maintenance, repair and operating supplies such as spare parts and consumable stores, which do not
go into final product but are consumed during the production process

Raw materials / production

Inventory

Work in progress inventory

Manufacturing aspect Finished good inventory

M.R.O inventory

Miscellaneous inventory

Service aspect Lot size stocks

Inventory Anticipation stock

Fluctuation stocks

Risk stocks

A – Items inventory

Control aspect B – items inventory

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 C – Items inventory

 Finished good inventory:

Finished good inventory includes the products ready for dispatch to the consumers or distributors /
retailers.

 Miscellaneous inventory:

Items excluding those mentioned above, such as waste, scrap, obsolete, and unsaleable items arising
from the main production process, stationary used in the office and other items required by office,
factory and other departments, etc. are called miscellaneous inventory.

 Service inventory:

It can be classified into 4 types,

 Lot size stocks:

Lot size means purchasing in lots. The reason for this is to

 Obtain quantity discounts

 Minimize receiving and handling costs
 Reduce purchase and transport costs

For example, it would be uneconomical for a textile factory to buy cotton every day rather than in
bulk during the cotton season.

 Anticipation stock:

Anticipation stocks are kept to meet predictable changes in demand or availability of raw materials.

For example, the purchase of potatoes in the potato season for sale, preservation products
throughout the year.

 Fluctuation stocks:

Fluctuation stocks are carried to ensure that there is no risk of complete production break down.
Risk stocks are critical and important for production.

 Control aspects:

ABC analysis.

6. Objectives of inventory control:

1. To make effective and efficient use of invested capital i.e. the balancing of unit cost,
operating cost, and customer service with cost of capital.

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 2. To provide efficient customer service – a quantity purchase assured optimum customer
service and provides efficient scheduling of internal options.
3. Quantity purchases permit lower unit cost.
4. Optimum purchases permit efficient use of man, machines, and facilities.

7. Principles of inventory control:

The main principle of inventory control is that items for which annual consumption is high, orders
are placed frequently so that the inventory level is as low as possible. For items whose annual
consumption is not high, sufficient stocks are maintained and orders placed less frequently.

For proper control of inventories, the following terms should be understood properly:

• Lead time
• Buffer stock (Safety stock or reserve stock)
• Optimum safety stock

Lead time:

Lead time is the average duration of time in days between the placing of order and the receipt of
materials. When determining the quantity of any item to be ordered we have to take into
consideration this 'Lead Time' so that orders could be placed at a time when the existing stocks are
sufficient for the needs of the hospital during the lead time.

The lead time to procure any item can be divided into two parts, namely, the internal lead time and
the external lead time. Internal lead time is the time required for organizational formalities to be
completed. External lead time is the time taken in placement of order and receipt of goods. The total
lead time can be computed by working out the time taken in internal and external procurement
processes.

TOTAL LEAD TIME

Internal Lead Time External Lead Time Internal Lead Time

(I.L.T) + (E.L.T) + (I.L.T)

Requisition Placement of order Taking unit in

Order and receipt of goods stock

It is a common belief that external lead time should be controlled and reduced, but in actual practice
the internal lead time constitutes a considerable part of total lead time and offers ample scope for
reduction. The internal lead time is within the purview of the administration. By streamlining the
procedures and cutting red tapism, this can usually be cut down by at least 50 per cent. The external
lead time cannot be avoided but it can be prevented from exceeding the stipulated time by:

• timely reminders and follow up;

• judicious expediting and maintaining good relations with the suppliers; and
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• Penalty for delayed supplies

Buffer stock(Safety or Reserve Stock):

Buffer stock is the quantity of stock set apart as a safeguard against the variations in demand and
procurement period. This quantity of item can be used only at the time of emergency for unforeseen
demands. It is calculated by multiplying the difference between maximum and average consumption
rate per day by the lead time for the item.

Reorder Level

This term is used to denote the stock level at which fresh order has to be placed. This is equal to the
average consumption per day multiplied by the lead time plus the buffer stock. At the time of
ordering when the stock reaches the reorder level we will be assured that the chances of 'Stock out'
are practically nil.

Optimum safety stock:

If the safety stock maintained is inadequately low, the Inventory carrying charges on the safety
stock would be low but stock outs will be frequently experienced and stock out costs would be very
high. Hence it calls for inventory costs to arrive at an optimum safety stock. Stock outs may affect
the functioning of the hospital in the following ways:

• Quality of patient care is affected adversely

• Patient dissatisfaction
• Emergency purchase of stores at high cost
• Extra transportation charges
• Overloading of machines or men.

8. Steps in inventory control:

 Fixing minimum quantities or ordering points and maximum quantities or amounts to order
on all materials.
 Arranging a method for allocation of material and orders which are in process.
 Creating stores accounts, which will control the store room.

9. Inventory analysis:

This is a systematic analysis of all items in stores for achieving the objectives of inventory control.
There are three following levels of analysis:

9.1 Over all analysis:

This analysis takes a bird's-eye view of the total inventory over a period of time to find out trends, if
any. This type of analysis is very useful for the top management in keeping track of inventory
behavior. To be more useful to the management, inventory holding should always be expressed in
'months' consumption rather than in absolute figures.

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9.2 category analysis:

This is the second level of analysis wherein stocks of each category (group of similar items) is
analyzed. It has been found that even if the overall position of stocks is satisfactory, stores carry
higher inventory of some categories and low of some other, resulting in locking up of the capital in
high inventory categories and having stock out in low inventory categories. In order to achieve
optimum stock level and effective controls, the

Management should fix targets for each category of items according to various conditions like lead
time, nature of items, etc.

9.3 Individual team analyses:

It is desirable to classify or group the items and subject each class or group of items to controls
commensurate with its importance. The items can be classified according to their use, consumption,
value, lead time, etc. The various types of analysis are discussed depending upon the characteristics
of an item and each analysis has a specific objective.

10. Inventory costs

There are three cost factors associated with inventory systems:

The cost of material itself or shortages cost (Cs):

This is by far the most important cost factor. It is the cost of running out of an item and it includes:

• Cost of lost goodwill

• Overtime special effort to obtain an item

• Lost revenue.

Inventory carrying cost (Ca) :

This is the cost associated with keeping the materials in the stores. This comprises the interest
charges in the cost of the inventory, storage and handling cost, cost of insurance and physical
deterioration and obsolescence. As the amount and items of drugs increases, the cost of maintaining
the inventory also increases. This cost includes:

• Opportunity Cost: Loss of interest on money invested in the stock of materials which can be
equal to the rate of interest paid by the banks on this money. It will be logical to charge all this
money. This constitutes the opportunity cost.
• Insurance Cost: It is the cost of insurance charges on stores and building paid as premium.
• Wealth Tax/Property Taxes: Property taxes are levied on the assessed value of assets. Greater
the value, greater the taxes to be paid.'
• Storage Cost: This includes cost on account of salaries, cost of fringe benefits, operating
supplies, building maintenance, repairs utilities, depreciation expense for facilities and equipments.

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• Cost of Obsolescence and Deterioration: Due to technological advances and innovation, certain
drugs and equipments may become obsolete. The drugs may expire in the storage due to the human
failure of checking the items or when order quantity is not correlated with usage pattern.

• Inventory Shrinkage Cost: It represents the cost of pilferage. Pilferage and wastage are
universal in Indian situations.

Inventory acquisition cost or replenishing cost (Cr):

It is the cost incurred in placing an order (ordering cost). The annual expenditure of the purchasing
department can be considered to be on the purchase order it places during a year. Inventory
acquisition cost includes:

• Salaries and wages of staff working in the purchasing department

• Rent for the space and electricity used by the purchasing department
• Depreciation on the equipment and furniture
• The postage, telegrams and telephone bills
• The stationery and other consumables
• Entertainment charges
• Any traveling expenditure incurred
• Lawyers and court fees due to any legal matters arising out of purchases.

Total annual inventory cost:

The total inventory cost (TC) is the sum of all the three costs, that is,

T.C. = Cs + Ca + Cr

As one cost decreases, one or both of the other costs increases, For example, as replenishment cost
decreases, the cost of possession generally increases. These three costs help in determining the
economic order quantity.

under stocking cost (Ku) and over stocking cost (Ko):

Under stocking cost is the cost incurred when an item is out of stock. It includes the cost during the
period of stock out and the extra cost per unit, which might have to be paid for emergency purchase.

Over stocking cost is the cost of carrying inventory, which results when the demand for an item has
terminated. The items left over at the end of their demand period will have very little or not salvage
value.

11. Inventory control system:

Like other types of controls inventory control lends itself to a system approach. There are two types
of inventory control systems:

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 Cyclic ordering system;

This is a time-based system in which stock position is reviewed at definite intervals of time with
regard to availability, consumption rate, etc., in order to place orders. The quantity ordered at each
time will vary according to the stock position and its future requirements based on past years' rate of
consumption. The frequency of review varies from organization to organization. The stock levels
can be monitored by physical inspection by a visual review of perpetual inventory cards, or by
automatic computer surveillance.

Advantages This system suits well for materials whose purchases are planned months in advance
and also works well for materials which show an irregular or seasonal usage.

Disadvantages In this system there is no provision for unforeseen demands.. It does not admit the
adoption of ordering based on economic order quantity formula and tends to peak the purchasing
work round the reviewing dates. A special variation of cyclic ordering system is the 'Flow Control
System'. This system can be adopted for items required often, for which a long-term contract is
entered into for the delivery of definite quantities of these items at scheduled intervals.

Fixed order quantity system:

This system is based on the quantity ordered rather than on the time factor. The quantity of material
to be ordered is fixed and order is placed when stock reaches a predetermined level and not at
definite intervals. This system permits ordering the optimum quantity required for each and every
item, based on price and rate of consumption. A variation of the basic fixed order quantity system is
the Two Bin System.

Two Bin Systems: The distinguishing feature of this system is the absence of perpetual inventory
record. In this system, the stocks are separated into two bins or parts. The first bin contains stock to
satisfy demand between the arrival of one order and the placing of the next order. When the stock in
first bin is finished, a reorder is placed for a fixed quantity based on the EOQ formula. The second
bin supplies the requirements of the items during the lead time. The total stock in the second bin,
which represents the reorder level, is equal to the mean expected demand during the lead time plus
the safety stock. The latter ensures that even if the lead time is for some reason slightly exceeded
there will be no stockout. The maximum and minimum stock levels are determined and an order
point is then established (reorder level) between the two levels. The order point is so fixed that by
the time the supplies against new orders are received the stock will fall to the minimum and when
the receipt is accounted the stock will rise to the maximum.

Advantages

Each material can be procured in the most economical quantity. Also, purchasing and inventory
control personnel automatically devote attention to items they need only when required. Further,
positive control can easily be exerted to maintain total inventory investment at the desired level
simply by manipulating the planned maximum and minimum values.

Disadvantages

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It functions correctly only if lead time and usages are stable. When these change, a new order point
and order quantity has to be worked out.

12. Store management:

Stores play a vital role in the operations of a hospital. It is in direct touch with the user departments
in its day to day activities. The most important purpose served by the stores is to provide
uninterrupted service divisions. Further, stores are often equated directly with money, as money is
locked up on the stores.

12.1. Store keeping:

Alford and beathy have described store keeping as that aspect of material control which is
concerned with physical storage of goods.

12.2. Objectives of store management:

1. To safe guard all goods in storage against losses.

2. To have available all such goods ready for prompt delivery.
3. To provide maximum store keeping service to the manufacturing and sales department at a
minimum cost.

12.3. Functions of store keeping:

1. Receipt of materials into storage: raw materials, supplies and purchased parts are usually
received stock, unloaded, inspected and then moved into store keeping.
2. Record store keeping of materials in storage: it is important locate incoming and outgoing
materials quickly and accurately, to provide the necessary information where about of the
materials and cost keeping departments with correct and timely data.
3. Storage of materials: the proper storage and protection of material until thay are required
by authorized requisitions.
4. Maintaining stores: proper store maintenance measures may range from special covering or
periodic lubrication to controlled atmospheric conditions.
5. Issuing stores: These functions should be performed most efficiently promptly and
accurately and a proper record should be kept of all the instance store.
6. Co – ordinating store keeping with materials control: duly authorized storage requisition
must originate at the proper source and records of storage changes must be maintained for
using the materials and cost control centers

12.4. Protection of stores:

1. Protect goods from fire: store them in fire proof building and bins, with adequate automatic
sprinkle provision. Adequate fire fighting equipment, such as high pressure water lines,
modern sprinker system, suitable chemical extinguishers, and ladder should be provided.
2. To protect goods from damage by dust: storage should be in boxes in closed cabinets. In
city areas, where there are considerable dust in the atmosphere, air conditioned storage areas
may prove advisable for such materials.

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 3. Protection against weather conditions: materials stored out of doors can be protected by
open sheds or plastic coverings.
4. Protection against deterioration: some materials deteriorate with age. Such materials
should not be over stocked and a first in first out storage system should be adopted.
5. Protection against theft: protection against theft can be insured by locking the store room
and excluding all person not directly concerned with the receipt and issue stores. Stores
should be under one authority.

12.5. Locations and Lay Out: More often than not, in the matter of locating the stores, materials
management is rarely consulted. The normal practice is to locate the stores near the consuming
departments. This minimizes handling and ensures timely dispatch. In stores layout, the governing
criteria are easy movement of materials, good house keeping, sufficient space for men and material
handling equipments, optimum utilization of storage space, judicious use of storage equipments,
such as shelves, racks, pallets and proper preservation from rain, light and other such elements.
These problems are more important in the case of items that have a limited shelf life. Comfortable
working conditions must be provided to the stores personnel to get maximum efficiency and morale.
The important factors in the design of stores building can be summarized as follows:

1. Lighting: Clear and adequate lighting is a must for a proper work environment. Lighting effects
can be accentuated through a judicious choice of colors for the walls. For stores personnel who
work day in and day out in the stores receiving, checking, stocking, handling and issuing goods, a
pleasing environment goes a long way in reducing monotony. Any attempt to reduce these facilities
will prove to be false economizing in the long run.

2. Safety: This factor is perhaps the most important aspect. In stores a large volume of goods are
handled every day. Accidents considerably reduce the morale and effectiveness of the system. The
following measures are necessary if accidents are to be checked:

a. Safety consciousness should be instilled in the minds of stores personnel through training
programmes, visual aids and literature.

b. Safety appliances, such as goggles, hand gloves, etc., must be provided and their use must be
encouraged.

c. Good house keeping is essential. Stocking must be in appropriate locations so that handling is
minimum. Factors to be considered while locating the store room:

a) The location of stores should be carefully considered in terms of ensuring maximum efficiency.

b) The store location should minimize the cost involved in carrying of inventories and other stores
operation. Further proper protection to the materials is also to be ensured.

c) Stores location depends upon the nature and value of materials and frequency of consumption of
materials.

d) Stores should be easily accessible to all user departments and there by material handling should
be reduced to minimum.

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e) In big organizations having number of service units and each one is located far from the central
office; decentralized storage system should be followed.

9 11

10 10

(1)

6 6

8 7 8

5 2
6 6

6 4

1. Incoming materials receiving gate

2. Place for dumping materials
3. Place for sorting and checking materials and medicines
4. Place for materials and medicine inspection
5. Place for temporary storing of material before placing racks, bins etc.
6. Proper place for storing each type of material
7. Main aisle
8. Side aisle
9. Service window
10. Boxed containing material to be brought from container issues
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 11. Counters for keeping materials to be issued.

12.6 Storage:

Reduction in the storage space and handling cost ensures maximum return on capital invested. The
following points will come up for consideration:

a. where to store:

The following factors govern the lay out

(i) Similarly. Items are stored by class, viz., Medicines, Capital equipments, and hard wares etc.

(ii) Popularity. Turnover should be considered. Fast moving items should stored near point of
issues.

(iii) Size. Large items require being stored near point of issues.

(iv) Capacity. Location of doors and size, size of platforms and ramps, etc., should be considered.

(v) Characteristics. Characteristics of materials such as hazardous, sensitive, and perishable,

require careful consideration.

b. How to store:

Materials should be located by bin labels or sign boards giving descriptions and code numbers. The
highest standards of cleanliness and orderliness should be aimed at. The following ways may be
adopted.

(i) unit piling. Certain materials lend themselves easily adaptable to this system where each stack,
tray, shelf contains a given number.

(ii) slotted angle sheiving. This allows for a great deal of flexibility in storing.

(iii) Pallestisation. This is of immense use when frequent handling of heavy materials is involved.

(iv) Aisies. Aisies should be adequate for easy access. But not too wide to waste space.

(v) special storing. Certain materials like inflammable require special cover and due care, etc.

12.7 Stores records:

The store keeper has to maintain two stores records namely Bin card and Stores ledger.

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No. Max. Qty.

Name of article Min. Qty.

Symbol Previous year

Unit Consumption

Bin no.

Stores ledger folio

Ordered Date Ref Received Issued Balance Remarks

No. Date Qty. Date

Reserved

Job No. Qty Date

Bin card is the stores record in which the items received and issued are clearly specified by the
store keeper. Whenever the materials are received, the store keeper has to prepare a stores received
note indicating the type of materials and quantity and based on that he has to fill up the receives
column in the bin card after placing the materials in their respective bins.

When any issue of material is made he has to check for the authorization of the requisition before
issuing the materials. On making the issues he has to enter into the issues column that quantity of
the material is issued.

The column reserved indicates the number of items and their type kept as reserve for important jobs.

Stores ledger:

It is same as bin card; the difference is only with regard to the addition of amount column in this
stores ledger. Whenever the materials are received from the supplier, after checking the
consignment, the number of items received must be shown in the received column, under quantity.
After the invoice sent by the supplier is verified, the rate and amount column are also filled up.

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Name of material Minimum Qty

Symbol Unit Maximum Qty

Bin no. Previous year consumption

Bin card no. Period of delivery

Ordered Date Received Issued Balance Received Issued Balance Rate Rema

rks

When any issue is made, the store keeper on checking the authorization of materials requisition has
to make entries in the bin card and stores ledger.

The main advantage of stores ledger is that it adds as a counter check for the entries shown in the
bin card. Both bin cards and stores ledger must be properly updated in order to facilitate the
physical checking of inventories. All discrepancies have to be corrected then and there, and thereby
the stores records are helpful for perpetual inventory control.

12.8. Stores accounting:

In relation to the estimation of the cost of the service for pricing decisions, stores accounting
assumes a key role. Material costing is very important in terms of the valuation of the cost of
materials consumed by the service department as well as in terms of the estimation of the value of
materials held in stock. We will discuss the materials costing under classifications of toe receipt of
materials, issue of materials, and of the stocks held at the end of the accounting period.

12.8.1. Costing of the receipt of materials:

The factors that are to be included in the building up of the cost of the materials received are
material price, freight charges, insurance and taxes. Price usually refers to the price quoted and
accepted in the purchase orders.

Prices may often be stated in various ways, such as net prices, prices with discount terms, free on
board, cost insurance and freight, etc. For costing purposes we have to work out the actual cost

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incurred by taking price quoted by supplier as the basis, subtracting the discounts and adding any
other expenses not recovered.

The freight costs incurred in transporting the goods are usually collated under a separate head.
Sometimes prices may include this element. Hence care should be taken to ensure that there is no
double counting.

Goods in transit are mostly covered by insurance. All such insurance expenses must be calculated
and added to the base cost and transportation cost.

Under the miscellaneous head, we need to classify costs incurred by way of customs duties, taxes,
and packages. Such separate classifications give a setter framework for cost control. In sum, we can
say that cost of the materials received is equal to the price quoted less discounts, plus freight,
insurance, duties, taxes and package charges. Very often such detailed classification helps in
quicker analysis and effective control. Duty drawback statements, for example, are prepared by
many organizations which want to avail of the exemption of duties in respect of the value exported.
Such statements require 2 detailed break-up of various elements of cost. In the absence of the
detailed classifications discussed above, it will become very difficult to prepare such statements.

12.8.2. Costing of the issues to production:

First in first out (FIFO), average cost, standard cost, base stock method, market price at the time of
issue, latest purchase price, replacement of current cost are some of the methods used in costing the
issues of service.

FIFO:

The assumption made here is that the oldest stock is depleted first. Therefore at the time of
issue, the rate pertaining to that will be applied. This is logical in the case of items which deteriorate
with time. Since actual prices are used, there cannot be any profit or loss in the pricing
arrangements.

LIFO:

The basic assumption here is that the most recent receipts are issued first. In a period of rising
prices, latest prices are charged to the issues, there by leading to lower reported profits and hence
savings in taxes.

12.9. Stock verification:

It is the process of physically counting, measuring or weighting the entire range of items in the
stores and recording the results in a systematic manner. The purposes served by stock verification
are as follows.

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  To reconcile the stock records and documents for their accuracy and usefulness.
 To identify areas which require more disciplined document control.
 To backup the balance sheet stock figures; and to minimise pilferage and fraudulent
practices.

Stock verification is usually carried out by the materials audit department, reporting to either the
materials manager or the internal audit. One person is usually given the exclusive responsibility
with adequate facilities and authority.

Physical verification can be carried out periodically or a continuous basis.

12.9.1. Periodic Verification:

Under this system, the entire cross-section is verified at the end of one period, which is usually the
accounting period. In big organizations this is not achieved in a day and usually several days are
taken to complete this task. As no transactions can take place during the verification, this could pose
some problems. Physical verification requires careful planning and execution.

12.9.2. Continuous Verification:

Under this system, verification is done throughout the year as per a predetermined plan of action. A
- Items may be verified thrice a year, B-items twice a year and C-items once a year. It, therefore
presupposes that a perpetual inventory record for each item is maintained showing all transactions
so that reconciliation can be done.

12.9.3. Process of Verifications

Items are verified by counting in the case of bearings, by weight in the case of sheets, by measuring
in the case of lubricants and so on. However, when large stocks of items such as sand, scrap and ore
fuel need to be verified, it s based only on estimates as the question of exact measurement is ruled
out. In the actual process of stock verification, the stores personnel should involved, as they
intimately know the locations of various items, which result in quicker identification of items. For
instance, some items may be located in many places. By virtue of their experience, only stores
personnel will be able to locate them. So the material audit people will have to work in close
coordination with them. Discrepancies must be discussed with Stores so that any omissions may be
rectified and then only should they be reported to top management. Major discrepancies may require
a re-verification. Such discrepancies may be due to pilferage on a large scale, wrong posting of
records and documents control. They require careful analysis and immediate measures.

After discrepancies have been noted, stock adjustments must be using standard stock adjustment
documents duty signed by the appropriate authority. A typical stock adjustment form is shown
below;

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Discrepancy voucher

Date Of Verification: Serial no.

Part Number: Serial no. ref. no.

Part Description: Stock verification sheet:

Location Code:

Quantity As Per Record:

Quantity On Verification:

Discrepancy: Amount: value:

Prepared by: Surplus:

Approved by: Deficient:

After the approval, the stock records can be corrected. Surprise checks and verifications are made
by materials audit department to detect any fraudulent acts. Material audit plays the role of the
watch dog of stores, pointing out weak areas and remedying them. It assists in accurate records –
keeping and smooths finalization of annual accounts.

12.10. Value analysis:

Value analysis developed in U.S.A in 1947. Lorry D. Miles who has working at G.E found this
value analysis as a cost reduction technique. Value analysis was introduced because of the inherent
desire in the man to make cheaper and to sell cheaper; without any change in the utility of the
products.

Value = function or utility

Cost

Value is the cost proportionate function. To increase the value of the product, the utility of the
product should be increased otherwise the cost should be decreased. Value can be divided into the
following classifications.

1. Use or functional value: the properties and qualities which accomplish a use, work or service.

2. Esteem value: the properties, features or attractiveness which causes us to want to own it.

3. Cost value: the sum of labor, material and various other costs required to produce it.
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4. Exchange value: its properties or qualities which enable us to exchange it for something else we
want.

Definition of value: value can be defined as “the minimum money has to be expended in
purchasing or manufacturing a product to create the appropriate use or esteem factors”.

Definition of value analysis:

Value analysis can be defined as “organized creative approach which has as its objective – the
achievement of the value of the product”. Value analysis aims at reducing the cost value to the value
of the product.

Stages of value analysis:

The value engineering exercise proceeds systematically through following six stages. These are:

a. organization

b. evaluation

c. speculation

d. investigation

e. recommendation

f. implementation

a. Organization stage: It is composed of product selection and its analysis.

b. Evaluation stage: This is also called information stage. It is desirable to design an evaluation
sheet on which to record all the collected information. The information that is to be recorded on the
evaluation sheets includes

 Design
 Purchasing
 Derived information
 Service
 Costing

c. Speculation stage:

Speculation stage can be regarded as the heart of the matter. The essential technique of this is
functional approach. This has the following steps

 The functional approach to cost reduction

 Assessing the value of the function
 Alternative actions following functional assessment
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  Further studies during the speculation stage
- What are the functions, whether essential or can be eliminated?
- What material is used or proposed or can another material be used?
- What factors control the amount of material used?
- How much of the basic material is wasted during service?
- What labor operations are involved?

Thus the crux of the speculation stage is only critical thinking.

d. Investigation stage:

Design contribution: this includes change in design, the material used, the dimension and
limits etc.
Service contribution: covers process of service use of standard components, reduction
labor costs etc.
Purchase contribution: to reduce the cost of material and parts which is supplied.
The recommendation: the proposed alteration and comparison of costs before and after
all to be submitted for final recommendation by management.

e. Implementation: this is the stage at which management revives and decides upon the value
engineering suggestions submitted.

12.11. Identification and control:

The combing process of combining the stock records and movements I analysis has been found very
effective in locating such stocks in the total inventory. Stock issue cards should be combed and
items which have not been consumed (non-moving) for a period of one year must be isolated. A list
of such items and their value in terms of money and time must be made. Similarly, such | lists must
be prepared for items which have not moved for 2 years, 3 years, 5 years and above. Such lists can
then be put up to top management disposal action. Care must be taken to prepare a separate list of
imported spares and insurance items. Such combing and movement analysis must be done on a
continuous basis.

SI. Mo Part number ABC Last date of issue Stock on hand In Value of orders on hand
description number of days
consumption

(The statements will be prepared in such a way that items with no issue for a long time will appear
on of the statement. This will help in canceling the orders and tapering off the stock on hand.)

Whenever changes in service programme, design and service lines are contemplated, a senior
executive from materials management must definitely be kept in the picture. This helps in several
ways. He is in a position to inform top management of the amount of stock of materials on hand that
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are likely to be rendered obsolete if and when the changes are introduced. This could even guide the
management as to when the changes are introduced. This could even guide the management as to
when the changes are introduced. This could even guide the management as to when the changes
could be made sc that the existing stock can be consumed in full. The materials manager in turn can
freeze further orders for such materials and try to negotiate with the suppliers to take back the stock.
For some items he can introduce the buy-back clause where in the supplier takes back items not
consumed with in a sped] period. For new item, which may be required, he can try to develop and
place orders so that changes can be expeditiously introduced. All highlights that a close
coordination is required in order to avoid stock piling obsolete and surplus items. Selective control
based on ABC analysis, a forecasting techniques and proper preservation minimises such
accumulation

Many organizations have introduced formal documentation in introducing changes in design or

service. It is called the "Effective Point Advice". This popularly known as EPA. Here, the proposed
changes, details of new materials and products required, details of materials and products which will
be invalid / obsolete when the change occurs and the approximate date when the change is expected
to be introduced are detailed and circulated to concerned departments. EPA thereby helps in
tapering off the stocks of “invalid” items, cancellation of orders for such items, placing orders for
buying and / or manufacturing new items and related activities. EPA systems help in better
coordination for profitable introduction of changes with minimum “side effects” such as
accumulation of obsolete items.

The reclamation of scarp has not attracted the attention of the top management in Indian industry.
Big organizations have a full fledged scrap salvaging departments. These departments segregate the
scrap into categories. Color coding the scrap is also done to avoid the mixing of different categories
of scrap.

13. Economic order quantity:

The EOQ Formula

The total inventory cost in a year is determined by the following formula:

Total annual cost = (purchase cost) + (order cost) + (holding cost)

TC = RP+ RC / Q + QH / 2

Where,

R = annual demand in units

P = purchase cost of an item

C = ordering cost per order

H = holding cost per unit per year

Q = order quantity in units.

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 In effect, the total cost equation determines the annual purchase cost by multiplying the annual
demand by the purchase cost per unit. The annual order cost is obtained by multiplying the number
of orders per year (R/Q) by the cost of placing an order (C). The annual holding cost is the average
inventory (Q/2) multiplied by the annual unit holding cost (H). The sum of the three costs
(purchase, order and holding) will be the total inventory cost per year for any given purchased item.

Solving the above equation for Q, we get the EOQ formula:

Q = √2CR / H

Example: Never-Die Hospital purchases 1,600 pairs (units) of surgical gloves each year at a unit
cost of Rs. 15.00. The order cost is Rs. 100.00 per order, and the holding cost per year is computed
at Rs. 8.00. The economic order quantity Q will be:

1. Q = √2CR / H = √2*100*1600/ 8 = 200 units.

2. The total annual cost = RP+HQ = (1600 * 15) + (8 * 200) = Rs. 25,600.
3. the number of orders to place in one year when the lead time is 2 weeks

R/Q + 1600 / 200 = 8.

EOQ Models:

Static risk model:

This model is useful for project purchases and purchase of capital and insurance spares. Examples
in this category are publication of hospital calendars, diaries, yearbooks, buying capital spares, etc.
which are one time decisions, but the quantities can be estimated in the probability values. The costs
relevant for consideration are the under stocking and over stocking. It is the pointless to consider the
supply side costs as the purchase is not repetitive. The optimum stocking policy in this situation is
to stock up to level “S”, which denotes service level. Where,

S= Ku

Ku+Ko

Dynamic certain (EOQ) model:

The costs relevant for consideration in this model are the costs of ordering and inventory carrying.
Since the demand is certain, the under stocking and over stocking costs become irrelevant for
consideration.

Let the annual demand be M (deterministis). Let Co be the cost of ordering, Cc the unit price of an
item. The total annual ordering cost when the orders are placed in quantity Q is

M / Q * Co

The average inventory carried is Q / 2 and, therefore, the annual inventory carrying cost is = Q / 2,
sCc.

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=M/Q * Co + Q/2 * sCc.

The cost to be minimum.

OR

Q (optimum) = EOQ = √2MCo/ sCc

EOQ is calculated basis on the following assumptions:

Demand for the product is constant and uniform through out the year.
Lead time is always constant
Price / unit of service is constant
Ordering cost is constant
All demands for the service will be satisfied.

The three costs taken into account are ordering costs, inventory carrying costs, total costs.

The EOQ can also be graphically shown –

Annual total cost

Annual inventory
carrying cost
C

O
Annual ordering
S cost

EOQ Ordering quantity

1. Inventory carrying cost (ICc) – varies directly with the size of the order.

2. Ordering cost (Co) – varies inversely with the size of the order.

3. Total cost (TC) – it decreases first because of the fixed ordering cost and then raises because of
decrease in ordering cost and increase in carrying cost.

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‘EOQ’ represents the optimum quantity, which minimizes the total cost of inventory control. When
dealing with EOQ in real situations, the following terms should be considered, lead time, reorder
point, safety stock.

Inventory control model:

14. Inventory control techniques:

ABC ( always better control)analysis:

Expensive inventories and their control are costly, but inventory shortages and lack of control can
be equally costly. Economics of materials control is a matter of self-preservation in today's
competitive environment. Since materials control is a matter of rupee control, it is axiomatic that
stringent controls must be placed on higher-value items, although this should not be construed as
licensee for less control on lower value items.

The ABC principle:

A small number of items represent a large percentage of the cost value. Conversely, a large
percentage of the items represent only a small portion of the cost value. The procedure adopted to
determine varying levels of control is called the ABC analysis.

Procedure of ABC analysis:

The list of all items in the store and the current annual consumption cost (in rupees) of each item are
noted from records. These records will be available from the stores (total consumption quantity) and
451
from the purchase department (total annual value, or number of units multiplied by unit cost of each
item). The items in the list are them rearranged in the descending order of annual consumption cost,
beginning with the item of highest value at the top and ending with the item of lowest value at the
bottom. It is advantageous to deal with items of general stores and consumable, and medicines,
drugs and dressings separately.

ABC stands for 'Always Better Control'. The intention is to control the best, then better and, lastly,
the good. ABC analysis is the analysis of stores on cost criteria. By analysis of the total cost of
various inventories it has been found that inventories can be divided into three groups as A, B, and
C. The analysis has revealed that 10 per cent of items of inventory attribute to nearly 70 per cent of
the value of the inventory, 20 per cent of the items attribute to 20 per cent of the value of the
inventory, and 70 per cent of items of inventory will be of low value and attribute only 10 per cent
of the value of the inventory.

Control: Lower value items require a lower investment cost even with enhanced level of safety
stock. Larger quantities of such items can be purchased, and because of the higher stock levels the
physical inventory can be lengthened. Conversely, higher value items require a higher investment
cost. Therefore safety stocks should be as low as possible, and minimum economical purchases
should be made, and closer controls are called for. Without ABC analysis, the ordering policy may
be to order all items once a quarter or on as required basis, and the position may become chaotic.

Based on ABC analysis, an average pattern of percentage of items and percentage of their respective
rupee values can be worked out as follows:

Item Percentage of items Percentage of rupee value

'A' Items 10 70

'B' Items 20 20

'C Items 70 10.

It has been seen that a large number of items consume only a small percentage of resources and vice
verse. 'A' items represent high cost centre, 'B' items intermediate cost centre and 'C items are low
cost centers. So far as inventory control is concerned, the following guidelines help in keeping the
system optimum:

'a' items

• Tight control should be exercised.

• Rigid estimates of requirements should be maintained.
• Strict and close watch should be kept.
• Safety stocks should be low.
• Management of items should be done at top management.
• Exact cost of individual items should be counted.

'b' items

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• Moderate control should be exercised.
• Purchase should be based on exact requirement.
• Reasonably strict watch and control should be kept.
• Safety stocks should be moderate.
• Management should be done at middle level.

'c' items

• Ordinary control measure may be exercised.

• Purchase can be based on usage estimates.
• Controls exercises may be done by storekeeper.
• Safety stocks should be high.
• Management should be done at lower levels.

From the above, it is observed that 'A' class items receive strict control and 'B' class items receive
moderate control from overstock and stock out points of view, and 'C class items are not subjected
to much control or attention.

The ABC approach helps in selective control. It is impossible to give equal attention to all the items
in the inventory. The principle of selective inventory management recognises that it is impossible to
manage and control every item in inventory holding in the same way and still meet the objectives of
inventory management.

VED (vital, essential and desirable analysis)analysis:

VED Analysis

This analysis is based on the criticality of the items in relation to the functioning'of the hospital. The
items can be classified into vital (V), essential (E), and desirable (D) items.

'v' items

These are vital items without which the hospital cannot perform its functions, that is, patient care.
These items should have more safety stocks to ensure a higher degree of safety. These items should
be available at all times, and they should be controlled by the top management.

'e' items

These are essential items without which the hospital can function for a short period but which may
affect the quality of patient care to a limited extent. These items can be controlled by middle-level
managers.

D' ITEMS

These are desirable items, the non-availability of which for a considerable period may not affect the
functioning of the hospital. Such items can be controlled at the lower management level.

Use of ABC and VED Analysis

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ABC and VED analyses can lead to the formulation of categories as shown below:

Cat. I II III

A AV AE AD

B BV BE BD

C CV CE CD

The findings of ABC and VED analysis can be coupled and further grouping can be done to evolve
a priority system of management of stores. In another model the stores can be grouped as under:

Cat. I II III

A AV AE AD
B BV BE BD
C CV CE CD

Cat. I = AV items

Cat. II = AE, BE and BV items

Cat. Ill = AD, BD, CD, CV and CE items

Category I items: These items are most important and require the control of the administrator
himself.

Category II items: These items are of intermediate importance and should be under the control of
the Officer-in-charge of the stores.

Category III: These items are of least importance which can be left under the control of the
storekeeper.

Grouping will essentially depend upon the strategy of management and the environment of
functioning. However, these simple techniques can be very effective in a materials management
system.

The Hospital Review Committee for Delhi Hospital (1978-9), in its report, has recommended that
techniques like ABC and VED analysis be used extensively to improve the availability of important
and essential materials in the hospital.

SDE Analysis

This analysis is based on the availability of an item; especially in developing countries where
certain items are scarce, this analysis is very useful.

'S' Items: These are 'SCARCE ITEMS', especially imported, and those which are in short supply.
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'D' Stems: These are 'DIFFICULT' items which are available in indigenous market but cannot be
procured easily. For example, items which have to be managed from far-off cities or for which
reliable suppliers are difficult to find.

'E' Items refers to items which are 'EASILY AVAILABLE' (mostly local items).

HML (high medium and low classification):

HML Analysis The cost per item or per unit is considered for this analysis and all items are
classified as High cost (H), Medium cost (M) and Low cost (L) items. This type of analysis is useful
for keeping control over consumption at the department level and for deciding the frequency of
physical verification.

FSN(fast moving, slow moving, non moving):

FSN Analysis Here the quantity and rates of consumption are analysed to classify the items as Fast
Moving (F), Slow Moving (S), and Non-Moving (N) items. Fast and slow moving classifications
help in arrangement of stocks in the store and in deciding the distribution and handling methods.
Whenever there is huge stock of stores in hospitals, the following steps should be taken:

• A list of non-moving drugs should be circulated to ail patients care areas with necessary
information so as to classify these into:

- drugs which can be used in future

- drugs which need modification for use in future
- Drugs which cannot be used.

• Drugs which cannot be used in hospitals should be sent to other similar organizations.

15. Maintenance management:

Maintenance is the function that has not been rendered obsolete by advance technology. The most
important factors in maintenance is to strike a balance between various costs, when a machine
breaks down, various kinds of costs occurs potential service, idle direct and indirect labor delays,
increased scrap, customers dissatisfaction because of other delays in delivery and actual cost of
repairing machines.

Definition: maintenance is the function of service management that is concerned with day to day
problems of keeping the hospital in good operating condition. It is an essential activity in every
service establishment because it ensures the availability of machines, building and services by
various parts of the organization for the performance of their functions at an optimum return on
investment.

Scope and functions:

The main functions constitute the following activities – primary and secondary function.
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Primary functions:

Maintaining the existing hospital equipment: regular inspection, repair of

equipments.
Maintaining the existing hospital building and structures. Regarding cleaning,
alterations, regular paintings etc.
Installation of new building structures and equipments: purpose of expansion,
up gradation of equipments, technological up gradation, implementing better
working conditions.
Maintenance of utilities, operation and distribution: making alterations in
existing equipments.

Secondary functions:

 Store keeping
 Plant protection against human and natural calamities
 Insurance administration
 Waste disposal
 Salvage
 Pollution control
 Property accounting

Types of maintenance:

 Operational maintenance
 Break down or corrective maintenance
 Preventive maintenance / predictive maintenance
 Scheduled maintenance
 Planned maintenance

Operational Maintenance:

This type of maintenance is confined to small instruments where the technicians who handle the
instrument possess the qualifications necessary to control and perform maintenance of his own
machines.

Break down maintenance:

As the name suggests it is a corrective measure and emergence repair work, repairs are made after
the equipment is out of order. Eg: when an electric motor start, conveyor belt is ripped off.

Preventive maintenance:

This is contract to break down maintenance which is under taken before the break down occurs and
it aims at minimizing the possibility of unanticipated production interruption or major break downs.

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Predictive maintenance:

It is the new type of maintenance that has been anticipated to gain increasing attention. It is a type
of preventive maintenance that involves the use of sensitive instruments like resistance – gauge,
amplitude meters, pressure gauge, etc.

Scheduled maintenance:

It involves taking joint decisions by the service and maintenance department in identifying the items
or equipments that have to the considered for maintenance at regular periods.

Planned maintenance:

Planned maintenance involves the process of deciding in detail and analyzing the programmed work
in a precise and planned / systematic manner.

Advantages of maintenance:

1. Systematic maintenance of procedures offers tremendous savings in the following

areas.
 Increased life of equipments
 Reduction in over time
 Efficient running of equipments
 Maintenance of service quality
 Optimum utilization of inventory
2. The success of maintenance department is dependent on the types of organization
nature of business and the guidelines framed for a adopting a specific technique.
3. Maintenance management is very effective when there is understanding,
coordination, cooperation among all the personnel in the organization.

16. Disposal / condemnation:

In case of nonconsumables like capital equipment, instruments, linen, furniture, etc. excess stock
may build up in user departments for want of adequate controls. It should be possible for a user
department to return the excess stock to the stores as soon as it is detected. The store takes it back
on charge for issue to other user departments. It is necessary to make the administrative staff of the
user department responsible to periodically inspect the complete range of stores held in the
department.

An occasion where consumable items ate requited to be inspected lot -write oil, should arise only
exceptionally. The very fact that date expired items ol consumable storesremain in shelves in the
main store or in deparmental substore points to a lackadaisical system o\r inventory' control. 11
despite all efforts nonmoving and other items accumulate, such items should be reviewed by a
Condemnation Board

Many items have a scrap value. Bottles, IV bags, used linen can be sold as scrap. Some other items
are required to be destroyed by burning or destroyed beyond recognition, to prevent reuse. It may be
possible to use some parts of condemned equipment. Cannibalisation of parts, i.e. removing usable
457
parts of irrepairable equipment for fixing the same to some other equipment to make it usable—may
be possible.

A condemnation board should be convened at least once in a year, or more, to centrally review all
used as well as surplus materials and make recommendation for their disposal.

Waste Management:

Wastages are formed after completion of a process or during the process or etime it takes place at
storeroom itself. Some kinds of wastages are listed low.

1. Waste of water (eg.excessive rain water)

2. Waste of electricity (eg. Using electrical equipment unnecessarily)
3. Waste of land (due to poor and inadequate irrigation system lack of pollution control
procedures).
4. Waste of time (particularly in production plant as machine and labour idle time)
5. Under-utilisation of productive resources.

Obsolete items are those materials and equipment which is not damaged which have economic
worth but which are no longer useful for the hospital ration owing to many reasons such as changes
in service line, process, materials, and so on. Surplus items are those materials and equipment,
which have no immediate use but have accumulated due to faulty planning, forecasting and
purchasing. However, they have a usage value in future. Scrap defined as process wastage.

From the above definitions we can list the reasons for the generation and accumulation of
obsolete, surplus and scrap items:

1. Changes in service design:

This may lead to some items getting invalid so far as the final product is rned. Hence, the entire
stock of such items becomes obsolete.

2. Rationalization:

Sometimes materials are rationalized so as to minimise variety and simplify procurement. The
rationalization process renders some items as surplus or etc.

3. Cannibalization:

When a machine breakdown occurs, sometime it is rectified using parts of identical machine, which
is not functioning due to various reasons. When continued unchecked, this results in obsolete and
scrap items

4. Faulty planning and forecasting;

The marketing department may have projected a service forecast which might be on the higher side.
Any materials planning have to be based on sales forecasts and this could result in surplus items.
Wrong indenting by the user departments also leads to accumulation.
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5. Faculty purchase practices:

Sub - optimising decisions like buying in bulk to take care of discounts and transportation economy
without taking into account factors such as shelf life storage space requirements and technological
changes once again lead to the accumulation of surplus and obsolete stocks.

6. Other causes:

Many items are held as insurable spares for many years without an,, consumption. Faulty store-
keeping methods, without adequate preservaticr lead to spoilage. Inferior materials handling,
improper codification and poor manufacturing methods also result in obsolete, surplus and scrap
items.

Factors Involved In Waste Formation:

(1) Faulty Transportation methods:

Improper transportation leads to waste formation. When materials are transported in bulk, wastage
occurs by spillage materials. In some volatile elements, wastage is in the form of evaporation losses
(e.g. Petrol). During loading and unloading materials are damaged due to careless handling.

(2) Improper Storage:

Improper storage facilities lead to waste formation. During storage wastages and deterioration in
quality occur, due to corrosion, improper use of preservatives, humidity, dust, excessive heat, cold,
rain and other environmental factors. So the application of scientific warehousing methods reduces
the wastages.

3) Lack of Control procedures:

This factor also contributes in formation of wastages. When the production planning is made,
materials purchase and utilization should be planned carefully.

Methods of Waste Control:

The following two methods are used separately or jointly to control the wastes.

1. Technical Research
2. Managerial Research

1. Technical Research:

Through technical research waste can be converted to a profit-making stable product. At that time,
the gain is double, since the expense relating to waste disposal is eliminated. Frequently, through
research a waste is turned into a by-product that becomes a profitable co-product of the operation.

2. Managerial Research:

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Managerial Research concentrates on the proper analysis of requirement, innovative organization,
better control of consumption and a well-designed information system with inbuilt checks on the
bottlenecks.

Suggestion schemes have been implemented in a few organizations to reduce the incidence of
waste. It is also necessary to introduce norms for category of waste at every generating point, with a
view to reducing. Both the technical research and managerial research must be implemented to
make the waste control effectively.

Minimising Loss and Pilferage:

Pilferage is a phenomenon closely associated with materials of all types. Stores may be pilferaged
by the transporter, receiving clerk, other stores personnel and users in wards/ departments. To
minimise thefts from stores, access to all stores buildings and storage should be limited. Locking
and unlocking of stores and the handling of keys should be strictly controlled, intense vigilance is
required by all materials personnel.

Intensive vigilance is also required to prevent frauds involving purchasing personnel in collusion
with vendors. Commissions under the table and kickbacks may induce stores personnel to
compromise the interest of the hospital, especially in case of emergency purchases. Inflating prices,
accepting substandard goods, and making fraudulent payments are sometimes utilized by stores
personnel in collusion with suppliers, especially local suppliers. A system of internal audit as part of
the control process can point out possible loopholes in the system that may lead to pilferages and
frauds. All such loopholes should be plugged with appropriate organization and methods and
policies and procedures.

Chapter – VII shiva

sankari

PLANNING EQUIPMENTS AND SUPPLIES FOR NURSING CARE UNIT, AND HOSPITAL

INTRODUCTION

Effective management and efficient maintenance of health care equipment have deep economic
consequences, have an impact on all aspects of health care delivery, and are vital for the smooth
functioning of every health care facility from the primary health centre to the most sophisticated
hospital in every country.

Available information indicates that a developing country will seldom have 50 per cent of its
equipment in usable condition. Wastage of national health resources persists due to lack of specific
policies, proper management and infrastructure for maintenance of equipment.

Factors contributing to the wastage include purchase of sophisticated equipment which is under
utilized or never used, due to lack of technical expertise to maintain and use it, reduced lifetime of
equipment due to mishandling and lack of maintenance and repair, additional purchase of
accessories, extra spare parts and modification to facilities initially unforeseen due to lack of
expertise in choosing appropriate equipment, lack of standardization, resulting in increased cost of
spare parts or additional purchases and extra workload on limited competent staff, excessive
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downtime of equipment due to lack of preventive maintenance, inexperience in repair and lack of
spare parts,. and shortage of foreign exchange reserves.
Various problems confronting developing countries are lack of organizational policy, lack of
information support, ineffective health care technical services, and lack of manpower development
and training.

Health planners often ignore the costs of maintenance and replacement of equipment. 1nspite of a
large amount of money involved and its enormous social impact, procurement is usually handled by
persons with little knowledge or experience of technology management.

The extreme sophistication of health technology requires qualified staff ranging from technicians
who operate and repair the equipment to the managers who are responsible for planning and
procurement. Greed and short-sightedness of manufactures and suppliers to sell their equipment,
without any commitment to deal with problems of operation and management compound the
problem. Another problem of equipment management develops due to entering of maintenance
contracts with the firms having no local or regional representation. The response time is, therefore,
6 months or longer in most cases.

Circuit diagrams for sophisticated equipment are seldom available. Often, physical facilities and
space, for keeping biomedical equipment are not available. Further, warranty periods are lost even
before the equipment is made operational because the physical facility was either not ready or was
in some stage of construction.

A number of times single specialty doctors, trained abroad, are influential in securing the
procurement of highly sophisticated equipment that are rarely used. When these doctors leave the
public service the equipment is likely to become idle, if there are no other trained persons capable of
using it. Developing countries offer very limited market opportunities to most manufacturers, who
consequently find that they cannot set up profitable after sales service networks as they do in the
industrialized countries. They find it profitable to adopt a ‘wait and replace’ attitude since the old
models breakdown and the after sales service is not available. Then they present new models and
sell them showing the additional features, and thus remain in business. Essential equipment is thus
discarded because of minor faults.
1. Equipment Planning and Utilization

With advances in technology, emphasis on cost containment and required coordination of

departmental needs demand that management should assume the responsibilities of inventory and
evaluating existing equipment, preparing and monitoring equipment lists and budgets, preparing
specifications, and coordinating procurement and installations.

Physical facility planning is to be done carefully in the hospitals in order to accommodate the ever-
increasing variety of equipments. A properly planned facility will curtail unnecessary and wasteful
movement of staff and materials. Planners have to design sufficient flexibility in health care facility.
A properly managed equipment facility gives reduced down time, increased life of equipment and
maintenance of product quality.

2. Equipment Purchasing

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The steps in the process of equipment procurement include:

1. Identifying equipment needs;

2. Collecting information from manufacturers or from other hospitals using the equipment;

3. Product evaluation and specification (it takes a combination of professional, administrative and
technical judgment to select the most appropriate equipment);

4. Identification of source (selection of vendor) and selection of the desired product (evaluated on
the basis of pre-written protocol);

5. Preparation of purchase order, which should include a complete description, specifications and
model number (the purchase process should include negotiation of cost, the delivery date, users’
training, and inspection upon receipt);

6. Planning the installation—needs major engineering decisions; a checklist of installation planning

should be made which should include facility requirement. This should be done preferably in
advance; and

7. Equipment control by means of inventory control methods (I. D. number, location, cost,
description, expected life, model, purchase data, manufacturer, etc.).

It takes a combination of professional, administrative and technical judgment to select the most
appropriate equipment. The purchase process should include negotiation of cost, delivery date,
user’s training, and inspection upon receipt.

A complete equipment management system takes into consideration equipment inventory, storage,
installation, distribution, utilization, maintenance, spares and accessories, safety

3.Equipment Maintenance

Equipment maintenance is the application of scientific and managerial tools, techniques and
approaches for the productive utilization of the equipment resources of the organization, through a
system of continuous and periodic performance evaluation so as to achieve the optimal efficiency as
indicated in the equipment design and also to match the overall organizational objective.

The organization of maintenance operations will depend upon the size of the hospital, the quantity
and the quality of the equipment, and the use of the relevant facilities at different times. The task of
maintenance also depends on the ways the people interface with biomedical equipment. A system of
maintenance generally varies from operational testing to component testing and repair.

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METHODS OF MAINTENANCE

i.Unit Maintenance System

Each unit—electrical, mechanical, biomedical, or civil engineering—performs its own component

of the total maintenance work.

ii.Maintenance by Specialized Crews

Each crew is trained to do a particular job such as repair of X-ray machines, boilers, lifts, etc. The
crew moves from one unit to another to perform its specialized work.

iii.Contractual Maintenance System

Well-trained experts are hired for each job. It is not inconceivable that the entire maintenance
function could be handled by having the various maintenance jobs carried out by contractors.

The best application of this method is in very remote areas where travel takes a great deal of time, in
jobs requiring a high degree of specialization, where the job is not done routinely, and where there
is a relatively low demand for the job to be done.

In practice, a combination of all the three systems will have to be used. It is possible to bring about
80 per cent of the equipment maintenance under the first two methods and the dependence on
external contracts reduced to about 20 per cent. This can be further reduced if any regionalization of
equipment maintenance services is done.

Maintenance contracts should, where necessary, cover provision of training for local workers,
access to consultation, and the availability of specialized personnel.
All the in-house maintenance staff should be trained at the supplier’s facility or other centre’s in
order that they feel confident about the repairs. All the parts that are replaced should be properly
accounted for. They may be either reconditioned for subsequent use or disposed off.

Other Methods

Large hospitals can offer equipment maintenance services to smaller hospitals at costs less than
those normally offered through service contracts. The purchasers of these services receive high
quality workmanship from skilled professionals who ensure the reliability of their equipment. The
providers of these services gain revenue that can be used to effect their own operational costs.

iv.DIFFERENT SYSTEMS OF MAINTENANCE

EMERGENCY MAINTENANCE

Maintenance that needs to be taken immediately to avoid serious consequences is termed as

emergency maintenance.

PLANNED MAINTENANCE

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Maintenance organized and carried out according to a predetermined plan is called planned
maintenance.

CORRECTIVE MAINTENANCE

Maintenance carried out to restore any item that has ceased to be in an acceptable condition is called
corrective maintenance.

PREVENTIVE MAINTENANCE

Preventive maintenance is one that is carved out at predetermined intervals or in accordance with
other prescribed criteria, in order to reduce the likelihood of an item ceasing to be in an acceptable
condition. –

RUNNING MAINTENANCE

Maintenance that can be carried out when an item is in service is termed as running maintenance.

SHUTDOWN MAINTENANCE

Maintenance that can only be carried out when the item is out of service is called shutdown
maintenance.

MAINTENANCE PREVENTION

This can be achieved through a planned procurement of equipment that has been designed to
minimize down time and maintenance effort and to maximize operating life. The real answer to the
problem of maintenance prevention lies with the equipment designers.

CLINICAL ENGINEERING

The functions of a clinical engineer include training program me for users; equipment repair
service; preventive maintenance program me; inspection of equipment before purchasing;
designing, developing or modifying equipment for special needs; and advising on repair and
replacement. The emergence of clinical engineering as a distinct specialty for in-house maintenance
program me is gaining popularity.

TOTAL PRODUCTIVE MAINTENANCE (TPM)

TPM advocates that operators be responsible for maintenance. The activities of this system run in
close collaboration with the quality circles. This concept has produced revolutionary impact, and
has improved productivity and quality.

PREDICTIVE MAINTENANCE

It is the use of graphic trends of measured parameters against known engineering limits for the
purpose of detecting, analyzing and correcting equipment problems before failures occur. These soft

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ware’s are available and could be used without the need for specialist computer skills and at an
affordable cost.

There are three types of predictive maintenance systems—

 Periodic manual monitoring,

 Automatic surveillance, and

 Continuous monitoring.

COMPUTERIZED HOSPITAL

MAINTENANCE SYSTEM

The computer system accomplishes tasks that include maintaining inventory of thousands of clinical
instruments, documenting the repair, preventive maintenance and inspection history for each of
them, generating the list of all items due for scheduled maintenance in the coming month,
generating activity reports and obtaining information regarding the status of various equipment
owned by the hospital. The paper workload can be reduced. Computers could also be involved in
the diagnosis and formulation of the most probable treatment strategies for the sick equipment.

EVALUATION A system of critical analysis of the organizational efficiency through internal or

external experts/consultants, with the prime objective of improving the system, acts as a tonic, It is
imperative that all data related to various maintenance input and output parameters be recorded
meticulously every day. Various indices that can be used are those related to maintenance cost,
work flow and efficiency, material and overhead charges, availability, meantime between failure,
meantime to repair, maintenance breakdown severity, and maintenance improvement.

STEPS IN MAINTENANCE

Equipment maintenance can be carried out by fault diagnosis, fault rectification, and
recommissioning.

Fault Diagnosis

The following is a list of tasks to be carried out in order to diagnose a fault:

• find out the cause of malfunctioning or breakdown;

• maintain a log book for each major equipment and record the description of malfunctioning;
• better record keeping, which is an essential tool;

• maintain a history card for each equipment which will help in predicting the frequency of failure
and in turn the life of spares.

Fault Rectification

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The fault, once diagnosed can be rectified by replacing. the damaged parts, reconditioning and
realignment of dislocated parts.

Recommissioning

Recommissioning of an equipment implies to put the equipment in operation and then handing over
the same to user.

CURRENT PRACTICE

Invariably most of the hospitals have a tendency towards having annual maintenance contract with
the suppliers. Huge amounts are being spent on these contracts. Sometimes the suppliers do not
have an office in the city where these equipments are located with the result that they are unable to
provide immediate support leading to longer equipment down time.

BREAK DOWN TIME

The objective of any maintenance function is to reduce the breakdown time to a large extent (very
near to zero in an ideal situation)

The breakdown time of any equipment consists of time taken up in knowing about the malfunction
or stoppage of the equipment and informing the maintenance personnel, reaching of maintenance
crew to the equipment for fault diagnosis, arranging required tools and spares, fault diagnosis, repair
and maintenance, and recommissioning. These can be reduced to a minimum level if proper
planning is done for maintenance function.

All the equipment should be categorized based on the breakdown cost and its importance to the
hospital. Breakdown of the most important category should be taken up as a top priority for
maintenance. Time taken in fault diagnosis can be reduced by adopting a proper record maintenance
system, and then properly trained persons should be deployed for maintenance. By having a planned
maintenance approach (e.g., preventive maintenance), the time required for arranging tools and
spares can be reduced

Proper spares requirement planning can be made by analysis of the equipment history, the frequency
of failure of particular spares and their replacement, etc. By adopting proper systems and procedures
the time taken up in recommissioning can be minimized. Computerized maintenance management
system designed by Management Information Systems (MIS) specialists can be of great help.

The hospitals should have a maintenance cell with technical staff to look after the breakdown of
equipment, undertake preventive maintenance and maintain the basic maintenance record of the
equipment. The salient advantages of such a system have been identified as:

a. Reduction in idle time and continuous availability of equipment.

b. Increased life of the equipment

c. Timely replacement of spares.

d. Continued service.

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e. Optimal operational costs.

f. Satisfactory quality of service.

g. Safety of operation.

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NURSING UNIT

1.Supplies and Equipment

There must be well functioning equipment and adequate supplies to provide optimum nursing care
Insufficient and ill functioning equipment results in increased work and waste of time by the staff
and may even prove danger to patient’s life. Each hospital should set up a method where by a Sister
(head nurse) or charge- nurse can put a requisition for necessary equipment repairs and maintenance
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All equipment Should be so kept that it is easily available and as near as possible to the place where
it will be required for use. Constantly moving the place for keeping articles causes confusion and
waste of time. The keys must be always carefully kept at a fixed place as certain things have to be
kept in locked Cupboards or store- rooms. The keys must be in the ward all the time and all staff
members should know where and with whom they are available. If this practice is not followed
there will be difficulties and time wasted at the time of emergencies.

Some hospitals maintain a central supply of equipment and supplies. This helps to reduce the total
amount needed in the hospital. However there should be good system for the wards to avail of them
and return them.

The charge nurse is responsible to keep an adequate amount of equipment and supplies on the ward,
to see it in good Conditions, repair conveniently located, All the personnel on the ward should
clearly know who may use the articles or equipment and who assumes responsibility for it. The
head nurse must Watch for, and prevent waste or misuse by educating the staff in economical and
appropriate use of all equipment and materials, she may sometimes arrange a ward class to enable
the staff to know the cost of the equipment.

There are three steps to be taken to ensure an adequate stock of available supplies on the ward or
unit.

(1) Set a standard for the quantity of each item to be maintained on the ward all the time.
(2) Have a satisfactory system for replacement of broken or worn out equipment.
(3) Make regular inventories of all the items. She should draw a regular program for inventories.

2.Standards of quality and quantity of equipment

How to work out the number and the type of each article that is needed? It will vary in each unit.
Factors that serve as guides in getting the standard equipment include:

(1 )The number of beds in the unit

(2) The type of service given on the unit
(3) The age of the patients
(4) The sex of the patients
(5) The severity and types of disease

(6) The cost of the item

(7) Durability of the item.

(8) The period of time between ordering and receipt of new stock.
Some articles need to be equal to the number of beds whereas others in adequate proportion. Certain
articles as per number of beds such as bed mattresses lockers and beds are required. Other articles
such as bedpans should be in proportion to the number of beds. Bedpans’ may be one for three or
four patients. A surgical units may require many items not required by medical unit, children ward
requires different furniture and, items than the ward for adults. Elderly patients and unconscious
patients will require rail beds. There are differences in requirements on men’s and women’s wards.

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An intensive care unit will need emergency equipment and supplies not needed in other units.
Expensive articles will have to be Supplied in small numbers and shared by other units. for
example respirators Defibrillator etc.

Perishable articles will have to be kept in greater number in the stock than those are non-perishable.
Those articles which can be used once such as dressing, Foley’s catheters’ will need to be stocked in
large quantity or number.

3.Replacement: -

The frequency of ordering new supplies is very important. Some supplies need to be indented daily;
some weekly or monthly. Some items last for many years and require to be replaced after a long
period. There should be regularized method for ordering the equipment and supplies. The
departments and persons from whom new articles are obtained should be clearly known by all staff
members.

There must be regular system for replacing certain items when they are broken, perished or no
longer in use. The usual system followed in almost all hospitals is getting the old or irreparable
articles condemned; before the new articles are supplied The broken or useless articles are presented
before the person or a committee for condemning and issuing new

4.HEAD NURSES RESPONSIBLITIES/NURSES

 To keep an adequate supply of materials on hand at all times in good condition ,available for
use ,and conveniently located.

 To delegate to someone the responsibility for handling equipments and supplies.

 To be observant of waste and misuse.

 To educate Nurses, Doctors, and other personnel in the economical use of materials

5.REQUISITIONS

A requisition is a written order for supplies and equipment or for their repair.

i.FREQUENCY OF ORDERING

 Materials perishablity e.g. foods such as milk, egg and fruit must be ordered daily. Sterile
supplies which may become outdated are also ordered each day or every other day.

 Storage space on the wards

 Cost and convenience of handling and filling requisitions and transportation.e.g.once a week
for nonperishable supplies.

ii.principles involved in writing requisitions

 To make accuracy and ease of handling

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 a. Articles are specified by catalogue number or description: Asepto, #1046

b.Amounts are indicated in proper form: safety pins 20 should be ordered in a packing

C.A separate requisition is made for each department from which supplies are delivered; that
is storeroom, pharmacy, etc.

 To ensure authorization and reception of articles.

a. The head nurses name appears on each requisition together with the initials of the
individual making the order.

b. There is a place on the form for the approval of persons in authority—the staff officer in
the nursing service, who is in charge of supplies and equipment and a member of the
hospital administrative staff.

c. The, requisition is signed by the individual on the ward who receives the articles
indicating that she assumes responsibility for their receipt.

 To prevent over ordering and errors an ordering the head nurse is provided with a list of
equipment with specifications, and of supplies with the standards for ordering. If these lists
are not included on the requisition form they may be mimeo graphed and placed in a loose
leaf notebook

iii.Requisitions for Exchange items

Articles for exchange may be listed on the regular requisition form or a special one. Complete
specifications are necessary as with other requisition .Duplicate copies of the order may be required,
,one to accompany the articles for exchange, the other to be sent with the set of requisitions for
approval.

iv.Requisitions for Replacements

To bring up the supply to standard or to increase the standard, requisitions accompanied by a

staternent explaining their need may be required.

v.Requisitions for Repair or Construction

These are usually written on a special form and give an exact description of the job to be done.

6.Method of Ordering Supplies.

Before writing the order a ‘systematic check needs to be made to determine the amounts which are
on hand The check may be made by an aide or the ward clerk The head nurse then considers her
expected needs, compares them with the amounts on hand and the list of standards ‘for ordering,
determines .the amount needed, and writes the- requisition. She allows a small margin for
emergencies as she gains in experience she will be, able to judge needs fairly accurately. If. She
inadvertently orders incorrect items or an Oversupply they usually cannot be returned if the hospital

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keeps a perpetual inventory Materials in this way may be wasted; This is one of the important
reasons why ordering should be done by the same individual: consistently and. certainly never by
one who’ has not received complete instructions and supervision.

i.Ordering Linen.

Methods of ordering linen often vary from those of other supplies.

METHOD 1. ‘Sometimes each ward is issued a standard ‘supply of linen in which case it is labeled
with the name of the ward and the date of issue. The latter, helps to determine the life of the article.

After laundering, the linen is sorted and returned to the proper wards. Maintaining standards is
achieved by .inventory and replacents for worn or lost linen in the same way as other equipment is
re placed .This system requires the time of maids to sort it by wards and it also permits linen to be
stocked on the shelves when the census is light. A larger total supply is therefore needed ‘than
would otherwise be necessary.

METHOD 2 some hospitals consider it less expensive ant more efficient to use a central linen room
The linen which is issued marked-with ‘the name of the hospital. (and .the date)but is not-
designated for a specific ward. All linen is returned after laundering to the central linen, room.
Sorting of torn articles is done either in the laundry or in the linen room, preferably the former
because tears are more easily detected as articles are being -folded. Mending is done in the sewing
room. When, a central, linen room is used distribution-to the wards, may be accomplished by one of
several methods.

One method requires a requisition from, the head nurse (or her assistant.)’ who estimates the ward
needs on the basis of’ a standard; that is, one sheet per patient per day plus enough extras for
patients who need .an additional supply and enough ,to make up fresh beds. Following the
discharge’ of. Patients. A daily shelf count must be made as a guide in ordering. This method
involves considerable time, on. the part of’ the head purse and is apt to lead to shortages due to
hoarding on wards where needs are not accurately estimated

METHOD -3 To overcome these disadvantages another distribution method is sometimes used.

Linen issued to the wards daily or at periodic intervals in accordance with a fixed standard in
relation to the number and type of patients and, ‘the number of discharges. The calculation of needs
is made in the linen room. A shelf count is made on each ward by a member of the linen, room staff
or by the ward maid and the amounts on hand are deducted from the estimated needs. This method
saves considerable time for the head nurse ‘and’ works, in a satisfactory’ manner in many
institutions where it has been tried Sometimes linen is put up in bundles one for each patient,
containing the usual daily allotment of a sheet pillow case, face towel, and such An extra supply of
each item is sent for emergency use and for patients who require additional linen Complete sets of
linen each containing the items necessary to make up a unit are’ also sent’, ‘the number,
corresponding with the number of’ patients -to be discharged. To minimize ‘handling and save time
for the. Ward staff the daily bundles may be delivered directly to the patient’s rooms the afternoon
or evening before they are to be used

7.Delegation of Responsibility for the Handling of Supplies and Equipment.

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 In a busy ward, the head nurse cannot carry responsibility for all details of ward management.
Indeed she tries to. do so she will not be a very successful .administrator Some. aspects of
management in regard: to supplies and- equipment can easily be delegated to other individuals.

A student nurse may have a:short experience in assuming responsibility for: Supplies and
equipment, usually in connection with her treatment room assignment. In some instances a nurse’s
aide or the ward clerk can perform the mechanical aspects of the function. A noñ nurse assistant
could relieve the head nurse of the entre responsibility in this area.

i.Keeping Shelves Stocked

Any one of these individuals could easily keep a check on the amounts in cupboards or: on shelves
ready for’ use, making sure that there is always enough available. The - excess is kept in storage and
a small amount removed at a time to keep the shelves stocked .Workers should be instructed, to see
that the oldest supplies are placed where they will be used first and to remove outdated surgical
goods for reSterilizatlon; Supplies need to he kept well labeled and arranged so that they can be
easily located ‘and quickly identified. Both equipment and supplies must be protected against
damage or deterioration.:

ii.Keeping the treatment room in order.

If equipment is sterilized on the ward, this responsibility as well as the task of keeping the treatment
room in order and the cupboards and drawers clean can be specifically delegated to a nurse with a
maid or aide to assist her. it should be the definite responsibility of one individual to make sure that
ample supplies are available for the evening and night nurses, especially when it is difficult to
Obtain materials from a central ‘source after certain hours.

Iii.Taking inventory

The individual assigned to the task of handling supplies and equipment may also take the periodic
(daily and weekly) counts of equipment as necessary to keep track of at She keeps the head nurse
informed of losses and misplacement of equipment-and shortages in supplies. She also may make
the daily Or weekly report of supplies on find to be used by the head nurse in writing requisitions
.Preparation of broken or worn equipment for exchange and compiling the necessary lists is a
function the head nurse herself need not perform.

iv.Need for a Routine Procedure ‘The Only way to ensure the efficient management of the
aciivities’associated with Supplies equipment is to establish a definite routine and setup specific
directions for its accomplishment This material should be placed in writing and used for teaching
the person to whom the duties are delegated Directions should be in usable form and located
conveniently for references. Time is saved when methodical measures are adopted for mechanical
functions.

v.Reporting Deficiencies.

It should be the function of every individual to report breakage, equipment which is in need of
repair and low stocks of material. Again, if there is to be efficiency, a definite system for reporting
should be instituted. Preferably. a writ ten memorandum is made of the information to be reported
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A notebook ‘or ‘a spindle with pencil and paper at hand are useful if they are located in a
convenient’ place, ‘are checked daily, and if necessary measures are taken to correct the shortages
.A system for tagging impaired equipment and a definite place for depositing it should be known to
all .Here again It is advisable that a uniform system be. adopted throughout the hospital to save
confusion. Daily review of supplies on hand and frequent checking of the condition of electric,
plumbing and other equipment will minimize the amount of reporting which the staff will need to
do

vi.Observation of Waste and Misuse

It is necessary that the head nurse know the needs of the ward so that excessive use of supplies can
be detected. For example, if the number of dressings per day and the approximate amount of
dressing materials needed are known, it is possible to detect waste and a check can be made to
determine the cause. Perhaps more materials are being removed from drums ,Cans, or packages than
are needed for a dressing or treatment. In this case the ward supply is depleted unnecessarily.
Although clean materials can be salvaged, time is required to transport, repack, resterilize, and
reissue the goods. Waste of dressing materials occurs also when clean outside dressings, such as
pads, are discarded instead of being reapplied when the dressing is changed.

A few other sources of waste will be. enumerated briefly. Each head nurse needs to study, with the
help of her staff, the causes of waste on her own ward.

Linen is wasted when there is failure to protect the bed adequately for treatments and by the use of
regular linen, instead that which may be worn or already stained, when medications such as gention
violet or oils used in treating the patients skin.

Foods wasted in ward are four items e.g. Bread, Butter, Milk, Eggs. Minimizing services who
cannot eat.

Rubber goods-needs to be stored after drying or inflating.

8.Education of personnel in economical use of hospital property.

 Instruction in the causes of breakage and deterioration as well as the proper care of
equipment.

 Use of illustrative material and bulletin boards to emphasize the costs of the equipments and
the need for its careful handling.

 Group conferences

 Use of the ward budget as a source of educational data.

9.The central supplies service

Few hospitals have established a central department where equipment and supplies are stored and
from which they are dispensed to wards usually on loan or exchange basis. All types of equipments
may be issued from the central department while commonly used articles are stored in the wards.
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A ward is equipped with a standard number of treatment sets which are exchanged in the central
supplies room after use. In this instance the tray is setup or the equipment prepared for use on the
ward. After reuse these are washed and returned in a set to the central supply room where it is
thoroughly cleaned, checked, packed and resterilized.

Inventory
Introduction
The inventory may be defined as the physical stock of good, units or economic resources that are
stored or reserved for smooth, efficient and effective functioning of business. Many companies
have wide-ranging inventories, consisting of many small items such as paper pads, pencils, and
paper clips, and fewer big items such as trucks, machines, and computers. A particular company's
inventory is related to the business in which it is engaged. A tennis shop has an inventory of tennis
rackets, shoes, and balls. A television manufacturer has parts, subassemblies, and finished TV sets
in its inventory. A theater has an inventory of seats, a restaurant has an inventory of tables and
chairs, and a public accounting firm has an inventory of accountants.
Without inventories customer would have to wait until their orders were filled from a source or
were produced. In general, however, customer will not like to wait for long period of time. Another
reason for maintaining inventory is the price fluctuation of some raw material, (may be seasonal), it
would be profitable for a buyer to procure a sufficient quantity of raw material at lower price and
use it whenever needed. Some researchers also argue that maintaining inventories on display
attracts more customers resulting increase in sale and profits.
Just as inventory is the stock of any item or resource used in an organization, an inventory system
or management is the set of policies and controls that monitor levels of inventory and determine
what levels should be maintained, when stock should be replenished, and how large orders should
be.

Definitions of inventory control:

Inventory is the sum total of all supplies, official and non official, wherever they may be stored,
that have not yet been used.
It may be defined as planning, ordering and scheduling of materials used in the service process.
Types of Inventory:
The inventory is divided into two categories; viz direct inventory and indirect inventory. The direct
inventory is one that is used for manufacturing the product. It is further sub-divided into following
groups.
1. Raw material inventories
2. Work-in-process inventories
3. Finished – goods inventory
4. Spare parts inventory

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As figure 1.1 shows, raw materials originate at the supplier and the manufacturing plant keeps
them in inventory. The manufacturer then processes these raw materials into component parts,
which are also inventories. The manufacturer may purchase other component parts directly from
the supplier and then partly assemble those components, which creates a work-in-process
inventory. Final assembly turns the work-in-process inventory into finish goods inventory.
Manufacturers can hold their finished goods inventories at the plant, distribution centers, a field
warehouse, wholesalers, and retailers.

Second Type of inventory is indirect inventory. The indirect inventory does not play any role in
finished goods product but it is required for manufacturing. Thus, indirect inventory acts as catalyst
which only speeds up / down the reaction.

The indirect inventory is classified as follows:

1. Fluctuation inventory: This acts as a equilibrium between sales and production. The reserve
stock that is kept to maintain fluctuations in the demand and lead – time, affecting the production
of items is called fluctuation inventory.
2. Anticipation inventory: This is programmed in advance for the seasonal large sales, slack
season, a plant shut down period etc.
3. Transportation inventories: The existence of transportation inventories is mainly due to
movement of materials from one place to another.
4. Decoupling Inventories: These inventories are maintained for meeting out the demands during
the decoupling period of manufacturing or purchasing.

How to Measure Inventory

Inventory is a hot topic in manufacturing circles today. Managers closely monitor and control
inventories to keep them as low as possible while still providing acceptable customer service.
To monitor and control inventories, managers need ways to measure inventories. Typically
inventories are measured in three ways: average aggregate inventory value, weeks of supply and
inventory turnover.

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Measuring inventories begins with a physical count of units, or a physical measurement of volume
or weight. Because the monetary value of various units may vary a great deal, managers use the
average aggregate inventory value to calculate the average total value of all items held in inventory
during some time period. We compute the average aggregate inventory value by multiplying the
average number of units of each item (the beginning inventory plus ending inventory, divided by
two) by its per unit value to obtain the total average value of each item and then add the total
average values of all items. The average aggregate inventory value tells the inventory manager just
how much of the company's total assets are invested in inventory.
To calculate the second measure of inventory, weeks of supply, divide the average aggregate
inventory value by the value of the sales per week. The numerator of this measure includes the
value of all inventory items (raw materials, work in process, and finished goods), whereas the
denominator includes only the cost of the finished goods sold.
To calculate the third measure of inventory, inventory turnover (turns), divide the annual value of
the sales by the average aggregate inventory value maintained during the year.

Reasons for Holding Inventories

Inventories serve a number of important functions in various companies. Among the major reasons
for holding inventories are
1. To satisfy expected demand. Companies use anticipation stock ( buffer stock) to satisfy
expected demand, and it is particularly important for products that exhibit marked seasonal demand
but are produced at uniform rates. Air conditioner, rain suit manufacturers and children's toy
manufacturers build up anticipation stock, which is depleted during peak demand periods.
2. To protect against stock outs. Manufacturers use safety stock to protect against uncertainties in
either the demand or supply of an item. Delayed deliveries and unexpected increases in demand
increase the risk of shortages. Safety stock provides insurance that the company can meet
anticipated customer demand without backlogging orders. In Figure 1.1, the plant can invest in
safety stocks at several points. Raw materials and component parts can have safety stocks within
the manufacturing plant. Finished goods can have safety stocks throughout the materials flow (at
the plant, field warehouses, distribution centers, wholesalers, and retailers).

3. To take advantage of economic order cycles. Companies use cycle stock to produce (or buy)
in quantities larger than their immediate needs. Because of the cost involved in setting up a
machine, companies usually find producing in large quantities economical. Similarly, to minimize
purchasing costs companies often buy in quantities that exceed their immediate requirements. In
both cases, periodic orders, or order cycles, produce more economical overall production costs.
The quantity produced is called the economic lot size. The quantity ordered is called the economic
order quantity (EOQ).

4. To maintain independence of operations. The successive stages in the production and

distribution system require a buffer of inventories between them so that they can maintain their
independence of operations, for example, the raw materials inventory buffers the manufacturer
from problems with a supplier. Similarly, the finished goods inventory buffers factory operations
from problems in the distribution system.
5. To allow for smooth and flexible production operations. A production-distribution system
needs flexibility and a smooth flow of material, but production cannot be instantaneous so work-in-
process inventory relieve pressure on the production system. Similarly, manufacturers use in-transit

477
or pipeline inventory to offset distribution delays. Both work-in-process inventories and pipeline
inventories are part of a broader classification, called movement inventories.
6. To guard against price increases. Manufactures sometimes use large purchase, or large
production runs, to achieve savings when they expect price increases for raw materials or
component parts.

Objectives of inventory control

Inventory control has two major objectives. The first objective is to maximize the level of customer
service by avoiding under stocking. Under stocking causes missed deliveries, backlogged orders,
lost sales, production bottlenecks, and unhappy customers.
The second objective of inventory control is to promote efficiency in production or purchasing by
minimizing the cost of providing adequate level of customer service. Placing too much emphasis
on customer service can lead to over stocking, which means the company has tied up too much of
its capital in inventories.
These two objectives often conflict. Achieving high levels of customer service by maintaining
certain inventories leads to higher inventory costs and less efficiency in production or purchasing.
Inventory control becomes a balancing act. Many a times a manager selects a desired level of
customer service and attempts to control inventory in a manner that achieves that level of customer
service at the lowest cost possible . Thus the problem is striking a balance in inventory levels,
avoiding both overstocking and understocking.
The basic purpose of inventory analysis in manufacturing and stock keeping services is to specify
(1) when items should be ordered (when to order)and
(2) how large the order should be (how much to order).
Many firms are tending to enter into longer-term relationships with vendors to supply their needs
for perhaps the entire year. This changes the "when" and "how many to order" to "when" and "how
many to deliver."
In this chapter, we will try to answer these questions under variety of circumstances.
In making decisions about inventory levels, companies must address a variety of costs. Hence,
before we proceed to answer the above two questions, let us discuss about the costs involved in
inventory decisions.

Functions of inventory control:

 To carry adequate stock to avoid stock-outs
 To order sufficient quantity per order to reduce order cost
 To stock just sufficient quantity to minimize inventory carrying cost
 To make judicial selection of limiting the quantity of perishable items and costly materials
 To take advantage of seasonal cyclic variation on availability of materials to order the right
quantity at the right time
 To provide safety stock to take care of fluctuation in demand/ consumption during lead time
 To ensure optimum level of inventory holding to minimize the total inventory cost.

Costs Involved In Inventory Problems:

The costs play an important role in making a decision to maintain the inventory in the organization.
These costs are as follow:

1. Purchase Cost:
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The actual price paid for the procurement of items is called purchase cost. The purchase cost
becomes relevant if a quantity discount is available. A company offering quantity discounts drops
the price per item when the order is sufficiently large. This becomes an incentive to order greater
quantities.

2. Inventory Holding Cost:

The holding cost is the cost associated with maintaining an inventory until it is used or sold.
Holding or storage cost includes the cost of maintaining storage facilities, the cost of insuring the
inventory, taxes attributed to storage, costs associated with obsolescence, and costs associated with
the capital that is committed to the inventory. The latter is called the opportunity cost, an expense
incurred by having capital tied up in inventory rather than having it invested elsewhere, and it is
frequently the most important component of the inventory holding cost. The opportunity cost is
generally equal to the biggest return that the company could obtain from alternative investments.
The holding or storage cost is usually related to the maximum quantity, average quantity, or excess
of supply in relation to demand during a particular time period. For example, a company could
estimate that its annual inventory holding cost is approximately 13 to 15 percent of the original
purchase price of the commodity. So another common practice is to estimate the annual holding
costs as a percentage of the unit cost of the item.

3. Shortage Cost:
The stock out or shortage cost occurs when the demand for an item exceeds its supply. When a
stock out or shortage occurs, a company faces two possibilities:
• It can meet the shortage with some type of rush, special handling or priority shipment.
• It cannot meet the shortage at all.

The cost associated with a stock out or shortage depends on how the company handles the problem.
Consider first the cost incurred when the inventory is on back order. In theory, demand for the
back-ordered item is satisfied when the item next becomes available. From a practical standpoint,
accurately determining the nature and magnitude of the back-ordering cost can be difficult. A small
portion of the back-ordering cost, such an the cost of notifying the customer that the item has been
back ordered and when delivery can be expected, may be fairly easy to determine. Another portion
of the back-ordering cost may involve explicit costs for overtime, special clerical and
administrative costs for expediting, and extraordinary transportation charges. Such costs are much
more difficult to determine. Finally, a major portion of the back-ordering cost is an implicit cost - it
reflects the loss of the customer's goodwill. This is a difficult cost to measure, because it is a
penalty cost that accounts for lost future sales, for example, an equipment retailer might have a
shortage cost composed primarily of loss goodwill, which it can estimate as 15 percent of the
original purchase cost of the equipment. But when back ordering is not possible or the customer
chooses to order from another company, the shortage costs include the costs of notifying the
customer, the loss in profit, from the sale, and the future loss of goodwill.
The shortage cost may also depend on the size of the shortage and how long the shortage lasts. For
example, customers may have written into their purchase contracts specific penalty clauses that are
based on shortage amounts and times. In other instances the shortage cost may be a fixed amount
regardless of the number of units unavailable or how long the shortage exists.

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4. Set-Up Cost ( or the ordering cost):
Each time a company places a purchase order with a supplier or a production order with its own
shop, it incurs an ordering cost. To buy an item someone has to solicit and evaluate bids, negotiate
price terms, decide how much to order, prepare purchase orders, and follow up to make sure that
the shipment arrives on time. For example, when we order an item from a supplier, we might incur
a Rs.100 cost for placing the order and a cost of Rs.5 for each unit we are ordering. The purchasing
cost function for this situation is Rs.100 + Rs.5x where x is the number of units. The fixed portion
(Rs.100) of the total purchasing cost is independent of the amount ordered; it is primarily the cost
of the clerical and administrative work. Placing a production order for a manufacturing item
involves many of the same activities; only the type of paperwork changes .

The setup cost is the cost involved in changing a machine over to produce a different part or item.
While someone is adjusting a machine, it is idle and the company incurs the additional costs of the
setup workers. Sometimes the machines are producing trial products, and they will make defective
parts until the machine is fine-tuned. For example, we have a production process for manufacturing
TV cabinets. The setup cost for a production run is Rs.1,000, and each TV cabinet costs Rs. 55 to
manufacture. The manufacturing cost function for this situation is Rs.1,000 + 55x where x is the
number of TV cabinets.
Companies treat setup costs as a fixed cost and try to make the production lot size as big as
possible to spread the setup cost over as many units as possible.

5. Total Inventory Cost:

If price discounts are available, then we should formulate total inventory cost by taking sum of
purchase cost (PC), Inventory Holding Cost (IHC), Shortage Cost (SC) and Ordering Cost (OC).
Thus, the total inventory cost; TC, is given by
TC = PC + IHC + SC + OC
When price discounts are not offered then total cost (TC) is given by
TC = IHC + SC + OC
Establishing the correct quantity to order from vendors or the size of lots submitted to the firm's
productive facilities involves a search for the minimum total cost resulting from the combined
effects of four individual costs: holding costs, setup costs, ordering costs, and shortage costs. Of
course, the timing of these orders is a critical factor that may impact inventory cost.
Apart from costs, the other variables which play an important role in decision making are as
follows:
1. Demand:
The size of the demand is the number of units required in each period. It is not necessarily the
amount sold because demand may remain unfulfilled due to shortage or delays. The demand
pattern of the items may be either deterministic or probabilistic. In the deterministic case, the
demand over a period is known. This known demand may be fined or variable with time. Such
demand is known as static and dynamic respectively. When the demand over as period is uncertain
but can be predicted by a probability distribution, we say it is a case of the probabilistic demand. A
probabilistic demand may be stationary or non-stationary over time.
Independent versus Dependent Demand
In inventory management, it is important to understand the difference between dependent and
independent demand. The reason is that entire inventory systems are predicated on whether
demand is derived from an end item or is related to the item itself.

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Briefly, the distinction between independent and dependent demand is this: In independent
demand, the demands for various items are unrelated to each other. For example, a workstation
may produce many parts that are unrelated but meet some external demand requirement. In
dependent demand, the need for any one item is a direct result of the need for some other item,
usually a higher-level item of which it is part.
In concept, dependent demand is a relatively straightforward computational problem. Needed
quantities of a dependent-demand item are simply computed, based on the number needed in each
higher-level item in which it is used. For example, if an automobile company plans on producing
500 cars per day, then obviously it will need 2.000 wheels and tires (plus spares). The number of
wheels and tires needed is dependent on the production levels and is not derived separately. The
demand for cars, on the other hand, is independent—it comes from many sources external to the
automobile firm and is not a part of other products; it is unrelated to the demand for other products.
To determine the quantities of independent items that must be produced, firms usually turn to their
sales and market research departments. They use a variety of techniques, including customer
surveys, forecasting techniques, and economic and sociological trends. Because independent
demand is uncertain, extra units must be carried in inventory. This chapter presents models to
determine how many units need to be ordered, and how many extra units should be carried to
reduce the risk of stocking out.
2. Lead – Time:
It is the time between placing an order and its realization in stock. It can be deterministic or
probabilistic. If both demand and lead–time are deterministic, one needs to order in advance by a
time equal to lead-time. However, if lead-time is probabilistic, it is very difficult to answer - when
to order?
3. Cycle Time:
The cycle time is time between placements of two orders. It is denoted by T. It can be determined
in one of the two ways.

I) Continuous Review: Here the number of units of an item on hand is known. In this case, an
order of fixed size is placed every time the inventory level reaches at a pre-specified level, called
reorder level. Many authors referred this as the two-bin systems or fixed order level system.

II) Periodic Review: Here the orders are placed at equal interval of time and size of the order
depends on the inventory on hand and on order at the time of the review. This is also called the
fixed order interval system

Concepts relevant in controlling inventory costs:

The following concepts are relevant in controlling the inventory costs:

Periodic/ cyclic system: this system involves review of stock status at periodic/ fixed intervals and
placement of orders depending on the stock on hand and rate of consumption. The ordering interval
is thus fixed but the quantity to be ordered varies each time.
Two bin system: it is a system where the stock of each item is held in two bins, one large bin
containing sufficient stock to meet the demands during interval between arrival of an order
quantity and placing of next order, and the other bin containing stocks large enough to satisfy
probable demands during the period of replenishment. When the first bin is empty, an order for
replenishment is placed, and the stock in the second bin is utilized until the ordered material is
received.
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Lead time: this is the period required to obtain the supply once the need is determined. It is
therefore the average number of days between placing an indent and receiving the material. Lead
time is composed of two elements: administrative or buyer‟s lead time (i.e. Time required for
raising purchase requisitions, obtaining quotations, raising purchase order, order to reach supplier
etc) and delivery or supplier‟s leading time ( i.e. Time required for manufacture, packing and
forwarding, shipment, delays in transit)
Minimum/safety/ buffer stock: this is the amount of stock that should be kept in reserve to avoid a
stock-out in case consumption increases unexpectedly or in case the lead time turns out to be
longer than normal. It is also the level at which fresh supply should normally arrive, failing which
action should be taken on an emergency basis to expedite supply and replenish the stock.

Safety stock = maximum daily consumption-average daily consumption x total lead time
Maximum order level: this is the maximum quantity of the materials to be stocked, beyond which
the item must not be in the inventory. If the inventory is maintained beyond this point, there would
be loss to the hospital by way of expiry of life items beyond the shelf life of items, loss incurred on
the capital locked up in the inventory, unnecessary use of items just to exhaust the inventory

Re-order level: this is the value which is very important from the point of view of the inventory
control. This is the point at which we have to place an order for procurement for replenishing the

stock. It is derived by the formula (minimum order level + buffer stock)

Deterministic Continuous Review Models:

Notations:
The following notations for the discussion of models

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Economic Order Quantity (EOQ) Model with Constant Rate of Demand:
EOQ is one of the oldest and most commonly known techniques. This model was first developed
by Ford Harris and R.Wilson independently in 1915. The objective is to determine economic order
quantity, Q which minimizes the total cost of an inventory system when demand occurs at a
constant rate. The model is developed under following assumptions:

 The system deals with single item.

 The demand rate of D units per time unit is known and constant.
 Quantity discounts are not available.
 The item is produced in lots or purchasers are made in orders. The ordering cost is constant.
 Shortages are not allowed. Lead – Time is known and is constant.
 Replenishment rate is infinite.
 Replenishment size, Q, is the decision variable.
 T is cycle time.
 The inventory holding cost, Ch per unit per time unit is known and constant during the
period under review.

The following figure shows the graphic depiction of this particular inventory situation. Each
inventory cycle begins with the receipt of an order of Q units. i.e Q units are ordered and stocked in
the system. Demand is occurring at the rate of D units per time unit during cycle time T.

At the reorder point R, when the on-hand inventory is barely sufficient to satisfy demand during
the lead time, LT, an order of Q units is placed. Since the demand rate and the lead time are
constant, the order of Q units is received exactly when the inventory level reaches zero. This means
that there are no shortages.

The inventory level varies from Q to zero, so the average inventory level during the inventory
cycle is Q/2. So, the inventory holding cost is obtained by multiplying this quantity with the cost of
holding one unit per time unit. Hence, IHC = ( Q/2) Ch . This cost is a linear function of Q.

The number of orders placed during the planning horizon would be D/Q and hence the inventory
ordering cost OC will be a function of the number of orders placed and the ordering cost per order.
483
Thus, OC = (D/Q) Co. Because the number of orders made in the planning horizon, D/Q, decreases
as the order size, Q, increases, OC is inversely proportional to Q.
The cost of the individual item is assumed to be constant, regardless of the size of the order. So the
purchase cost of the item is a horizontal line as shown in the following figure. It only increases the
total inventory cost by the constant amount, DC, during the entire quantity range. It does not affect
the optimal order quantity, Q*. Therefore, it is not really a relevant cost for the economic order
quantity decision and we can eliminate it from further consideration in the model.
Hence,
Total Inventory Cost TC = Ordering cost + holding cost
TC = (D/Q) Co + (Q/2) Ch

The total cost curve is U-shaped and reaches its minimum at the quantity for which the carrying
and the ordering costs are equal. We can equate both these values to obtain the optimal order
quantity Q*.
Alternatively, we can use calculus to obtain the expression for Q*, setting the first derivative of TC
to zero and solving for Q.
Thus,

484
Also, since (d2TC/dQ2) > 0, Q* is minimum
The resulting expression of Q* obtained above is called the economic order quantity or the
economic lot size.
The number of orders during the planning horizon is = D/Q*
The length of the order cycle t is = Q*/D 2DCCoh
And the minimum total inventory cost TC* = ( D/Q*) Co + ( Q*/2) Ch
Note:
(1)Over a period of time, a company can use two policies for making inventory decisions. First, it
can keep the order size small. This will result in a small average inventory, and inventory carrying
costs will be low. But this policy will lead to frequent orders, and the total ordering costs will
increase. Second, the company can increase its order size. This will result in less frequent orders,
so the total ordering costs will be low. But this will result in a high average inventory, and the total
inventory carrying costs will increase.
(2) If unit cost is taken into account then TC = CD + ( D/Q) Co + ( Q/2) Ch

Sensitivity of lot-size model:

For the lot-size model, we have total cost of an inventory system per time unit as TC =
(D/Q*) Co + ( Q*/2) Ch and Q* as given above. Now suppose that instead of ordering for Q0 – units
(given as Q* above) and suppose that for it the total cost of the inventory system is TC (Q0), we
replenish another lot-size (say) Q1. Such that Q1 = bQ0,
b > 0 and let TC1 (Q1) be the corresponding total cost of an inventory system.

The ratio is known as the measure of sensitivity of the lot-size model. TC

Limitations of the EOQ Formula:

Note that the EOQ formula is derived under several rigid assumptions which give rise to limitation
on its applicability.
 In practice, the demand is neither known with certainty nor is uniform over the time period.
If the fluctuations are mild, the formula is practically valid; but when fluctuations are wild, the
formula looses its validity.
 It is not easy to measure the inventory holding cost and the ordering cost accurately. The
ordering cost may not be fixed but will depend on the order quantity Q.
 The assumptions of zero lead-time and that the inventory level will reach to zero at the time
of the next replenishment is not possible.
 The stock depletion is rarely uniform and gradual.
 One may have to take into account the constraints of floor-space, capital investment, etc in
stocking the items in the inventory system.

Using the following information, obtain the EOQ and the total variable cost associated with the
policy of ordering quantities of that size. Annual demand = 20,000 units, ordering cost = Rs. 150
per order, and inventory carrying cost is 24% of average inventory value.

Solution: Given D = 20,000 units, Co = Rs. 150 / order, Ch = Rs. 0.24 / unit / annum. Then using
the above formulas for Q and TC,

485
Q* = 5000 units and TC (Q*) = Rs. 1,200.

Example 1.1: An oil engine manufacturer purchases lubricants at the rate of Rs. 42 per piece from
a vendor. The requirement of these lubricants is 1,800 per year. What should be the order quantity
per order, if the cost per placement of an order is Rs.16 and inventory carrying charge per rupee
per year is 20 paise.

Solution: Given D = 1,800*42 = 75,600 units, Co = Rs.16 / order and Ch = 0.20 per unit / year.
Then
Q* = 34,776 units.
Thus, the optimum inventory quantity of lubricant at the rate of Rs.42 per lubricant =Q*/42 = 83
lubricants.
Example 1.2 : A company uses rivets at a rate of 5,000 kg per year, rivets costing Rs.2 per kg. It
costs Rs.20 to place an order and the carrying cost of inventory is 10 % per annum. How frequently
should order for rivets be placed and how much?

Solution: Given D = 5,000 kg / year. C = Rs.2 / kg., Co = Rs. 20 / order and Ch = 2 * 10 % per
unit/year.
Then Q* = 1,000 kgs. and T* = Q*/D = 1/5 years = 2.4 months.

A supplier ships 100 units of a product every Monday. The purchase cost of product is Rs.60 per
unit. The cost of ordering and transportation from the supplier is Rs.150 per order. The cost of
carrying inventory is estimated at 15 % per year of the purchase cost. Find the lot-size that will
minimize the cost of the system. Also determine the optimum cost.
Solution: Given D = 100 units per week, Co = Rs.150 /order, Ch = 15% of 60 = Rs. 9 per unit / year
= Rs.9/52 per unit / week. Then Q*= 416 units, and optimum cost = CD + TC(Q*) = Rs.6,072

EOQ Model with constant demand and shortages allowed:

The inventory problem in the above section becomes slightly more complicated when a company
permits shortages, or backorders, to occur. However, in many situations shortages are
economically desirable. Permitting shortages allows the manufacturer or retailer to increase the
cycle time, thereby spreading the setup or ordering cost over a longer time period. Allowing
shortages may also be desirable when the unit value of the inventory and therefore the inventory
holding cost is high.
In the back order situation customers place an order, no stock is available, and they simply wait
until stock becomes available, at which point the order is filled. The company hopes that the
waiting period for the back order will be short and its customers will be patient.
For this model we will use the assumptions of a known and constant demand rate and
instantaneous delivery of goods to inventory like the basic EOQ model. If S represents the amount
of the shortage ( size of the back order) that has accumulated when the new shipment of size Q
arrives, the economic order quantity model with constant demand and permissible shortages has
the following major characteristics and graphic depiction.

486
When the new shipment of size Q arrives, the company immediately ships the back orders of size S
to the customers. The remaining units Q-S immediately go into inventory.
 The inventory level will vary from a minimum of -S units to a maximum of Q-S units.
 The inventory cycle of T units is divided into two distinct parts: t 1 when inventory is
available for filling orders and t2 when inventory is not available, stock outs occur, and back orders
are made.
Here apart from the notations introduced in the previous model we introduce two new notations as
follows:
Cs: cost of back order, per unit per unit time
S: the number of units short or back ordered.
Now,
The inventory ordering cost is a function of the number of orders made, D/Q, and the inventory
ordering cost per order, Co.
OC =No. of orders × Cost per order = (D/Q) Co
Also we know that t1 = (Q-S)/D and t2 = S/D
The inventory holding cost can be calculated from the figure as:
The average inventory for the time period t = [ (Avg. inventory over t1) + (Avg. inventory over t2) ]
/t
The positive inventory level ranges from Q-S to 0. This means that the average inventory level is
(Q-S)/2 for the time period t1. For t2 it is 0.
IHC = Average inventory × cost of holding one unit

The backordering cost is computed in a similar way. From the figure we can see that the shortage
ranges from 0 units to S units. This means that the average shortage is S/2 while there is shortages
i.e during the time period t2.
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SC = Average number of units short × cost of one unit being short

For this inventory model the total cost is calculated as tQ

TC = ordering cost + holding cost + shortage cost = OC + IHC + SC

Since TC is a function of two variables Q and S, therefore to determine the optimal order size and
the optimal shortage level S, we need to differentiate the total variable cost function with respect to
Q and S, set the two resulting equations equal to zero and solve them simultaneously. By doing so,
we get the following results

The number of orders for the planning horizon = D/Q*

The maximum inventory level = Q* - S*
The average positive inventory level is = (Q* - S*) / Q*
The length of time during which there are no shortages = t1* = (Q* - S*) / D
The length of time during which there are shortages = t2* = S* / D
The length of the inventory cycle = t* = Q* / D
The minimum total inventory cost during the planning horizon =

The demand for a certain item is 16 units per period. Unsatisfied demand causes a shortage cost of
Rs.0.75 per unit per short period. The cost of initiating purchasing action is Rs. 15.00 per purchase
and the holding cost is 15% of average inventory valuation per period. Item cost is Rs. 8.00 per
unit. Find the minimum cost and purchase quantity.

Solution: Given D = 16 units, Cs = Rs.0.75 per unit short, Ch = Rs. 8 * 15% = Rs. 1.20 and Co =
Rs.15.00 / order.

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A television manufacturing company produces its own speakers, which are used in the production
of its television sets. The television sets are assembled on a continuous production line at rate of
8,000 per month. The company is interested in determining when and how much to procure, given
the following information:
(I) Each time a batch is produced, a set-up cost of Rs.12, 000 is incurred.
(II) The cost of keeping a speaker in stock is Rs. 0.30 per month.
(III) The production cost of a single speaker is Rs.10.00 and can be assumed to be a unit
cost.
(IV) Shortage of a speaker, (if there exists) costs Rs. 1.10 per month.

Solution: Given D = 8,000 televisions per month, Co = Rs.12, 000 per production run, Ch =
Rs.0.30 per unit per month, Cs = Rs.1.10 per unit short per month.

Case (i) When Shortages are not allowed, = 25,298 speakers and T = Q*/D = 3.2
months.
Thus, 25,298 speakers are to be produced every 3.2 months.

Case (ii) When shortages are permitted = 28,540 speakers and T =

Q*/D = 3.6 months

Hence, when shortages are permitted, 28,540 speakers are produced at every 3.6 months.

Optimal number of speakers stored = 22,424 speakers.

Thus, a shortage of 6,116 (= 28,540 – 22,424) speakers is permitted.

Or else optimal shortage level = = 6116 ( approx)

THE CONTINUOUS REVIEW MODEL: When to order
Here we consider a continuous review inventory system. Here the inventory level is being
monitored on a continuous basis so that a new order can be placed as soon as the inventory level
drops to the reorder point.
Personals, in practice, make a physical count of inventory at periodic intervals to decide how much
of each item to order. Using the continuous review system to determine when to reorder, we review
the remaining quantity of an item each time a withdrawal is made from inventory. In practice,
operations managers make a physical count of inventory at periodic intervals (daily, weekly, or
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monthly) to decide how much of each item to order. Many small retailers use this approach, simply
checking the quantities on shelves and in the storeroom on a periodic basis.
Another very elementary type of continuous review system is the traditional two-bin system, which
sets aside two containers, or bins, to hold the total inventory of an item. Items are withdrawn from
the first bin until it is empty, at which point it is time to reorder the quantity that will again fill the
bin. The second bin contains enough stock to satisfy demand until the order comes in, plus an extra
amount to provide a cushion against a stock out.
In recent years, two-bin systems have been largely replaced by computerized inventory systems.
Each addition to inventory and each sale causing a withdrawal are recorded electronically, so that
the current inventory level always is in the computer. Therefore, a computer will trigger a new
order as soon as the inventory level has dropped to the reorder point.
The continuous review system is also called a reorder point (ROP) system, or a fixed order
quantity system. It is also called a (R,Q) policy. It works this way:
“Place an order for Q units whenever a withdrawal brings the inventory to the reorder point R.”
The continuous review system has only two parameters, Q and R, and each new order is of size Q.
For a manufacturer managing its finished products inventory, the order will be for a production run
if size Q. For a wholesaler or retailer, the order will be a purchase order for Q units of the product.
Let us address the question of “when to order”. At the time of placing a new order, the stock in
hand should be sufficient to meet the demand until the new order arrives.
When both demand and the lead time are deterministic ( known with certainty), the reorder level is
calculated as:
Reorder level (ROL) = Demand during the replenishment lead time = d × LT

Example : Demand for an item is 5200 units a year and the EOQ has been calculated as 250 units.
If the lead time is 2 weeks, then the ordering policy will be ROL = (5200 / 52) × 2 = 200 units.
This means that as soon as the stock level falls to 200 units an order equal to EOQ = 250 units
should be placed. This rule of ordering is applicable only if the lead time is shorter than the stock
cycle. Here, the stock cycle is T = Q*/d = 250/100 = 2.5 weeks.
But if the lead time is 3 weeks, then the ROL = 100 × 3 = 300 units. Since EOQ = 250 units,
therefore stock level varies between zero and 250 units. Thus lead time demand of 300 units
suggests that there should be one outstanding order. In such cases, an order is placed when
Lead time demand = stock on hand + stock on order
300 = stock on hand + 250
or ROL = Lead time demand – stock on hand
In general, an ordering policy is stated as: “when lead time is between n × T and (n+1) × T, order
an amount Q* whenever stock on hand falls to d × LT – n × Q*, where n is number of stock cycle
and lead time exceeds cycle time T”. For example, lead time of 3 weeks is between 2 and 3 stock
cycles, so n = 2, then
ROL = d × LT – n × Q*
= 100 × 3 – 2 × 250
= 50 units.
i.e. each time the stock on hand declines to 50 units, an order of 250 units is placed.
Example: The annual demand for a product is 3,600 units with an average of 12 – units per day.
The lead-time is 10 days. The ordering cost per order is Rs.10 and the annual carrying cost is 25%
of the value of the inventory. The price of the product per unit is Rs. 3.00.
(I) What will be the EOQ?

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(II) Find the purchase cycle time?
(III) Find the total inventory cost per year?
(IV) If the safety stock of 100-units is considered necessary, what will be the reorder level and the
total annual cost of inventory which will be relevant to inventory decision?

Equipment condemnation and disposal

The life cycle of equipment is fairly simple, but one process that seems to cause problems is
deciding when to condemn and how to dispose of equipment.

When looking at condemnation and disposal, the engineer in charge of the department should have
the experience, knowledge, and authority to decide when a piece of equipment should be scrapped
and removed from use.

The reasons for condemning equipment will usually be:

 Beyond economical repair - Where equipment comes in and the cost of repairing it is
considered too high after looking at the current value (taking depreciation into account), and the
age of the equipment.
 Technically obsolete - Parts and service support are no longer available.
 Clinically obsolete - The clinician using the device (or manufacturer) recommend
replacement for clinical reasons. (Diagnostic ultrasound imaging usually becomes clinically
obsolete after 5 years due to the rapid improvements in imaging technology, but can still be used
and supported by the supplier.)
 Equipment that has been damaged by contamination.

The information supplied to the user must include the date of condemnation, whom the equipment
belongs to and who authorized the condemnation. This would usually be the Manager on a
condemnation form.

When sending out the notification of condemnation copies should be sent to senior managers
responsible for procurement, and users of the equipment. An equipment condemning note/memo
should be individually numbered and logged onto the equipment database with an individual job
number, equipment description, including the make, model, serial number, control (asset) number,
purchase date (age), reason for condemning and any additional information.

You should also state the equipment location (Dept / Ward) and at which Hospital.

If the manager/user requires further information, contact details must be added, such as your
telephone, e-mail, fax, etc.

Finally, the manager should sign off the condemnation letter.

If a replacement is required the cost for new equipment needs to be included in the capital bids
processes (where the equipment is over £5000) giving financial priority to the most urgent
purchase based on need and risk.

A record of all condemnations should be kept on the database.

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Disposal

Once the equipment has been condemned it should be quarantined or thrown away. To quarantine
the equipment means removing it from clinical use and putting it somewhere it cannot be used
which is allocated as an area for scrapped equipment. There may be an alternative use for this
equipment:

 Third world charity

 Research project
 Training
 Sold on to vet nary practice, etc.

If there is an alternative use, the equipment may be held in the quarantine area until it can be
handed over. Whoever takes the equipment must sign a form agreeing that the equipment is 'taken
as seen'. All service and inventory labels must be removed, and all patient information deleted
(where the device has IT storage capability)

The equipment that cannot be found an alternative use must be disposed of safely. This will usually
include:

 Removal of lead acid, Nickel Cadmium or other alkaline batteries for separate disposal in
line with trust policies.
 Evacuation of Cathode ray tubes to prevent the risk of implosion (Usually by breaking off
the nipple at the back of the tube).
 Removal of in line fuses.
 Cleaning and decontamination.
 Removal of all means to power up the device. (i.e. On hard wired devices the mains cable
should be cut off.)
 Removal of all hoses able to pressurize a device (if driven by gases)

Once these precautions have been taken, the equipment may be thrown in the skip to be taken to
the local landfill site, or incinerated where appropriate.

XI. Minimizing Loss and Pilferage

Pilferage is a phenomenon closely associated with materials of all types. Stores may be pilfer aged
by the transporter, receiving clerk, other stores personnel and users in wards/departments. To
minimize thefts from stores, access to all stores buildings and storage should be limited. Locking
and unlocking of stores and the handling of keys should be strictly controlled. Intense vigilance is
required by all materials personnel.

Intensive vigilance is also required to prevent frauds involving purchasing personnel in collusion
with vendors. Commissions under the table and kickbacks may induce stores personnel to
compromise the interest of the hospital, especially in case of emergency purchases. Inflating prices,
accepting substandard goods, and making fraudulent payments are sometimes utilized by stores
personnel in collusion with suppliers, especially local suppliers. A system of internal audit as part
of the control process can point out possible loopholes in the system that may lead to pilferages and

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frauds. All such loopholes should be plugged with appropriate organization and methods and
policies and procedures.

Application to Nursing Service, Education

Ensuring regular and adequate flow of supply of necessary equipment, supplies, drugs and
solutions.

Monitoring and sustaining the quality and safety of the materials used including drugs and
solutions. Issuing of items on the basis of “First in First Out” and regular checking of expiry
dates of drugs contribute towards safety.

Indenting, receiving, storing, checking and timely replenishing of all necessary equipments,
supplies, drugs and solutions.

Maintaining of emergency and buffer stocks.

Arranging for preventive maintenance wherever necessary.

Maintaining inventory and stock of all items and supplies.

Arranging for condemnation of articles in accordance with the laid down policies of the
organization and maintaining of dead stock register.]

Arranging and assisting in audit of materials.

Participation in policy making for material management.

Participation in tender/procurement sub-committees.

Orienting Nursing personnel on material management policies from time to time.

Evaluating the efficacy of the material management system followed in particular Nursing
Unit.

CHAPTER- VIII SONIYA

Quality assurance – Continuous Quality Improvement(Standards,Models ,Nursing audit)

1.INTRODUCTION:

Quality is a relative term that describes something with high merit or excellence as compared to an
accepted standard or norm. Today’s society demands a greater accountability and increased
efficiency from the health care system where professional survival and efficiency are directly
linked. Both the consumers and the providers of care have a vested interest in the quality of the
health care system.

Evolution of nursing as a scientific discipline, its commitment to direct accountability, concerns

about cost of health services, consumer right and prospective payment mechanisms demands
quality assurance in nursing profession also.
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Quality assurance includes monitoring of the activities of client care to determine the degree of
excellence attained in the implementation of activities in nursing it implies that a level of quality
can be defined and measured and that the public can be assured of that level of care

DEFINITION OF QUALITY ASSURANCE:

Quality assurance means delivery of efficient and effective medical care in accordance with the
professional standards.

Quality assurance is a planned programme which objectively monitors and evaluates the clinical
performance of all practitioners, which identifies opportunities for improvement, and which
provides a mechanism through which action is taken to make and sustain those improvements.

Quality Assurance is the defining of nursing practice through well written nursing standards and
the use of those standards as a basis for evaluation on improvement of client care (Maker 1998).

Quality assurance refers to the planned and systematic activities implemented in a quality system
so that quality requirements for a product or service will be fulfilled.”Donabedian (1986)

OBJECTIVIES OF QUALITY ASSURANCE

According to Jonas (2002), the two main objectives are,

 To ensure the delivery of quality client care

 To demonstrate the efforts of the health care providers to provide the best possible
results.

Other objectives are:

 To formulate the plan.

 To attend the patients physical and non-physical needs.
 To evaluate achievement in nursing care.
 To support delivery of nursing care with administrative and managerial services.

PURPOSE OF QUALITY ASSURANCE:

 Help patients and potential patients by improving quality of care.

 Assess competence of medical staff
 Bring to notice of hospital administration the deficiencies and in correcting the causative
factors.
 Helps to exercise a regulatory function, restricting undesirable procedures.

PRINCIPLES OF QUALITY ASSURANCE;

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 1. The principles of non maleficence: Do not harm has been a basic principles of the health
care since the writing of the Hippocratic oath .
2. The principles of beneficence : Do good work is the basic principles of professionalism.
3. Ethics: The strong social work ethic is our culture , place a high value on doing a good
job.

PRINCIPLES OF QUALITY ASSURANCE IN NURSING:

Quality assurance system should be understandable to stakeholders, effectively

administered, publicity accountable and cost effective to operate.
Qualifications should be accessible to all candidates who have the potential to achieve them.
The criteria which define the performance required of candidates for them achieve
qualifications should be appropriate to purpose, explicit and in the public domain.
Each unit, course and group award should be unique and necessary and should comply with
the relevant qualification specification.
Assessments should be valid, reliable and practicable and assessment results should be valid,
in line with qualification criteria.
Qualifications should be offered in centres which have the resources and expertise to asses
candidates against the qualifications criteria.
Staff in centres should be provided with effective support in assessing candidates for
certification.
Responsibility for quality assurance should be developed to centres where this is consistent
with the maintenance of national standards.

GOALS OF QUALITY ASSURANCE;

 Three major goals of an effective nursing quality assurance program. These areas-
 Evidenced of nursing accountability for services rendered and compliances with standards of
practice.
 A defined mechanism to identify, measures and resolves, clinical issues related to practice.
 A defined mechanism of evaluating quality indicators, collecting data, developing corrective
action and assessing outcomes.

COMPONENTS OF QUALITY ASSURANCE PLAN;

A quality assurance plan provides the foundation and framework of all quality control activities. A
quality assurance plan should include the following components.

Clearly stated goals

Measurable objectives of how the goals will be met
Designated accountability for written objectives
Delineated methods of QA activities
Outlined responsibilities conducting QA activities
Outlined mechanisms of reporting of reporting data
Outlined mechanisms of corrective action

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 Clear statement of confidentiality

The World Health Organization in their booklet 'The principles of Quality Assurance' (1983) set
out four particular components that must be addressed in any quality assurance activities. They are:

Performance ( technical quality)

Resources use ( efficiency )
Risk management ( the identification and avoidance of injury or illness associated with
service provided)
Patient satisfaction with the services provided.

QUALITY ASSURANCE PROCESS

 Establishment of standards or criteria Identify the information relevant to criteria

 Determine ways to collect information
 Collect and analyze the information
 Compare collected information with established criteria
 Make a judgment about quality
 Provide information and if necessary, take corrective action regarding findings of
appropriate sources
 Reevaluation

FACTORS AFFECTING QUALITY ASSURANCE IN NURSING ;

Lack of Resources: Insufficient resources , infrastructure , equipment ,consumables, money for

recurring expenses and staff make it possible for output of a certain quality to be turned out
under the prevailing circumstances.

Personnel problem: Lack of trained , skilled and motivated employees , staff indiscipline affects
the quality of care.

Improper maintenance: Building and equipment require proper maintenance for efficient use. If
not maintained properly the equipment cannot be used in giving nursing care.

Unreasonable patients and attendants:Illness , anxiety , absence of immediate response to

treatment , unreasonable and unco-operative attitude that in turn affects the quality of care in
nursing.

Absence of well informed population: To improve quality of nursing care, it is necessary that the
people become knowledgeable and assert their right to quality care. This can be achieved
through continuous educational program.

Absence of accreditation laws: There is no organization empowered by legislation to lay down

standard in nursing and medical care so as to regulate the quality of care. It requires a legislation
that provides for setting of the stationary accreditation /vigilance authority .

 Inspect hospital and ensures that basic requirements are met.

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  Enquire into major incidence of negligence
 Take actions against health professional involved in malpractice.

Lack of incident review procedure; During a patients hospitalization reveal incidents may occur
which have a bearing on the treatment and the patients final recovery . These critical incidents
may be:

 Delayed attendance by nurses , surgeon , physician

 Incorrect medication
 Burns arising out of faulty procedure
 Death in corridor with no nurse / physician accompanying the patients etc

Lack of good and hospital information system ; A good management information system is
essential for the appraisal of quality of care.

 Workload , admission procedure and length of stay.

 Activity audit and scheduling of procedure.

Absence of patients satisfaction surveys; Ascertainment of patients satisfaction at fixed points on

an ongoing basis . such surveys carried out through questionnaires , interview to by social
worker , consultant group and help to document patients satisfaction with respect to variables
that are

1. Delay in attendance by nurses and doctors .

2. Incidence of incorrect treatment

Lack of nursing care record;Nursing care records are perhaps the most useful source of
information on quality of care rendered . The records

1. Detail the patients condition

2. Document all significant interaction between patients and the nursing
personnel .
3. Contain information regarding response to treatment .
4. Have the dates in an easily accessible form.

Miscellaneous factors;

i. Lack of good supervision.

ii. Absence of knowledge about philosophy of nursing care.
iii. Lack of policy and administrative manuals.
iv. Substandard education and training.
v. Lack of evaluation technique .
vi. Lack of written job description and job specification.
vii. Lack of in –service and continuing educational program.

STEPS IN QUALITY ASSURANCE

There are major steps in establishing in quality assurance

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  Decide what information you need
 Collect the data
 Use the information and result

I. DECIDE WHAT INFORMATION YOU NEED

Select health services to be monitored .A given health system provides a large number of
services , not all of which can be monitored . Monitoring should focus on those services
which are considered to have the highest priority.

a) Select health services to be monitored : A given health system provides a large

number of services not all of which can be monitored .monitoring should be focus
on the services which are considered to have the highest priority .
b) Describe the process of care: the health care process to be monitored must be made
explicit by listing the critical activities that must be conducted for the correct
delivery of the services or management of the health condition .A flow chart may
be the useful tool for mapping the main steps of care process.
c) Draw a system view of services: A system perspective of the services that will be
monitored will help to better understand the process to be monitored and to
identify the critical inputs and expected outcomes.
d) Make critical standards explicit: Standard must be defined for each critical system
component whose performance is to be monitored.
e) Develop performance indicators: Indicators to measure performance according to
each standard are then developed. Such indicators measure the gap between
observed and expected performance according to standard.

II. COLLECT THE DATA

a) Choose appropriate data collection method: Quality monitoring data may be

collected through a variety of methods , including direct observation ,patient
exit interview, interview with health care provider, and records review. Each
methods has its advantage and disadvantage and none is adequate for all the
situation. The right combination of methods will depend on the resource
available, the familiarity of the data collectors with the method .
b) Design the monitoring tool: Forms to collect the data and tabulate the findings
must be developed and data collectors trained in their use .Using structured
forms helps to decrease variation in the results obtained by different
observers.
c) Test the monitoring tool: Data collection forms should be reviewed with the
intended users of the forms and field tested to verify their appropriateness.
d) Select the monitoring strategy: The monitoring strategy involvers determining
whose performance will be monitored , the optional frequency for data
collection , how existing information and monitoring systems will be used for
quality monitoring purposes , and how the accuracy and validity of the data
will be ensured.
e) Collect data: Implementing the quality monitoring system requires planning
to prepare and mobilize data collectors . Data collection may be carried out
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 by the term specifically organized for this purpose or may be collected by
supervisors as part of routine supervision.

III. USE THE INFORMATION AND THE RESULT

a) Tabulate results: after the data have been collected , they must be
tabulated and used to calculate the performance indicators.
b) Analyze the information : Data analysis seeks to determine the overall
performance level of the providers or facilities being monitored ,identify
the best ,and worst performers and identify patterns or trends in
performance .
c) Interpret and use results: The data obtained through quality monitoring
are then used to identify performance gap and the root causes of poor
performance .
d) Design the data storage and retrieval system: Once the data are collected
regularly they must be stored in an accessible form and location that
allows for regular updating or monitoring data.
e) Disseminate information :information obtained through quality monitoring
should shared first with the staff whose performance was assessed.
Dissemination workshop, management meetings newsletters , and other
informational methods may be used to disseminate monitoring results to
internal and external audience.

APPROACHES FOR A QUALITY ASSURANCE PROGRAMME:

Two major categories of approaches exist in quality assurance they are:

A. General
B. Specific

A. General Approach:

It involves large governing of official body’s evaluation of a persons or agency’s ability to meet
established criteria or standards at a given time.

1) Credentialing:

It is generally defined as the formal recognition of professional or technical competence and

attainment of minimum standards by a person or agency.

 Licensure: It is a contract between the profession and the state, in which the profession
is granted control over entry into and exists from the profession and over quality of
professional practice.
 Accreditation: National league for nursing (NLN) a voluntary organization has
established standards for inspecting nursing education’s programs. In the part the
accreditation process primarily evaluated on regency’s physical structure,
organizational structure and personal qualification. In 1990 more emphasis was placed

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 on evaluation of the outcomes of care and on the educational qualifications of the
person providing care.
 Certification: Certification is usually a voluntary process with in the professions. A
person’s educational achievements, experience and performance on examination are
used to determine the person’s qualifications for functioning is an identified specialty
area.

B. Specific Approach:

1. Peer Review Committee:

These are designed to monitor client specific aspects of care appropriate for certain levels of care.
The audit has been the major tool used by peer review committee to ascertain quality of care.

2. Utilization review:

Utilization review activities are directed towards assuring that care is actually needed and that the
cost appropriate for the level of care provided.

3 types of Utilization review:

i. Prospective: It is an assessment of the necessity of care before giving service

ii. Concurrent: A review of the necessity of care while the care is being given.
iii. Retrospective: In analysis of the necessity of the services received by the client after
the care has being given.

Utilization review has been used primarily in hospitals to establish need for client admission end
the length of hospital stay. The Utilization review process includes the development of explicit
criteria that serves as indicators of the need for services and length of services.

Advantages of Utilization Review:

 It is designed to assist clients to avoid unnecessary care

 It may serve to encourage the consideration of care options by providers, such as
home health care rather than hospitalization.
 It can provide guidelines for staff of program development.
 It provides a measure of agency accountability to the consumer.

The major disadvantage to Utilization review is that hot all clent fit for the classic picture presented
by the explicit criteria that serves as the basis for approval or dermal of care.

3. Evaluation Studies:

Three major models have been used to evaluate quality they are:

a. Donabedian’s structure – process – outcome model

b. The tracer model
c. The sentinel model
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 4. Client Satisfaction:

Client satisfaction can be assessed using person or telephone interviews and mailed questionnaire.
Data from client satisfaction surveys are used to measure structure, process and outcome of care
given.

5. Incident Review:

During a patient’s hospitalization several incidents may occur which have a bearing on the
treatment and patients final recovery. The report should contain the name, age, exact time and
place, description of how it occurred any precaution taken conditions of patient before and after the
incident etc. since these reports are of legal value it should be written carefully given importance to
all the details and should be filed safely.

6. Risk Management:

It can be defined in a program that is developed for the propose of eliminating or controlling health
care situations that has the potential to inure endangers or create risk to clients. Risk management
activities are directed towards the identifications, analysis and evaluation of situations to prevent
injury and subsequent financial loss.

7. Malpractice litigation:

It is a specific approach to be imposed on the health care delivery systems by the legal systems.
Malpractice litigation results from client dissatisfaction with the provider and with the content of
care received.

Quality Assurance Committee (QAC):

The committee should consist of the following:

1. Medical administrator
2. Two senior clinicians
3. Pathologist
4. Radiologist
5. Nurse administrator
6. Medical records officer – secretary
7. Additional personnel such as super-specialists and consultants can be co-opted on the
committee as and when required.

Quality Assurance Committee in Nursing:

The members of the committee should include representative of all levels of professional
nursing including

 Client Care coordinators

 Supervisors
 Head Nurses
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  Clinical Specialists
 Nurse Clinicians
 Licensed practical Nurses
 Nursing Assistants
 Other client care personnel
 Medical records Administrator

Functions of the QAC:

1. Coordination:

 Collecting information
 Consider activities that should ne related, e.g. quality appraisal and continuing
education
 Communicate across patient care disciplines
 Coordinate actions of hospital authority groups

2. Information:

 Provide a centralized source of reports to the board

 Suggest need for intervention to hospital authority groups

3. Planning:

 Establish priorities

4. Prodding:

 Insist on effective, productive quality appraisal efforts from all hospital components

5. Consultation:

 Provide specific assistance, usually through the coordinator

6. Response:

 Internally, acknowledge issues of importance to individual and departments when

suggesting high-priority areas for immediate attention
 Externally, provide the organizational home for responding to quality requirements
of external agencies, if any, e.g. medical companies.

7. Search for expertise:

 Operate openly, not behind closed doors seek out the specific clinical and/or
management expertise necessary to reach sound conclusions

8. Follow-up:

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Insists on reports of the impact of implemented changes. Correcting the orientation of committee
members is crucial in view of the subtle approach that must be used if quality assurance is to be
effective rather than threatening, controversial, and counterproductive. Committee members must
recognize that their major functions are:

i. To coordinate, not to control

ii. To inform, not to scold
iii. To plan, prod, and suggest priorities, not to do detailed studies “in committee”, and
iv. To recommend and report, not to intervene directly.

3.DEFINITION OF QUALITY IMPROVEMENT (QI):

The Joint Commission on Accreditation of health care organizations (JCAHO) 1997 defines
quality improvement as an approach to the continuous study and improvement of the process of
providing health care services to meet the needs of clients and others.

JCAHO’S 10 STEPS FOR QUALITY IMPROVEMENT:

1. Establish responsibility and accountability for a QI Program

2. Define the scope of service for a chemical area
3. Define the key aspects of service for the chemical area
4. Develop quality indicators to monitor the outcomes and appropriateness of care
delivered.
5. Establish thresholds for evaluation of indicators
6. Collect and analyze data from monitoring activities
7. Evaluate results of monitoring activities to determine the need for change in practice
8. Resolve problems through development of action plans
9. Reevaluate to determine if the plan was successful
10. Communicate QI results to the organization.

FACTORS AFFECTING QUALITY IMPROVEMENT

Nursing’s self regulation

In the mid-1800s, nurses began to assume responsibility for maintaining standards in the services
they provided by requiring minimum levels of education.

Peer review is an ongoing process of assessing performance against the standards and criteria that
indicate quality care in a specific agency. It involves periodic review of care giving practices by
staff nurses, who may make shared home visits with their peers or observe peers teaching groups of
clients or implementing the services of programs or projects.

The ANA has contributed to formal quality improvement evaluative processes through the
development of models, quality of care and peer review guidelines, and nursing care standards,
including those. for community health nursing and home health nursing. In addition, nursing case

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management and managed care concepts have been incorporated in publications produced by the
ANA since 1982.

in addition, there is a trend in nursing practice for nurses to practice evidence-based nursing, which
involves the process of making clinical decisions using the best available research evidence,
clinical expertise, and client preferences, in the context of available resources.

The American Nurses Credentialing Center (ANCC) was 'established in 1989 and assumed
responsibility for the ANA certification programs. Professional certification is a confirmation of
knowledge and expertise within a defined area of nursing. It assures the public that the credentialed
nurse is competent at an advanced level and has had this competency confirmed through
examination and years of practice. Continuation of the credential is maintained by further
examination, practice, or other actions deemed examples of expertise in the area. ANCC (2003)
provides an opportunity for clinical certification of nurses who have achieved the baccalaureate
(BSN) and have had several years of clinical practice in more than 25 clinical specialties.

Certification and accreditation of health care organizations

The hospitals and health care agencies have many responsibilities to their client, staffs, boards of
directors, and the funders complicate their functioning and have the potential to compromise care.

As these organizations have developed and diversified, many methods for managing their large
staffs, multiple departments, and missions have emerged. Institutional attention to quality-of-care
issues first appeared in the 1940s and 1950s. At that time, it became clear that organizations
delivering health care services needed to monitor those services to meet trie goals of the
organization and its consumers and to survive in a competitive environment. External certification
and accreditation processes began at about the same time (Catalano, 2003). These processes verify
an organization's ability to provide adequate service. Voluntary accreditation boards, such as the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), examine all types of
health care organizations—inpatient and outpatient care facilities health care networks, and health
plans—and help them attend to all facets of their operations thus establishing appropriate priorities.

In reviewing an organization for accreditation, they consider how quality is affected by such
factors as staff recruitment, organizational structure, management effectiveness, billing practices,
and planning. They also require, in all agencies that they certify, evidence of effective quality
measurement and improvement programs that use an interdisciplinary team approach.

Through the 1970s, accrediting bodies focused most of their attention on hospitals. In the 1980s,
the alternation shifted to include ambulatory or outpatient care, long term care, and home health
care. That shift occurred for many reasons, but the high costs of care and competition for health
care dollars were the leading reasons why such agencies sought accreditation.

Legislation and regulation

Legislation and regulation of health care services are the function of individual states. Agencies
must be licensed by the state, staffed by trained and licensed people, and prepared to provide the
services offered. State licensure or accreditation standards are monitored by regular state inspection

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and annual surveys. If an agency provides a variety of technically sophisticated services, such as
mammography or ultrasonography, additional state inspection may occur.

Most often health care organizations apply for and receive federal or state grants to support specific
programs or services. These grants are often a major part of the agency budget, and if the services
do not maintain a specified standard of quality, funding will be discontinued. The withdrawal of
financial support may cause other services to be discontinued as well clients with fray continuous
care.

Financial reimbursement

Financial reimbursement is often linked to the state through grants that provide fund for
immunization programs, maternal and child health programs. Without this important source of
financial support, many agencies would have to limit their services.

Monitoring of specific aspects of care is often done in response to flinders' requirements for
periodic progress reports rather than as part of a program of quality management. If monitoring is
done only for reimbursement purposes, the total quality of the program is not the agency goal, as it
should be. Health care agencies cannot survive without relying on reimbursement sources, but
quality management should be a mission of the agency regardless of the source of funding.

Consumer demands

Which health care provider or health care agency consumers choose to use is often based on
presumed or assumed care giving services and the quality of those services. Health care consumers
are provided with much choice when selecting health care services. This competition in the health
care market place is beneficial to consumers. When consumers are knowledgeable receivers of
health care services, they can demand quality care as they define it.

They make decisions regarding health care services based on quality domains, such as
Proficiency—capability, expertise, or knowledge of the staff and the manner in which services are
provided Judgment—consistency, objectivity, and reasonable interpretation of regulations
Responsiveness—timeliness, assistance, and guidance Communication—clarity of verbal and
written expression Accommodation—the behavior or interpersonal skills of staff Relevance—
significance and pertinence of the encounter with staff The decisions regarding these domains are
based on consumers" perception of the care received This perception is an important piece of the
quality measurement and improvement program within an organization.

4.STANDARDS OF QUALITY ASSURANCE

DEFINITION:

Standard is an establish rule as basis of comparison in measuring or finding capacity quality

context and value of object in the same category. standard is board statement of quality.

IMPORTANCE OF STANDARDS IN NURSING:

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  It is an authoritative statement by which the quality of nursing practice service and education
can be judged.
 In nursing practice, standards are established criteria for the practice of nursing.
 It is a guideline and a guideline is a recommended path to safe conduct an aid to professional
performance.
 It provides a baseline for evaluating quality of nursing care, increases effectiveness of care
and improve efficiency.
 Standard, help supervisors to guide nursing staff to improve performances.
 Standards may help nursing to clearly define different levels of care.

PURPOSES OF STANDARDS:

The purposes of publishing, circulating and enforcing nursing care standards are to,

Improve the quality of nursing

Decreases the cost of nursing
Determine the nursing negligence.

To give direction and provide guidelines for performance of nursing care.

To provide a baseline for evaluating quality of nursing care, ranging from excellent care to
unsafe care.
To help to improve quality of nursing care, increase effectiveness of care and improve
efficiency.(Quality assurance)
To improve documentation of nursing care provided i. e maintain record of care.
Help to determine the degree to which standards of nursing care maintained and take
necessary action time.
To help supervisors to guide nursing staff to improve performance.
To help to improve the decision making and devise alternative system for delivering nursing
care.
It may help justify demands for resources association or improvement.
To help to clarify nurses area of accountability.
To help nursing to define clearly different levels of care.
Help to decrease the costs of nursing care of eliminating nonessential nursing tasks.
Be used as a framework or basis for determining nursing negligence.
Motivate nurses to achieve excellence.

CHARACTERISTICS OF STANDARDS:

 Statement must be broad enough to apply a wide variety of settings.

 Must be realist, acceptable and attainable.
 Members of the nursing profession must develop nursing care.
 Must be understandable and started in unambiguous term.
 Must be reviewed and revised periodically.
 Must be based on current knowledge and scientific practice.
 Must be directed towards an optimal standard.

NURSING CARE STANDARDS:

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 It can be divided into end and mean standards

End standards: The end standards are patient oriented. They describe the change as designed
a patients physical status or behaviour.
Mean standards: The mean standards are nursing oriented. They describe the activities and
behaviour designed to achieve end standards. End standards require information about the
patients. A mean standards calls for information about the nurses performance.

Nursing care standards can be classified according to frame of references, relating to

nursing structure, process and outcome.

 Structure standard: A structural standard involves the setup of the institution. The
philosophy, goals and objectives, structure of the organizations, facilities and
equipments and qualifications of employees are some of the components of the
structure of the organization.
 Process standard: Process standards describe the behaviours of the nurse at the
desired level of performance. A process standard involves the activities concerned
with delivery patient care . These standards measure nursing action or of actions
involving patient care. The standards are stated in action verbs that are in observable
and measureable terms.
 Outcome standard: patients results are outcome of nursing intervention. An outcome
standard measures changes in the patient health status. This change may be due to
nursing care, medical care, or as a result of variety of services offered to the patient.
Outcome standards reflect the effectiveness and results rather than the process of
giving care.

ADVANTAGES OF STANDARD:

 They establish norms and allow community members and individuals to know what level of
service to expect/ demand. Because they are written down they can be made public.
 They demonstrate quality provision and act as a bench mark to monitor quality performance.
 They focus on the core and critical tasks that must be performed in the actual situation and
can be tailored to meet specific and local situation.
 They improve efficiency and lead to better utilization of resources.
 They improve staff utilization and staff motivation.
 They can be used to access the practical aspects of both basic and post basic education and
training.

APPROACHES:

A frame work for implementing the standards considers three possible approaches:

Centralized/ National approach

Decentralized/ Local approach
Combined approach

Centralized/ National approach:It relies on the centre taking a lead, making all the decisions and
initiating all the activities. For this approach to be effective there should be an effective
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management system. This approach has not been successful because it relies on decisions made at
levels away from where the activities will eventually take place. Sometimes local level difficulties
arise which can not be foreseen at the national level at the time when the plan is being developed.

Decentralized/ Local approach:This approach is when the centre takes the lead in making the
policy decision to use midwifery standards as a major component of quality assurance. However
the planning of activities and adaptations of the midwifery standards are left to the local districts.

Combined approach:The Centre at the National level remains responsible for the overall
implementation of the midwifery standards; but uses local demonstration sites to try them out, to
learn lessons on how they can be implemented elsewhere, and what adaptations are required to
make them specific to the country situation. The Centre must therefore work closely and take
action with the local demonstration sites at all stages, right from the initial decision making and
planning stages to the evaluation stage.

THE STANDARDS DEVELOPMENT CYCLE.

Step 1. Define and agree. In this step, the goal is to define and agree on several areas and issues
that will define the standards.

Clarify the consensus process, both for topic selection and approval

Clarify the approval process for the standards.

Step 2. Select who should be involved. Identify, at the outset of the process, all stakeholders, I .e,
those individuals or groups with a vested interest in the successful development of the standards.

Step 3. Gather information. In this step, the working group information about the topic under
review and other resources that can help define the key elements that should be included in the
standards. A flowchart may be developed to better understand the points in the current process
requiring the development of standards.

Step 4. Draft standards. There are several components to drafting standards:

Decide the structure and format of the standards, depending on their purpose. After the format is
decided, the working group drafts the standards.

Develop indicators to measure performance according to the standards.

Prior to field testing, the graft standards should be evaluated internally.

Step 5. Test the standards. Once indicators are developed, the working group must decide whether
a field test is needed.

Step 6. Communicate the standards. Although the standards -setting process might be completed
with the approval of the standards, the impact of well- developed standards depends on health care
providers using the standards. Standards communication and implementation strategies are critical
to achieving healthcare provider performance according to the standards.
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Standards of Professional Performance:

Standard I: Quality of care

The nurse administrator evaluates the availability, accessibility, acceptability, quality, and
effectiveness of nursing practice for the population

Standard II: Performance Appraisal

Evaluates his or her own nursing practice in relation to professional practice standards and relevant
statutes and regulations.

Standard III: Education

Acquires and maintains current knowledge and competency in nursing practice

Standard IV:Collegiality

Establishes collegial partnerships while interacting with health care practitioners and others and
contributes to the professional development of peers, colleagues and others.

Standard V:Ethics

Applies ethical standards in advocating for health and social policy and delivery of public health
programs to promote and preserve the health of the population.

Standard VI:Collaboration

Collaborates with the representatives of the population and other health and human service
professionals and organizations in providing for an promoting the health of the population.

Standard VII:Research

Uses research findings in practice

Standard VIII:Resource Utilization

Considers safety, effectiveness, and cost in the planning and delivery of health services when using
available resources to ensure the maximum possible health benefit to the population

ANA Standards of practice

I. Assessment

The nurse collects comprehensive data pertinent to the patients health or situation

2.Diagnosis: The nurse analyzes the assessment data to determine the diagnoses or issues
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3.Outcomes identification:

The nurse identifies expected outcomes for a plan individualize to the patient or the situation

4:Planning: The nurse develops a plan that prescribes strategies and alternatives to attain expected
out comes

5:Implementation

The nurse implements the identified plan of care

5A:Co-ordination of care. The registered nurse coordinates care delivery.

5B:Health teaching and health promotion

5C: consultation: the advanced practice registered nurse and the nursing role specialist provide
consultation to influence the identified plan, enhance the abilities of others and effect change.

5D: Prescriptive Authority and Treatment: the advanced practice registered nurse uses prescriptive
authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws
and regulations.

6:Evaluation

The nurse evaluates progress towards attainment of outcomes

5.QUALITY ASSURANCE MODEL IN NURSING

Quality assurance model in nursing is the set of elements that are related to each other and
comprise of planning for quality development of objectives setting and actively communicating
standards developing indicators, setting thresholds, collecting data to monitor compliance with set
standards for nursing practice and apply solutions to improve care.

PURPOSE OF QUALITY ASSURANCE MODE

Ensure quality nursing care provided by nurses in order to meet the expectations of the
receiver, management and regulatory body
It also intends to increase the commitment of the provider and the management.

GOALS OF QUALITY ASSURANCE MODEL

 Develop confidence of the receiver that quality care is being rendered as per assurance
 Develop commitment of the management towards quality care Increase commitment of
providers to adhere to set standards for nursing practice and strive for excellence

MODELS OF QUALITY ASSURANCE

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SYSTEM MODEL FOR QUALITY ASSURANCE.

The basic components of the system are,

i) Input:- Can be compared to the present state of the system.

ii) Through put:- The through put to the developmental process.

iii) Out put:- To the finished product.

iv) Feed Back:- It is the essential component of the system because

it maintains and nourish growth

INPUT THROUGHPUT OUTPUT

Present Developmental Finished
state of process products
systems

AMERICAN NURSES ASSOCIATION MODEL FOR QUALITY ASSURENCE

Identify values
Identify structure, process and outcome standards and criteria
Select measurement
Make interpretation
Identify course of action
Choose action
Take action
Re evaluate

ANA MODEL

Take action

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Identify Value: In the ANA value identification looks as such issue as patient/client, philosophy,
needs and rights from an economic, social, psychology and spiritual perspective and values,
philosophy of the health care organization and the providers of nursing services.

Identify structure, process and outcome standards and criteria: Identification of standards and
criteria for quality assurance begins with writing of philosophy and objective of organization. The
philosophy and objectives of an agency serves to define the structural standards of the agency.
Standards of structure are defined by licensing or accrediting agency. Another standard of structure
includes the organizational chart, which shows supervisory methods, communication patterns, staff
patterns and sometimes staff assignments. Evaluation of the standards of structure is done by a
group internal or external to the agency.

Select measurement needed to determine degree of attainment of criteria and standards:

Measurements are those tools used to gather information or data, determined by the selections of
standards and criteria. The approaches and techniques used to evaluate structural standards and
criteria are, nursing audit, utilization’s reviews, review of agency documents, self studies and
review of physicals facilities.

The approaches and techniques for the evaluation of process standards and criteria are peer
review, client satisfactions surveys, direct observations, questionnaires, interviews, written audits
and videotapes.

Make interpretations: The degree to which the predetermined criteria are met is the basis for
interpretation about the strengths and weaknesses of the program. The rate of compliance is
compared against the expected level of criteria accomplishment.

Identify Course of Action: If the compliance level is above the normal or the expected level, there
is great value in conveying positive feedback and reinforcement. If the compliance level is below
the expected level, it is essential to improve the situations. It is necessary to identify the cause of
deficiency. Then, it is important to identify various solutions to the problems.

Choose action: Usually various alternative course of action are available to remedy a deficiency.
Thus it is vital to weigh the pros and cons of each alternative while considering the environmental
context and the availability of resources. In the recent that more than one cause of the deficiency
has been identified; action may be needed to deal with each contributing factor.

Take Action: It is important to firmly establish accountability for the action to be taken. It is
essential to answer the questions of who will do? What? By when?. This step then concludes with
the actual implementation of the proposed courses of action.

Re evaluate: The final step of QA process involves an evaluation of the results of the action. The
reassessment is accomplished in the same way as the original assessment and begins the QA cycle
again.

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Careful interpretation is essential to determine whether the course of action has improves the
deficiency, positive reinforcement is offered to those who participated and the decision is made
about when to again evaluate that aspect of care.

DONABEDIAN MODEL

Donabedian, the country’s premier researcher on health care quality, proposed a model for the
structure, process and outcomes of quality that has been widely used over the past 35 years as the
framework for more elaborate models. The cage environment structure from philosophy, to facility
resources, to personnel is the first component. Next are the processes responsible for improving or
stabilizing the client’s health status, such as standards, attitudes, and effectiveness of tools used in
care giving (eg: nursing care plans). Finally, the resultant outcomes are causally linked indicators
of quality, such as client health care goals and effectiveness of service.

The Donabedian model is recognized as a simplistic and basic method of measuring quality. It
lends itself to rehabilitation and is the model used in several settings. It has been part of federally
supported research conducted at Duke University in Durham, North Carolina.

6.AUDIT

Nursing audit may be defined as a detailed review and evaluation of selected clinical records in
order to evaluate the quality of nursing care and performance by comparing it with accepted
standards.

AUDIT /AUDITING:

Auditing is the systematic and independent examination of data, statement, records, operations and
performances for a stated purpose -“R.Chand”.

Audit is defined as the systematic critical analysis of the quality of medical, care including
diagnosis, treatment, outcome, use of resources and effects on quality of life for the patient. –
“The dept of health”.

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NURSING AUDIT:(1955)

Nursing audit refers to assessment of the quality of the clinical nursing –“Elisons”

Nursing audit is a formal detailed systematic review of records or observation of the nursing
actions in order to evaluate the quality of nursing care by comparing the documented evidence with
accepted standards and criteria. –“Renf" 1985

Nursing audit may be defined as a process to evaluate, judge how for the goals set out in the policy
are met.

OBJECTIVES:

 To improve quality of nursing education.

 To provide basis for determining nursing negligence.
 To decrease the cost of nursing care.
 To determine truth .
 To detect errors and frauds
 To advise the management.
 To evaluate nursing care given
 To achieve deserved end feasible quality of nursing care.
 To contribute to research.

AUDIT PROCESS:

The audit process consists of six steps:

Select a topic for study

Select explicit criteria for quality care
Review records to determine whether criteria are must
Do a peer review for all cases that do not meet criteria
Make specific recommendations to correct problems
Follow up to determine whether problems have been eliminated.

AUDIT PROCESS:

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 Topic Explicit
for criteria
study selected for
selected quality care

Follow
Records
up of
reviewe
problem
d
s

Recommendation
s for correcting Peer review of
deficiencies and all cases not
follo w up of meeting criteria
problems

TYPES OF AUDIT:

CONCURRENT AUDIT:

Is a process audit that evaluates the quality of ongoing care by looking at the nursing
process. Concurrent audit is used by medi care and medi aid to evaluate care being received by
public health/ home health clients. The audit data look at the group, population, or community
served. The advantages of this method are,

 Identification of problems at the time care is given

 Provision of a mechanism for identifying and meeting client needs during the
intervention.
 Implementation of measures to fulfil professional responsibilities
 Provision of a mechanism for communicating on behalf of the client.

The disadvantages of the concurrent audit:

 It is time consuming
 It is more costly to implement than the retrospective audit
 Because the intervention is ongoing, it does not present the total picture of
the outcomes of the intervention that the client ultimately will receive.

THE RETROSPECTIVE AUDIT:

The retrospective audit, or outcome audit, evaluates quality of care through evaluation of the
nursing process at the end of a program or as an audit of the long-term impact of a program within
the health care system.

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ADVANTAGES:

 Comparison of actual practice to standards of care.

 Analysis of actual practice findings
 A total picture of care given to a population or group of clients.
 More accurate data for planning corrective action

DISADVANTAGES:

 The focus of evaluation is directed away from ongoing care

 Client problems (group or population or community) are identified after care
is offered through the program. Thus corrective action can be used only to
improve the care of future clients.

Role of Nursing in Quality Assurance:

PLANNING;

Developing objectives for auditing

Identifies the present needs related to auditing
Investigates, evaluates & secures resources.
Formulates the plan of action.
Selects & organize the nursing audit

ORGANIZING;

 Nurses are responsible for managing the caseload of client with needs of varying degrees of
urgency. Using the resources available, they must provide priority services that will promote
the highest possible level of person and group functioning and health.
o Some quality improvement activities for nurses include daily prioritizing care needs,
seeking supervision or skills, development for difficulty case, systematizing charting
so that needed documentation is effectively completed proposing better ways to
organize care of chronically ill client, or establishing new agency procedures. All
these action demonstrate that nurses are evaluating their work and looking for ways
to improve care.
o Staff meetings quality circle meeting, peer review and case conferences are common
settings for nurses to bring the lessons of their practices to the larger group for
examination and potential adoption.
o It is the role of nursing administrator to develop a formalized quality program that
includes a three prolonged focus based on a classic approach to quality management.
 Review organizational structure, personnel and environment
 Focus on standards of nursing care and methods of delivering nursing care
 Focus on the outcomes of care
o Thus, any activities the nurse engages in to realize these goals contribute to the
quality management program.

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  Nurses are responsible for managing the caseload of client with needs of varying degree
of urgency . Using the resources available , they must provide priority services that will
promote the highest possible level of person and group functioning and health.
 Data collection by nurses related to a quality initiative serves as one of the best ways for
the professional nurses to understand and participate in the QI.
 Professional nursing continues to study the effects of nursing care on client outcomes
.Client outcome that arise directly from nursing assessment and intervention are known
as nursing sensitive outcome.

DIRECTING;

In nursing education programs, many times nursing students strive for perfection in all
assignments. Sometimes faculty members hold students to a level of clinical perfection
when caring for clients in clinical settings . Some nurses perceive that errors result from
carelessness , inattention to detail, indifference, or lack of knowledge.
Nurses work endlessly to consider the client’s best interest .When participating in
quality improvement activities , nurses advocate for all clients. Improvement in work
process reduce care errors. Nurses who acknowledge the effects of physical and mental
fatigue advocate for clients when refusing to work overtime.

Professional nurses act as change agents when they identify needed in work process
to improve the quality of nursing care. Change occurs rapidly in the health care area. As
new health care devices , medication , and treatment advances become available , nurses
need to change practice procedures. Nurses , as stakeholders in the delivery of health care,
continuously examine which rituals and routines remain applicable and determine which
one should be discarded
Before adopting an innovation , staff must be educated about the reasons for the innovation
, change in practice policies and how to operate new equipment . Staff educational
programs may be planned using the teaching / learning principles. Interdepartmental
educational programs provide staff with the opportunity to network , share successes with
change , and support each other.

COORDINATING;

As care coordinators, nurses must assess work colleagues for their ability to perform safe,
effective client care. Physical and mental fatigue impair work performance. As coordinator
of care , professional nurses must seek ways to provide quality of care while using
resources effectively. When specialized nurses provide care with continuity , lower rates of
pneumonia and cardiac arrest were reported along with shorter length of hospital stays.
High levels of nurses manager support have been associated with reduced levels of
pressure ulcer prevalence and client mortality.

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TEXT BOOK ON

NURSING

MANAGEMENT

PART III

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 Chapter- VIII Srimathi shakthi

Introduction:

Performance Appraisal is the systematic evaluation of the performance of employees and to

understand the abilities of a person for further growth and development. Performance appraisals in
some form existed in olden times. Wei Dynasty (221-265 AD) in China introduced performance
appraisals in which an imperial rater appraised the performance of the members of royal family.
Performance appraisal in the present form was adopted in 1883, by New York Civil Service, since,
then and mainly after the world war I, performance in formal way was adopted by many business
organizations.

Performance appraisal also called merit rating or efficiency or service rating, and also it is the
process of reviewing in individual is performance and progress in a job and assessing his potential.
It is a systematic method of obtaining, analyzing a recording information about a person doing a
specific job, rather than assessing the job itself as in the case of job analysis.

The ability to use appraisal to develop and motivate employees is one of the core management
skills. Regular constructive feedback on performance is vital, if the employees have to build on
their strengths, achieve their full potential and make maximum contribution towards organization’s
success and excellence.

In Hospital, performance appraisal is a systematic evaluation of personnel by supervisors or other

familiar with their performance because employers are interested in knowing about employee
performance. Appraisals are essential for making many administrative decisions, selection training,
promotion, transfer, wage and salary administration, etc.

Performance Appraisal: Definition:

 According to Edwin D Flippo, “Performance appraisal is the systematic, periodic and an

impartial rating of an employee’s excellence in the matters pertaining to his present job and
his potential for a better job”
 Performance Appraisal is the evaluation of work done (quantity, quality and the manner it is
carried out) during a specified period against the background of the total work situation.
 Performance appraisal is the process of obtaining, analyzing and recording information
about the relative worth of an employee.
 Performance appraisal is a systematic way of reviewing and assessing the performance of an
employee during a given period of time and planning for his future.

Objectives of Appraisal:

1) Administrative

(Information needed by the organization for administrative purposes)

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  To provide data for management decisions concerning merit, salary, increments, incentives,
rewards, promotion, transfer, demotion or discharge from service.
 To weed out low performers;
 To consider the employee’s suitability for different types of assignments;
 To have on hand information required for purposes like letters of recommendation,
domestic enquiry, avoidance of arbitrary on-the-spot decisions, re-employment;
 To create a desirable culture and traditions in the department;
 To meet the requirements for manpower planning and Organizational Development, like
identification of employees with promotion potential and their development needs-what is
expected of them, what strengths they can build on and what specific weaknesses they need
to overcome.

Performance Improvement:

(Information specific to employees and appraisers for self-improvement and for achieving
individual and organizational goals).

2) Employee’s Objectives:

 Employee gets a feedback of his or her performance which motivates him or her to perform
better. It tells a subordinate how he or she is doing, brings about a awareness of the
strengths and weaknesses and suggests needed changes in attitude, skills or knowledge of
the job;
 Employee develops role clarity with regard to the job, especially when told what is
expected of him or her;
 Employee is able to clarify his or her career plan in the organization.

3) Appraiser’s Objectives:

 Superior gets feedback on how well the institutional objectives have been communicated to
the subordinates, facilities provided for their effective performance and ability to motivate
them to perform;
 Review of the work situation with the employee and identification of the latter’s resource
requirements, and helps the appraiser defining his or her own and department’s contribution
to institutional objectives.

Purposes:

 To review the performance of the employees over a given period of time.

 To judge the gap between the actual and the desired performance.
 To help the management in exercising organizational control.
 To diagnose the training and development needs of the future.
 Provide information to assist in the HR decisions like promotions, transfers etc.
 Provide clarity of the expectations and responsibilities of the functions to be performed by
the employees.
 To judge the effectiveness of the other human resource functions of the organization such as
recruitment, selection, training and development.
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  To reduce the grievances of the employees.
 Helps to strengthen the relationship and communication between superior – subordinates
and management – employees.

Benefits of Performance Appraisal:

 Motivation and Satisfaction:

Performance appraisal provides employees with recognition for their work efforts. The power of
social recognition as an incentive has been long noted. In fact, there is evidence that human beings
will even prefer negative recognition in preference to no recognition at all.

 Training and development:

Performance appraisal offers an excellent opportunity - perhaps the best that will ever occur - for a
supervisor and subordinate to recognize and agree upon individual training and development needs.

Performance appraisal can make the need for training more pressing and relevant by linking it
clearly to performance outcomes and future career aspirations.

 Recruitment and Induction:

Appraisal data can be used to monitor the success of the organization's recruitment and induction
practices. Appraisal data can also be used to monitor the effectiveness of changes in recruitment
strategies.

 Employee evaluation:
Though often understated or even denied, evaluation is a legitimate and major objective of
performance appraisal.

CLASSIFICATION:

Performance appraisal may be classified under 3 distinct categories namely,

1. Performance Review:

It is related to the need to improve the performance of individuals and there by improve the
effectiveness of the organization as a whole.

2. Potential Review:

It attempts to deal with the problem of predicting the level and type of work that the individual will
be capable or doing in future.

3. Reward Review:

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It relates to the distribution of rewards such as salary, power, status etc. performance appraisal
often takes the form of an annual review conducted by a department head or section officer, for
determining the worth of employees to the business in order to assess their effectiveness, potential
for future promotion or placement in the salary scale.

PROCESS OF PERFORMANCE APPRAISAL:

Performance appraisal involves an evaluation of actual against desired performance

It is a multistage process in which communication plays an important role.

Establishing performance standards

Communicating the standards

Measuring the actual performance:

Comparing the actual with the desired

performance

Discussing results
(providing feedback)

Decision Making-taking corrective

actions

1. Establishing performance standards

First step in the process of performance appraisal is the setting up of the standards which
will be used to as the base to compare the actual performance of the employees. This step requires
setting the criteria to judge the performance of the employees as successful or unsuccessful and the
degrees of their contribution to the organizational goals and objectives. The standards set should be
clear, easily understandable and in measurable terms. In case the performance of the employee
cannot be measured, great care should be taken to describe the standards.

2. Communicating the standards

Once the standard is set, it is the responsibility of the management to communicate the standards to
all the employees of the organization.

The employees should be informed and the standards should be clearly explained to them and
create a feeling of involvement. This will help them to understand their roles and to know what
exactly is expected from them. The standards should also be communicated to the appraisers or the
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evaluators and if required, the standards can also be modified at this stage itself according to the
relevant feedback from the employees or the evaluators.

3. Measuring the actual performance:

The most difficult part of the Performance appraisal process is measuring the actual performance
of the employees that is the work done by the employees during the specified period of time. It is a
continuous process which involves monitoring the performance throughout the year. This stage
requires the careful selection of the appropriate techniques of measurement, taking care that
personal bias does not affect the outcome of the process and providing assistance rather than
interfering in an employees work.

4. Comparing the actual with the desired performance

The actual performance is compared with the desired or the standard performance. The comparison
tells the deviations in the performance of the employees from the standards set. The result can
show the actual performance being more than the desired performance or, the actual performance
being less than the desired performance depicting a negative deviation in the organizational
performance. It includes recalling, evaluating and analysis of data related to the employees’
performance.
5. Discussing results

The result of the appraisal is communicated and discussed with the employees on one-to-one basis.
The focus of this discussion is on communication and listening. The results, the problems and the
possible solutions are discussed with the aim of problem solving and reaching consensus. The
feedback should be given with a positive attitude as this can have an effect on the employees’
future performance. The purpose of the meeting should be to solve the problems faced and
motivate the employees to perform better.

6. Decision Making

The last step of the process is to take decisions which can be taken either to improve the
performance of the employees, take the required corrective actions, or the related HR decisions like
rewards, promotions, demotions, transfers etc.)

7. Feedback

After the formal appraisal stage, a feedback session is desirable. This session should involve verbal
communication, listening, problem solving, negotiating, compromising, conflict resolution and
reaching consensus.

PRE-REQUISITES FOR AN EFFECTIVE PERFORMANCE APPRAISAL SYSTEM

 Determination of Objective:The management before introducing an appraisal programme

should set out the objectives of appraisal programme. i.e. whether to appraise one’s performance
on his present job or to determine his potential for a higher job or to determine the training and
development needs of employees or for transfer or increase in pay etc.

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 Selecting and Training of Appraiser: The management should select a proper person to
appraise the employees and also to give him sufficient training in the methods of appraisal.
 Establishing Standards of Performance: Determining the standards of performance in
clear cut terms for various individuals on their jobs and put it in writing and communicating it to
the subordinates well in advance is another important requisite. This enables the subordinates to
know well in advance what management experts from them.
 Standards – the standards set should be clear, easy to understand, achievable, motivating, time
bound and measurable.
 Goal : The job description and the performance goals should be structured, mutually decided
and accepted by both management and employees.
 Frequency of Appraisal: It should be decided on the basis of the objectives and scope of
performance appraisal programme.
 Preparation of Forms: The management should design suitable forms of the purpose of
appraisal. The contents and design of the form should be based on the nature of job objectives of
performance appraisal etc.
 Ease of understanding: if an appraisal system is too complex or too time consuming, it may be
grounded by its own dead weight of complications, which nobody but only the experts
understand.
 Support of line workers: if the line workers think that the system is too ambitious or
unrealistic, or that it has been imposed on them by ivory-towered, staff or consultants who have
no comprehension of the actual demands on the time of line workers, they will resent it.
Therefore goodwill and understanding is essential between the rater and the rates.
 Suitability to the operations and structure: a system may function extremely well at an
organization whose activities are compact. Likewise, where the operations are interdependent
and interlinked, performance data of any one individual cannot be regarded as adequately
discrete or reliable for appraising his or her performance.
 Validity and reliability: the validity of rating is the degree to which the system truly indicates
the intrinsic merit of employees. Reliability of rating is the consistency with which the ratings
are made, either by several different raters or by one rater at different times.
 Provision of incentives: the system should have appropriate built in incentives to be awarded
after satisfactory performance.
 Documentation – means continuous noting and documenting the performance. It also helps the
evaluators to give a proof and the basis of their ratings.
 Practical and simple format - The appraisal format should be simple, clear, fair and objective.
Long and complicated formats are time consuming, difficult to understand, and do not elicit
much useful information.
 Evaluation technique – An appropriate evaluation technique should be selected; the appraisal
system should be performance based and uniform. The criteria for evaluation should be based
on observable and measurable characteristics of the behavior of the employee.
 Communication – Communication is an indispensable part of the Performance appraisal
process. The desired behavior or the expected results should be communicated to the employees
as well as the evaluators. Communication also plays an important role in the review or feedback
meeting. Open communication system motivates the employees to actively participate in the
appraisal process.
 Feedback – The purpose of the feedback should be developmental rather than judgmental. To
maintain its utility, timely feedback should be provided to the employees and the manner of
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 giving feedback should be such that it should have a motivating effect on the employees’ future
performance.
o Impersonal feedback: Feedback must be impersonal if it is to have the desired effect.
Personal feedback is usually rejected with contempt, and eventually de-motivates the
employee.
o Feedback must be noticeable: The staff member being appraised must be made aware of
the information used in the appraisal process. An open appraisal process creates
credibility.
 Personal Bias – Interpersonal relationships can influence the evaluation and the decisions in the
performance appraisal process. Therefore, the evaluators should be trained to carry out the
processes of appraisals without personal bias and effectively.
 Reliable and consistent -Appraisal should include both objective and subjective ratings to
produce reliable and consistent measurement of performance.
 Regular and routine- While an appraisal system is expected to be formal in a structured
manner, informal contacts and interactions can also be used for providing feedback to
employees.
 Participatory and open -An effective appraisal system should necessarily involve the
employee's participation, usually through an appraisal interview with the supervisor, for
feedback and future planning. During this interview, past performance should be discussed
frankly and future goals established. A strategy for accomplishing these goals as well as for
improving future performance should be evolved jointly by the supervisor and the employee
being appraised. Such participation imparts a feeling of involvement and creates a sense of
belonging.

 Relevance and responsiveness - Planning and appraisal of performance and consequent

rewards or punishments should be oriented towards the objectives of the programme in which
the employee has been assigned a role. For example, if the objectives of a programme are
directed towards a particular client group, then the appraisal system has to be designed with that
orientation.

 Commitment - Responsibility for the appraisal system should be located at a senior level in the
organization so as to ensure commitment and involvement throughout the management
hierarchy.

CHALLENGES OF PERFORMANCE APPRAISAL

The main Performance Appraisal challenges involved in the performance appraisal process are:

 Determining the evaluation criteria

Identification of the appraisal criteria is one of the biggest problems faced by the top management.
The performance data to be considered for evaluation should be carefully selected. For the purpose
of evaluation, the criteria selected should be in quantifiable or measurable terms

 Create a rating instrument

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The purpose of the Performance appraisal process is to judge the performance of the employees
rather than the employee. The focus of the system should be on the development of the employees
of the organization.

 Lack of competence

Top management should choose the raters or the evaluators carefully. They should have the
required expertise and the knowledge to decide the criteria accurately. They should have the
experience and the necessary training to carry out the appraisal process objectively.

 Errors in rating and evaluation

Many errors based on the personal bias like stereotyping, halo effect (i.e. one trait influencing the
evaluator’s rating for all other traits) etc. may creep in the appraisal process. Therefore the rater
should exercise objectivity and fairness in evaluating and rating the performance of the employees.

While evaluating the performance of the employees, experts have been identified four types of
bias/problems, i.e. halo effect, horns effect, central tending error and self-aggrandizing effects.

1. Halo Effect: It is the tendency to over rate a person’s performance or overemphasize

a positive event, i.e. rating the person higher-than-deserved, for various reasons.
2. Horn Effects: It is the tendency to rate an employee lower than that performance, for
various reasons or overemphasize a negative event and underrate total performance
3. Central tendency error: In this performance a person is not observed and medium
rating given for all tasks.
4. Self-aggrandizing effect rates worker so as to create favorable view of manager.

 Resistance
The appraisal process may face resistance from the employees and the trade unions for
the fear of negative ratings. Therefore, the employees should be communicated and clearly
explained the purpose as well the process of appraisal. The standards should be clearly
communicated and every employee should be made aware that what exactly is expected
from him/her.

APPROACHES IN PERFORMANCE APPRAISAL

Einstein and LeMere-Labonte, 1989; and Monga, 1983:

 Intuitive Approach

In this approach, a supervisor or manager judges the employee based on their perception of the
employee's behaviour.

 Self-Appraisal Approach

Employees evaluate their own performance using a common format.

 Group Approach
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The employee is evaluated by a group of persons.

 Trait Approach This is the conventional approach. The manager or supervisor evaluates the
employee on the basis of observable dimensions of personality, such as integrity, honesty,
dependability, punctuality, etc.
 Appraisal Based On Achieved Results In this type of approach, appraisal is based on concrete,
measurable, work achievements judged against fixed targets or goals set mutually by the subject
and the assessor.
 Behavioral Method This method focuses on observed behavior and observable critical
incidents.

METHODS OF PERFORMANCE APPRAISAL:

TRADITIONAL MODERN
METHOD METHOD

Essay Appraisal Method

Assessment Centre
Grading
Management by Objectives
Ranking Method
Human Resource Accounting
Checklist Method Method
Rating Scales 360 degree Feedback
Critical Incident Method Computerized and Web based
Behaviourally anchored rating performance appraisal
scale Psychological Appraisals
Forced Choice Method
Paired Comparison Method
Confidential Report

I. TRADITIONAL METHOD

 Essay Appraisal Method (free form)

• The assessor writes a brief essay providing an assessment of the strengths, weaknesses and
potential of the subject.
• In order to do so objectively, it is necessary that the assessor knows the subject well and
should have interacted with them.
• The rater considers the employee’s :
• Job knowledge and potential
• Understanding of company’s programs, policies, objectives etc
• Relation with co-workers and supervisors
• Planning, organizing and controlling ability
• Attitude and perception
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 • Essay appraisal method-limitations
• Highly subjective
• Supervisor may write biased essay
• Difficult to find effective writers
• A busy appraiser may write the essay hurriedly without assessing properly the actual
performance of the worker
• If the appraiser takes a long time it becomes uneconomical from the view point of
the firm

 Ranking Methods:

Under ranking system of performance appraisal, subordinates are rated on an overall basis with
reference to their job performance, instead of individual assessment of traits. In this way the best is
placed first in the rank and poorest occupies the last rank.

A variation of this technique is the method of paired comparison. This technique is basically the
other way of achieving a rank order listing of employees on a more systematic basis compared to
the simple ranking methods under the paired comparison method, each member is compared with
all others in the group obviously the number of rank orders would be N[N-1]/2. The paired
comparison method suffers from a prime weakness in terms of number of judgments made
particular when the group is large.

Example:

If managers are ranked four nurses, they must deal with six possible pairs; this number can be
calculated as follows:

N [N-1]/2 = 4(3)/2 = 12/2 = 6

Example of ranking using paired comparison:

Nurses Possible pairs

Asha A with J J with R
Janci A with R J with S
Roshini A with S R with S
Saranya

Advantages of Ranking Method

• Employees are ranked according to their performance levels.

• It is easier to rank the best and the worst employee.

Limitations of Ranking Method

• It is very difficult to compare individuals possessing various individual traits.

• This method speaks only of the position where an employee stands in his group. It
does not test anything about how much better or how much worse an employee is
when compared to another employee.
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 • When a large number of employees are working, ranking of individuals become a
difficult issue.
• There is no systematic procedure for ranking individuals in the organization.
• The ranking system does not eliminate the possibility of snap judgements.

 Rating Scale Method:

The rating scale does more than just note the absence or presence of desirable
behavior. It locates the behavior at a point on a continuum and notes qualitative and quantitative
abilities. The numerical rating scale usually includes numbers against which lists of behaviors are
evaluated:

Observation of working hours 12345

Ability to get along with others 12345

Rate the staff member on the items below. Responses have the following values:

1 = Never

2 = Sometimes

3 = About half the time

4 = Usually

5 = Always

A. Observation of working hours 12345

B. Ability to get along with others 12345

Example for Graphic Rating Scale:

Below Average
Unsatisfactory

Outstanding
Average
Average

Above

_______________________________________________________________________________
__

Observation of working hours

Example for Descriptive Graphic Rating Scale:

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 Usually on
Sometimes
Usually

time
Late

late
_______________________________________________________________________________
_____

Observation of working hours

Example for percentage rating scale:

Observation of working hours

10% 20% 40% 20% 10%

Bottom Top

Advantages

• Locates behavior on a continuum

• Notes qualitative and quantitative abilities

Limitations

• Not very reliable

• Use own judgment

 Little understanding of what behavior qualifies for what rating

 Man to Man Comparison/ paired comparison:

In this method, certain personal factors such as initiative, dependability, leadership, sincerity etc,
are selected for purposes of analysis for each factor, a scale is developed. For the purpose of
comparison, the factors selected for purposes of analysis are taken as basis; one factor at a time is
comported. Even though this method is very useful in measuring job, it is of limited use in
measuring people. Example: Nurse-to-Nurse Comparison Scale

Observation of working hours

Nurse Below Above
Lowest (1) Average (3) Highest (5)
Average (2) Average (4)
Asha X
Arunthati X

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 Roshini X
Saranya X
Zeyera X

 Grading:

In this system of appraisal, certain categories of worth are identified in advance and the persons
who are appraised are placed in a particular grade depending upon their worth. Example: Grades
may be defined as outstanding, satisfactory and unsatisfactory.

Forced Distribution Method:

This method forces the rater to distribute the ratings and because of this method is known as forced
distribution method. In this method the employees are rated for overall performance and not for
each trait. This method requires the rater to distribute his ratings to follow predetermined
distribution.

Example: A group of workers doing the same job would fall into some such grouping as Superior
(10%), Above Average (20%), Average (40%), Below average (20%), poor (10%).

This method is easy to understand and to administer and also minimizes the bias of the rater.

Advantages of Forced Distribution

• This method tends to eliminate raters bias

• By forcing the distribution according to pre-determined percentages, the problem of
making use of different raters with different scales is avoided.

Limitations of Forced Distribution

• The limitation of using this method in salary administration, however, is that it may
lead low morale, low productivity and high absenteeism.
• Employees who feel that they are productive, but find themselves in lower
grade(than expected) feel frustrated and exhibit over a period of time reluctance to
work.

 Checklist

In this method, the rater does not evaluated the performance of the employee but simply reports it
to the personnel department which does the job of final rating, the rater is presented with a number
of questions in the form of checklists relating to the employed and his behavior and he will have to
indicate his answers to the questions with a tick mark in the ‘yes’ column or ‘no’ column provided
for that purpose.

For Example: Yes No

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 i. Is he interested in the job? [ ] [ ]
ii. Does he follow orders? [ ] [ ]
iii. Does he take initiative [ ] [ ]

In this method as the rater is only to report to the personnel department without evaluating the
performance of the employee.

• Advantages of Checklists and Weighted Checklists

• Most frequently used method in evaluation of the employees performance.
• Limitations of Checklists and Weighted Checklists
• This method is very expensive and time consuming
• Rater may be biased in distinguishing the positive and negative questions.
• It becomes difficult for the manager to assemble, analyze and weigh a number of
statements about the employees characteristics, contributions and behaviours.

 Critical Incident Method:

The performance of an employee is rated on the basis of certain events or incidents which may
have really happened. Some examples of such events or incidents are as follows.

i. Refused to cooperated with fellow workers

ii. Refused to undergo further training
iii. Becomes upset or angry over work.

Limitation of this technique are:

• The supervisor has to note down the critical incidents as and when they occur.
• Negative incidents may be more noticeable than positive incidents.
• Impractical and may delay feedback to employee
• Results in very close supervision which may not be liked by the employee.

 Forced Choice Method:

In this method the rater has to choose between descriptions and statements of seemingly equal
worth describing the person in question. This task of scoring in this method is not given to the
supervisor but to the personnel department. This method is used particularly with the object of
avoiding the rater’s biases or prejudices.

 Field Review Method:

In this method a trained employee from the personnel department interviews the supervisors about
their respective subordinates. The supervisor is asked to give his opinion on his subordinates
regarding their performance progress, etc.

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This method is useful for large organizations with a large number employees and appears to
overcome a number of weakness found in some of the other methods of appraisal.

 Confidential Report:

A confidential report by the immediate supervisors is still a major determinant of the subordinate’s
promotion or transfer. The format and pattern of this report varies with each organization.

A sample of such report is

Name……………………………………………………….

Designation and present duties……………………..

Service with the company…………………………….

Age………………..Qualifications………………………

Present scale and salary……………………………….

Next increment data……………………………………

Date Manager

Review Date Director

Final review Data Committee of management

 Critical Job requirements:

In this method, the first step is to draw up for each job, a list of critical job requirements that is,
those requirements which are vital for success or failure on the job.

For Example: In the job of a salesman, the following factors may be considered as critical factors,

A. Planning Ahead
B. Carrying out promises
C. Persisting on tough accounts
D. Using new scales techniques and methods
E. Knowing the requirements of customers
F. Initiating new ideas of selling.

II. MODERN METHODS

 ASSESSMENT CENTRES

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 Assessment centre refers to a method to objectively observe and assess the people in action by
experts or HR professionals with the help of various assessment tools and instruments. Assessment
centers simulate the employee’s on the job environment and facilitate the assessment of their on
the job performance.

The major competencies that are judged in assessment centers are

 interpersonal skills
 intellectual capability
 planning and organizing capabilities
 motivation
 career orientation etc.

assessment centers are also an effective way to determine the training and development needs of
the targeted employees.

An assessment centre typically involves the use of methods like social/informal events, tests and
exercises, assignments being given to a group of employees to assess their competencies and on
the job behavior and potential to take higher responsibilities in the future. Generally, employees are
given an assignment similar to the job they would be expected to perform if promoted. The trained
evaluators observe and evaluate employees as they perform the assigned jobs and are evaluated on
job related characteristics.

An assessment centre for Performance appraisal of an employee typically includes:

• Social/Informal Events – An assessment centre has a group of participants and also a few
assessors which gives a chance to the employees to socialize with a variety of people and also to
share information and know more about the organization.
• Information Sessions –information sessions are also a part of the assessment centres. They
provide information to the employees about the organisation, their roles and responsibilities, the
activities and the procedures etc.
• Assignments- assignments in assessment centres include various tests and exercises which are
specially designed to assess the competencies and the potential of the employees. These include
various interviews, psychometric tests, management games etc. all these assignments are
focused at the target job.

The following are the common features of all assessment centres:

 The final results is based on the pass/fail criteria

 All the activities are carried out to fill the targeted job.
 Each session lasts from 1 to 5 days.
 The results are based on the assessment of the assessors with less emphasis on self-assessment
immediate review or feedback are not provided to the employees.
 An organization’s human resources can be a vital competitive advantage and assessment centre
helps in getting the right people in right places. The major competencies that are judged in
assessment centres are interpersonal skills, intellectual capability, planning and organizing

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 capabilities, motivation, career orientation etc. assessment centres are also an effective way to
determine the training and development needs of the targeted employees.
 360 DEGREE PERFORMANCE APPRAISALS

360 degree feedback, also known as 'multi-rater feedback', is the most comprehensive appraisal
where the feedback about the employees’ performance comes from all the sources that come in
contact with the employee on his job.

360 degree respondents for an employee can be his/her peers, managers (i.e. superior),
subordinates, team members, customers, suppliers/ vendors - anyone who comes into contact with
the employee and can provide valuable insights and information or feedback regarding the "on-the-
job" performance of the employee.

360 degree appraisal has four integral components:

• Self appraisal
• Superior’s appraisal
• Subordinate’s appraisal
• Peer appraisal.

SELF-APPRAISALS

Employees are increasingly being asked to submit written summaries or portfolios of their work-
related accomplishments and productivity as part of the self-appraisal process. Portfolios often
provide examples of how the employee has implemented clinical guidelines and achieved patient
outcomes, as well as including sample patient care documentation (Taylor, 2000). The portfolio
also generally includes the employee's goals and an action plan for accomplishing these goals.

There are advantages and disadvantages to using self-appraisal as a method of performance

review. Although introspection and self-appraisal result in growth when the person is self-aware,
even mature people require external feedback and performance validation.

Some employees may look on their annual performance review as an opportunity to receive
positive feedback from their supervisor, especially if the employee receives infrequent praise on a
day-to-day basis. Asking these employees to perform their own performance appraisal would
probably be viewed negatively rather than positively.

In addition, some employees undervalue their accomplishments or may feel uncomfortable giving
themselves high marks in many areas. In an effort to avoid this potential influence on their rating,
managers may wish to complete the performance appraisal tool before reading the employee's self-
analysis, or they should view the self-appraisal as only one of a number of sources of data that
should be collected when evaluating worker performance. When self-appraisal is not congruent
with other data available, the manager may wish to pursue the reasons for this discrepancy during
the appraisal conference. Such an exchange may provide.

Subordinates appraisal gives a chance to judge the employee on the parameters like
communication and motivating abilities, superior’s ability to delegate the work, leadership qualities

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etc. Also known as internal customers, the correct feedback given by peers can help to find
employees’ abilities to work in a team, co-operation and sensitivity towards others.

Self assessment is an indispensable part of 360 degree appraisals and therefore 360
degree Performance appraisal have high employee involvement and also have the strongest impact
on behavior and performance.

It provides a "360-degree review" of the employees’ performance and is considered to be one of

the most credible performance appraisal methods.

 PEER REVIEW

When peers rather than supervisors carry out monitoring and assessing work performance, it is
referred to as peer review.

Most likely, the manager's review of the employee is not complete unless some type of peer
review data is gathered. Peer review provides feedback that can promote growth. It also can
provide learning opportunities for the peer reviewers. Taylor (2000) suggests that peers who work
together have a level of insight into each other’s clinical practice, and that peer review provides
employees with an opportunity to receive better feedback about self-improvement.

The concept of collegial evaluation of nursing practice is closely related to maintaining

professional standards. Peer review has the potential for increased professionalism, performance,
and professional accountability among practicing staff and is gaining popularity in the United
States and internationally (Vuorinen, Tarkka, 8c Meretoja, 2000).

Peer review is widely used in medicine and by faculty in universities; however, healthcare
organizations have been slow to adopt peer review for the following five

1. Staff are poorly oriented to the peer review method.

2. Peer review is viewed as very threatening when inadequate time is spent orienting
employees to the process and when necessary support is not provided throughout the
process.
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Peers feel uncomfortable sharing feedback with people with whom they work closely, so they omit
needed suggestions for improving the employee's performance. Thus, the review becomes more
advocacy than evaluation.

Peer review is viewed by many as more time-consuming than traditional superior-

subordinate performance appraisals.

Because much socialization takes place in the workplace, friendships often result in inflated
evaluations, or interpersonal conflict may result in unfair appraisals.

Because peer review shifts the authority away from management, the insecure manager may feel
threatened.

Peer review has its shortcomings, as evidenced by some university teachers receiving unjustified
tenure or the failure of physicians to maintain adequate quality control among some individuals in
their profession. Additionally, peer review involves much risk taking, is time-consuming, and
requires a great deal of energy. However, nursing as a profession should be responsible for setting
the standards and then monitoring its own performance. Because performance appraisal may be
viewed as a type of quality control, it seems reasonable to expect that nurses should have some
input into the performance evaluation process of their profession's members.

Peer review can be carried out in several ways. The process may require the reviewers to share the
results only with the person being reviewed, or the results may be shared with the employee's
supervisor and the employee. The review would never be shared only with the employee's
supervisor.

The results may or may not be used for personnel decisions. The number of observations, number
of reviewers, qualification and classification of the peer reviewer, and procedure need to be
developed for each organization. If peer review is to succeed, the organization must overcome its
inherent difficulties by doing the following before implementing a peer review program:

• Peer review appraisal tools must reflect standards to be measured, such as the job description.
• Staff must receive a thorough orientation to the process before its implementation. The role
of the manager should be clearly defined.
• Ongoing support, resources, and information must be made available to the staff during the
process.
• Data for peer review need to be obtained from predetermined sources, such as observations,
charts, and patient care plans.
• A decision must be made about whether anonymous feedback will be allowed. This is
controversial and needs to be addressed in the procedure.
• Decisions must be reached on whether the peer review will affect personnel decisions and, if
so, in what manner.

Peer review has the potential to increase the accuracy of performance appraisal. It also can provide
many opportunities for increased professionalism and learning. The use of peer review in nursing
should continue to expand as nursing increases its autonomy and professional status.

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 Peer review, when implemented properly, provides the employee with valuable feedback that can
promote growth.

360 degree performance appraisal is also a powerful developmental tool because when conducted
at regular intervals (say yearly) it helps to keep a track of the changes others’ perceptions about the
employees. A 360 degree appraisal is generally found more suitable for the managers as it helps to
assess their leadership and managing styles. This technique is being effectively used across the
globe for performance appraisals. Some of the organizations following it are Wipro, Infosys, and
Reliance Industries etc

Arguments Against 360 Degree Performance Appraisal

Despite the fact that 360 degree appraisals are being widely used throughout the world for
appraising the performance of the employees at all levels, many HR experts and professionals
argument against using the technique of 360 degree appraisals. The main arguments are:

• 360 performance rating system is not a validated or corroborated technique for Performance
appraisal.
• With the increase in the number of raters from one to five (commonly), it become difficult to
separate, calculate and eliminate personal biasness and differences.
• It is often time consuming and difficult to analyze the information gathered.
• The results can be manipulated by the employees towards their desired ratings with the help of
the raters.
• The 360 degree appraisal mechanism can have a adversely affect the motivation and the
performance of the employees.
• 360 degree feedback – as a process requires commitment of top management and the HR,
resources(time, financial resources etc), planned implementation and follow up.
• 360 degree feedback can be adversely affected by the customers perception of the organisation
and their incomplete knowledge about the process and the clarity of the process.
• Often, the process suffers because of the lack of knowledge on the part of the participants or the
raters.

PSYCHOLOGICAL APPRAISALS

• It focuses on the future potential of an employee

• past performance or the actual performance is not taken into consideration
• Evaluation is based on employee’s intellectual, emotional, motivational and other related
characteristics

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PERFORMANCE APPRAISAL TOOLS:

Forced
Distribution
Scale
Structured
Graphic Rating
Scale
Performance Behaviorally
Appraisal Tools anchored
Rating Scale

Management
Flexible
by Objectives

Peer review

Structured:

i) Forced Distribution Scale:

They comprise a numbering system that indicates high and low values for evaluating performance.
This is popular because it is easy to construct and easy to use.

ii) Rating Scale:

It is easy to construct and easy to complete. On the downside, they usually consist of
generalization, not specific behaviors, and the rating is relatively subjective in nature. Some
managers never give a 5 with the rationale that no employee always exceed expectations.

Flexible:

i) Behaviorally Anchored Rating Scale:

BARS can be implemented as a collaborative or flexible approach. The focus is on behavior and
should include employees in the development. This scale is also considered more advantageous in
terms of litigation.

BARS describe the employee’s performance both quantitatively and qualitatively the primary
drawback of this scale is that it is expensive to develop and time consuming to implement.

Example: Emergency room staff nurse responsibilities for patient admitted with chest pain.

1. Vital signs recorded within 5 mts of admission

2. Cardiac monitor, IV, lab tests and ECG done within 15 minutes
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 3. If sublingual nitroglycerin given, vital signs recorded every 5 minutes

For 30 minutes.

a. Chest pain changes evaluated per protocol

b. Post chest pain 12 lead ECG documented.

Advantages

 Evaluates behavior related to specific demands of the job

 Gives examples of specific job behaviors
 Reduces the amounts of personal judgment needed
 Reduces rating errors
 Is more accepted by staff
 Identifies performance deficiencies and needs for development

Limitations

 Takes time
 Is expensive to use
 Separate BARS is needed for each job
 Is applicable to physically observable behaviors rather than conceptual skills

Management by Objectives:

One method that has been used for many years, is management by objective [MBO] Arnold
and Pulich [2004]., state MBO involves establishing performance goals jointly between the
manager and the employee for the upcoming appraisal period. An MBO approach requires that the
employee establish clear and measurable objectives at the beginning of each rating period. In effect
the employee has created a ‘performance contrail as well as having defined goals for future
professional performance’.

Advantages

• Tool for effective planning and appraisal

• Focuses attention on individual achievement
• Motivates individuals to accomplish
• Measures performance in terms of outcomes
• Staff have input and some control over their future
• Staff know the standard by which they will be evaluated
• Staff have knowledge of the manager’s goals, priorities and deadlines
• Emphasizes the future that can be changed.
• Indicates personnel development needs
• Is a basis for promotion and compensation
• Manager is coach vs. judge
• Better managerial planning
• Better use of employees

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Limitations of MBO

• Not easy to implement

• Is hard to maintain
• Process must be taught and reinforced
• Assumes staff will define suitable standards
• Too many outcomes standards
• Too long or too short time periods
• Imbalanced emphasis
• Non measurable outcomes or outcomes that are too costly to measure

Peer Review:

It is also a flexible or contemporary strategy. It is also may be considered a developmental

method of evaluation. That is employees are involved in the development and implementation
process. Nurses tend to function in their normal patterns in the presence of peers, and this can be
very solid rating method. The employees must trust and respect each other to participate willingly
in the peer appraisal process. Arnold and Pulich [2004] state that objectivity may suffer as some
employees seek to sabotage the ratings of those they dislike or view as rivals for a future
promotion.

Advantages

 Provides feedback for sharing ideas

 Compares consistency of performance with standards
 Recognizes outstanding performance
 Identifies areas needing development
 Increases professional growth
 Increases job satisfaction from receiving recognition

Limitations

 Staff need to be oriented to the process

 Committee needs to be formed
 It takes time to prepare the folder for review
 Recommendation should be made by consensus
 Is can be threatening
 It can be time consuming

Self Appraisal:

Employees are increasingly being asked to submit written summaries or portfolios of their work-
related accomplishments and productivity as part of the self-appraisal process. Portfolios often
provide examples of continuing education, professional certifications, awards, and recognitions.
The portfolios also generally includes the employee’s goals and an action plan for accomplishing
these goals.

Appraisal of one’s own job performance is advocated because:

541
  Each individual knows himself best, and he is aware of his strengths and weaknesses and of
his efforts to achieve his personal and his organization’s goals;
 Self appraisal is an important factor in Participative Management and in the achievement of
individual and organizational goals. However, self appraisals are not widely used, the
reasons being
 Individuals do not wish to reveal their weaknesses and shortcomings on the job, more so as
this information may be used against them when administrative decisions are taken
 In general, self-appraisals are ‘inflated’ as most employees have an unrealistically favorable
perception of their own performance.

Advantages

 Promotes dignity and self respect

 Promotes acceptance of plans for improvement
 Staff are the best source of information
 Ensures preparation for discussion

Increases perception of fairness

Disadvantages

 Staff may be fearful of punishment

 May rate self low to prevent disagreement with the boss
 May evaluate self high to influence the manager
 May undervalue own achievements
 May feel uncomfortable giving self high ratings

Could provide inaccurate picture if used alone

APPRAISAL INTERVIEW

Planning the Appraisal Interview

Evaluation whether positive or negative can be very useful if it is communicated to the

employee. Many organizations require their supervisors, managers, and other raters to have
periodic discussions with employees about their performances and negative evaluation so that the
employee gets a chance to ‘explain’. This takes care of the process of natural justice.

Appraisal Interview Serve these Broad Purposes:

1. They provide feedback to the employee which helps him ensure appropriate performance in
future.
2. They help the organization to get some idea of its working often problems and issues raised
by employees, difficulties faced in the execution on their duties and ways and means to
improve the functioning are brought to the surface.
3. The organization can ascertain the training needs of its employees, which is very important.
Given the socio economic conditions in India, employers have a social obligation to ensure

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 continuity of jobs for their employees. It becomes increasingly difficult to sack a person
because he has not performed well.

Norman Maier has described four appraisal interviews each with a specific and slightly different
objective.

The Tell and Sell Method:

The purpose is to communicate the rater is evaluation to the employee as accurately as

possible. It assumes that the evaluation was done in fairness. The rater’s purpose is to communicate
to the employee his performance, to gain his acceptance of the evaluation, and to draw up a plan of
improvement for him. The employee is likely to question the rater’s evaluation. Which might place
the latter in a face saving situation. Patience, understanding, sensitivity to employee’s resistance,
and the ability not to use a supervisor’s power are the most important characteristics of a rater.

Interviewer

Desk

Interviewee

Tell-and-Sell Arrangement

The Tell and Listen Method: The purpose of this method is to communicate the evaluation
to the employee, and the let him respond to it. The first part covers the strengths and weaknesses of
the employee, and the second explores his feelings about the evaluation. In contrast to the first
method, the rater, having initiated the disclosure, listen to the employee. Since there is less fear of
reprisal and of annoying the superior there might be less resistance from the employee, and the
atmosphere, can be friendly and cordial. This might lead to a positive relationship between the two.

The Problem Solving Approach:

Unlike in the first two methods the appraisal need not even be communicated according to
this method. The thrust is on employee development, and the rater is more of a helper than a judge.
He does not point out the areas for improvement, but stimulates the employee into thinking about
improving his performance. Since problem solving involves exploration of various solutions, the
rater should help the employee to seek alternative.

Walls

Table
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 Interviewer

Interviewee

Problem-Solving Arrangement

Goal/Outcome Setting:Goal setting is future oriented. It focuses attention on the employee’s

achievement and consequently stimulates accomplishment. This method integrates institutional and
personal achievement goals. It clarifies objectives or outcomes and because it focuses on results
and not methods, encourages the person closest to a job to decide how to do it.

Table Table

Interviewer Interviewee Interviewee

Goal-Setting Arrangement

PERFORMANCE APPRAISAL: A DIFFERENT PERSPECTIVE:

The following situations of inconsistencies and deficiencies in performance evaluation make the
authority system incompatible with the employee’s achievement of personal goals [acceptance
level].

1. Contradictory Evaluation:

This results when one rater’s evaluations reach employee acceptance level but another rater’s
evaluation does not as when an employee is contradictorily evaluated by two raters, or on two
occasions by the same rater. This problem can occurs when a single task or two or more tasks are
evaluated, for example, working fast and working carefully.

2. Uncontrollable Evaluation:

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This refers to inconsistency between the acceptance level and evaluations based on outcomes
beyond the control of employees. For example in interdependent tasks the outcome of employee Y
may be a function of low employee X performs the previous segment. In interdependent tasks the
mistakes of one are carried over through the whole process.

3. Unpredictable Evaluation:

Incompatibility between evaluations and acceptance level in this case occurs because the employee
has little or no information about what he is evaluated on. He is unable to adjust to adjust his
performance to maintain evaluation at the acceptance level.

4. Unattainable Evaluation:

This results when the employee is evaluated on that aspect for which he lacks facilities to perform
at accepted levels of standards, despite his best efforts. An understanding of these situations is
significant in improving organizational effectiveness and achieving employee satisfaction.

HUMAN RESOURCES DEVELOPMENT (HRD):

Performance appraisal has acquired a new dimension as a result of the Human Resources
Development continuously helps the employees in a planned way to acquire and sharpen
capabilities needed for present and future work, to help them discover their potential and to
develop an organization culture where collaboration and teamwork are valued. Performance
appraisal plays a key role in achieving the objectives of Human Resources Development.

It can be used for performance planning and culture building. Appraisal can help in
identifying development areas and growth potential. It can also be used for performance reviews
and counseling. Effective appraisal should help in identifying strengths and weakness of the
employees.

OBSTACLES TO EFFECTIVE APPRAISAL SYSTEM:

Personnel appraisals, although very widely used, have well recognized short comings and
limitations. Even when the process emphasizes appraisal rather than counseling, it is fare from
universally satisfactory. There are certain barriers which work against the effectiveness of appraisal
system. The identification of these barriers is necessary to minimize their impact on the appraisal
system.

Among the principle barriers to effective appraisal programmes are

1. Faulty assumptions
2. Psychological blocks
3. Technical pitfall.

1. Faulty Assumptions:

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 The faulty assumptions of the parties concerned superior and his subordinate in appraisal
system. It does not work properly or objectively.

These assumptions work against an appraisal system in the following manner.

 The assumption that managers naturally wishes to make fair and accurate appraisals of
subordinates is untenable. Both superiors and subordinates show tendencies to avoid formal
appraisal processes as well as to need them in their respective work roles. Their assistance
lies partly in their psychological characteristics, partly in their organizational roles and partly
in technical deficiencies and the unwise management of appraisal polices and procedures.
 Another faulty assumption is that managers take a particular appraisal system as perfect and
feel that once they have launched a programme that would continue forever. They expect too
much from it and rely too much on it, or blame for their results.
 Managers sometimes assume that personal opinion is better than formal appraisal and they
find little use of systematic appraisal and review procedures.
 Manager’s assumption that employees want to know frankly where they do stand and what
their superiors think about them are not valid.

2. Psychological Blocks:

The value of any tool, including performance appraisal, lies largely on the skills in the user.
Therefore, the utility of performance appraisal depends upon the psychological characteristics of
managers, no matter whatever the method is used. There are several psychological blocks which
work against the effectiveness of an appraisal system.

3. Technical Pitfalls:

The design of performance appraisal forms has receives detailed attention from
psychologists but the problem of finding adequate criteria still exists there. At best appraisal
methods are subjective and do not measure performance in any but in the most general sense. The
main technical difficulties in appraisal fall into two categories. The criterion problem and
distortions that reduce the validity or results.

PROBLEMS IN PERFORMANCE APPRAISAL:

Source of error in performance evaluation is criterion contamination and bias because of a

variety of circumstances and functions beyond the control of the rater and the rater. These are
critical biases and must be taken into account to make appraisal as objective as possible sources of
bias are.

1. Opportunity Bias:

This results when the amount of output is influenced by factors beyond the control of employees.
Some employees have better working conditions, supportive supervisors, more experienced co
workers, and thence their output may be greater than others working on identical tasks. For
instance, one salesman might have better display facilities, a better sales counter and a more
conductive geographic location than the other. In such circumstances, a comparison of the
performance of two employees will have limitations.
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 2. Group Characteristics Bias:

The characteristics of an individual’s group made a dent in his performance. Since the
individual’s performance is greatly determined by the groups’ definition of a fair day’s work, this
factor must be kept in mind while evaluating the individual employee’s performance.

3. Knowledge of Predictor Bias:

A rater’s knowledge of the performance of an employee on predictors can influence his

appraisal ratings. An employee who topped in the selection list might have the impression that he is
the best among the employees and hence may railroad the rater to better evaluation despite a
moderate performance. The rater should never be permitted to have access to the employee’s
selection data.

Bias in ratings:

The rater’s own biases and competence in rating can influence the objectivity of
performance appraisals. All appraisal methods are subject to validity and reliability test there is
very little evidence on these two counts. Since most appraisal methods involve personal judgement
it is difficult to ascertain their reliability and validity. Group appraisal methods and rating by
multiple judges are some technique which can make evaluation reliable and valid.

Several research studies have noted other problems in appraisal. The answer to “why
performance appraisal fails is summarized as follows.

1. The supervisor plays the dual and conflicting role of both judge and helper
2. Too many objectives often cause confusion.
3. The supervisor feels that subordinate appraisal is not personally rewarding.
4. A considerable time gap exists between two appraisal programmes.
5. Poor communication keeps employees unaware about what is expected from them.
6. Feedback on appraisal is generally unpleasant for both supervisor and subordinate.

STRATEGIES TO ENSURE PERFORMANCE APPRAISAL ACCURACY:

 Develop self-awareness regarding own biases and prejudices

 Use appropriate consultation
 Gather data adequately over a period of time
 Keep accurate anecdotal records for the length of appraisal period
 Collect positive data and areas where improvement is needed
 Include employee’s own appraisal of his or her performance
 Guard against the halo effect, horns effect, central tendency trap, and Matthew effect.

CONFLICTS IN APPRAISAL

 Choice of Appraisal objectives

Most Appraisals attempt at gathering information for administrative purposes’ and also for self
improvement and growth of the individual. Simultaneous attainment of both these objectives is not
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practicable as the pertaining to weakness of the person is not revealed in the Appraisal process. The
organization should therefore be clear about what objectives are to be achieved through the
Appraisal processes.

 Focus on Traits versus Behaviors

Assessment of personality traits in preference to work behaviors is associated with grave

implications, in that the ratings are not reliable, they tend to focus on an individual’s personality
rather than on his contribution to the organization, and the interpretation of traits varies markedly
with people and therefore tends to be subjective.

 Multiple Criteria Scores versus a Composite Score:

Composite Scores are often required when comparing the performance of several individuals for
selection, placement, promotion, incentives, etc. however, they have the drawbacks that the facts of
performance are not brought out through Composite Scores and further such Composite Scores are
not useful for feedback and for analysis of the individual’s performance.

LEGAL IMPLICATIONS FOR PERFORMANCE APPRAISAL:

The equal pay act of 1963, which prohibits paying personnel of one gender at a different rate
from personnel of the gender for the same work; the Civil rights Act of 1964, which prohibits
discrimination on the basis of race, color, religion, gender, or national origin; and the Age
Discrimination in Employment Act of 1967, which prohibits discrimination against persons 40 to
70 years of age, all require that employers document the equality of employee performance before
making decisions about selection, training, transfer, retention and promotion.

 The most legally defensible content of performance appraisals should be based on job analysis.
 It should be objective, verifiable, specific, and job related rather than global.
 Individual traits such as attitudes should not be evaluated.
 Performance standards, performance results, the appeal process, and antidiscrimination laws
should all be communicated to personnel.
 Raters should have written instructions for how to do an unbiased appraisal.
 Using more than one rater is desirable.
 Thorough written record of evidence should be collected including evaluations, counseling
about performance deficits, and methods employed as corrective actions before termination
decisions are made.

Sample of checklist to evaluate programme of field work

Name__________________ Date____________________

Position_________________ Department______________

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 Evaluation

List of behaviors Satisfactory Non-Satisfactory

I. Knowledge

 Clinical Knowledge
 Nursing care needs
 Needs of subordinates

II. Skills and ability

 Teaching
 Guiding and supervision
 Communication
 Leadership
 Reports and records

III. Attitude

 Initiative
 Dependability
 Commanding
 Teaching spirit
 Reaction to supervisor
 Professional ethics

Remarks Signature of Head

PERFORMANCE APPRAISAL DOCUMENTATION FORM

Performance Appraisal for:

Name:
____________________________________________________________________________

Unit:
______________________________________________________________________________

Prepared By:
______________________________________________________________________

Reason:
___________________________________________________________________________
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(Merit, Terminal, end of probation, general reviews)

Date of appraisal conference: ____________________________________________________

Comments by employee: _________________________________________________________

Employee’s Signature:_____________________________

(Signature of employee denotes that the appraisal has been read. It does not signify acceptance or
agreement. Space is provided for any comments the employee wishes to make.) Comments by
appraiser.(These comments are to be written at the time of the appraisal conference and in the
presence of the employee)

_______________________________
_____________________________

Employee’s signature (date) Evaluator’s signature (Date)

PERFORMANCE REPORT

FOR STAFF NURSES AND WARD SISTERS/MASTERS

1. Name in block letters

……………………………………………………………………………………………
2. For the year
……………………………………………………………………………………………………
…….
3. Designation
……………………………………………………………………………………………………
……..
4. Date of appointment in the present position
………………………………………………………..
5. Date since posted in this institution
………………………………………………………………………
6. Does she/he has any infirmity or any other cause appear to be unfit or unsuitable for present
duties or those which should cause unfit after promotion to the higher grade
……….……………………………………………………………………………………………
……………………………
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7. Does she. /he has special qualification or experience benefiting her/him for any special duties
……………………………………………………………………………………………………
…………………….............
8. Make remark on the following considered suitable on her/him:

a. Punctuality
b. Tactful with the members of health team
c. Capacity for administration and organization
d. Care of patient does she take
e. Control of hospital equipment and supplies
f. Maintenance of professional knowledge and skill
g. Participation in extracurricular activities
h. Discharging duties consciously
i. Attitude towards nursing
j. Self disciplined

9. Integrity ………………………………… nothing has come to my knowledge which causes any

reflexion of the integrity
……………………………………………………………………………………………………
…………………………
10. Capacity for teaching
……………………………………………………………………………………………………
………………………
11. Fit for promotion
……………………………………………………………………………………………………
…………………………….
12. Confirmed yet or not
……………………………………………………………………………………………………
………………………
13. Special remark to justify Sl.No.11
………………………………………………………………………………………………..……
……………………………

Counter signed Signature of Nursing Supdt.

Date ……………………………….

Office Seal

Conference with the nurse for improvement

Summary discussion………………………………………….

CHAPTER- VIII srimathi shakthi

SUPERVISION AND MANAGEMENT : CONCEPTS & PRINICPLES

SUPERVISION:
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Definition:

 Supervision means overseeing the employees at work. It has been defined as the
authoritative direction of the work of one’s subordinates. It is a necessary concomitant of
their hierarchical organization in which each level of subordinate to the one immediately
above lit and subject to its orders.
 Supervision is an act of a superior person to see the work of the personnel working under
him or her.
 Supervision is “guiding and directing efforts of employees and other resources to
accomplish stated work outputs”. (Terry and Franklin)
 Supervision is the process by which workers are helped by a designated staff member to
learn according to their needs, to make the best use of their knowledge and skills and to
improve their abilities so that they do their jobs more effectively and with increasing
satisfaction to themselves and the agency (Williamson)
 Supervision is a teaching learning process which provides

i. Constant observation
ii. Monitoring
iii. Evaluation and
iv. Guidance to workers to enable them to
v. Perform their activities effectively and efficiently maintaining the
vi. Required standards

CONCEPT OF SUPERVISION:

The word meaning of “Supervision” is overseeing.

The word ‘super’ means above and ‘vision’ means seeing. Thus supervision is an act of superior
person to see the word of the personnel working under him or her. This overseeing also means
directing, investigating, guiding, helping and advising the subordinates in their performance with
the purpose of achieving the established objectives.

Supervision is a twofold process on one side it is a guiding process, on the other fold it is
superintending the work of subordinates. If one analyses the job of a person for each job, arousing
interest in each person in his/her work by teaching him/her performance, giving feedback and
administering corrections wherever needed, acknowledging and appreciating the efforts of the
worker.

Supervision may thus be defined as

 A two way dynamic and social process

 Undertaken for the specific purposes of fulfillment of organizational goals
 By striving to maintain the required quality of performance
 Through constantly supporting and assisting the worker to perform their best.
 The main aspects of supervision cover the workers, the method and procedures followed by
workers and the quality of performance vis-à-vis the organizational goals.

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BASIC TENETS OF SUPERVISION:

 Supervision is an ongoing process invariably interwoven with motivation, performance

appraisal, staff development and leadership
 Supervisors are always accountable for the performance of the subordinates under her/his
span of control
 Supervisors are to help the workers improve, develop and reinforce knowledge and skills
according to their individual learning needs
 Supervisors are required to help the workers develop the right attitude
 Another essential tenet of supervision includes assisting the workers to perform in the best
possible way to yield the best results in terms of realization of the organizational goals.

AIMS:

The important aims of supervision are as follows:

1. To improve the work of the employee

2. To ensure correct and adequate performance
3. To supervise satisfactory implementation of the administrative activities
4. To stimulate, coordinate and guide the efforts of the supervisor
5. To evaluate the scholastic performance of the employees
6. To ensure continuous evaluation of practice in the hospitals

OBJECTIVES:

 Help the staff to do their job skillfully and effectively to give maximum output with
minimum resources – Cost effectiveness
 Help the staff develop the individual capacity to the fullest extent with a view to channelize
the same in favor of work.
 Guide and/or assist in meeting predetermined work objectives or targets in nursing
preventive, promotive, curative and rehabilitative care to people.
 Help to promote effectiveness of the subordinates/staffs. Ensuring that the subordinates staff
or supervise does what he/she supposed to do.
 Help to motivate subordinates to maintain high morale. i.e., promotion of motivation and
morale among all the nursing staff.
 Help the members of the team to recognize problems, identify solutions and to take action.
 Help to develop team spirit and promote team work for effective functioning
 Help to improve the attitudes of the members towards the work or programme.

FEATURES OF SUPERVISION:

 Supervision is Philosophic:

Supervision is dynamic. It always seeks new truth. It reaches out beyond the issues of management
and seeks to understand the issues of society in which management develops. It evaluates its aims
and objectives continuously.
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  Supervision is cooperative:

Supervision works with supervisors towards the solution of mutual problems. It creates situations
in which supervisors become aware of their problems and seek assistance in their solution.

 Supervision is Creative:

Creative Supervision seeks latent talent. It encourages initiative, originality, self-reliance and self-
expression. The employees are encouraged to share their views and thoughts with the supervisor
and colleagues. Suitable environment is also created to make the employees to think freely for
themselves.

 Supervision is Scientific:

Supervision applies the scientific method to the study of the supervisory process. It stimulates
constructive, critical thinking. It evaluates objectively the results of instruction. Scientific
supervision encourages experimentation under proper controls. It seeks constantly objective
evidence as to the results of the experimentation.

FACTORS OF EFFECTIVE SUPERVISION:

Following factors are responsible for effective supervision.

1. Human relations skill

2. Technical and managerial knowledge.
3. Leadership position
4. Improved upward relations
5. Relief from non-supervisory duties
6. General and loose supervision.

1. Human relations skill:

Supervision is mainly concerned with instructing, guiding and inspiring human beings towards
greater performance. For purposes of directing, the supervisor has to rely on leadership counseling,
communication and other determinants of human relations.

2. Technical and managerial knowledge:

Guidance implies a complete understanding of all work problems, for which the supervisor should
have good knowledge about technical aspect of job and also the managerial aspects.

3. Leadership position:

The authority of supervisors must be made commensurate with their duty so as to make the job of
supervision a satisfying, rewarding and challenging one. So, the supervisors are to be vested with
necessary authority for enabling them to exercise leadership over the group and influence the
employees.

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4. Improved upward relations:

To ensure good quality of supervision, the supervisor’s upward relations must be well established,
which means to say that supervisors should be regularly allowed to present their views and
suggestions to top executives in regard to the personnel and their work performance, for which, the
top management must pay adequate attention and thought on supervisory jobs to ensure good
quality supervisions.

5. Relief from non-supervisory duties:

To make the supervisory duties purposeful, the supervisors are to be relieved of many routine
activities that divert their attention from the real job.

6. General and loose supervision:

According to some experience, the general and loose supervision is more productive than close
supervision. Here the leader must allow freedom and initiative to his followers for pursuing a
common course of action.

FUNCTIONS OF SUPERVISION:

Supervisors are 6the line executives with command authority. They are entrusted with the task of
securing work accomplishment by employees in accordance with predetermined standards of
performance. For purposes of such work accomplishment, the supervisors give orders, issue
instructions, prescribe methods, determine procedures, explain institutional policies and inspire
human beings by exercising leadership as well as communicative skills.

The major supervisory functions are as follows:

 Orientation of Newly posted staff:

Transfers and postings or new postings of personnel are common in all organizations. All new
corners should be informed about their functions, the methods that they should use, the personnel
with whom they will work and the community wherein they will work, that needs an orientation.

 Assessment of the workload of individuals and groups:

It must be ensured that the workload is within the physical and mental competence of a worker.
Otherwise job should not be assigned to them. A supervisor should to expect from workers a level
of effort that is beyond them.

 Arranging for the flow of materials:

A supervisor must find out the needs for supplies and equipment and arrange for their supply in
good time.

 Coordination of the efforts:

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A supervisor coordinates the work of his/her workers and agencies and promotes team work.

 Promotion of effectiveness of workers:

This may be done through performance evaluation and introducing concepts of staff development

 Promotion of social contact within the work team:

Social contacts help to bring the staff together and increase group cohesiveness. A good supervisor
should provide opportunity for it.

 Helping individuals to cope with their personal problems: Personal problems are likely to
come up while dealing with workers. Those may be outside the supervisors’ duties but a
sympathetic understanding on his part improves the individual morale.
 Facilitating the flow of communication:

A free flow of communication among members is necessary for team work. Supervisor should
encourage free communication among peer team members.

 Raising the level of motivation:

All good work should be given due credit through recognition. Supervisor must provide
opportunities for growth and achievements.

 Establishment of control:

Supervision is a control measure as well as leadership techniques. The supervisor must know what
work is being done and with what effectiveness. As number of techniques such as observation and
record review can be used for this purpose.

 Development of confidence:

Supervisors must know the background of workers and try to develop mutual confidence. There is
a need to combine understanding with firmness and to take a personal interest without sacrificing
impartiality or discipline.

 Emphasis on achievement:

It has been proved that the development of a smooth work routine and the improvement of human
relations without corresponding emphasis on goal achievement are not likely to increase
productivity.

 Record Keeping:

The supervisor should maintain good record system for many purposes

 Other Functions:

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  Develop and maintain team spirit
 Improve the knowledge and skill of the workers
 Maintain interpersonal relationship
 Allocation of specific work plan
 Assess training needs of the staff and do needful
 Have knowledge of rules and regulations of agency
 Identify problems and help subordinates to find out solutions
 Maintain of his own image

PRINCIPLES OF SUPERVISION:

1. Supervision should not be overburdened to any individual or group

2. Supervision causing unreasonable pressure for achievements results in low performance and
low confidence in the supervisor
3. Supervise diagnosis, do not over estimate his understanding and memory
4. Human behavior with due consideration to human weaknesses. This should be kept in minds
of supervisors.
5. Supervisors should create atmosphere of cordiality and mutual trust.
6. Supervision should be planned and adopted to the changing conditions. It calls for good
planning and organization.
7. Supervisors must possess sound professional knowledge.

8. Supervision to be exercised without giving the subordinate a sense that they are being
supervised.
9. Supervision strives to make the unit a good learning situation. It should be a teaching learning
process.
10. Supervision should foster the ability of each staff-member to think and act for
herself/himself.
11. Supervision should encourage workers’ participation in decision-making.
12. Supervision needs good communications.
13. Supervision should have strength to influence downwards depends on capacity to influence
upwards.
14. Supervision is a process of co-operation and co-ordination.
15. Supervision should create suitable climate for productive work.
16. Supervision should give autonomy to workers depending from personality, competence and
characteristics.
17. Supervision should respect the personality of the staff.
18. Supervision should stimulate the workers/staff ambitions to grow in effectiveness.
19. Supervision should focus on continued staff growth and development.
20. Supervision is responsible for checking and guidance.
21. Good leadership is part of good supervision.

TYPES OF SUPERVISION:

Generally there are two types of Supervision, i.e.

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  Direct Supervision
 Indirect Supervision.
Direct Supervision:

Direct supervision means concurrent observation of the workers while they are performing various
nursing tasks. Thus on the spot appraisal of the nurses as well as their performance is done in this
method. This is done through face-to-face talk with the workers. This can be exercised at the
ward/unit level in the hospital or PHC or sub centre of the community setting.

The following considerations are essential in direct Supervision:

 Do not loose temper or abuse.

 Use democratic approach and avoid autocrate methods.
 Reprimand if necessary in private and do it promptly.
 Give workers a chance to reply.
 Do not talk too much and too fast.
 Be human in behavior.
 Do not take it granted that the worker had understood everything told to him.
 Do not give instructions in a haphazard way.

Examples:

o Efficacy of nursing care services rendered to the patients in institutional settings.

o In community settings:

- Home visits
- Enumeration of eligibles
- Conducting clinic activities
- Conduct of mother’s meetings
- Mobilization of TBAs
- Meeting influential leaders

Indirect Supervision:

It is done with the help of record and reports of the workers and through written instructions or
through some agency between the supervisor and supervisee. This includes:

 Ensuring that every worker is carrying out allowed work in accordance with the plan of
operation and with the prescribed methodology and in keeping pace with the time as far as
possible.
 Analyzing the monthly progress reports to know the input of efforts and the achievement of
the workers and their relations with each other.
 Analyzing what amount of work allotted for the month has been done with reasons for non-
performance and providing suitable guidance for the same.

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  Providing support and guidance to all the workers in the implementation of various
activities.
 Analyzing the stage of programme or job in each sector/unit and village (Public Health) and
to suggest plan for future months on the above basis.
 Ensuring that the worker is utilizing his/her full capacity in the programme. How many
hours per day have been spent in the field or unit/ward, and what efforts have been done by
him/her during this time.

Examples:

o Institutional Settings:

- Patient’s records and reports

- Patient’s history sheets, treatment records, results of investigations and diagnostic
procedures
- General order books
- Round books
- Dangerous drug records and registers
- Nursing care plans
- Nurse’s notes
- Call books
- Admission and discharge registers; death register

o Community settings:

- Work diary of the individual workers

- Performance reports of the individual workers
- Counterfoils of the mother and child cards
- Eligible couple and child registers
- Copies of monthly reports sent to the authorities
- Other records available in specific settings

METHODS OF SUPERVISION:

Supervision is a co-operative process that has for its objective the improvement of nursing service.
To achieve these objectives, there are different methods of supervision which include:

1. Technical vs. creative supervision

2. Co-operative vs. authoritarian supervision
3. Scientific vs. intuitive supervision.

Technical vs. creative supervision:

Technical methods are some of 6the basic supervisory skills which need to be trained. Group
conferences, group discussions. For example, technique of service study, record construction, time
study etc. creative supervision provides maximum adaptation to the situation. For example, instead

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of an orientation period of two weeks for each new staff member, a variable plan in both contents
and time according to the needs of each individual should be formulated.

Co-operative vs. Authoritarian Supervision:

In co-operative supervision there is a full participation of each member of the group in planning,
action and decision whereas in authoritarian supervision responsibility centers entirely on the
supervisor, with the staff following his/her orders. Both are needed according to situation and
circumstances.

Scientific vs. intuitive supervision:

Scientific supervision relies on objective study and measurement than personal judgment or
opinion. Whereas intuitive supervision needs to maintain the interpersonal relationship. The
supervision needs a sensitive and intuitive reaction to the emotional needs of another person.

MODELS OF SUPERVISION:

1. Developmental Model: Stoltenberg and Delworth(1987)

2. Functions Model: Kadushin(1976) Proctor (1987)
3. Key Issues Model: Gilbert and Clarkson
4. Training Models: Holloway (1995)-A Systems Approach
5. Process Models: Hawkins and Shohet
6. Therapy specific Models
7. Heron’s model of supervision (1989)
8. Powell’s model of supervision (1993)
9. Gebhard ‘s models of supervision

1. DEVELOPMENTAL MODEL (STOLTENBERG &DELWORTH):

Developmental models of supervision have dominated supervision thinking and research since the
1980s. Developmental conceptions of supervision are based on two basic assumptions:

 In the process of moving toward competence supervisees move through a series of

stages that are qualitatively different from one another.

 Each supervisee stage requires a qualitatively different supervision environment if

optimal supervisee satisfaction and growth are to occur.

Stoltenberg and Delworth (1987) described a developmental model with three levels of
supervisees:

1) Beginning
2) Intermediate
3) Advanced

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Within each level the authors noted a trend to begin in a rigid, shallow, imitative way and move
toward more competence, self-assurance, and self-reliance for each level. Particular attention is
paid to

(1) Self-and-other awareness (the trainee’s awareness of self and others)

(2) Motivation (toward the developmental process)
(3) Autonomy (the amount of dependency or autonomy displayed by the trainee)

For example, typical development in beginning supervisees would find them relatively dependent
on the supervisor to diagnose clients and establish plans for therapy. Intermediate supervisees
would

depend on supervisors for an understanding of difficult clients, but would chafe at suggestions
about others. Resistance, avoidance, or conflict is typical of this stage, because supervisee self-
concept is easily threatened. Advanced supervisees function independently, seek consultation when
appropriate, and feel responsible for their correct and incorrect decisions.

Stoltenberg and Delworth described three developmental levels of the supervisee and eight
dimensions

1. Intervention skills

2. Assessment techniques

3. Interpersonal differences

4. Client conceptualization

5. Individual differences

6. Theoretical orientation

7. Treatment goals and plans

8. Professional ethics

Helping supervisees identify their own strengths and growth areas enables them to be responsible
for their life-long development as both therapists and supervisors.

Level 1 Level 2 Level 3 Level 4

Child Adolescent Early Adulthood Maturity
Dependent on Fluctuating Increased Self-confidence Autonomous
supervisor Autonomy
Anxious/Insecure Fluctuating Increased Insight Personal

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 Confidence security
Motivated May become Stable motivation Stable
disillusioned and motivation
blame supervisor
Single focused on Aware of Sees client in wider context Addresses
specifics not complexity of personal and
whole therapy professional
issues in
context

Integrated Developmental Model -Stoltenberg and Delworth:

Level Motivation Autonomy Self-other awareness

1 High motivation Dependent on supervisor, Limited self-awareness.

need for structure, direct Focus on self: anxiety
High anxiety feedback, minimal direct performance, Difficulty
confrontation seeing strengths/weakness
Focus on skills
acquisition

2 Fluctuating. Dependency-autonomy Focus more on client, can

conflict. Specific help empathise. May become
More complexity enmeshed, need balance
shakes confidence. Dependent/evasive

3 Stable Firm belief own autonomy Accepts strengths/

weaknesses
Remaining doubts not Sense of when necessary to
disabling seek consultation Can focus on client and
process info. Including use
Total professional of own reactions.
identity and how
therapist role fits

Using this developmental framework suggest how supervision should be adapted for a first, second
and third year trainee.

• Think about how supervision should be delivered?

• The main focus of supervision
• The types of cases/interventions provided
• The techniques used in supervision

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IMPLICATIONS FOR SUPERVISION/ TRAINING ACROSS LEVELS:

Level One: (Level 1: Self centred)

• Provide structure; manage anxiety, supervisor as expert role model, clarity of skills and
theory.
• Clients: Mild /maintenance problem focus
• Interventions: Facilitative, prescriptive
• Mechanisms: Observation, skills training, role play

Level Two: (Level 2: Client centred)

• Less structure, encourage more autonomy, continue use of modelling bur less diadactic
• Clients: More difficult ,severe presentations
• Interventions: Facilitative, occasionally prescriptive, confrontive, hightlight process

Mechanisms: Observation. less role play, process focused

Level Three: (Level 3: Process centred)

• Most structure provided by the trainee, more focus on personal /professional

integration (don’t assume this level for all)
• Interventions: Facilitative, Confrontive occasionally, conceptual from personal
orientation, process, re blocks
• Mechanisms: Peer/ Group supervision

Level 4: Process in context centred

2. FUNCTIONS MODEL: KADUSHIN (1976) PROCTOR (1987)

Functions of supervision- Kadushin (1976)

It is at this point that Alfred Kadushin's discussion of supervision in social work becomes helpful.
He goes back to earlier commentators such as John Dawson (1926) who stated the functions of
supervision in the following terms:

 Administrative - the promotion and maintenance of good standards of work, co-ordination of

practice with policies of administration, the assurance of an efficient and smooth-running
office;
 Educational - the educational development of each individual worker on the staff in a
manner calculated to evoke her fully to realize her possibilities of usefulness; and
 Supportive - the maintenance of harmonious working relationships, the cultivation of esprit
de corps.

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The primary foci of supervision (after Hawkins and Shohet 1989)

1 To provide a regular space for the supervisees Educational

to reflect upon the content and process of their
work
2 To develop understanding and skills within the Educational
work
3 To receive information and another Educational/Supportive
perspective concerning one's work
4 To receive both content and process feedback Educational/Supportive

5 To be validated and supported both as a person Supportive

and as a worker
6 To ensure that as a person and as a worker one Supportive
is not left to carry unnecessarily difficulties,
problems and projections alone
7 To have space to explore and express personal Administrative
distress, restimulation, transference or counter-
transference that may be brought up by the
work
8 To plan and utilize their personal and Administrative
professional resources better
9 To be pro-active rather than re-active Administrative
10 To ensure quality of work Administrative/Supportive

Functions model Proctor (1987):

Proctor (1986) also has a similar view of the key functions of supervision although her terminology
is different. She refers to the normative, formative and restorative aspects of supervision.

1) Normative - the supervisor accepts (or more accurately shares with the supervisee)
responsibility for ensuring that the supervisee's work is professional and ethical, operating
within whatever codes, laws and organizational norms apply.

The main activities of the normative function is

• Administration & Quality Assurance

• Manage projects
• Ensure patient safety
• Assess & assure quality
• Improve practice

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2) Formative (Education & Professional Development) - the supervisor acts to provide feedback
or direction that will enable the supervisee to develop the skills, theoretical knowledge,
personal attributes and so on that will mean the supervisee becomes an increasingly competent
practitioner.

The main activities of the formative function is

 Skills & knowledge

3) Restorative (Support & Assistance with Coping) - the supervisor is there to listen, support,
confront the supervisee when the inevitable personal issues, doubts and insecurities arise.

The main activities of the restorative function is

 Identify solutions to problems in practice

 Alleviate stress

Proctor Functional Model

Application of this Model in Supervision:

 Normative (management, safety, assurance)

 Meetings
 Observation of care
 Formal evaluation
 Telephone consultation
 Documentation in hard & electronic media
 Patient records
 Activity logs
 Restorative (support & assistance with coping)
 Group supervision
 Case conferences
 Identification of solutions to problems in practice
 Formative (education & professional development)
 Continuing education

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3. KEY ISSUES MODEL: GILBERT AND CLARKSON

• Reduction of harm
• Ethics/professional practice
• Skills /techniques
• Conceptual framework
• Transference/Counter transference
• Developmental
• Personal issues
• Treatment/ Goals
• Assessment

4. TRAINING MODELS: HOLLOWAY (1995)-A SYSTEMS APPROACH

• Goals of model: to analyse learning within the context of relationship

• Uses a supervision process matrix
• Supervision tasks + functions= process
• Helps to illustrate change in focus and different styles of supervision

Tasks: Therapy skill, conceptualisation, professional role, emotional awareness, self evaluation

Functions: monitoring/evaluating, advising/instructing, modelling, consulting, supporting/ sharing

5. PROCESS MODELS: HAWKINS AND SHOHET (or seven-eyed supervision model):

In the late 1980’s along with Robin Shohet developed a more in depth model of supervision,
which later became known as the seven-eyed supervision model, and has been used across many
different people professions in many countries in the world. Its purpose is the exploration of the
various different influences on supervisory activity in the room. It is based on a systems
understanding of the ways things connect, inter-relate and drive activity. This model though, also
integrates insights and aspects of psychotherapy and the internal life of individuals. I will set out in
more detail these seven areas of potential focus to supervisor and supervisee in reviewing their
practice.

This model explores the Double Matrix Model of supervision. It turns the focus away from the
context and wider organization issues to look more closely at the process of the supervisory
relationship.

All supervision situations involve at least four elements:

1. A supervisor

2. A supervisee

3. A client

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4. A work context.

The supervision process involves two interlocking systems or matrices:

1. The therapy system, which interconnects the client and the therapist and

2. The supervision system or matrix which involves the therapist and the supervisor.

Process Matrix:

The Double Matrix Model of Supervision divides supervision styles into two main categories:

1. Supervision that pays attention directly to the therapy matrix and

2. Supervision that pays attention to the therapy matrix as it is reflected in the supervision process.

Each of these two major styles of managing the supervision process can be subdivided into three
categories creating six modes of supervision.

Mode One: Reflection on the Content of the Therapy Session

 Attention is concentrated on the actual phenomena of the therapy session.

 The goal of this form of supervision is to help the therapist pay attention to the client and the
client’s choices.

Mode Two: Focusing on Strategies and Interventions

 Here the focus is on the choices of intervention made by the therapist- what, when, and why.
 The aim and goal would be to increase the therapists choices and skills and intervention.
 Simple brainstorming and active role-playing can generate new options and possibilities.
 Supervisors need to be aware of dangers in offering their own intervention. It is preferable to
help supervisees develop their own improved interventions.

Mode Three: Focusing on the Therapy Process

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  The supervisor focuses on the conscious and unconscious interaction between the therapist
and client. The supervisor must have the interest of both parties in balance.
 The main goal is for the therapist to have greater insight and understanding of the dynamic
of the therapy relationship.

Mode Four: Focusing on the Supervisees Counter-transference

 The focus is on the internal process of the supervisee and how these are affecting the therapy
they are exploring.
 Important to distinguish between the four different types of counter-transference: 1.
transference feelings of the therapist stirred up by this particular client, 2. feelings and
thoughts of the therapist that arise out of playing the role transferred on to him or her by the
client, 3. therapists feelings, thoughts, and actions used to counter the transference of the
client, and 4. projected material of the clients that the therapist has taken in somatically,
physically, or emotionally.

Mode Five: Focusing on the Supervisory Relationship

 The supervisor focuses on the relationship in the supervision session in order to explore how
it might be unconsciously playing out or paralleling the hidden dynamic of the therapy
session.
 It is the job of the supervisor to name the process and thereby make it available to the
conscious exploration and learning.

Mode Six: Focusing on Supervisors own Counter-transference

 The supervisor pays attention to their own here-and-now experience in the supervision-what
feelings, thoughts, and images the shared therapy material stirs up in them.
 The supervisor must examine the fantasy relationship between the client and supervisor.
Supervisors may have all sorts of fantasizes about their supervisees� clients even though
they have never meet them.

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HAWKINS & SHOHET PROCESS MODEL

6. THERAPY SPECIFIC MODELS:

• Eg: Cognitive Therapy, Cognitive Analytical Therapy, Psychodynamic Therapy

• Structure and processes and techniques in supervision parallel those of a therapy
session.
• Advantages: Provides modelling of therapy skills in supervision. Learning by reflexive
practice

7. HERON’S MODEL OF SUPERVISION (1989):

 Authoritative Supervision Interventions

 Prescriptive – direct behavior

 Informative – give information/instruct
 Confronting – challenge
 Facilitative Supervision Interventions

 Cathartic – release tension/strong emotion

 Catalytic – encourage self-exploration
 Supportive – validate/confirm
8. POWELL’S MODEL OF SUPERVISION (1993):
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  Components
o Administrative
o Evaluative
o Clinical
o Supportive

 Conceptualization of supervisor as a servant leader who

o Is self-aware
o Operates with focus & energy
o Is proficient in many aspects of the job
o Makes the organization’s mission & vision clear by standing ahead of the followers
while standing behind their actions
o Shares power
o Values people by caring for them

9. GEBHARD ‘S MODELS OF SUPERVISION:

Gebhard(1990) proposes six following models of supervision:

1. Directive
2. Alternative
3. Collaborative
4. Non-directive
5. Creative
6. Self-help/Explorative.

GEBHARD ‘S MODELS OF SUPERVISION

In the directive model of supervision the supervisor is given a direction of how to conduct
a class and then he would be supervised; in the alternative model of supervision the supervisor
would be suggested a variety of alternatives of teaching ;in the collaborative model of supervision
the supervisor instead of directing the supervisor is engaged in collaborative works with the
supervisor; in the non-directive model the supervisor is given the freedom to adopt any approach of
teaching; creative supervision can be the combination of more than one model of supervision or an
adoption of a novel supervising method or the supervision of other source than the supervisor; self-
help model is the observation of an outsider supervisor of the work of other supervisors having the
goal of extension of the repertoire.

TECHNIQUES OF SUPERVISION:

1. Group conference
2. Individual conference
3. Anecdotal records
4. Initial conference
5. Control of early experience
6. Assistance with bedside care
7. Reassurance

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 8. Supervision of nursing procedure
9. Conferences-individual, groups
10. Incidental teaching

 Example as a method of teaching

 Answering and asking questions
 Demonstration of desirable performance
 Positive suggestions
 Making an opportunity for observation of unusual symptoms.

STAGES OF SUPERVISORY TECHNIQUE:

Supervision is a means and not an end in itself for attaining the organizational goals. Whether
supervision is done in a nursing care unit or in a specialized functional unity like operation theatre,
labour room, out patient’s department, etc. or in a community nursing setting, as a nursing
supervisor have to go through three stages. This whole process is based mainly on three stages.

Stage One – Preparation for supervision

Stage Two – Supervision

Stage Three – Follow-up of Supervision

Stage One: Preparation for supervision

As a nursing supervisor, you have to make the necessary preparation for successful supervision.
While getting prepared to supervise you should focus on specific issues like efficacy of the services
provided to the patients.

 Relevant problems which may arise.

 The performance of individual members of staff.
 The effective utilization and management of limited resources covering 3 M’s i.e.
manpower, material and money. In other words these refer to human, material and financial
resources.

Proper preparation includes the following activities:

 Study of documents – You have to study all the documents related to hospital policy,
routine, rules, guidelines, procedure manuals, job description of each category of personnel,
standard norms, targets etc. in details.
 Identification of priorities for supervision – Priorities areas, activities and tasks related to
nursing care services in a hospital or in a community which should be supervised. This will
make your supervision most effective. This is the time when you have to identify the tasks,
the activities, the areas, the units and the staff who must receive priority attention from you
as a supervisor.

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  Preparation of a supervision schedule – It is essential that you prepare checklists for
observation in the wards in the institutional settings and for field visits in the community
settings. You have to prepare plan and schedule of visits on the basis of the priority needs
and content supervision as set out in the checklist. For community nursing including MCH
nursing as well as institutional nursing care, you have to have your work plan for giving
desired attention to the priority areas and units.

Stage two: Supervision

You have done the preparation; you are now ready to begin your supervisory work. In this
stage the tools which you are to use may include:

- Job description
- Task description
- Weekly time table
- Checklist and or rating scale for each task

The supervisor should perform the following activities in this stage:

 Establish contacts
 Supervisor must know about other members of the team providing comprehensive care to
the patients in the wards or people in the community.
 Review of the objectives, targets and norms will the subordinates/supervisees.
 The supervisor should also review the job description especially the description of the
duties, activities and tasks, the duty roster and weekly timed table, to ensure that each
member of nursing staff knows, understands and accepts them.
 The nursing supervisor along with the nursing staff are to examine how much time is at
present spent on each of the duties mentioned in the job description, in the duty roster and in
the weekly work plan. This will give you an estimate on the proportion of time a actually
spend on each function; compare these with established norms and discuss discrepancies.
Observe the impact of the time table on the performance of activities.
 Supervisor should observe the nursing staff’s motivation about the actual use of work time
and its effects on performance of activities through her actual performance.
 The supervisor should not if any actual or potential conflicts are there between the work
objectives and the underlying motivation of the nursing staff, between her and her
colleagues and immediate superiors.
 The supervisor should observe the individual nursing staff carry out his/her tasks.

The supervisor should observe the performance of all tasks with particular regard to:

- The skills (technical, managerial, conceptual)

- The attitude (towards patients, relatives, colleagues, community leaders, families
under supervision, other members of the team etc.)
- The organization of resources (of equipment, materials including stationery etc.)
- The utilization of resources (supplies, time, other supportive staff etc. for cost
effectiveness).

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  Supervisor should have to identify gaps and needs for follow up action based on your
feedback data attained through your observation. Jointly identify particular needs of staff or
improve the staff’s knowledge, attitudes and practical skill with regard to activities under
priority supervision.

- Supervisor should ask each staff to suggest specific ways in which the necessary
learning can be accomplished.
- Supervisor should note the needs for logistic support, supplies or other relevant to the
proper performance of the tasks.
- Supervisor should consults with the other members of the team in the ward or health
team providing community services.
- Since one of the main nursing care activities is to continue the therapeutic care
delegated by the medical professionals, always discuss and consult with them
regarding the objectives of the patient’s care and efficacy of the nursing care
provided by the nursing staff.

Stage three: Follow up of Supervision

Your functions in the role of a supervisor does not end in performing the activities involved in
stage two i.e. supervision. Unless actions to follow up the gaps and needs identified during stage
two are taken, supervision remains incomplete. Each supervision must prepare a report on the
observations made during supervision. This report is used as a tool for taking follow up actions
which may include:

i) Organizing in-service training programme/continuing education programme for the

nursing personnel.
ii) Reorganization of time table/work plan/duty roster.
iii) Initiating changes in logistic support or supply system.
iv) Initiating actions for organizing staff welfare activities.
v) Counseling and guidance regarding career development and professional growth.

STYLES OF SUPERVISION:

There are two main styles of functioning which are observed. They are:

Task Centered:

When the supervisor emphasizes the tasks more than the performer whom she/he supervises. This
type of supervisors probably believe that ‘Ends’ are more important than the ‘Means’: since her/his
concern for the task is high, he/she often neglects the human aspects in dealing with the staff. The
staff may view her as a tough task master.

Employee centered Supervisor:

Such supervisors are people oriented. They believe that a concern for worker/staff, their needs and
welfare is very important. Therefore, if employees are well taken care of, they will be able to work
well and be capable of taking on responsibilities. However, such a supervisory style at an extreme
can also lead to inefficiency if the subordinates take them as lenient persons. The effectiveness of a
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style depends on various factors like nature of the task, the nature of the employee and the
situation.

Other supervisory styles:

There are three other supervisory styles which may be seen being practiced by different
supervisors. According to the style adopted, the supervisor may become:

1) An automatic or critical supervisor who can not tolerate any deviation from norms, lack of
quality in work, lack of discipline etc. The decisions are always made by herself/himself and
such supervisors demand subordinates only to follow their directions as given.
2) A benevolent supervisor who is very protective of her subordinates, keeps telling them what
they should do and what they should not, thus providing constant direction. Such supervisors
are usually liked by workers but are effective as long as they are physically present as they
tend to develop the subordinates as dependent followers.
3) A democratic supervisor who believes in a style of “let us agree on what we are to do” in
dealing with the subordinates. Such supervisor provides guidance only when requested by
the subordinates. The subordinates with this type of supervisor tend to develop confidence in
their work. They are quite independent and cooperate with one another and work together.

TOOLS OF SUPERVISION:

The following are the tools of supervision:

 Checklists:

It is one of the most important and common tools of supervision that can be used both in direct or
indirect methods of supervision. It is a list of essential components of a task or activity which a
performance as well as a performer is being supervised. It helps in effective and systematic
supervision, avoids duplication, includes essential components of a task, skill or activity being
supervised and ensures objectivity by providing factual data.

Example:

Checklist for an aspect preoperative care i.e., immediate for patients undergoing abdominal
surgery.

Components Yes/No
1. Patient’s blood group and Rh factor done, checked and recorded

2. Intravenous fluids ordered for checked, sent to OT

3. Patient’s and/ or patient’s guardian consent for operation and for general
anesthesia taken.

 Rating Scales:

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It is same as that of checklists but instead of Yes/no, a scale for rating is prepared, this can be a 3
point, 5 point or 7 point rating scale.

Example:

Very Good Good Satisfactory Poor Very poor

5 4 3 2 1

 Nursing Rounds:

Nursing rounds may be considered to be another tool of supervision in nursing. While taking
rounds of patients in the hospital indoor, the nurse asks questions about the individual patients as
also general questions regarding the ward where your supervisee is working. Then it is comparing
the supervisee’s answers with factual data and assesses how much she knows about her patient and
the wards. This technique can also be used in the hospital outdoor and clinics as also during home
visits made by public health nursing staff viz the auxiliary nurse midwives and health supervisors
as well as village level workers.

Example in Maternity Units:

 Give me your ward census

 How many normal deliveries have taken place up to this morning?
 How many among them are primis and how many multis?
 How many of them have had episiotomies?
 Has there has been any forceps delivery today?
 Has there been any caesarean section today?
 Have the new babies been put to breast? How soon after delivery did you put the newborns
to breast?
 How many mothers are under observations? Show them to me. Show me your observation
charts on FHS.

 Nurse’s Reports:

Day and night reports written by charge nurses daily during morning, evening and night also save
as tools of supervision particularly in the indirect method of supervision. Here we can get the
charge nurse’s knowledge and awareness about their patients- their condition, what has been done
for them and who require priority attention.

DUTIES OF THE SUPERVISOR:

1. To understand the duties and responsibilities of his own position.

2. To plan the execution of the work
3. To divide the work among subordinates and to direct and assist them in doing it
4. To improve his own knowledge as technical expert and leader
5. To improve his work methods and procedures
6. To train the personnel

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 7. To evaluate the performance of the employees
8. To keep subordinates informed about policies and procedures of the organization and above
the changes to be made.
9. To correct mistakes, solve employees’ problems and develop discipline
10. To cooperate with colleagues and seek advice and assistance when needed, and
11. To deal with employee suggestions and complaints.

RESPONSIBILITIES OF THE SUPERVISOR:

Upward Responsibilities:

 Identify the activities the hospital authorities or the district health authorities want to be
done.
 Arrange to carry out these activities
 Keep your higher authorities posted on what is being done
 Suggest measures for improving efficiency of workers and efficacy of performance
 Act as a liaison between your higher authorities in the health management and the nursing
personnel, interpreting the requirements of the district helath authorities and the hospital
authorities to your workplace and vice-versa.
 Refer matters to your supervisors for their timely and appropriate interventions without
bothering them unnecessarily at the same time.

Downward responsibilities:

 Assist in selecting, orienting and training new staff nurses, new students
 Teach them demonstrate concern decorum, manners, tact and courtesy in their day to day
dealings.
 Help them in effectively humanely communicating with their clientele and all others
concerned.
 Build good interpersonal relationship among the workers
 Help nurse performers in performing different procedures effectively and in assessing the
efficacy of their performance
 Assign duties and responsibilities to nurse performers
 Arrange for their days off and plan for their rotation
 Make contingency plans for emergencies in advance
 Appraise the nurse’s performance, give feedback guide and counsel them
 Help the workers make adjustments as and when necessary
 Assist the nurses to take pride in their work, urging them to do their best with dedication,
human concern and a sense of involvement
 Help them to develop a value system that would be beneficial to the clientele, to the
management and to all concerned as well as themselves
 Develop a spirit of dedication, team work, cooperation and harmony among the workers

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  Take interest in the nurses you supervise as persons enabling them to maintain a high
standard of performance at all times

QUALITIES OF A SUPERVISOR:

 Forcefulness, integrity and firmness

 Full awareness of the job and the rules and regulations
 Full awareness of the existing situations
 Intelligence and willingness to grow
 Good judgment
 Ability to delegate duties and responsibilities
 Non-interference unless indicated
 Continuous guidance, cooperation and coordination
 Sympathetic attitude and good listening
 Willingness to adopt new policies and accept changes according to good health,
enthusiasm for work and human interests.
 Approachability and fair
 Ability to communicate information tactfully and skillfully
 Ability to work with others
 Knowledge of the activities, techniques and procedures
 Objectivity, impartiality and fairness in dealing

Chapter- VIII K.Umamaheswari

Discipline [Service Rules, Self Discipline, Constructive Versus Destructive Discipline, Problem
Employees, Disciplinary Proceedings Enquiry, Application To Nursing Service & Education]

MEANING

The word ‘discipline’ comes from the latin term ‘disciplina’ which means teaching, learning,
and growing. Discipline refers to a condition or attitude, prevailing among the employees, with
respect to rules and regulations of"an organisation. Discipline in the broadest sense means,
orderliness, opposition and confusion. It does mean a strict and technical observable of rules and
regulations. It simply means working, cooperating and behaving in a normal and orderly way, as
any responsible employee would do.

Discipline is defined as "a force that prompts individuals or groups to observe the rules,
regulations and procedures which are deemed to be necessary for the effective functioning of an
organisation". According to Ordway Tead, discipline - is the orderly conduct of affairs by the
members of an organisation, who adhere to do necessary regulations because they desire to
cooperate harmoniously in forwarding the end which the group has in view, and willingly recognise
that. To do this their wishes must be brought into a reasonable union with the requirements of
group in action". Discipline is said to be good when employees willingly follow company's rules

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and it is said to be bad when employees follow rules unwillingly or actually disobey regulations.
Webster's dictionary gives three basic meanings of the word 'Discipline' viz.

i. It is training that currents, moulds, strength reins or perfects.

ii. It is control greeted by enforcing obedience, and
iii. It is punishment or chastisement.

DISCIPLINE:

Definition:

 Discipline can be defined as a training or molding of the mind or character to bring about
desired behaviors.
 Disciplining can mean taking corrective action or bringing about self-concept through
instruction or training. (Webster Dictionary, 1995)
 Discipline refers to working in accordance with certain recognized rules, regulations and
customs, whether they are written or implicit in character.
 Discipline means orderliness, obedience and maintenance of proper subordination among
employees and a check or restraint on the liberty of individual.
 Discipline is a force which prompts an individual or group to observe certain rules,
regulations and procedures that are considered to be necessary for the attainment of an
objective.

AIMS AND OBJECTIVES OF DISCIPLINE:

1. To obtain a willing acceptance of the rules, regulations and procedures of an organization so

that organizational goals cane be attained
2. To impart an element of certainty despite several differences in informal behavior patterns
and other related changes in an organization.
3. To develop among the employees a spirit of tolerance and a desire to make adjustments
4. To give and seek direction and responsibility.
5. To create an atmosphere of respect for the human personality and human relations
6. To increase the working efficiency and morale of the employees so that their productivity is
stepped up, the cost of production brought down and the quality of production improved.

PURPOSES OF DISCIPLINE:

1. Creates a climate under which individual excellence is encourages, group performance

improved and harmonious working is developed.
2. Sets a pattern of acceptance behavior and performance on the part of human beings, i.e., it
provides a code of conduct for the guidance of the group.
3. Promotes individual growth
4. Develops human capacity
5. Stimulates will to perform effectively, i.e. it helps in morale building.

APPROACHES OF DISCIPLINE:

There are two main approaches in discipline, i.e

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 1. Traditional Approach
2. Developmental approach
3. Positive discipline approach
4. Self controlled discipline approach
5. Enforced discipline approach

1. Traditional Approach:
This emphasizes punishments for undesirable behaviors. The main purposes of
traditional discipline are:
 To implement punishment for sin
 To enforce conformity to custom
 To strengthen authority of old over the young
Here discipline is always applied by superiors to subordinates, the severity of punishments is
designed to be proportional to the severity of the offense, and when no single individual admits to
the violation, the whole group is punished to motivate group members to identify the violator or
punish him or her themselves.
2. Developmental approach: This emphasizes discipline as a shaper of desirable behavior.

The main purposes of this approach are:

 To shape the behavior by providing favorable consequences for the right behavior or
unfavorable consequences for wrong behavior.
 To avoid physical punishments, protection of rights of the accused and replacement of
arbitrary individual judgments with group judgment and guilt.
3. Positive discipline approach:
 It is based on the assumption that employee with self- respect, respect for authority ,
and interest in the job will adhere to high quality work standards; and when interested ,
respectful and self – respecting worker temporarily strays from his/ her usually high
standards , a friendly reminder is enough to redirect their efforts in the desired direction .
 Organization that have employed a positive discipline have noted a subsequent
decreased in absences , dismissals , disciplinary action , grievances and arbitration, along
with improvement of employee morale.

4. Self controlled discipline approach :

The employee bring his/her behavior into agreement with the organizational behavioral official
code. i.e. the employees regulate their own activities for the common goal of the organization .
as a result human beings are reduced to work for a peak performance under self controlled
discipline.
5. Enforced discipline approach:
A managerial action enforced compliance with organizations’ rules and regulations i.e. it is a
common discipline imposed from the top . here the manager exercises his authority to compel
the employees to behave in a particular way.

PRINCIPLES OF DISCIPLINE:

 Discipline should be administered promptly, privately, thoughtfully and consistently

following rule of infarction
579
  Discipline should e progressive in nature and preceded by counseling for severe offenses.
 Disciplinary action may have serious and long term consequence for the employee such as
loss of income and damage to professional reputation. In such case, situation is investigated
to ensure that discipline is warranted.
COMPONENTS OF A DISCIPLINARY ACTION PROGRAMME:
1. CODE OF CONDUCT:
The employees must be informed of codes of conduct. Agency handbooks, policy
manuals, and orientation programe may be used . eg. Employee code of conduct.
2. AUTHORISED PENALTIES:
The agency’s disciplinary action program should indicate that the current action is being
administered without bias and is directly related to the offense.
3. RECORDS OF OFFENCES AND CORRECTIVE MEASURES:
The personnel record should clearly indicate the offense, management’s efforts to
correct the problem and the resulting penalties.
4. RIGHT OF APPEAL:
Formal provision for right of employee appeal is a part of each disciplinary action
program.

PROGRESSIVE DISCIPLINE MODEL:

The progressive discipline model was developed in the 1930s in response to the National
Labor Relations Act (NLRA) of 1935. This model follows four progressive steps to address
identical offenses committed by an employee.

Step 1: Informal reprimand or verbal admonishment

Step 2: Formal reprimand or written admonishment
Step 3: Suspension

Step 4: involuntary termination or dismissal

Step 1: Informal reprimand or verbal admonishment The first step of the disciplinary process is
an informal reprimand or verbal admonishment. This reprimand includes and informal meeting
between the employee and manager to discuss the broken rule or performance deficiency. The
manager suggests ways in which the employee’s behavior might be altered to keep the rule from
being broken again. Often, an informal reprimand is all that is needed for behavior modification.
Step 2: Formal reprimand or written admonishment The second step is a formal reprimand or
written admonishment. If rule breaking recurs after verbal admonishment, the manager again meets
with the employee and issues a written warning about the behaviors that must be corrected. This
written warning is very specific about what rules or policies have been violated, the potential
consequences if behavior is not altered to meet organizational expectations and the plan of action
the employee is expected to take to achieve expected change. One copy of the written
admonishment is then given to the employee, and another copy is retained in the employees’
personnel file.

SAMPLE WRITTEN REPRIMAND FORM:

Employee name_____________________________________________________

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Position____________________________ Date of hire_______________________

Person completing report____________________________________________

Position________________________ Date report completed_________________

Date of incident(s) _____________________ Time ______________________

Description of the incident:

Prior attempts to counsel employee regarding this behavior (cite date and results of disciplinary
conferences):

Disciplinary contract (plan for correction) and time lines:

Consequences of future repetition:

Employee comments: (Additional documentation or rebuttal may be attached)

________________________________ ________________________________

Signature of individual making the report Employee signature

Date____________________________ Date____________________________

Step 3: Suspension

The third step in progressive discipline is usually a suspension from work without pay. If the
employee continues the undesired behavior despite verbal and written warnings, the manager should
remove the employee from his or her job for a brief time, generally a few days to several weeks.
Such a suspension gives employees the opportunity to reflect on their behavior and plan how they
might modify their behavior in the future.

Step 4: involuntary termination or dismissal

The last step in progressive discipline is involuntary termination or dismissal. In reality,

many people terminate their employment voluntarily before reaching this step, but the manager
cannot count on this happening. Termination should always be the last resort when dealing with
poor performance. However, if the manager has given repeated warnings and rule breaking or
policy violations continue, then the employee should be dismissed. Although this is difficult and
traumatic for the employee, the morale of keeping such an employee is enormous.

TYPES OF DISCIPLINE:

i) Constructive Discipline or positive discipline

ii) Destructive Discipline or negative discipline

i) Constructive Discipline:

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 It arises from the cooperation of employees. Under this type of discipline subordinates
comply with the rules not form fear of punishment, but from the desire to cooperate in achieving the
common goal of the organization. It encourages emotional satisfaction instead of emotional conflict,
and the increased cooperation and coordination reduces the need for formal authority.

Features of Constructive Discipline:

 Aims at improving the employee behavior.

 Focuses on employee's behavior, not on her or his person.
 Is genuine, without any prejudices.
 Is sincere and generous.
 Makes the employee ready for accepting criticism.
 Is far more helpful than a blunt criticism of the faults.
 Helps to identify their weaknesses and work on them.
 Allows the employee to make decisions.
 Is not mere rhetorical criticism.
 Gives real message to the employee that the manager truly want him to
improve.
ii) Destructive discipline :

It comes from the external environnent. It is identified with ensuring that subordinates adhere
strictly to rules and punishment is meted out in the event of disobedience or indiscipline.
Approaching discipline from this kind of a perspective has been proving increasingly ineffective for
various reasons.

Eight Destructive Discipline Techniques

The following eight “techniques” are not on the path to a well-behaved Employee:

 guilt
 humiliation
 hurtful talk
 physical abuse
 punitive and retaliatory action
 threats
 traps
 withholding affection

DIFFERENCE BETWEEN CONSTRUCTIVE AND DESTRUCTIVE DISCIPLINE:

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  Constructive discipline and guidance Teaches. Destructive discipline and guidance
Taunts.
 Constructive discipline and guidance Instructs. Destructive discipline and guidance
Insults.
 Constructive discipline and guidance Guides. Destructive discipline and guidance Goads.
 Constructive discipline and guidance Builds up. Destructive discipline and guidance Tears
down.
 Constructive discipline and guidance Discourages. Destructive discipline and
guidance Encourages.
 Constructive discipline and guidance Persuades. Destructive discipline and guidance
Dissuades.
 Constructive discipline and guidance Cheers. Destructive discipline and guidance Jeers.

FAIR AND EFFECTIVE RULES (HOT-STOVE RULE):

McGregor (1976) developed four rules to make discipline as fair and growth-producing as
possible. These rules are called “Hot Stove” rules because they can be applied to someone touching
a hot stove.

McGregor’s Hot Stove Rules for Fair and Effective Discipline:

Four elements must be present to make discipline as fair and growth producing as possible:

1. Forewarning:
All employees must be forewarned that if they touch the hot stove, they will be burned
(punished or disciplined). They must know the rule beforehand and be aware of the
punishment.
2. Immediate consequences:
If the person touches the stove, there will be immediate consequences (getting burned). All
discipline should be administered immediately after rules are broken.
3. Consistency:
If the person touches the stove again, he or she will again be burned. Therefore, there is
consistency; each time the rule is broken, there are immediate and consistent consequences.
4. Impartiality:
If any other person touches the hot stove, he or she also will get burned. Discipline must be
impartial, and everyone must be treated in the same manner when the rule is broken.

EMPLOYEE DISCIPLINE:

The promotion and maintenance of employee discipline in an organization is essential to its

progress and growth. It is said that employee discipline is at its best when there is a great amount of
self-discipline on the part of the employees. In order to realize that state of affairs it is necessary to
promote and retain high morale which makes for high self-discipline in an organization among the
employees.

In an ideal situation there may not be any need to enforce rules and regulations, penalties
and disciplinary actions, because every employee is highly disciplined in the sense that he follows
the rules and regulations of the organization willingly. But whenever the employee does not follow
the rules or instructions or causes acts of indiscipline to occur, he requires to be disciplined.

583
 Megguison offers three distinct meanings of the word “discipline”.

1) Self – discipline
2) The necessary condition of orderly behavior.
3) The act of training and punishment.

Self discipline:

The highest level and most effective form of discipline is self-discipline. When employees
feel secure, validated, and affirmed in their essential worth, identity and integrity, self –discipline is
encouraged. Self Discipline is defined as the case in which the employee brings her or his behavior
into agreement with the organizations, official behavior code, i.e. the employees regulate their own
activities for the common good of the organization.

By self-discipline he means the training that corrects, moulds and strengthens. It refers to
one’s efforts at self-control for the purpose of adjusting oneself to certain needs and demands.

This form of discipline is based on two psychological principles. First punishment seldom
produces the desired results. Often, if produces undesirable results. Second, a self-respecting person
tends to be a better worker than one who is not.

FIVE PILLARS OF SELF DISCIPLINE:

Acceptance

Will Power

Hard Work

Industry

Persistence

1. ACCEPTANCE:

The first of the five pillars of self-discipline is acceptance. Acceptance means that you
perceive reality accurately and consciously acknowledge what you perceive. This may sound
simple and obvious, but in practice it’s extremely difficult.

2. WILL POWER: Will power is the ability to overcome laziness and procrastination.
It is the inner power that overcomes the desire to indulge in unnecessary and useless habits,
and the inner strength that overcomes inner emotional and mental resistance for taking
action.
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 3. HARD WORK: Most people will do what’s easiest and avoid hard work — and that’s
precisely why you should do the opposite. When you discipline yourself to do what is hard, you
gain access to a realm of results that are denied everyone else.
4. INDUSTRY: Industry is working hard. In contrast to hard work, being industrious doesn’t
necessarily mean doing work that’s challenging or difficult. It simply means putting in the
time. You can be industrious doing easy work or hard work.
5. PERSISTENCE: Persistence is the fifth and final pillar of self-discipline. Persistence is the
ability to maintain action regardless of your feelings. When you work on any big goal, your
motivation will wax and wane like waves hitting the shore. Sometimes you’ll feel motivated;
sometimes you won’t. But it’s not your motivation that will produce results it’s your action.
Persistence allows you to keep taking action even when you don’t feel motivated to do so, and
therefore you keep accumulating results.

PROBLEM EMPLOYEE:

A variety of personal difficulties can lead to poor performance in the workplace. Most
notable would be problems related to chemical impairment. Chemical impairment refers to
impairment due to drug or alcohol addiction.

 Indiscipline:

Indiscipline means non-conformity to formal and informal rules and regulations. Indiscipline often
leads to chaos, confusion and finally reduces the efficiency of the organization. It leads to strikes,
go-slows, absenteeism, resulting in loss of production, profits and wages.

Forms of Indiscipline:

Some common problems resulting from these impairments are:

 Excessive absenteeism
 Insubordination
 Violation of organizational rules
 Gambling
 Decreased quality of work
 Errors in judgment
 Work-related accidents
 Damage to property
 Strikes
 High rates of turnover
 Dishonesty & other forms of disloyalty, etc.

When evaluating employees, the manager should note when these problems occur with
regularity. Excessive absenteeism, tardiness and sick leave can create a serious staffing deficiency
unless guidelines or policies exist.

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Causes of indiscipline and Suggestions:

CAUSES OF INDISCIPLINE SUGGESTIONS

1. Faulty disciplinary actions taken by the Disciplinary actions must be consistent
authorities may lead to indiscipline enough to provide equal justice to all
concerned, for which managerial actions in
regard to discipline must be free from any
bias, privilege or favoritism

2. Neglect of employee’s grievances: Grievances of the employees should be

Neglecting or deferring the settlement of settled by enquiring as early as possible.
employees grievances cause indiscipline Otherwise it leads to poor performance,
poor morale and serious indiscipline.
such as strikes, agitation and others.

3. Wrong placement and promotions or Taking prompt decision for right

remunerations also leads to indiscipline. placement, timely promotion and proper
remuneration helps to reduce such
indiscipline

4. Deficiency of well-defined code of The code of discipline should encompass

discipline also leads to indiscipline.
sufficient rules, regulations, customary
practices for the guidance and information
to employees. Hence, proper code of
discipline should be formulated and
circulated and communicated in clear and
simple language to all employees.

5. ‘Divide and rule’ policy in the organization This type of behavior on the part of te
also leads to indiscipline administration or management should not
be practiced at any cost the interest of the
organization

6. Improper attitude towards employee’s Understanding of the employee’s personal

problem leads to indiscipline: problems and individual difficulties help to
Basically attitudes influence human beings maintain discipline.
and their activities; moreover discipline
itself is a byproduct of attitude.

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 7. Ill-equipped supervisor may cause As the maintenance of discipline is the
indiscipline case of supervisory responsibilities,
indiscipline may spring from the want of
the right type of supervision.

Other Causes of Indiscipline:

 Lack of proper leadership to control, coordinate and motivate workers

 Very poor wages and working conditions
 There is no proper promotional opportunities due to which people feel stagnated
 There is no proper code of conduct to regulate behavior on both sides
 There is no proper redressal of workers grievances
 Unfair management practices
 There is no proper communication system
 Lack of workers education
 Work boredom
 Drunkenness and family problems
 Outside political influences
 Heavy work pressure and tension.

GUIDE FOR DISCIPLINE STRATEGIES:

Offense First Infraction Second Infraction Third Fourth

Infraction Infraction
Gross Dismissal
mistreatment of a
patient
Discourtesy to a Verbal Written suspension Dismissal
patient admonishment
admonishment
Insubordination Written suspension Dismissal

admonishment
Intoxication while Verbal Written Dismissal
on duty (this admonishment
offense is difficult admonishment
to prove)
Use of intoxicants Dismissal
while on duty
Neglect of duty Verbal Written suspension Dismissal
admonishment
admonishment
Theft or willful Written Dismissal
damage of
property admonishment
Falsehood Verbal Written Dismissal
admonishment
admonishment
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Unauthorized Verbal Written Dismissal
absence admonishment
admonishment
Abuse of leave Verbal Written Suspension Dismissal
admonishment
admonishment
Deliberate Verbal Written Suspension Dismissal
violation of admonishment
instruction admonishment
Violation of Verbal Written Dismissal
safety admonishment
admonishment
Fighting Verbal Written Suspension Dismissal
admonishment
admonishment
Inability to Verbal Written Suspension Dismissal
maintain work admonishment
standards admonishment
Excessive Verbal Written Dismissal
unexcused admonishment
tardiness admonishment
PRINCIPLES OF DISCIPLINARY ACTION:
1. Have a positive attitude:
The managers attitude is very important in preventing or correcting undesirable behavior.
People tend to do what is expected of them. Therefore the manager must maintain a positive
attitude by expecting the best from the staff.
2. Investigate carefully:
The ramification of a disciplinary action is serious. If a staff nurse is disciplined unfairly or
unnecessarily, the effect on the entire staff nurse may be severe. Therefore managers must
proceed with caution. They should collect facts, check allegations , and even ask the accused
employees for their side of the story.
3. Be prompt:
If the disciplinary action is delayed , the relationship between the punishment and the
offense becomes less clear.
4. Protect privacy:
Disciplinary action effect the ego of the staff nurse. Discussing the situation in private ,
causes less resentment and greater chance for future co- operation . however , a public
reprimand may be necessary for the nurse who does not take private criticism seriously.
5. Focus on the act:
When a disciplining a staff nurse , the manager should emphasize that it was the act that
was unacceptable, not the employee.
6. Enforce rules consistently:
Consistency reduces the possibility of favoritism, promotes predictability, and fosters
acceptance of penalties.
7. Be flexible :
Individuals and circumstances are never the same . a penalty should be determined only after
the entire record is reviewed.
8. Advise the employee:

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 The employees must be informed butt their conduct is not acceptable . anecdoctal notes can
be of little vlue if the staff nurse is not informed of the contents promptly.
9. Take corrective , consistent action:
The manager should be sure that staff nurse understands that the behavior was contrary to
the organization requirements.
10. Follow up:
The manager should quietly investigate to determine whether the staff nurse behavior
changed . if not, the manager should determine the reason for the nurse’s attitude.

Disciplinary strategies for the nurse-manager:

It is vital that managers recognize their power in evaluating and correcting employees’
behavior. Because a person’s job is very important to him or her-often as a part of self-esteem and
as a means of livelihood-disciplining or taking away a person’s job is a very serious action and
should not be undertaken lightly. The manager can implement several strategies to increase the
likelihood that discipline will be fair and produce growth.

The first strategy the manager must use is to investigate thoroughly the situation that has
prompted the employee discipline. A supervisor must investigate all allegations of misconduct even
if they initially appear to have no basis or are anonymously reported.

Questions the manager might ask include:

 Was the rule clear?

 Did this employee know he or she was breaking a rule?
 Is cultural diversity a factor in this rule breaking?
 Has this employee been involved in a situation like this before?
 Was he or she disciplined for this behavior?
 What was his or her response to the corrective action?
 How serious or potentially serious is the current problem or infraction?
 Who else was involved in the situation?
 Does this employee have a history of other types of disciplinary problems?
 What is the quality of this employee’s performance in the work setting?
 Have other employees in the organization also experienced the problem?
 How were they disciplined? Could there be a problem with the rule or policy?
 Were they any special circumstances that could have contributed to the problem in this
situation?
 What disciplinary action is suggested by organizational policies for this type of offense?
 Has precedent been established?
 Will this type ask all these questions so a fair decision can be reached about an appropriate
course of action?

Another strategy the manager should use is always to consult with either a superior or the
personnel department before dismissing an employee. Most organizations have very clear policies
about which actions constitute grounds for dismissal and how that dismissal should be handled. To
protect themselves from charges of willful or discriminatory termination, manager should carefully
document the behavior that occurred and any attempts to counsel the employee. Managers also must
be careful not to discuss with one employee the reasons for discharging another employee or to

589
make negative comments about past employees, which may discourage other employees or reduce
their trust in the manager.

DISCIPLINARY PROCEEDINGS:

Essentials of a Good Disciplinary System:

1. Awareness of code of conduct rules

2. Proper enquiry and action
3. Well defined procedure
4. Disciplinary action should be appropriate manner

Principles for Disciplinary Action:

No employer may penalize an employee without fair and proper enquiry. Natural justice
demands that the accused is informed about the charges alleged against him; this may be in the form
of a written charge-sheet. Further, he should be given full freedom and opportunity to answer all the
charges during the enquiry. The charges alleged should be proved beyond doubt, before declaring
any punishment. It is important that the whole procedure is carried out in good faith and with no
intent of victimization.

Model Standing Orders:

Model standing orders specify the terms and conditions which govern day-to-day employer,
employee relationships, infringement of which could result in a charge of misconduct. Model
standing orders therefore contain various provisions which relate to the following areas:

1. Classification of workmen into permanent, probationer, temporary, causal, apprentice and the
meaning of each.
2. Rules for publication of working time, holidays and pay days, wage rates, shift working etc.
3. Notices of change in shift working.
4. Provisions regarding attendance and late coming,
5. Provisions for payment of wages.
6. Provisions for leave and various types of leave.
7. Provision for stoppage of work.
8. Termination of employment.
9. Provision for a certificate on termination of service.
10. Disciplinary action for misconduct: Model standing orders specify certain acts as
misconduct like willful insubordination, disobedience any lawful and reasonable order of the
superior, theft, fraud or dishonesty in connection with the employers’ business or property,
etc. This list is not exhausted. Various forms of punishment like discharge dismissal etc. are
also specified.
11. Liability of manager.
12. Provision for exhibition of standing orders.

Misconduct:

The term misconduct shall denote any offense or act of commission or omission on the part
of an employee which falls within the general notation of the word misconduct as understood

590
generally and shall be deemed also to connote offences or acts of commission or omission under or
against prejudice to the foregoing and without being exhaustive.

Minor Misconduct:

1. Entering or leaving the premises or departments of the hospital except by the gates provided
for the purpose.
2. Late attendance or absence from duty without notice or permission or leave.
3. Leaving the place of work during working hours without permission or absence without
permission from the place of work.
4. Failure to carry identification card.
5. Smoking or eating in prohibited areas and patient areas.
6. Failure to wear uniforms, or wearing unclean uniforms or lack of personal cleanliness while
on duty.
7. Expectorating or spitting or such unhygienic act or committing nuisance in the premises of
the hospital except where expressly permitted.
8. Laziness, inefficiency or careless work.
9. Obtaining leave or attempting to obtain leave on false pretences.
10. Refusal to accept, receive or take delivery of notice, letters or any communication from the
management.
11. Borrowing or lending money within the hospital premises.
12. Loitering and wasting time during working hours or malingering.
13. Improper or discourteous behavior towards patients or members of the public in the
hospital premises, shouting, loud talking or making noises in the hospital premises.
14. Failure to report any disease an employee may have which may endanger any other person.

Penalty for Minor Misconduct:

1. Warning or censure.
2. Fine,
3. Suspension without pay and allowance upto four days.

Major Misconduct:

1. Entering any section or department other than his own except for purposes of assigned
duties.
2. Failure to observe safety instructions or make use of safety devices provided by the
management, or failure to take preventive measures against diseases as provided by the
management.
3. Unauthorized handling of any machine, apparatus or equipment.
4. Misusing or mishandling any machine, apparatus or equipment.
5. Failure to report the loss of any tool or materials entrusted to him in the performance of his
duties or failure to account for the same.
6. Furnishing false or incorrect information or withholding any relevant or pertinent
information at the time of appointment or at any other time.
7. Failure to report at once to superiors any accident or hazard noticed inside the hospital
premises or to report promptly any occurrence or defect or mistake which might endanger
lives of patients or persons in the hospital or that of any other.
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8. Using hospital facilities unauthorized for personal gain.
9. Gambling
10. Sleeping while on duty.
11. Refusal to accept or obey an order of transfer from one job to another or from one
department centre or branch of the hospital to another.
12. Insubordination or disobedience whether alone or in combination with others of any lawful
and reasonable order of a superior or instigating others to insubordination or disobedience.
13. Delaying in the performance of work or go-slow in work or instigation thereof.
14. Habitual late coming or habitual absence or absence without leave for more than three
consecutive working days.
15. Gross negligence on neglect of work.
16. Bringing liquor or other intoxicants to hospital premises, consuming any intoxicants on
hospital property, or reporting for work in an unfit condition because of previous
indulgence or under the influence of any intoxicant.
17. Riotous or disorderly behaviors or conduct inside the hospital premises. Fighting, abusing,
threatening, intimidating or coercing other employees or others, or assaulting or threatening
to assault co-employees or others.
18. Using indecent language or making false allegations against superiors or co-employees.
19. Any act subversive of discipline or good behavior in the hospital premises or outside the
hospital premises if it affects the discipline or administration of the hospital or has a bearing
on the smooth and efficient working of the hospital.
20. Participating in a strike or stay-in-strike or abetting, inciting, instigating or action in
furtherance of a strike or stay-in-strike.
21. Holding a meeting without permission, staging or participating in demonstration, shouting,
coercing others to join in group action or pocketing within the hospital premises or within a
radius of 50 metres from the boundary of the hospital premises.
22. Organizing, holding, attending or taking part in any meeting, exhibiting, sticking or
distributing and handbills, notices, leaflets, booklets, pamphlets or posters in the hospital
premises without prior without prior written permission of the management.
23. An act or conduct within the premises of the hospital which is likely to endanger the life or
safety of any person.
24. Possessing firearms, other weapons or any other article in the hospital premises detrimental
to the security of the hospital or persons.
25. Gheraoing or surrounding or forcibly detaining superiors or other employees of the hospital
or resorting to satyagraha, hunger strike or similar action in our outside the hospital
premises.
26. Trespassing or forcible occupation of any portion of the hospital premises, unauthorized
use or occupation of the hospital accommodation or refusal or vacate the same when called
upon to do so by the management.
27. Damage to work process or to any other property of the hospital.
28. Preaching of or inciting disaffection or violence in relation to matters and people
concerning the hospital.
29. Theft, attempt of theft, fraud or dishonesty in connection with hospital property or activity
or property of other employees, patients, or visitors of the hospital.
30. Tampering with records of the hospital, falsification, defacement or destruction of any
records of the hospital including those pertaining to employees and patients.

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 31. Soliciting, demanding, offering or accepting bribe or any illegal gratification.
32. Soliciting, demanding, collecting the canvassing the collection of any money from anyone
or sale of any kind of tickets within the premises of the hospital for any purpose or reason
without prior written permission of the management.
33. Disclosing to any unauthorized person any information affecting the interests of the
hospital with regard to procedures, practices and functioning of the hospital without its
authority, or divulging information pertaining to medical treatment of patients of the
hospital to unauthorized persons.
34. Engaging in private work or trade within the hospital premises, engaging in other
employment while in the service of the hospital or engaging in the same or similar
profession outside the hospital without the written permission of the management.
35. Commission of any offence punishable under the Indian Penal Code whether committed
inside or outside the hospital or conviction by a court of law for any criminal offence.
36. Any conduct prejudicial to the interest or reputation of the hospital or any act or conduct
involving moral turpitude or immoral behavior or act inside or outside the hospital
premises.
37. Carrying on or canvassing political activity in the hospital premises.
38. Unauthorized removal from or affixing of notice on the notice boards or any other place in
the hospital and its premises.
39. Breach of service rules or any rules or regulation in force in the hospital.
40. Committing a minor misconduct three times.

Penalty for Major Misconduct:

1. Suspension without pay and allowances for a period upto 30 days.

2. Stoppage of one or more increments
3. Demotion to a lower post.
4. Discharge
5. Dismissal.

Procedure for Disciplinary Action:

1. No order of punishment shall be made without the employee having been given an opportunity
of explaining to the satisfaction of the management the circumstances alleged against him
through an oral or recorded enquiry.
2. In the case of any major misconduct there shall be a recorded enquiry in accordance with the
procedure stated below provided no such recorded enquiry shall be necessary if the employee
concerned admits the charges in writing. The employee concerned shall be issued a charge-
sheet, otherwise called a show-cause notice, clearly setting forth the charges against him and
stating under what ambit of misconduct as listed in the service rules or any other rules,
regulations and practices the charges fall, and calling for his explanation.
3. If the employee does not admit the charges or his explanation is not satisfactory and when the
circumstances appear to warrant it, the management may arrange to hold a recorder enquiry on
the charges of misconduct in accordance with the principles of natural justice.
4. For the purpose of conducting the enquiry the management may appoint any enquiry officer
from amongst the staff of the hospital or an outsider to hold the enquiry and where necessary a
presenting officer from amongst the staff of the hospital.

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5. An employee shall present himself at any reasonable time for enquiry into the misconduct
alleged against him or against another employee when called upon to do so by the
management. If an employee charged with misconduct fails to appear at the enquiry for reasons
which the management or the enquiry officer considers unsatisfactory, the enquiry shall be
proceeded with ex-parts in his absence.
6. The employee subjected to enquiry shall be permitted to be assisted by a co-employee of the
hospital. No outsider or legal practitioner shall be permitted to assist or defend him in the
enquiry. The employee shall be p4ermitted to cross-examine any witness depositing in support
of the charges and also to produce witnesses, if any, in his defense. The statements of the
witnesses examined at the enquiry on either side and the employee’s please shall be recorded.
7. On conclusion of the enquiry, the enquiry officer shall recorded his findings whether all or any
of the charges leveled against the employee are established.
8. If charges are proved in the enquiry, the management shall take into account the gravity of the
misconduct, the previous record of the employee and any other extenuating or aggravating
circumstances that may assist in awarding punishment under these rules. The nature and
quantum of punishment shall be at the discretion of the management. The order passed by the
management shall be communicated to the employee concerned.
9. Where disciplinary proceedings against an employee are contemplated or are pending or where
criminal proceedings against an employee in respect of any offence are in progress and the
management is satisfied that it is necessary or desirable to place the employee concerned under
suspension, pending investigation, enquiry, trial and final disposal, the appointing authority
may, by order in writing, suspend him without salary or allowances with effect from such date
as may be specified in the order.
10. If the employee found quietly in the conclusion of the enquiry or the criminal proceedings as
the case may be, is discharged or dismissed, he shall be deemed to have been discharged or
dismissed with effect from the date of suspension unless otherwise indicated in the order of
discharge or dismissal.
11. If the employee found guilty on the conclusion of the enquiry or the criminal proceedings, as
the case may be, is punished by suspension for a period which is less than the total period he
has been under suspension, pending investigation, enquiry, or trial, then the period over and
above the period of penal suspension shall be treated as on duty and he shall be entitled to
salary and allowances for that period.
12. If the employee on being found guilty on conclusion of the enquiry or the criminal proceedings,
as the case may be, is awarded any other punishment such as fine or stoppage of annual
increment or reduction in rank, the employee shall be deemed to have been on duty during the
period of suspension, pending investigation, enquiry or trial and entitled to the same salary and
allowances as he would have received if he had not been placed under suspension.
13. If on the conclusion of the enquiry or the criminal proceedings, as the case may be the
employee has been found to be not guilty of any charges framed against him, he shall be
deemed to have been on duty during the period of suspension and shall be entitled to the same
wages as he would have received if he had not been placed under suspension.

DEVELOPING ORGANIZATIONAL POLICIES FOR ABSENTEEISM, TARDINESS AND

SICK LEAVE:

1. Recognize the existence of employee problems

2. Take a proactive approach for dealing with the problem
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 3. Review existing policies
4. Solicit employee input
5. Determine how many absences per year are considered excessive
6. Determine how many successive sick days are permitted with a given period
7. Decide what action should be taken for violations of the policy
8. Develop a staffing protocol to be instituted when absenteeism and sick leaves occur
9. Distribute policy to all employees, post policy on each unit, and add it to the policy manual.

Although most organizations have a personnel department to deal with all kinds of issues that
develop during corporate changes such as reorganization and downsizing, the nurse manager may
find herself called upon for input when the nursing staff is involved. Nurse managers may also be
involved at the decision-making level when it comes to transferring or terminating nursing staff.

TRANSFERS AND TERMINATION:

Transfers and termination within an organization can lead to increased productivity and success.
Good employees may be transferred to other areas within an organization as part of a promotion
package or to make better use of their potential. In some instances problem employee may be
transferred to other areas where they may to more successful.

When an employee exhibits problem behavior that is unlikely to change and may be detrimental to
the organization, she should be terminated. Restructuring within an organization may result in the
termination of employees, even those with good performance records.

Transfers:

Transfers are common in the corporate world; they often involve moving an employee to a new
location, often with a promotion and an increase in salary. Many employees, especially the nursing
staff, are place-bound and unwilling or unable to move to another location.

Types of transfers:

Lateral Transfer:

Lateral transfer means the individual would be moved to a position with a similar scope of
responsibilities within the same organization.

Downward Transfer:

This type of transfer occurs when someone take a position within the organization that is below his
or her previous level.

Termination:

While termination is certainly possible with restructuring, the shortages of nurses make it unlikely
that nursing personnel would be let go. More often it is unlicensed personnel whose jobs are in
jeopardy. Termination should be the final step I the performance appraisal process, when other
measures have failed to bring about improvement of the employee’s performance. The guidelines
should be followed strictly by the nursing administrator, after efforts at coaching, counseling, and
disciplining have proved unsuccessful.

DEALING WITH DISCIPLINARY PROBLEMS:

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When dealing with disciplinary problems, it is better to conduct disciplinary conference. While
conducting disciplinary conference both directive interview techniques can be used. To guide the
discussion in the conference, the manager:

 Should begin with clear statement of the broken behavior rule, i.e. gives description of the
specific rule broken by the employee.
 Should describe corrective action expected by the employees, i.e. action that employee
should take to correct the problem.
 Should specify the time allowed to employee to remedy his short comings, i.e. amount of
time allowed the employee to correct his or her behavior.
 Further discipline to result if specified behavior change is not made
 See that disciplinary conference documented and included in employment record

Disciplinary action may be ineffective because of methodological weakness or of procedural

omissions by the manager. Methodological problems result from improper documentation of
disciplinary interview and procedural problems from failure to apply discipline in a timely
fashion and to follow due process.
1. DESCIPLINARY CONFERENCE:
It is a group discussion using both directive and non directive interview techniques . it
is damaging to employee ‘s self esteem to receive criticism from an authoritative figure .
thus a disciplinary conference is anxiety provoking situation for both employee and
manager.
2. DISCIPLINARY LETTER:
It is a letter to the nurse /employee immediately after the conference, documenting the
interview content from the managers view point. It is needed as sometimes employees
anxiety may black perception of the painful feedback offered by the manager.
3. MODEL STANDING ORDERS:
It specifies the terms and conditions which govern day to day employer – employee
relationship , infringement of which could result in a charge of misconduct.
ERRORS IN DISCIPLINIG EMPLOYEE:

The frequent errors encountered while disciplining the employees are:

 Delay in administering discipline

 Ignoring in rule violation in hope that it is an isolated manager to “ blow up”

 Administering sweetened discipline

 Failure to administer progressively severe sanction failure to document disciplinary actions

accurately

 imposing discipline disproportionate to the seriousenessof the seriousness of the offense.

 Disciplining inconsistently.

THE DISCIPLINARY CONFERENCE:

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 When coaching is unsuccessful in modifying behavior, the manager must take more
aggressive steps and use more formal measures, such as a disciplinary conference. After
thoroughly investigating an employee’s offenses, managers must confront the employee with
their findings. This occurs in the form of a disciplinary conference. The following steps are
generally part of the disciplinary conference.

1. Reason for disciplinary action:

Begin by clearly specifying why the employee is being disciplined. The manager must
not be hesitant or apologetic. Novice managers often feel uncomfortable with the disciplinary
process and may provide unclear or mixed messages to the employee regarding the nature or
seriousness of a disciplinary problem. Managers must assume the authority given to them by
their role. A major responsibility in this role is evaluating employee performance and suggesting
appropriate action for improved or acceptable performance.

2. Employee’s response to action:

Give the employee the opportunity to explain why the rule was not followed. Allowing
employee’s feedback in the disciplinary process ensures them recognition as human beings and
reassures them that your ultimate goal is to be fair and promote their growth.

3. Rationale for disciplinary action:

Explain the disciplinary action you are going to take and why you are going to take
it. Although the manager must keep an open mind to new information that may be gathered
in the second step, preliminary assessments regarding the appropriate disciplinary action
should already have been made.

This discipline should be communicated to the employee. The employee who has
been counseled at previous disciplinary conferences should not be surprised at the
punishment, because it should have been discussed at the last conference.
4. Clarification of expectations for change:

Describe the expected behavioral change and list the steps needed to achieve this change.
Explain the consequences of failure to change. Again to not be apologetic or hesitant, or the
employee will be confused about the seriousness of the issue. Because they may lack self-
control, employees who have repeatedly broken rules need firm direction. It must be very clear
to the employee that timely follow-up will occur

5. Agreement and acceptance of action plan:

Get agreement and acceptance of the plan. Give support, and let the employee know that
you are interested in him or her as a person. Leader-manager administers discipline to
promote employee growth rather than to impose punishment.

ERRORS IN DISCIPLINARY CONFERENCE:

 Delay in administering discipline

 Ignoring rule violation in hope that it is an isolated event
 Accumulation of rule violations causing irritated manager to ‘blow up’.
 Administering sweetened discipline
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  Failure to document disciplinary actions accurately
 Imposing discipline disproportionate to the seriousness of the offence
 Disciplining inconsistently

INFORMAL AND FORMAL DISCIPLINARY ACTION:

If an employee's performance or conduct does not meet your standards, you should try to
help that employee to improve. Have an informal discussion with the employee as soon as problems
arise, explain the problem and agree actions with them. This kind of informal chat is not part of any
formal disciplinary procedure.

If the employee's poor conduct or performance persists, you may have to take formal
disciplinary action. Note that the employee has the right to be accompanied at the formal
disciplinary meeting by a colleague or union representative.

1. Formal disciplinary action for misconduct:

In cases of misconduct, you should have a meeting with the employee to explain the disciplinary
procedure and your reasons for going ahead with it.

After this, you could either drop the matter or issue:

 a verbal warning
 a written warning
 a second written warning, or
 a final written warning, if necessary

After giving a warning, you should allow the employee time to improve their behaviour. You
should only issue a further warning or hold a formal disciplinary hearing if the previous warning has
no effect.

In certain cases of very serious misconduct, it may be appropriate to bypass a stage in order to deal
with the matter quickly.

2. Formal disciplinary action for poor performance

In cases of poor performance, the procedure is different. As a first step, meet with the employee
to agree an improvement plan. This should include a realistic timescale for improvement, details of
support to be given to the employee - eg training - and a date for a performance review. Make notes
of what you agree and use it as an agenda for the review.

If your employee's performance has not improved after the review, you should consider issuing a
verbal warning. Carry out a further review - if performance still hasn't improved, you should
consider issuing a written - or final written - warning.

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If their performance continues to fail to meet the required standards, you should consider either
issuing a final written warning or, if you have done this already, holding a formal disciplinary
hearing.

DISCIPLINE AND PENALTIES:

Justice demands that each one is given his due. Hence, if an employee or an employee has
failed in his undertaking, he needs to be corrected; but on no account the punishment should be
arbitrary, nor disproportionate to the gravity of the misconduct.

Fairness demands that discipline is given:

a. Immediately so that the punishment may be connected with the misconduct.

b. After warning so that the penalty is known ahead, and seen as fair and reasonable
c. Consistently so that it is given as often as there is violation, and
d. Impartially so that there is no favoritism

The penalty should be proportionate to the gravity of the misconduct for, there are several
kinds of penalties, such as: warning, fine, suspension, withholding of increment, demotion,
discharge and dismissal. Some of them are of minor consequence, whereas others are very serious.

Types of disciplinary penalty:

After a disciplinary hearing, you could:

 drop the matter

 issue another written - or a final written - warning
 provide counseling or training to help resolve the matter
 apply a disciplinary penalty, eg demotion or dismissal

Take account of factors such as the employee's previous record and any special circumstances in
making your decision. For a list of possible factors to consider see the page in this guide on
investigating disciplinary matters.

a. Warning – If the misconduct is not very serious and yet it is a breach of discipline and it is
proved as misconduct, the usual penalty is warning.
b. Fine – It is either for damage or loss of goods entrusted to employee, or by way of
punishment for misconduct. No fine should be above 3 % of the wages and recovery i.e. the
deduction of the wages that is due for the time of absence.
c. Suspension – When a charge is brought against an employee and while investigations are
going on, he may be suspended from duty. Misconduct is also punishable with suspension
for a period of time.
d. Withholding increment – It is a usual penalty for a serious misconduct.
e. Demotion – This is also a serious penalty for irresponsibility or competence.
f. Discharge – This is very serious penalty, terminating the services of an employee according
to the standing orders, or according to other established terms and conditions of
employment, without prejudice.

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 g. Dismissal – It is a permanent termination of the services of a workman by way of penalty
for a very serious misconduct.
h. Oral repayment: for minor violations that may have occurred for the first time ,
managers may opt to give an oral warning in private . when oral warning is given ,
the nurse manager is advised to make an anecdotal record of time , place ,occasion an
gist of the reprimand.
i. Writtenrepairment: if the offense is more severe or repeated , the reprimand may
be written . the written notice should include the name of the employee , name of
manager, nature of the problem, the plan for correction , and consequences of future
repetition. The employee has to sign it , to indicate that the employee has read it. A
copy should be given to the employee and one retained for the personnel file. If
again the terms are not met , other penalties will probably be necessary.
j. Other penalties:
 Fines may be charged for offences such as tardiness.
 Loss of privileges might include transfer to a less desirable shift and loss
preference for assignments.
 Demotion is a questionable solution. it creates hard feeling which may be
contagious and more likely places offenders in a position for which they are
overqualified.
 Suspension: for a period of time
 Withholding increment
 Termination ( dismissal) : permanent termination of services.

DISCIPLINARY PROCEEDING:

. Definition Discipline is defined as a training or molding of the mind and character to bring about
desired behaviours.

4. Causes of disciplinary proceedings

(A) Acts

1. Acts amounting to crimes

a. Embezzlement
b. Falsification of accounts not amounting to misappropriation of money
c. Fraudulent claims (e.g. T.A.)
d. Forgery of documents
e. Theft of government property
f. Defrauding government
g. Bribery
h. Corruption
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 i. Possession of disproportionate assets
j. Offences against other laws applicable to government servants.
2. Acts amounting to misdemeanour
a. Disobedience of orders
b. Insubordination
c. Misbehaviour
1. With superior officers
2. With colleagues
3. With subordinates
4. With members of public
3. Acts amounting to misconduct
1. Violation of conduct rules
2. Violation of standing orders
3. Intrigues and conspiracy
4. Insolvency
5. Other forms of misconduct.

(B) Omission
1. Habitual late attendance
2. Absence without leave
3. Negligence and carelessness:
a. In work
b. In conduct
4. Irresponsibility
5. Residuary

Disciplinary Proceedings and Managements as per CCSR (General Civil Services Rules) and
KCSR (Karnataka Civil Services Rules):

General Civil Services Rules

The essence of Government service is the sense of discipline to which all Government
employees are subject and the privilege to which type, in general, are entitled. They relate to the
employees code of conduct and discipline. They are consulted in Government offices in connection
with discipline cases.

Article 311 of the constitution enumerates two fundamental principles upon which practically
the whole procedural law concerning departmental punishments on civil servants rests. The first
clause of that article contains the guarantee that no civil servant shall be dismissed or removed by an
authority subordinate to that by which he was appointed. The second clause guarantees to him a
reasonable opportunity of defense on the charges against him, supplemented by a second
opportunity of showing cause why, if after enquiry it is proposed to dismiss or to remove or to
reduce him in rank, such a punishment should not be imposed upon him, provided that the second
clause shall not apply.

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 a. Where a person is dismissed or removed or reduced in rank on the ground of conduct which
has led to his conviction on a criminal charge, and or
b. Where the authority empowered to dismiss or removed a person or to reduce him in rank is
satisfied that for some reasons, to be recorded by that authority, it is not reasonably
practicable to hold such inquiry, or
c. Where the President of India/Governor is satisfied that in the interest of the security of the
State it is not expedient to hold such an inquiry.

Causes of Disciplinary Proceedings

a. Acts
1. Acts amounting to crimes
a. Embezzlement
b. Falsification of accounts not amounting to misappropriation of money.
c. Fraudulent claims (e.g. T.A.)
d. Forgery of documents
e. Theft of government property
f. Defrauding government
g. Bribery
h. Corruption
i. Possession of disproportionate assets
j. Offences against other laws applicable to government servants.
2. Acts amounting to misdemeanor
a. Disobedience of orders
b. Insubordination
c. Misbehavior
1. With superior officers
2. With colleagues
3. With subordinates
4. With members of public
3. Acts amounting to misconduct
1. Habitat late attendance
2. Absence without leave
3. Negligence and carelessness:
a. In work
b. In conduct
4. Irresponsibility
5. Residuary
B. Omissions;
Eg. Habitual late attendance, irresponsibility, negligence.
DISCIPLINARY PROCEEDINGS:

DISCIPLINARY PROCEEDINGS ENQUIRY IN MANAGEMENTS AS PER CCSR

(GENERAL CIVIL SERVICES RULES) AND

KCSR (KARNATAKA CIVIL SERVICES RULES)

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 A) Warning / Admonition / Reprimand [ Swamy's — Compilation on Confidential Reports ]
1. There may be occasions when a superior officer may find it necessary to criticize
adversely his subordinate's work or call for an explanation bringing the defects to the notice
and giving him an opportunity to explain. If the lapse is not serious enough, like
negligence, carelessness, lack of thoroughness, etc., to justify the imposition of the formal
punishment of censure, but calls for some formal m lion such as the communication of a
written warning / admonition / reprimand, it may be administered and a copy of such a
warning, etc., should be kept in the personal file of the subordinate.
2. Written warning, admonition or reprimands should not be administered or placed on record
unless the authority is satisfied that there is good and sufficient mason to do so.
3. If in the reporting officer's opinion, despite the warning, etc., the official concerned has not
improved, he may make appropriate mention against the relevant column in the Confidential
Report. This will constitute an adverse entry mid requires to be communicated.
4. Where a copy of the warning is also kept in the Confidential Report Dossier, it will be taken
to constitute an adverse entry and the officer concerned has the right to represent against the same.
5. Warning should not be issued as a result of regular disciplinary proceedings. If it is
found that some blame attaches to the official, then the penalty of censure at least should be
imposed.
6. Warning is not a punishment and cannot be equated to a formal Censure.
2. DISCIPLINARY PROCEEDINGS [SWAMY'S — CCS (CCA) RULES ]
The procedure to be followed in disciplinary cases against Government servants is laid
down in detail in the CCS (CCA) Rules.
1. Penalties.— The following are the penalties that may be imposed on a Government servant:—
 Minor Penalties:—
(i) Censure;
(ii) Withholding of promotions;
(iii) Recovery from pay of the whole or part of any pecuniary loss to Government caused by
the official's negligence or breach of orders;
(iii-a) Reduction to a lower stage in the time-scale of pay by one stage for a period not
exceeding three years, without cumulative effect and not adversely affecting his pension;
(iv) Withholding of future increments of pay.

 Major Penalties:—
(v) Reduction to a lower stage in the time-scale of pay other than (iii-a)\
(vi) Reduction to a lower time-scale of pay, grade, post or service for a period to be specified
in the order of penalty;
(vii) Compulsory retirement;
(viii) Removal from service;
(ix) Dismissal from service.— Rule 11.

2. Inquiry Mandatory.— Inquiry as laid down in the CCS (CCA) Rules should be held in the
following cases:—
1. To impose any of the major penalties (in respect of those charges which are not accepted);
or

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 2. In minor penalty proceedings, after representation, if it is proposed—
(a) to withhold increment for a period exceeding three years; or
(b) to withhold increment with cumulative effect for any period; or
(c) to withhold increment which is likely to affect adversely the pension admissible to
the official; or
3. When the Disciplinary Authority decides that an inquiry should be held, even though
proceedings have been initiated for imposition of minor penalties only.— Rules 14 (2) &
16 (1-A).
3. Procedure — Major Penalties.—
1. The charged official should be served with a charge-sheet together with a statement of
imputations of misconduct or misbehaviour and reasonable time and opportunity given to him to
reply to the charges or to be heard in person.
2. Inquiry is a must to consider charges refuted by him. It must be conducted by the Disciplinary
Authority or an Inquiry Officer appointed by it. It should also appoint a Presenting Officer to
present the charges.
3. The delinquent official has a right—
(a) to inspect documents referred to in the annexure to the charge- sheet;
(b) to engage any other serving or retired Government servant to assist him;
(c) to engage a legal practitioner, if the Presenting Officer is a legal practitioner. In other
cases, the Disciplinary Authority may permit such an engagement, having regard to
the circumstances of the case.
4. If at the inquiry the Government servant pleads guilty to any of the article of charge, the Inquiry
Officer should record a finding of guilt in respect of those articles and hold inquiry only in
respect of the remaining, if any.
5. Government side has the first priority to present the case and produce witnesses and
evidence.
6. Delinquent official will be allowed to offer his defence witnesses and evidence.
7. Witnesses on both sides may be examined, cross-examined and re-examined.
8. The defendant may examine himself as a witness in his own behalf, if he so desires. If he has
not done so, the Inquiry Officer may generally question him to enable him to properly explain
the circumstances cited in the evidence against him.

9. Defence may be in writing or oral. Oral defence will be recorded, got signed and a copy
supplied to the Presenting Officer.
10. Thereafter, Inquiry Officer will hear arguments on both sides or take written briefs
from both. Presenting Officer's brief will be taken first, copy thereof supplied to the defendant
and his reply brief obtained thereafter.
11. Entire proceedings should be recorded in writing, every page to be signed by the
respective witness, the defendant and the Inquiry Officer, and copies furnished to the defendant
and the Presenting Officer.
12. If the delinquent official does not attend, ex parte enquiry may be conducted,
observing the procedure in full.
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 13. On completion, the Inquiry Officer will submit his report and his findings on each
article of the charges to the Disciplinary Authority.
14. Disciplinary Authority may accept or disagree (recording reasons for disagreement),
record its own findings and make a final order.
15. If the Disciplinary Authority who initiated the case is competent to award only
minor penalties, and is of the opinion that major penalty is to be imposed, it should send the
entire records and findings without recording any opinion with regard to the imposition of the
penalty to the Competent Disciplinary Authority which will record its findings and pass orders
as deemed fit.
16. The Disciplinary Authority should forward a copy of the report of the Inquiring Authority
together with its tentative reasons for disagreement, if any, with the findings to the Government
servant giving him fifteen days' time to make any representation / submission.
17.The representation, if any, submitted by the Government servant should be considered before
passing final orders.— Rules 14, 15 and GIDs.

18. Along with the final orders, the Government servant should be supplied with—
i. a copy of the findings on each article of charge;
ii. a copy of the advice, if any, given by the UPSC.
iii. where the Disciplinary Authority has not accepted the advice, a brief statement of
reasons for such non-acceptance.— Rule 17.
19. Disciplinary Authority should take final decision on the enquiry report within 3 months.
4. Procedure — Minor Penalties.—
1. The Government servant should be given a copy of the charge- sheet with a statement of
imputations of misconduct.
2. He should be given reasonable time and opportunity to submit his defence.
3. On receipt of the defence, the Disciplinary Authority may pass appropriate orders, or may
hold an inquiry if—
i. it is of the opinion that such inquiry is necessary, or
ii. the inquiry is mandatory in view of the punishment proposed.
The procedure for the inquiry will be as for major penalty.— Rule 16.
5. When prescribed procedure need not be followed.—
Following are the special circumstances where the prescribed procedure for inquiry need not
be followed:
1. Where a penalty is due to conviction on a criminal charge, or
2. Where the Disciplinary Authority is satisfied (reasons should be recorded in writing) that it is
not reasonably practicable to hold an enquiry in the manner provided, or
3. Where the President is satisfied that in the interest of the security of the State, it is not
expedient to hold an enquiry in the manner provided.

In cases under Category (1), the Disciplinary Authority has to peruse the judgment of the
Criminal Court and take into account the gravity of the misconduct committed, its impact on the
administration and other extenuating circumstances or redeeming features. Once it is concluded that
the Government servant's conduct is blameworthy and punishable, it may impose such penalty as it

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is competent to do. The penalty should neither be grossly excessive, nor out of proportion to the
offence committed or one not warranted by the facts and circumstances of the case.

Regarding Category (2), detailed guidelines have been laid down in this regard. Inquiry
should not be dispensed with lightly or arbitrarily or out of ulterior motives or merely in order to
avoid the holding of an inquiry or because the Department's case is weak and is, therefore, bound
to fail. Further, it is a constitutional obligation that the Disciplinary Authority should record in
writing (preferably in the order itself) the reasons for its satisfaction that it was not reasonably
practicable to hold the inquiry. The reason, though brief, should not be vague or not just a
repetition of the language of the relevant rule.
In both the cases, the Government servant should be given an opportunity
of making representation against the penalty proposed.— Rule 19 and GIDs.
6. If the delinquent Government servant dies during the pendency of the disciplinary proceedings,
the proceedings should be dropped.
7. Streamlining of conduct of disciplinary proceedings to reduce delay.— The following measures
have been prescribed to ensure that disciplinary cases are not unduly delayed:—
(i) Cases should be carefully studied to decide whether major / minor proceedings are
required to be initiated;
(ii) Delay in framing charges should be avoided; responsibility should be fixed for
inordinate delay in framing charges without valid reasons;
(iii) To ensure that the charged officer submits written statement within the time-
limit;

(iv) The departmental officers appointed as Inquiry Officers are relieved from their
normal duties for a period up to 20 days in two spells for completion of inquiry on full-time basis
and submit report.— OM, dated 6-4-2004.
8. Adherence to time-limits in processing of disciplinary cases.— Delay in decision-making by
authorities in processing vigilance cases would be construed as a misconduct and would be liable to
attract penal action.— CVC letter, dated 10-8-2004.

9. Consultation with CVC in cases of action under Rule 19 (i).— Consultation with CVC in the
disciplinary cases under Rule 19 (/) is not necessary / required in such cases where Government
servants are convicted by Courts of Law on criminal charge.— OM, dated 8-4-2005.

7. Disciplinary proceedings and Management as per Karnataka Civil Services Rules (KCSR)

The essence of Government service is the sense of discipline to which all Government
employees are subject and the privilege to which type, in general, are entitled. They relate to the
employees code of conduct and discipline. They are consulted in Government offices in connection
with discipline cases.
Article 311 of the constitution enumerates two fundamental principles upon which
practically the whole procedural law concerning departmental punishments on civil servants rests.
The first clause of that article contains the guarantee that no civil servant shall be dismissed or
removed by an authority subordinate to that by which he was appointed. The second clause
guarantees to him a reasonable opportunity of defence on the charges against him, supplemented by
a second opportunity of showing cause why, if after enquiry it is proposed to dismiss or to remove
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or to reduce him in rank, such a punishment should not be imposed upon him. Provided that the
second clause shall not apply.
Where a person is dismissed or removed or reduced in rank on the ground of conduct which
has led to his conviction on a criminal charge, and or Where the authority empowered to dismiss or
remove a person or to reduce him in rank is satisfied that for some reasons, to be recorded by that
authority, it is not reasonably practicable to hold such inquiry, or
Where the President of India/Governor is satisfied that in the interest of the security of the
State it is not expedient to hold such an inquiry.
The provisions of the above article are absolute and no rules relating to public services can
trespass the rights guaranteed by article.
Thus, only the appointing authority can impose the major punishment of dismissal, removal
or reduction in rank. The power of punishment in such cases can never be delegated to any
subordinate authority.
Enquiry officer can be a suitable officer subordinate to the appointing authority. Enquiry
officer shall conduct formal enquiry after service or regular charges upon charged official. The
enquiry must compulsorily be open and in which the charged official takes full part. The enquiry
report shall contain findings of the charges, but there should be no recommendation about the
punishment. The enquiry officer may make recommendation in the covering letter.
In case the appointing authority considers, upon a perusal of the report, that some
punishment lighter than "major punishment" (dismissal, removal or reduction in rank) will be
appropriate, then he will pass orders straight away without any further formalities. On the contrary,
if he decides to impose 'major punishment', he shall draw up a provisional order of punishment and
serve it upon the delinquent, along with a copy of the enquiry report, requiring him to show cause
why the provisional order should not be made final. Any representation submitted by the delinquent
shall be fully considered by the appointing authority with an open mind, thereafter he will finally
determine the order to be passed. The order need only contain a list of the representation and the
final decision, indicating the reasons.

If any charge levelled against the delinquent is amended or any important evidence not
mentioned in the charge-sheet is to be admitted at any stage, the full procedure shall have to be
gone into afresh. Unless this is done, the proceedings would be vitiated.
In case the original appointing authority has ceased to exist the above punishments may be
imposed by an authority whose rank is higher than that of the extinct authority or by one of the
parallel rank.

GENERAL CIVIL SERVICES RULES:

STAGES OF DISCIPLINARY PROCEEDINGS:

o Major Punishment

o Minor Punishment

Sl.no Major Punishment (Dismissal, removal or reduction in rank)

1. Preliminary enquiry Fact finding enquiry conducted informally for
ascertaining the nature and extent of the
delinquent’s fault. (should be made when prima
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 facie good and sufficient reasons exist).
2. Decision to start formal departmental Taken by appointing authority after considering
enquiry the preliminary enquiry report.
3. Suspension When appointing authority decides to launch
departmental enquiry, it has to be decided
whether the delinquent should be suspended.
4. Charge-sheet and its service Allegations against the delinquent have to be cast
in the form of definite charges which shall be
clear and precise. The charge-sheet may be
served personally or through registered post
(requiring reply within a fortnight).
5. Appointment of Enquiry Officer Simultaneously with the framing of the charges
the disciplinary authority will nominate an
officer to conduct the enquiry. The name of this
officer will be stated in the charge-sheet.
6. Written statement of defence This will be submitted by the charged official to
the enquiry officer in accordance with the
directions contained in the charge-sheet. Before
submitting his explanation the charged official
can ask for inspection of relevant records as well
as for supply of copies of any important
documents not supplied with the charge-sheet.
7. Recording of evidence by Enquiry After receipt of explanation, the enquiry officer
Officer will begin his regular oral enquiry by recording
the evidence of witnesses. The charged official
will have the right to cross examine the3
witnesses brought in by the Department and to
examine his own witnesses in defense.
8. Personal hearing of charged official The charged official has also a right to make oral
submissions
9. Report of Enquiry Officer This will include the text of charges, the
discussion of evidence and the findings on each
charge. No recommendation about puni9shment
should be made in it. The report will be
submitted in duplicate to the disciplinary
authority, with a covering letter in which the
enquiry officer can give his opinion about
punishment. It is desirable for such an opinion to
be given invariably for the assistance
disciplinary officer.
10. Show-cause notice by disciplinary If after consideration the disciplinary authority
authority decides to award major punishment , he will
issue a notice to charged official to show cause
why that particular punishment should not be
imposed (allowing time of a fortnight to a
month)
11. Reply tio show-cause notice and Upon objective consideration of reply the
decision thereon disciplinary authority will reduce his conclusion
to a succinct, reasoned out order, which will be
communicated to charged official under the
signatures of disciplinary authority himself.
Order to be effective from date of service.
12. Review of punishment order In certain cases and subject to certain conditions
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13. Appeal or revision
14. Reinstatement an restitution
15. Show-cause notice against withholding
of emoluments for suspension period in
the case of a reinstated
the penalized official can request the disciplinary
authority to reconsider his order.
An appeal lies against the major punishment to
next higher authority.
i. If a suspended official is exonerated of
the charges by the disciplinary authority,
he is reinstated as a matter of course. He
is also restored to his original position as
far as may be practicable.
ii. If a dismissed or removed official is
reinstated by the appellate or revising
authority, he is allowed to regain his
original position if his acquittal is
honorable. In other cases restitution is
given to the extent directed by the
appellate or revising authority.
iii. Similar action will be taken if orders are
passed by a Court of Law.
iv. If upon reinstatement the disciplinary
authority proposes to withhold any
portion of the emoluments of the
reinstated official for the period of
suspension, then he must first officially
issue a show-cause notice to him before
taking a final decision.

MINOR PUNISHMENTS (OTHER THAN DISMISSAL, REMOVAL OR REDUCTION IN

RANK)

For Minor Punishments, no formal charge-sheet need be issued nor need a regular enquiry
officer be appointed. Action can be taken after calling for the delinquent’s explanation and then
straight away imposing upon him any of the minor punishments after due consideration of
explanation and then recording a speaking order.

Censure or stoppage at efficiency bar: these penalties may be imposed whenever the punishing
authority is satisfied that good and sufficient reasons exist for adopti9ng such a course. In such a
case it is not necessary to frame formal charges or to call for the officer’s explanation (Rule 55-8(a)
of CCA Rules).

With-holding of increment due to incertified integrity: the position stated above also applies
where an officer’s increment in the time-scale of his pay at any stage, other than an efficience bar, is
stopped due to his integrity remaining uncertified (Rule 55-8(a) of CCA Rules). Stoppage of an
official at the efficiency bar on the ground of his unfitness to cross the bar is not regarded as a
punishment.

DISCIPLINARY PROCEEDINGS AS PER CCSR:

1. The appointing authority may place a government servant under suspension as per CCSR, as
part IV Rule 10 such as any criminal offence, forgery documents, misappropriation of
money, theft of government property, bribery, corruption etc.
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2. As per appendix II A, Misdemeanor/misconduct such as disobedience of orders misbehavior
with superior officers, with colleagues, with public, violation of conduct rules, violation of
standing orders, etc. of government servants may place under suspension.
3. As per part V, rule 11 (4) action for furnishing false information at the time of appointment
4. As per Part V Rule 11 (7) action for unauthorized absence from duty.
5. As per Part V Rule 11 (10) Action to be taken for late coming deducting half-a-day casual
leave.

Whereas KCSR (Karnataka Civil Service Rules) more or less similar like CCSR except code
and rule numbers.

ROLES AND FUNCTIONS OF ADMINISTRATOR IN DISCIPLINE:

The following are the roles and functions of administrator/manager in discipline:

1. He or she, encourages employees to be self-disciplined in conforming with established

rules and regulations
2. Assists employees to identify themselves with organizational goals, ‘their increasing the
likelihood that the standards of conduct deemed be accepted by the organization and will
be accepted by its employees.
3. Humanistic ally uses discipline as a means of promoting employee growth.
4. Periodically assesses the need for existing rules and regulations and suggests
modifications as necessary
5. Is self aware regarding the power and responsibility inherent in having formal authority
to set rules ad discipline employees
6. Demonstrates sensitivity to the environment in which discipline is given.
7. Serves in the role of coach in performance deficiency coaching
8. Ensures that rules and regulations are clearly written and communicated to subordinates
9. Discusses rules and policies with subordinates, explaining the rationale for their
existence and encouraging questions
10. Enforces established rules in a fair and consistent manner.
11. Judiciously uses formal authority to take progressively stronger forms of discipline when
employees continue to fail to meet expected standards of achievement.
12. Carefully documents employees behavior(s) that prompts disciplinary action and any
attempts to counsel the employee.
13. Uses developed communication skills to do the following:
 Clearly explain the nature or seriousness of disciplinary problems
 Allow employees feedback in the disciplinary process
 Explain disciplinary actions to be taken and why
 Describe expected behavioral changes and what the consequences of failure to
change, will be
 Reach agreement and acceptance of the disciplinary plan with the employee
14. Disciplines union employees in accordance with the steps, penalties and time frames
established in the union contact.
15. Advises employees in seeking disciplinary action redress through informal and formal
grievance procedure.

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OUR INSTITUTIONAL DISCIPLINARY PROCEEDINGS & POLICIES:

Steps:

1) Preliminary Investigation:

The management should conduct a preliminary investigations I order to find out

whether a prima facie case of misconduct exists

2) Serving a charge-Sheet:

Charge-sheet is not a punishment in itself. It is merely notice of a charge that the

worker is responsible for some misconduct and that the management wants to know
what he has to say about it. It is also called as “show- cause notice”

3) Suspending of a worker pending enquiry, if needed

4) Issuing a notice of enquiry

5) Holding Enquiry

6) The enquiry officer (Judge) will record the findings

7) Punishing the employee

8) Communication of punishment

APPLICATION TO NURSING SERVICE AND NURSING EDUCATION:

Nursing Service:

 Creates a climate under which individual excellence is encouraged

 Improves the activities and work performance of the employee

 Help for having a control over the other employees

 Necessary and positive tool in promoting subordinate growth

 Helps for the friendly approach of the supervisor with the nurses

 Proper functioning and the attainment of the quality nursing care

 Encourages for the work excellence of the nurses

 Develops the knowledge, skill and attitude of the staff nurses

 Improves the administrative activities

 Improves the awareness of the responsibilities of the staff nurses and the nurse managers

 Develops the communication skills of the nurses

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Nursing Education:

 Plans for the proper implementation of the service rules

 Organizes the activities of the students and the faculties

 Helps to identify the rules and regulations of the students and the faculties

 Helps to meet the institutional goals and objectives

 Improves the students behavior and the activities

 Motivates the student in the development well developed discipline and behavior

 Improves the students level of excellence

 Encourages for the improvement of the knowledge, skill and attitude of the supervisor

 Helps for the proper identification of the needs and responsibilities

 Evaluates the level of performance of the students

 Helps in the change of indiscipline

 Prevents the occurrence of misconduct

Chapter- IX B.Vallatharasi

MEANING OF BUDGET

The word “budget” derived from the old English word “budget tee” means a tack or pouch
which the Chancellor of the Exchequer use to take out his papers for lying before the
parliament, the government, financial scheme for the ensuring year.

DEFINITION

Budget is a concrete precise picture of the total operation of an enterprise in monetary terms‖

(HM
Donovan)

Budget is a operation plan, for a definite period usually a year Expressed in financial terms
and bused an expected income and expenditure

“Budget can be defined as a numerical statement expressing the plans, policies and goals of
an organization for a definite period in future.”

PURPOSES

The purposes of budgeting are:

1. Budget supplies the mechanism for translating fiscal 1-year objectives into projected
monthly spending pattern.
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 2. Budget enhances fiscal planning and decision making.

3. Budget clearly recognizes controllable and uncontrollable cost areas.

4. Budget offers a useful format for communicating fiscal objectives.

5. Budget allows feedback of utilization of budget.

6. Budget helps to identify problem areas and facilities for effective solution.

7. Budget provides means for measuring and recording financial success with the objectives
of the institution.

8. Budget is needed for planning for future course of action and to have a control over all
activities in the organization.

9. Budget facilitates coordinating of various departmental and selection for realizing

organizational objectives.

10. Budget serves as a guide for action in the organization

11. Budget helps one to weigh the values and to make decision when necessary on whether
one is greater values in the programmes than the other.

FEATURES OF BUDGET

 It should be flexible

 It should synthesis at past, present and future.

 It should be product joint venture, co- operation of executives / department heads at different
levels of management.

 It should be in the form of statistical standard laid down in the specific numerical terms.

 Budget is needed for planning for future course of action and to have a control over all
activities in the organization.

 Budget facilitates coordinating of various departmental and selection for realizing

organizational objectives

 Budget serves as a guide for action in the organization.

 Budget helps one to weigh the values and to make decision when necessary on whether one
is of greater values in the programmes than the other.

It should have a support at top management throughout the period of its planning and
implementation.

PRINCIPLES OF BUDGET

Budget is an operational plan for a definite period, usually a year, expressed in financial
terms and based on expected income and expenditure.

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Budget needs certain principles as given below:

1. Budget should provide sound financial management by focusing on requirement of the

organization.

2. Budget should focus on objectives and policies of the organization. It must flow from
objectives and give realistic expression to the way of realizing such objectives.

3. Budget should ensure the most effective use of scarce financial and non-final resources.

4. Budget requires that programme activities planned in advance.

5. Budgetary process requires consistent delegation for which fixed duties and
responsibilities are required to be allocated to managers at different level for framing and
executing budget.

6. Budgeting should include co-coordinating efforts of various departments establishing a

frame of reference for managerial decisions, and providing a criterion for evaluating
managerial performance.

7. Setting budget target requires an adequate checks and balance against the adoption of too
high or too low estimate. Utmost care is a must for fixing targets.

8. Budget period must be appropriate to the nature of business or service and to the type of
budget.

9. Budget is prepared under the direction and supervision of the administrator or financial
officer.

10. Budgets are to be prepared and interpreted consistently throughout the organisation in
the communication of planning process.

11. Budget necessitates a review of the performance of the previous year and an evaluation
of its adequacy both in quantity and quality

12. While developing a budget, the provision should be made for its flexibility.

13. Nurse managers at all levels of the organization need skills in development, management
and evaluation of a budget to be successful professionally as well as to assist their
organization to survive and prosper. While making budget one should consider these
principles.

14. Normally, budget must be balanced one: This means this budget should be balanced. It
should not exceed the estimated income. When the amounts of expenditure and revenue in a
budget are equal or nearly so it is called a balanced budget.

15.Budget Estimates should be on a cash based: It mean that its estimation of expenditure
and income should relate to what is expected to be actually spent or received during the year
and not to liability or demands which incurred or such demands within the year but on to be
realized in some other years. Eg. Certain sums on account of arrears of tax relating to the
year 1994-95 are received in the year 1995-1996. They should be shown in the budget
estimates of the latter year and not of the former (1995-96).
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16. Budget Revenue and capital portion should be kept distinct: The third principle of
budget making is that the distinction between recurring expenditure and income on the one
hand, and capital payment on the other hand should be maintained and the two should shown
in two separate part of the budget known as the current or revenue and the capital budget. If
they are not separated, it should lead to confuse financial picture.

17. Budgeting should be gross and not net: Gross budgeting means that all the transactions
both of receipt and expenditure should be shown and not merely the resultant position. If
this rule is not followed, it could result in laxity of financial control and incomplete account.
Eg. Department estimated expenditure of 4 lakhs and receipt of 2 lakhs could go to the
legislature with a request for grand of 2 lakhs. Thus, the legislature is deprived of the
control over half of its expenditure which is met out of its receipts.

18. Estimation should be as closed as possible: It means that estimation should be as exact
as possible. Over estimation would lead to heavy taxation and under estimation is achieved
by taking past three years average figures one aids to close budgeting.

19. The form of estimates should correspond to the form of accounts: It means that the
budgetary heads should be the same as those of accounts. This facilitates budget
preparation, budgetary and account keeping.

20. Rule of Lapse: The rule say that any part of the grant not spent within the financial year
cannot be kept for the future and should be returned.

TYPES OF BUDGET

Since budget express plans and an organization may have different types of plans, there may
be different types of budgets. These may be classified on the basis of

1. Coverage of functions master and functional budgets.

2. Nature of activities covered – capital and revenue budgets

3. Period of budgets – long term and short-term budgets

4. Flexibility adopted – fixed and flexible budgets.

1. Master and Functional budgets

A master budget is prepared for the entire organization incorporating the budget of different
functions (finance ministry). For example when we refer to the annual budget of government
of India, it incorporates the budget outlays of different ministries. In the business
organizations, the maser budget incorporates various functions and units and their outlays. It
generally includes sales, production, costs. A functional budget is prepared incorporating a
major function and its sub- functions. Since an organization may have a number of
functions, numerous functional budgets are prepared. Eg. Production budget, cash budget in
an organization.

2. Capital and Revenue budgets An organization activity involves two processes- creating
facilities for carrying out activities and actual performance activities. Creating facilities for
carrying out activities include capital expenditure whose returns accrue over a number of

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years. For such activities, capital budget is prepared which is essentially a list of what
management believes to be worthwhile projects for acquisition of new assets together with
the estimated cost of each project. Revenue budget involves the formulation of target for a
year or so in respect of various organizational activities such as production, marketing,
finance, etc. Thus, a revenue budget includes expenditure and earning for a specific period
like one year.

3. Long term and short-term budgets Many organizations integrate their yearly budgets
with long-term projections of business activities and along with yearly budgets; they prepare
budgets for a longer period of 2 – 3 years. When one budget period is over, budgets are
prepared for the next year and subsequent 2 -3 years. The short term budget is for a year and
is divided into a number of periods for effective implementation. For eg. Cash budgets are
on yearly basis as well as on monthly or quarterly basis to facilitate better cash management.

4. Fixed-celling and flexible budgets: Generally, organizations prepare which certain to

only certain projected fixed volume of operations for a year or so. Such budgets are known
as fixed of static budgets. When an organization’s volume of business can be predicted with
fair amount of precision, the fixed budget is satisfactory.

A budget which is designed to change in accordance with the activities of the organization is
known as flexible budget. It considers several level of activity and assumes that labour,
material or facilities used in production and hence cost vary with a known relationship to the
actual of activity.

OTHER TYPES OF BUDGET

1. INCREMENTAL BUDGET

It is one based on estimated changes in present operation, plus a percentage increase for
inflation, all of which is added to previous year budget.

2. OPEN ENDED BUDGET

Is a financial plan in which each operating manager presents a single cost estimate for each
programme in the unit, without indicating how the budget should be scaled down if less
funding is available.

3. FIXED CEILING BUDGET

Is a financial plan in which the upper most spending limit is set by top executive before the
unit and divisional managers develop budget proposals for their areas of responsibility

4. FLEXIBLE BUDGET

Consist of several financial plans, each for a different level of programmes activates. It is
based on the fact that operating conditions rarely conform to expectations.

5. ROLL OVER BUDGET

Is one that forecasts programmed revenues and expenses for a period greater than a year. To
accommodate programmed that greater target than annual budget cycle. Eg., NRHM
(extending of programmes).
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 6. PERFORMANCE BUDGET

It is one based on functions, which allocate function, not division.

Eg. Direct Nursing care, in service education, quality improvement, nursing research.

7. PROGRAMMED BUDGET

Is one which costs are computed for a total programmed, i.e, grouping total coasts for each
services programmed eg. MCH, FP and UIP etc. These base budgets requires the nurse
manager to examine, justify each cost of every programmed both old and new in every
annual budget preparation.

8. SUNSET BUDGET

It is designed to Self Destruct within a prescribed time period to ensure the cessation of
spend in by a predetermined date.

9. SALES BUDGET

Is the starting point in a budgetary programmed, since sales are basic activates which give
shape to all other activities. Sales budget are compiled in terms of quality as well as of
values.

10. PRODUCTION BUDGET

It is the budget that aims at securing the economical manufacture of products and
maximizing the utilization of production facilities Revenue and expanse Budget. It is
expressed in financial terms and takes the nature of a perform income statement for the
future. It may use prepared in a detailed form or in an abstract statement showing the items
of profit and loss under classified headings.

Line Item Budget

• Line item budgets are the most common type of budget and are often called incremental
budgets, because typically just a small amount of funding is added each year. The
advantages of a line item budget are:

• Easy to prepare

• Easy to understand

• Easy to justify.

Formula Budget

The formula budget is sometimes used in large library systems, and state or federal agencies.
It uses predetermined standards for allocation of resources. Budget criteria are established
and then applied across the board to all units within the system.

Example

• an allowance for a basic collection (minimum 85,000 volumes)

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• an allowance pre Full-Time-Equivalent (FTE) student

• an allowance per faculty member

• an allowance per Master's field

• an allowance per doctoral field

Operating or Revenue and Expense Budgets:

The operating budgets provides an over view of an agency’s functions by projecting the
planned operations, usually for the upcoming year. Revenue budget includes the revenue
received after providing services during the year. Expense budgets includes personnel costs
(Salaries), medical-surgical supplies, office supplies, repair and maintenance, fees, travel
and education, dues and miscellaneous.

Time, space, Material and Product budget:

Many budgets are better expressed in quantities rather than in monetary terms. Although
such budgets are usually translated into monetary terms, they are much more significant at a
certain stage in planning and control if they are expressed in terms of quantities. Among the
more common of these are the budgets for direct labour hours, machine hours, units of
materials, square feet allocated and units produced.

Capital Expenditure Budgets:

Capital expenditure budgets out specifically capital expenditure for plant, machinery,
equipment, inventories and other items, whether for a short term or a long one, these
budgets require care because they give definite form to plans for spending the funds of an
institution. These items are usually major investments and reduce the flexibility in
budgeting because it takes long time to recover the costs. The basic components of capital
equipment budgets are:

1. Equipment that exceeds the designate designated cost limit.

2. Equipment that does not generate direct revenue by charge.

3. Equipment that substantially changes the facility’s services.

4. Equipment that has an estimated life of more than one year.

5. Equipment not intended for sale to the patient in the course of operation.

Generally, requests for approval of capital expenditure go through, at least two, and as many
as all, of the following sources for approval is required prior to purchasing;

1. departmental head 2. purchasing 3. Maintenance 4. financial department and 5.

administration.

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Cash Budgets:

Cash budgets are planned to make adequate funds available as needed and to use any extra
funds profitably. This ensures that agency has enough, but not too much, cash on hand
during budgetary period. This is necessary because income does not always coincide with
expenditure. The manager must anticipate fluctuations in resource needs caused by such
factor as seasonal variations. Budgeting cash requirements may not significantly affect
profits, but they do ensure liquid position and are a sign of prudent management.

Such budgets express plans and an organization may have a large variety of plans there are
many types of budgets. The budgets may be classified on the basis of,

 Coverage of function

 Characteristics of activities

 Period

 Flexibility

Functional Budgets:

 Functional budget is the budget of income or expenditure appropriate for a particular

function. Function budget is also known as operating budget. This budget consists
of two parts: Programme budget and responsibility budget.

Master Budget:

 The master budget is the summary budget incorporating its component functional
budgets. Thus, this is nothing but the targeted profit and loss statement and balance
sheet of the organization.

Live budget:

 It is the oldest type of budget. Thus deals with the travel anticipated equipment and
supplies to the budget.

Labour or Personnel Budget:

 Personnel budget estimates the cost of direct labour necessary to meet the agency’s
objectives. They determine the recruitment, hiring, assignment, lay off and
discharge of personnel.

Eg. Nurse manager divides the types of nursing care necessary to meet the nursing needs of
the patients.

STEPS IN FINANCIAL PLANNING:

Financial planning a process where you plan your Investments in such a way which meets
your financial goals over time.

619
You must be very disciplined when you do this , you must know from where you the money
is going to come to you and how are you going to save or invest it , and in future how are
you going to achieve your goals.

We all know that making a financial plan plays an important role in wealth generation.
However, for some reason or the other we find excuses for not making one. If you have not
yet made a financial plan that charts your future earnings, expenses and returns from your
investments then perhaps it's about time you made one.

1. Identify and list down your future needs/ objectives

2. Converting needs into financial goals

3. Getting a grip of your current financial state

4. Stage I of the financial plan: Risk planning

5. Stage II of financial plan: Core cash flow study

6. Determining a suitable asset allocation strategy

7. Product selection and plan execution

8. Monitoring and evaluating your financial plan

EIGHT EASY STEPS THAT WILL HELP TO MAKE FINANCIAL PLAN.

1. Identify and list down your future needs/ objectives

Each individual aspires to lead a better and a happier life. To lead such a life there are some
needs and some wishes that need to be fulfilled. Money is a medium through which such
needs and wishes are fulfilled. Some of the common needs that most individuals would have
are: creating enough financial resources to lead a comfortable retired life, providing for a
child's education and marriage, buying a dream home, providing for medical emergencies,
etc.

The first step in a making a financial plan is to identify the goals which have to be met.
These goals are the needs and the objectives of the individual. Clarity in this respect would
be the starting point to help an individual work out the journey on the financial road which
needs to be followed.

2. Converting needs into financial goals

Once the needs/ objectives have been identified, they need to be converted into financial
goals.

But how do we convert the needs into financial goals?

Two components go into converting the needs into financial goals. First is to evaluate and
find out when you need to make withdrawals from your investments for each of the needs/
objectives. Then you should estimate the amount of money needed in current value to meet
the objective/ need today. Then by using a suitable inflation factor you can project what
would be the amount of money needed to meet the objective/ need in future.
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 For example, let us consider the need to create an education fund for your child which is
needed 15 years from now. Let us assume that the current cost of education today would
work out to around Rs 4 lakh. We can project what is the amount needed after 15 years for
your child by applying a suitable inflation factor to the current cost of education assumed as
Rs 4 lakh.

Assuming that cost of education would rise at 7 per cent per annum over the next 15 years,
the total amount required after 15 years would work out to Rs 11.03 lakh. Similarly you
need to estimate the amount of money needed to meet all such objectives/ needs. Once you
have all the values you need to plot it against a timeline. This is very easily done by using
spreadsheets. It will give you a broad idea about when and how much money you would
need during your life in future.

3. Getting a grip of your current financial state

To get clarity on your current financial state, it is necessary to create a family budget. As
part of this budget, you need to list down your income and expenses.

 Income should include the husband and wife's income as well as rental income if any

 The expenses part should be split under monthly expenses and annual expenses

 Under monthly expenses you should list down the regular monthly expenses like groceries,
phone bills, electricity, petrol, etc

 Under the annual expenses you need to include non-regular expenses like school fees, car
insurance, vacation, etc

This enables you to get an idea of the pattern of cash outflows (expenses) during the year.
Accordingly you can plan to keep adequate money liquid for the necessary expenses during
the course of the year. All Loan EMIs (equated monthly installments) paid should be kept
separate under the monthly expenses head, as after a finite number of years they will no
longer be part of your regular living expenses.

The most important information that you get from the above study is your current annual
cost of living (that part of expenses which supports your current lifestyle).

An analysis of the above figures would enable you to understand the amount of savings
(income less expenses) that you are left with on an average. This in turn will give you an
idea of surplus regular money available for investment. This is the savings that will take care
of you and your family when income from your work stops.

Hence it is extremely important to understand what is happening to your savings. A strategy

to invest the savings in the most appropriate way is critical for you to meet your financial
goals.

4. Stage I of the financial plan: Risk planning

The first component of the financial plan would cover the aspect of risk planning. The two
major risks are that of illness and death. The role of insurance is to cover risk (in financial
terms only). A suitable health insurance cover is worked out after taking into account the

621
situation of the family and in information about the availability of any cover from the
employer.

The next step is to estimate the amount of life insurance cover required. Loss of income in
case of death of an earning member may put the rest of the family into financial discomfort
(especially where he/ she may be the primary bread winner).

The role of insurance is to take care of this financial discomfort. The most suitable life
Insurance cover for this is a term cover. Information on financial goals and your current
financial state, when suitably modified, becomes a base from which to work towards
estimating the amount of life insurance and the tenure of the cover.

Once the risk planning is in place the cash flows for long term financial planning is worked
out.

5. Stage II of financial plan: Core cash flow study

You now have the basic inputs needed to work on your financial plan. The needs/ objectives
have been converted into financial goals. You know the amount of money and the time when
it is required for each of your financial goals. These financial goals will be met through
creating financial resources by investing your savings.

You have a basic understanding of your current cash flow (income and expenses statement)
through creating a family budget. From this you can get an idea of your potential savings.
By projecting your income and expenses into the future you can get an idea of the kind of
savings you can have each year.

By assuming that savings grow at different rates you would get an idea of how your
investment pool would grow into the future. You will have to work out at what rate of
growth of your savings would all your financial goals be met. If the rate needed is very high
then it gives you an idea that you may have to save and invest more or alternatively sacrifice
some financial goals.

In case the return needed is very low, you can explore the possibility of achieving financial
freedom earlier in life. You can mix and match and work out different scenarios and then
finalise a plan that suits you most. As this is a part that involves a lot of number crunching,
spread sheets make it easier to work.

6. Determining a suitable asset allocation strategy

Based on a projection of the estimates of long term cash flows done you know the rate at
which you need to grow your investments. The financial plan thus lays the broad investment
parameters in terms of an asset allocation strategy.

Different assets classes like debt, equity, real estate, etc. grow at certain natural growth rates
over the long term. You have to work out an investment strategy to invest the saving across
various asset classes in a suitable ratio so that you meet the targeted return as per the
financial plan.

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 If a higher return is needed then accordingly a higher exposure to higher growth assets like
equities is needed. Discipline in maintaining the asset allocation is the key to achieving
success in the long term.

7. Product selection and plan execution

Only after the asset allocation strategy as per the financial plan is in place does the question
of product selection and execution arise.

This strategy guides us on the allocation of money to various asset classes (example: debt,
equity, gold, etc). For each of the asset classes, suitable investment options are evaluated. A
thorough understanding of how different products work and the costs associated with them
is critical for this evaluation. The most suitable product which will help you meet the
expected returns as estimated in the financial plan is selected.

By growing the money at the expected rate you would be able to build enough financial
resources to fulfill your objectives and needs in life. A lot of individuals invest into an
investment option without understanding its overall long term impact on their lives. Due to
this reason they may find out that they are left with inadequate financial resources during
their later years.

They generally have to depend on someone (like their children) or have to drastically reduce
their lifestyle to lead a financially viable life. Hence it is extremely important for people to
evaluate before hand, the amount of financial resources they need to accumulate, in order to
lead a comfortable life post their working years.

8. Monitoring and evaluating your financial plan

The success in financial planning is achieved only when all the financial goals are met.
Hence financial planning does not end as soon as investments are made. It is a continuous
process where regular monitoring and periodic evaluation is necessary to ensure that things
are happening as per the plan. It is essential to ensure that planned contributions from your
savings are happening towards your investments.

In addition to this the returns being generated by the investments should be monitored and
rebalancing of investments should be made as per the asset allocation strategy. Based on the
above evaluation the financial plan should be fine tuned if necessary.

Adjustments to the financial plan maybe needed in certain scenarios. Any permanent change
in lifestyle over and above the estimated level would impact on your long term financial
situation. Similarly any major change in your existing situation -- new member added in the
family or reduction in income due to one member of the family taking time off from work to
raise children would require a reworking of the financial-plan.

STEPS IN FINANCIAL PLANNING PROCESS

• Conducting need analysis

• Evaluating existing resources

• Conducting risk assessment

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• Developing a financial plan

• Implementing the financial plan

• Monitoring the financial plan

a) Conducting need analysis:

This step involves -

o Identifying needs of protection, retirement, health, wealth creation, and preservation

o Quantifying these needs

o Arriving at the time frame

In this step, analyzing the macro and socio economic trends is called for. Growth of the
economy & progress of society are essential for all round development of the individual.

b) Evaluating existing resources:

• Existing resources of the client are evaluated as follows

– Cash flows such as Income & Expenses

– Net worth such as Assets & Liabilities

• The financial planner also needs to understand and quantify the present and future financial
flows of the customer.

• This helps in quantifying the surpluses available from time to time.

• A financial balance sheet of the customer also needs to be drawn to arrive at their net worth.

• The planner should be able to understand various classes of assets.

c) Conducting risk assessment:

Assessment of risk is conducted by

– Risk profile

– Asset Allocation

Risk profile

• It is important to determine the style of the investor before investing.

• Aggressive Investor - who likes to take risks to earn an extra bit of return

• Moderate investor - who is content and believes in earning slow and steady gains

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• Conservative investor - is risk averse investor whose primary objective is capital
preservation and wants a steady growth in income. They are also known as passive
investors.

Asset allocation:

• Asset allocation is the key to performance of portfolio. Assets can be sacred, serious or
aggressive assets.

• Sacred assets are sacrosanct such as house, gold or fixed deposits which have low risk and
low returns.

• Serious assets could be debt funds or bonds with higher returns and higher risks.

• Direct equity or equity mutual funds are of this type. Investors, who are willing to accept
considerable volatility in their portfolios, invest in aggressive assets.

d) Developing a financial plan

 Developing a financial plan for customer involves

• Developing the plan for fulfilling protection, retirement, health, and wealth creation/
preservation needs of the customer

• Explaining the plan and rationale to the customer

• Giving both upside potential and downside risk, keeping in mind customer's profile
& risk appetite

Understanding tax laws and operating regulatory framework.

e) Implementing the financial plan

• This step involves executing the plan through optimal investment.

• After getting the customer's approval, the financial plan needs to be implemented with the
help of various service providers.

• It is important to create a proper record of the financial plan and its implementation.

• Recording of essential details, due dates, and dates of receipt of flows.

f) Monitoring the financial plan

Some guidelines for monitoring the investments are:-

– Establish a systematic way of monitoring each investment

– Ensure that monitoring should be practical and routine function

– Call the client if market conditions change.

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 – Always contact the client in good as well as bad situations

– Monitor periodically and make notes for the next meeting

– Anticipate cash flows and be ready with an action plan

– Balance maintenance versus new ideas

– Be selective and document your recommendations

– Make investment advisory accessible to client through conference calls.

ETHICAL AND LEGAL ISSUES:

Budgeting and financial management involve intensive decision making about the allocation
of scarce resources. Conflicts and ethical dilemmas easily arise in the balancing of
competing needs and wants. For example, the institution has an advantage if labor budgets
are tightly restricted. However, clients may incur greater wait times or diminished direct
care time if nurses available and accessible. Furthermore, nurses experience greater stress
when workloads rise and clients’ care needs are difficult to meet in the time available.

Chronic stress saps nurses’ energy and is reflected in their ability to deliver client-oriented
service. In severe cases, patient safety is jeopardized and medical errors increase.

Ethical and moral problems occur as value clash. Ethical obligations of fidelity can be
interpreted as promise keeping, an obligation to act in good faith , fulfilling agreements,
maintaining relationships , and upholding trust and confidence. Professional fidelity or
loyalty means upholding the client’s interests as a priority over the professional’s self
interest or others’ interests in any conflict. This is also called advocacy. Divided loyalties
arise from the organizational and financial structure of health care. For example , issuing
orders, assignment of duties, or allegiance to other providers , employing agencies, funding
sources, corporate structures, or governmental agencies may compel an ethical choice.

INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN

FISCAL PLANNING:

Managers must understand fiscal planning, be aware of their budgetary responsibilities , and
be cost effective in meeting organizational goals . the ability to forecast unit fiscal needs
with sensitivity to the organizations economic, social and legislative climate is a high-level
management function. Managers also must be able to articulate unit needs through
budgeting to ensure adequate nursing staff, supplies, and equipment . finally , managers
must be skillful in the monitoring aspects of budget control.

Leadership skills allow the manager to involve all appropriate stakeholders in developing the
budget. Other leadership skills required in fiscal planning include flexibility, creativity, and
vision regarding future needs. The skilled leader is able to anticipate budget constraints and
act proactively. In contrast, many managers allow budget constraints to dictate alternatives.
In an age of inadequate fiscal resources, the leader is creative in identifying alternatives to
meet patient needs. The skilled leader, however, also ensures that cost containment does
not jeopardize patient safety. As well , leaders are assertive , articulate people who ensure
that their department’s budgeting receives a fair hearing. Because leaders can delineate unit
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 budgetary needs in an assertive, professional, and proactive manner, they generally obtain a
fair distribution of resources for their unit.

APPROACHES TO DEVELOP AN ORGANIZATION WIDE BUDGET

Organizations adopt different approaches for preparing their budgets. One of the most
common approaches is in the form of traditional budget in which the current year’s budget is
taken as a base with the provisions of some additions and deductions in the next year’s
budget. The traditional approach of budgeting does not eliminate the drawback of the past.
Therefore, newer approaches of budgeting have emerged. These have resulted into three
types of budgeting

1. Performance budgeting

2. Zero base budgeting

3. Strategic budgeting

1. Performance budgeting’s A performance budget is an input / output budget or costs and

results budget. Performance budget emphasis on non-financial measures of performance,
which can be related to financial measures in explaining changes and deviations from
planned performance. Performance measurements are useful for evaluating past performance
and for planning future activities. Performance budgeting, results into the following.

o It correlates the financial and physical aspects of every programme or activity.

o It improves budget formulation, review and decision making at all levels of the organization.

o It facilitates better appreciation and review of organizational activities by the top

management.

o It makes possible more effective performance audit.

o It measures progress towards long-term objectives.

2. Zero base budgeting This was applied for the first time in preparing the divisional
budgets of Texas instruments of the USA in 1971.

Zero base budgets is based on a system where each function, irrespective of the fact whether
it is old or new, must be justified in its entirety each time a new budget in detail from scratch
that is zero bases. The process of zero bases involves four basic steps:

o Identification of decision units, that is cluster of activities or assignments within a manager’s

operations for which he is accountable.

o Analysis of each decision units in the context of total decision package.

o Evaluation and ranking of all decision units to develop the budget request.

o Allocation of resources to each unit based

Benefits of zero base budgeting:

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1. Effective allocation of resources

2. Improvement in productively and cost effectiveness

3. Effective means to control costs

4. Elimination of unnecessary activities

5. Better focus on organizational objectives.

6. Saving time of top management.

3. Strategic budgeting

It is used as a tool of resource allocation to various strategic business units and other units of
an organization. Under strategic budgeting, in determining the resource needs of various
units

Formation of a budget committee:

Budgeting is a cooperative undertaking. In smaller organization, the task of budget

preparation may be entrusted to the accountant who works in close cooperation with the
general management and department heads. But in bigger concerns, the budget should be
prepared by each departmental/division manager. The accounts department assists in
providing necessary background information and coordinates the budget of different
departments. There may be a budget committee in an organization comprising of the
departmental heads and finance manager or a budget officer.

The function of the budget committee is to

a) Receive and approve all forecasts, departmental budgets, periodic reports showing
comparison of actual and budgeted income and expenditure.

b) The committee may also request for special studies of deviations from the budget and
consider revision of budget to meet changed conditions.

Essential requirements for budget preparation:

1) sound forcasting:

2) an adequate and well conceived accounting system

3) a well devised cost accounting system

4) a soundly constructed organization with fixed lines of responsibility.

5) Statistical informations

6) Support of top management

7) Length of budget period.

PLAN AND NON PLAN

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 A budget is a plan that numerical data to predict the activities of an organization over a
period of time, and it provides a mechanism for planning and control, as well as for
promoting each unit’s needs contributions
- (Carruth, & Noto, 2000).

CLASSIFICATION OF EXPENSES:

1. Fixed or variable.

2. Controllable or non controllable.

STEPS IN THE BUDGETARY PROCESS (FISCAL PLANNING):

• 1. Assessment.

• 2. Planning.

• 3. Implementation.

• 4. Evaluation.

The nursing process provides a model for the step in budget planning:

1. The first step is to assess what needs to be covered in the budget. Historically, top-level
managers frequently developed the budget for an institution without input from middle –or
first-level managers. Because unit managers who participate in fiscal planning are more apt
to be conscious and better understand the institutions long and short term goals, budgeting
today generally reflects input from all levels of the organizational hierarchy. Unit managers
develop goals, objectives, and budgetary estimates with input from colleagues and
subordinates. Budgeting is most effective when all personnel using the resources are
involved in the process. Managers, therefore, must be taught how to prepare a budget and
must be supported by management throughout the budgeting process.

A composite of unit needs in terms of manpower, equipment, and operating expenses can
then be compiled to determine the organizational budget.

2. The second step is to develop a plan. The budget plan may be developed in many ways.
A budgeting cycle that is set for 12 months is called a fiscal-year budget. This fiscal year,
which may or may not coincide with the calendar year, is then usually broken down into
quarters or subdivided into monthly, quarterly, or or semiannual periods.

Most budgets are developed for a one-year period, but a perpetual budget may be done on a
continual basis each month so that 12 months of future budget data are always available.
Selecting the optimal time frame for budgeting also is important; a budget that is predicted
too far in advance has greater probability for error. If the budget is shortsighted,
compensating for unexpected major expenses or purchasing capital equipment may be
difficult.

3. The third step is implementation. In this step, ongoing monitoring and analysis occur to
avoid inadequate or excess funds at the end of the fiscal year. In most healthcare
institutions, monthly computerized statements outline each department’s projected budget

629
 and any deviations from that budget. Each unit manager is accountable for budget
deviations in his or her unit .

Most units can expect some change from the anticipated budget , but large deviations must
be examined for possible causes, and remedial action must be taken if necessary. Some
managers artificially inflate their department budgets as a cushion against budget cuts from a
higher level of administration.

If several departments partake in this unsound practice, the entire institutional budget may
be ineffective. If a major change in the budget is indicated, the entire budgeting process
must be repeated. Top level managers must watch for and correct unrealistic budget
projections before they implemented.

4. The last step is evaluation. The budget must be reviewed periodically and modified as
needed throughout the fiscal year . With each successive year of budgeting , mangers can
more accurately predict their unit’s budgetary requirements. Managers develop a more
historical approach to budgeting as they grow more adept at predicting seasonal variations in
th population they serve or in their particular institution.

COMPONENTS OF EXPENDITURE

Budget documents classify total revenue expenditure into plan and non-plan expenditure.

a. Plan expenditure -Plan revenue expenditure relates to central Plans (the Five-Year Plans)
and central assistance for State and Union Territory Plans.

Plan expenditure forms a sizeable proportion of the total expenditure of the Central
government.

India has adopted economic planning as a strategy for economic development. For stepping
up the rate of economic development five-year plans have been formulated. So far ten five-
year plans have been completed. The expenditure incurred on the items relating to five year
plans is termed as plan expenditure. Such expenditure is incurred by the Central
Government.

A provision is made for such expenditure in the budget of the Central Government.
Assistance given by the Central Government to the State Governments and Union Territories
for plan purposes also forms part of the plan expenditure. Plan expenditure is subdivided
into Revenue Expenditure and Capital Expenditure.

• revenue expenditure

Broadly speaking, revenue expenditure consists of all those expenditures of the government
which do not result in creation of physical or financial assets. It relates to those expenses
incurred for the normal functioning of the government departments and various services,
interest payments on debt incurred by the government, and grants given to state governments
and other parties (even though some of the grants may be meant for creation of assets).

• Capital expenditure

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b. Non-plan expenditure: Non-Plan expenditure is a generic term, which is used to cover all
expenditure of Government not included in the Plan. It includes both developmental and
non-developmental expenditure.

The more important component of revenue expenditure, covers a vast range of general,
economic and social services of the government.

The main items of non-plan expenditure are interest payments, defence services, subsidies,
salaries and pensions. Interest payments on market loans, external loans and from various
reserve funds constitute the single largest component of non-plan revenue expenditure. They
used up 41.5 per cent of revenue receipts in 2004-05. Defence expenditure, the second
largest component of non-plan expenditure, is committed expenditure in the sense that given
the national security concerns, there exists little scope for drastic reduction. Subsidies are an
important policy instrument which aim at increasing welfare. Apart from providing implicit
subsidies through under-pricing of public goods and services like education and health, the
government also extends subsidies explicitly on items such as exports, interest on loans,
food and fertilizers. The amount of subsidies as a per cent of GDP has been falling from 1.7
per cent in 1990-91 to 1.66 per cent in 2002-03 to 1.45 per cent in 2004-05.

Ongoing expenditure by the government not covered by the Plans.

The expenditure provided in the budget for routine normal activities of the government is
called non-plan expenditure. Its examples are expenditure incurred on administrative
services, salaries and pension etc. There is no provision in the plan for such expenditure.
Non-plan expenditure is also sub-divided into revenue expenditure and capital expenditure.

• Non-plan revenue expenditure

• Non-plan Capital expenditure

PLANNING FINANCIAL GOALS

1. Assess needs

Evaluate your present financial situation. You need to decide what you need.

2. Set goals

The process of setting goals involves turning your needs into goals. Achieving successful
financial security starts with organized financial goals that are:

SMART : Specific, Measurable, Attainable, Relevant, Time- Related

3. Make a plan:

It is important to begin to develop a plan for your life. Ask yourself: “where do I want to be
in five, ten and 20 years from now?” then imagine the actions you need to take to achieve
those goals.

1. Take actions: the first step to accomplishing your goals is to take action. Many times goals
are not reached because the first step was never taken. An important part of taking action is
affirming your goals. Write them down. Say them aloud. Share them with your trusted
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friends. Seeing your goals in writing helps them to become reality. “Every month, I find I
don’t have enough money; if the months were 20 days long, budgeting would be daily
spending and saving decisions are at the centre of financial planning.

A budget or spending plan, if necessary for successful money management. The main
purposes of a budget are to help you:

• Live within your income

• Avoid borrowing more than you really need, if at all you have to borrow

• Reach your financial goals

• Prepare for financial emergencies

• Develop wise money-management habits

FOUR PRACTICAL STEPS TO BUDGETING

Step one: add up your income.

Step two: estimate your expenses.

Your budget starts with creating spending categories. How much you budget for
various items will

Depend on your current needs and future plans. A detailed record of your spending
will help you

Find out how much to budget in those categories.

Here are some broad categories as samples:

• Housing – (EMI or rent)

• Electricity/phone bills

• Food

• Personal expenses

• Household expenses

• Transportation

• Recreation and entertainment

• Eating out

• Gifts for friends and family

• Savings

• Miscellaneous

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 • Taxes

Step three: calculate the difference

Keep records of your actual income and expenses and look out for any “budget
variances”, the

Differences between the amount you budgeted for the month and what you actually
spent.

Step four: track, trim and target

As you track your monthly expenses, you need to trim them. Reducing an expense is
usually easier

than cutting it out altogether. Budgeting is an ongoing process. You will need to
review, and perhaps,

and perhaps, revise your spending plans on a regular basis.

Zero Based Budgeting

DEFINITION:

 A method of budgeting in which all expenditures must be justified each new period, as

opposed to only explaining the amounts requested in excess.

 A method of budgeting whereby all activities are reevaluated each time a budget is set.

 Zero-based budgeting starts from a "zero base" and every function within an organization is
analyzed

for its needs and costs.

 Budgets are then built around what is needed for the upcoming period, regardless of
whether the budget

is higher or lower than the previous one.

 Zero based budgeting enforces to review the expenditure periodically as the traditional
budgeting

system may not be relevant in the era of high technological advancements with very high
levels of

automation resulting in better utiliation, higher production, better quality , longer life of the
spares ,all with

less number of workmen.

This process requires

The identification of goals and objectives

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 The reason for the activity

Consequences of not implementing the package

Detailed measurement of performance and costs of the activity.

Ranking decision packages focuses decisions about the most important activities in each unit
of the organization.

After each unit identifies its priorities, the priorities of all units .

PARTS IN ZERO BASED BUDGETING

There are two parts in zero based budgeting

a. Conventional Budgeting

 Departments prepare their budgets based on the previous year's budgets.

 Departments justify only the increases in the expenses required for the current year; they
need not have

to justify the expenses/budget already approved in the previous year.

 It is taken for granted that the previous year's expenses will have to be made in any case to
maintain

 the regular business level.

b. Zero Based Budgeting:( Unconventional)

 In contrast to conventional budgeting, zero based budgeting system is unconventional.

 It is not based on previous year's budget.

 It is not formulated by just incrementing the previous year's expenditure for the current year.

 It starts with zero base. It's a clean slate approach.

 Departmental objectives are decided within the frame work of corporate or organizational

objectives and then broken down into detailed objectives and activities/tasks.

 Overall cost control and cost management are the important key aspects in drawing the zero
based budget.

 The budget thus formulated may be lower than or equal to or higher than the previous
year's budget.

But looks like, that it is necessary to allocate and use that kind of money for better
performance and better

profitability.

 This kind of budget seems more realistic and more precise.

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 Advantages of Zero Based Budgeting

 It questions the current budgets/expense levels, the effectiveness and efficiency of current
processes.

 Thus, overall cost management/control is in-built.

 It focuses on corporate or organizational objectives and within them, the departmental

objectives.

Thus budget supports their achievements; it supports the overall business very effectively.

 It drives the departments' plans and so, the planning process starts right away with the
formulation of

the budgets right at the beginning of the year.

 Ultimately focuses on value for money (VFM).

 It is based on current market and business realities and therefore, more realistic.

Disadvantages of Zero Based Budgeting

 More time and effort are required in zero based budgeting as compared to the incremental or
conventional

budgeting.

 Questioning the current ways of doing business may be threatening to some people within
the organization.

 Deciding the departmental objectives within the frame work of organization objectives
necessitates top down

communication of these objectives with lots of clarity. This is often not done.

Traditional vs. Zero-Base Budgeting

Zero–Based Budgeting (ZBB)

 Zero-Base Budgeting is a new technique of planning and decision-making.

 It reverses the working process of traditional budgeting.

 In traditional budgeting, departmental managers need to justify only increases over the
previous year budget.

 This means what has been already spent is automatically sanctioned.

 IN CASE OF ZBB, no reference is made to the previous level of expenditure.

 Every department function is reviewed comprehensively and all expenditures rather then
only increases are

approved.
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 ZBB is a technique, by which the budget request has to be justified in complete detail by
each division

manager starting from the Zero-base.

The Zero-base is indifferent to whether the total budget is increasing or decreasing

Traditional budgeting:

The traditional budgeting technique may be quite meaning in the present context when
management must

review or re-evaluate every task with a view to better utilization of scarce resources or to
improve performance.

The technique of zero base budgeting provides a solution for overcoming the limitations of
traditional budgeting

by enabling top management to focus on priorities , key areas and alternatives of action
throughout the organization .

 The techniques of zero based budgeting suggests that an organization should not only
make decisions

about the proposed new programme, but should also review the appropriateness of the
existing

programmes from time to time .

 Such a review should particularly done of such responsibility centres where there is
relatively

high proportion of discretion or policies of the responsibility centre top managers.

 These costs have no direct relation to volume of activity. Hence, management

discretion typically

determines the amount budgeted. Some examples are: expenditure on research and
development ,

personnel administration, legal advisory services.

Traditional Budgeting Zero Base Budgeting

Period of References are given to The budgeting process

Expenditure previous year estimates. starts from scratch.
Factors like inflation etc. Previous year prices
are adjusted to previous are not used for
estimates to arrive at the calculation.
figures of current year’s
budget.

Over Inflation Managers, in traditional In, ZBB over-

636
 of budget. method were able to estimation is not
manipulate their budget possible, as managers
estimates. have to justify their
budget estimates.

Responsibility Top management decides Managers of each unit

on the allocation of funds decide on their
division’s expenditure.

Orientation Accounting Decisions

Approach Routine Priority based.

Traditional - Approach

Zero Based Budgeting

PROCESS OF ZERO BASED BUDGETING

The following Steps are involved Zero-Based Budgeting:

637
Determining the objectives of budgeting- the objective may be to effect cost reduction in
staff overheads

or it may to drop, after careful analysis, projects which do not fit into achievement of the
organizations objectives etc.

Deciding on scope of application- the extent to which the zero base budgeting is to be
introduced has to

be decided, i.e. whether it will be introduced in all areas of the organization’s activities or
only in a few selected

areas on trial basis.

Developing decision units- decision units for which cost-benefit analysis is proposed have
to be developed

so as to arrive at decisions whether they should be allowed to continue or be dropped. Each

decision unit,

as far as possible should be independent of others units so that it can be dropped if the cost
analysis proves to be

unfavorable for it.

Developing decision packages- a decision package for each unit should be developed.
While developing a

decision package , answers to the questions such as- is it necessary to perform a particular
activity at all? If the

answer is in the negative, there is no need to proceed further? How much has been the
actual cost of the activity

and what been the actual benefit both in tangible as well as tangible forms? What should be
the estimated cost of the

level of activity and the estimated benefit from such activity? Should the activity be
performed in the way in

which it is being performed and what should be the cost ? if the project or activity is
dropped , can the unit be

replaced by an outside agency?

After completing decision packages for each unit, the units are ranked according to the
findings of

cost-benefit analysis. Essential projects are identified and given in the highest ranks .

the last stage is that of implementing the decisions taken in the light of the study made.

638
It involves the selection and acceptance of those projects which have a positive cost benefit
analysis or which are capable of meeting the objectives of the organization.

The above analysis shows the zero –base budgeting is in a way an extension of the method
of cost-benefit analysis to the area of the corpora

MID TERM APPRAISAL

MID-TERM APPRAISAL: THE PROCESS

The Mid-Term Appraisal is based on an analysis of sectoral data, review of official

documents and

other independent reports,1 consultations with experts in the field, discussions with nodal
departments

of the implementing ministries as well as the departments in state governments dealing with
the subject.

The Mid – Term Appraisal Of 11th Five Year Plan:

"The Cabinet has approved the proposal of the Planning Commission to put the MTA of the
current five year Plan before the NDC," Information and Broadcasting Minister Ambika
Soni told reporters here.

The mid-term appraisal (MTA) was placed before the full Planning Commission meeting
headed by Prime Minister Manmohan Singh on March 23.

In the MTA document, the commission had lowered the growth rate for the current plan to
8.1 per cent from 9 per cent in the wake of the global financial crisis that slowed the rate of
economic expansion.

The commission had projected in the MTA that the economy would expand by 8.5 per cent
in the current fiscal and rise to 9 per cent in 2011-12.

It is a practice that after getting the full Planning Commission's clearance, the MTA
document is placed before the Cabinet and thereafter before the National Development
Council (NDC) for final approval.

Headed by the Prime Minister, the full Planning Commission comprises key Cabinet
ministers, including Finance Minister Pranab Mukherjee and Agriculture and Food Minister
Sharad Pawar, Deputy Chairman Montek Singh Ahluwalia and all the full-time members of
the plan panel.

The Commission had set an average annual growth target of 9 per cent for the Eleventh Plan
-- beginning with 8.5 per cent in the first year and closing with 10 per cent in the last year of
the Plan period.

The MTA document said the economy exceeded expectations in the first year of the
Eleventh Plan (2007-08), with a growth rate of 9 per cent, but the momentum was
interrupted in 2008-09 because of the global financial crisis.

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 Following the global meltdown, the growth rate slipped to 6.7 per cent in 2008-09 from over
9 per cent in the preceding three years. Thereafter, the growth recovered to 7.4 per cent last
fiscal.

REVENUE BUDGET:

 The revenue budget consists of revenue receipts of the government (revenues from tax and
other sources),

and its expenditure.

 Revenue receipts are divided into tax and non-tax revenue. Tax revenues are made up of
taxes such as

income tax, corporate tax, excise, customs and other duties that the government levies. In
non-tax revenue,

the government's sources are interest on loans and dividend on investments like PSUs, fees,
and other

receipts for services that it renders.

 Revenue expenditure is the payment incurred for the normal day-to-day running of
government

departments and various services that it offers to its citizens.

The government also has other expenditure like servicing interest on its borrowings,
subsidies, etc.

 Usually, expenditure that does not result in the creation of assets, and grants given to state
governments

and other parties are revenue expenditures.

 The difference between revenue receipts and revenue expenditure is usually negative.

This means that the government spends more than it earns. This difference is called the
revenue deficit.

 Revenue spending (revenue expenditure) takes place from this budget.

 Salaries of government employees and military staff, perks for ministers, office furniture,
grants to

state governments, subsidies, interest to be paid on loans taken and pensions for ex-defense
staff are all

accounted for here and referred to as revenue spending.

 Any expenditure required for the normal running of the government.

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 This spending must be financed from the revenue that the government earns in the form of
taxes

(corporate, income), duties (excise, custom), receipts, fees, interest and dividends (if the
government makes

investments)

CAPITAL BUDGET:

MEANING

Capital budgeting decisions are of paramount importance in financial decisions because

efficient allocation of

capital resources is one of the most crucial decisions of financial management. Capital
budgeting is budgeting

for capital projects. It is significant because it deals with right kind of evaluation of projects.
The exercise

involves ascertaining / estimating cash inflows and outflows , matching the cash inflows
with the outflows

appropriately and evaluation of desirability of the project.. it is a management technique of

meeting capital

expenditure with the overall objectives of the firm. Capital budgeting means planning for
capital assets.

It is complex process as it involves decisions relating to the investment of current funds for
the benefit to be

achieved in future. The overall objective of capital budgeting is to maximize the

profitability of the firm/ the return

on investment .

Capital expenditure :

A capital expenditure is an expenditure is incurred for acquiring or improving the fixed

assets, the benefits of

which are expected to be receive over a number of years in future. The following are some
of the examples of

capital expenditure.

1. cost of acquisition of permanent assets such as land & building, plant & machinery,
goodwill etc.

2. cost of addition , expansion, improvement or alteration in the fixed assets.

3. cost of replacement of permanent assets.

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4. research and development of project cost etc.

Capital expenditure involves non- flexible long term commitment of funds.

CAPITAL BUDGETING – DEFINITION :

“ capital budgeting” has been formally defined as follows.

1.“ capital budgeting is long-term planning for making and financing proposed capital
outlay”.

- charles T. Horngreen

2. “the capital budgeting generally refers to acquiring inputs with long-term returns”.

- Richard & Greenlaw.

3. “capital budgeting involves the planning of expenditure for assets, the returns from
which will be realized

in future time periods”. - Milton H. Spencer.

The long term activities are those activities that influence firms operation beyond the one
period.

THE BASIC FEATURES OF CAPITAL BUDGETING DECISIONS ARE:

 There is an investment in long term activities.

 Current funds are exchanged for further benefits.

 The future benefits will be available to the firm over series of years.

NEED FOR CAPITAL INVESTMENT :

The factors that give rise to the need for capital investments are:

 Expansion

 Diversification

 Obsolescence

 Wear and tear of old equipment

 Productivity improvement

 Learning- curve effect.

 Produce improvement

 Replacement and modernization.

The firm’s value will increase in investments that are profitable. They add to the
shareholders’ wealth.

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 The investment will add to the shareholders’ wealth if it yields benefits, in excess of the
minimum benefits

as per the opportunity cost of capital.

It is clear from the above discussion what capital investment proposals involve

 Longer gestation period.

 Substantial capital outlay

 Technological considerations

 Irreversible decisions

 Environment issues.

FEATURES OF CAPITAL BUDGETING

The main features of capital budgeting are:

1. It involves the exchange of current funds for future benefit.

2. The future benefits are expected to be realized over a series of years in future.

3. The funds are invested in long term assets

4. It is a long term irreversible decision.

5. It involves huge initial funds.

6. There is relatively a long gap of time between investment of funds and the expected returns

(i.e it has longer gestation period).

7. It involves relatively a high degree of risk regarding the future benefits.

ROLE AND IMPORTANCE OF CAPITAL BUDGETING

Capital budgeting is concerned with heavy expenditure decisions. The benefits or returns
from such

expenditure is expected to be derived over many years in future. This makes the capital
budgeting

decisions more complex. These decisions affect the long term flexibility and profitability of
the enterprise.

Success or failure of an enterprise is dependent upon the quality of capital budgeting alone
in that

enterprise. Therefore proper planning and utmost care is needed while making capital
budgeting decisions.

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 The capital budgeting decisions are important, crucial and critical because of the following
reasons:

1. Huge investment :

Capital budgeting decisions involve huge investment in permanent assets. Hence it requires
careful

planning and appraisal. A mistake in capital budgeting can prove fatal to the enterprise.

2. Long term implications:

Capital budgeting decisions have long term effects on the future profitability and cost
structure of

the firm. A right decision may bring amazing returns, while a wrong decision may endanger
the

survival of the firm.

3. Irreversible decision:

Capital investment decisions once made cannot be reversed back easily. This is because it
is

difficult to dispose off fixed assets once they have been acquired.

4. Risk :

long term commitment of funds involve greater risk and uncertainty. The longer is the
period

of project, the greater may be the risk and uncertainty.

5. Growth :

The capital budgeting decisions affect the rate and direction of growth of a firm.

6. Impact on firm’s competitive strength :

The capital budgeting decisions affect the capacity and strength of a firm to face
competition.

It is so because the capital investment decisions affect the future profits and costs of the
firm.

This will ultimately affect the firm’s competitive strength.

7. Most difficult decision :

Capital budgeting decisions are very difficult to make. These decisions involve forecasting
of

future conditions for estimating the future cash flows and costs of different projects.

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 The benefits and costs are affected by economic, political and technological forces.
Therefore such

decisions are not so simple to be taken.

8. Cost control :

In capital budgeting there is a regular comparison of budgeted and actual expenditures.

Therefore

cost control is facilitated through capital budgeting.

9. Wealth maximisation :

The basic objective of financial management is to maximize the wealth of the shareholders.

Capital budgeting helps to achieve this basic objective.

CAPITAL BUDGETING PROCESS

The important steps involved in the capital budgeting process are

1. project generation ,

2. project screening

3. project evaluation,

4. project selection and

5. project execution and implementation .

Project generation:

Investment proposals of various types may originate at different levels within a firm.
Investment proposals

may be either proposals to add new product to the product line or proposals to expand
capacity in existing

product lines. Secondly , proposals designed to reduce costs in the output of existing
products without changing

the scale of operations .

The investment proposals of any type can originate at any level. In a dynamic and
progressive firm there is a

continuous flow of profitable investment proposals.

Project screening :

Each proposal is then subject to a preliminary screening process in order to assess whether
it is technically

645
 feasible, resources required are available, and the expected return are adequate to
compensate for the risks involved.

.Project evaluation :

Project evaluation involves two steps : i) estimation of benefits and costs and ii) selection of
an appropriate

criterion to judge the desirability of the projects . the evaluation of projects should be done
by an impartial

group. The criterion selected must be consistent . the criterion selected must be consistent
with the firm’s

objective of maximizing its market value .

Project selection :

There is no uniform selection procedure for investment proposals. Since capital budgeting
decisions are of

crucial importance, the final approval of the projects should rest on top management.

.Project execution and implementation:

After the final selection of investment proposals, funds are earmarked for capital
expenditures. Funds for the

purpose of project execution should be spent in accordance with appropriations made in the
capital budget.

Performance review:

After the start of the implementation of a project, its progress must be reviewed at
periodicals intervals. The

follow-up or review is made by comparing actual performance with the budget estimates.
This helps to make

corrective action.

LIMITATIONS OF CAPITAL BUDGETING:

 The results of decision taken is uncertain. This is so because it is difficult to say that
present

circumstances will exist in future also.

 Some factors affecting investment proposals are not measurable (i.e. cannot be expressed
in money values.

 It is difficult to estimate the period for which investment is to be made and income will
generate.

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  It is difficult to estimate the rate of return because future is uncertain.

 It is difficult to estimate the cost of capital.

CAPITAL BUDGETING TECHNIQUES OR TRADITIONAL METHODS

There are a number of appraisal criteria (or investment evaluation criteria ) to judge the
profitability of capital

projects. More than 30 criteria have been proposed to guide investment decision making .
the more important and

popular of these can be classified into three broad categories as follows:

1. Non discounting techniques or traditional methods

 Urgency method

 Pay back method

 Post pay back profitability method

 Average rate of return method

2. Discounting criteria or modern methods

* Discounted pay back method

* Net present value method

* Benefit cost ratio

* Internal rate or return

* Net terminal value method

3. Other methods

* The MAPI formula

* Nomograph method

1. Payback Period

Alright, let's get this out of the way up front: the Payback Period isn't a very good method.
After all, it doesn't

use the time value of money principle, making it the weakest of the methods that we will
discuss here. However,

it is still used by a large number of companies, so we'll include it in our list of popular
methods.

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What is the payback period? By definition, it is the length of time that it takes to recover
your investment.

For example, to recover $30,000 at the rate of $10,000 per year would take 3.0 years.
Companies that use this

method will set some arbitrary payback period for all capital budgeting projects, such as a
rule that only projects

with a payback period of 2.5 years or less will be accepted. (At a payback period of 3 years
in the example above,

that project would be rejected.)

The payback period method is decreasing in use every year and doesn't deserve extensive
coverage here.

2. Net Present Value

Using a minimum rate of return known as the hurdle rate, the net present value of an
investment is the

present value of the cash inflows minus the present value of the cash outflows. A more
common way of

expressing this is to say that the net present value (NPV) is the present value of the benefits
(PVB) minus the present

value of the costs (PVC)

NPV = PVB - PVC

By using the hurdle rate as the discount rate, we are conducting a test to see if the project is
expected to earn our

minimum desired rate of return. Here are our decision rules:

Should we expect to
If the NPV Benefits vs. earn at least Accept the
is: Costs our minimum rate of investment?
return?

Benefits >
Positive Yes, more than Accept
Costs

Benefits =
Zero Exactly equal to Indifferent
Costs

Benefits <
Negative No, less than Reject
Costs

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Remember that we said above that the purpose of the capital budgeting analysis is to see if
the project's benefits are large enough to repay the company for (1) the asset's cost, (2) the
cost of financing the project, and (3) a rate

of return that adequately compensates the company for the risk found in the cash flow
estimates.

Therefore, if the NPV is:

Positive, the benefits are more than large enough to repay the company for (1) the asset's
cost, (2) the cost of

financing the project, and (3) a rate of return that adequately compensates the company for
the risk found in the

cash flow estimates.

Zero, the benefits are barely enough to cover all three but you are at breakeven - no profit
and no loss, and

therefore you would be indifferent about accepting the project.

Negative, the benefits are not large enough to cover all three, and therefore the project
should be rejected.

3. Internal Rate of Return

The Internal Rate of Return (IRR) is the rate of return that an investor can expect to earn on
the investment.

Technically, it is the discount rate that causes the present value of the benefits to equal the
present value of the

costs. According to surveys of businesses, the IRR method is actually the most commonly
used method for

evaluating capital budgeting proposals. This is probably because the IRR is a very easy
number to understand

because it can be compared easily to the expected return on other types of investments
(savings accounts, bonds, etc.).

If the internal rate of return is greater than the project's minimum rate of return, we would
tend to accept the project.

The calculation of the IRR, however, cannot be determined using a formula; it must be
determined using a

trial-and-error technique.

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 Capital investment decision of the firm have a pervasive influence on the entire spectrum of
entrepreneurial

activities so the careful consideration should be regarded to all aspects of financial

management.

 In capital budgeting process, main points to be borne in mind how much money will be
needed of

implementing immediate plans, how much money is available for its completion and how
are the

available funds going to be assigned tote various capital projects under consideration.

The financial policy and risk policy of the management should be clear in mind before
proceeding to

the capital budgeting process.

The following procedure may be adopted in preparing Capital Budget:

(1) Organisation of Investment Proposal. The first step in capital budgeting process is the
conception of a

profit making idea. The proposals may come from rank and file worker of any department or
from any line

officer. The department head collects all the investment proposals and reviews them in the
light of financial

and risk policies of the organisation in order to send them to the capital expenditure planning
committee

forconsideration.

(2) Screening the Proposals. In large organisations, a capital expenditure planning

committee is established for

the screening of various proposals received by it from the heads of various departments and
the line officers of

the company. The committee screens the various proposals within the long-range policy-
frame work of the

organisation. It is to be ascertained by the committee whether the proposals are within the
selection criterion of the

firm, or they do no lead to department imbalances or they are profitable.

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 (3) Evaluation of Projects. The next step in capital budgeting process is to evaluate the
different proposals

Budget Estimates

 . The Chief Municipal Officer shall prepare in each year a budget estimate along with an
establishment

schedule of the Municipality for the ensuing year, and such budget estimate shall be an
estimate of the

income and expenditure of the Municipality.

 Subject to the provisions of section 10 and sub-section (2) of section 75, the budget estimate
shall

separately state the income and the expenditure of the Municipality to be received and
incurred in terms

of the various heads of accounts.

 The budget estimate shall state the rates at which various taxes, surcharges, cesses and fees
shall be levied

by the Municipality in the year next following.

 The budget estimate shall state the amount of money to be raised as loan during the year
next following.

 The Chief Councillor shall present the budget estimate to the Municipality on the 15th day
of February in

each year or as soon thereafter as possible.

Revised Estimates

 The revised estimate is an estimate of the probable receipts or expenditure for a financial
year, framed

in the course of that year, with reference to the transactions already recorded and
anticipation for the

remainder of the year in the light of the orders already issued or contemplated to be issued
or any other

relevant facts.

 It does not authorise any expenditure, nor does it supersede the budget estimate as the basis
for regulation
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 of the expenditure.

 If an excess is anticipated in the revised estimate under any particular head, it is necessary
for

controlling authority to apply separately in proper time for additional funds required, unless
the excess can

be met by re-appropriation of savings from other heads or has already been sanctioned by
the competent

authority.

 On the other hand, if the figure taken for the revised estimate is less, it is the duty of the
controlling

officer to see that as far as possible the expenditure during the remaining part of the year is
so restricted

that the total expenditure for the year does not exceed that figure.

 It is essential that the revised estimates should be prepared with great care, so that they may

approximate as closely as possible to the actual which will not be available for some months
after

the close of the financial year. These estimates, besides enabling the Government to arrive at
the

approximate closing balance of the current year (which will be the opening balance of the
next year)

are prima facie the best guide to the next year's estimates.

A revised estimate is based on : (i) ascertained actual of the past months of a

financial year, and

(ii) an estimate of the probable figure for the remaining months of that year.

Methods for framing the revised estimates. –

The revised estimates are generally based on the actual of the first six months of the year.
Assuming

that at the time of the preparation of the revised estimate the actual for the first six months of
the current

year are available.

The estimate will generally be framed in one of the following ways :

(i) by adding to the actual of the first six months of the current year those of the last
six months

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 of the previous year, or by taking a proportionate figure so that the revised estimate will be

twice the actual for the first six months, or by assuming that the revised estimate for the

current year will bear the same proportion to the actual of the first six months as the actual
in

the previous year bore to those of the first six months of that year.

Performance Budgeting

 The new performance budgeting emphasizes accountability, efficiency, and economy by

emphasizing outcomes and results instead of activities or outputs (Contino, 2001).

 Thus, the manager would budget as needed to achieve specific outcomes and would evaluate
budgetary success accordingly.

 For example, a home health agency would set and then measure a specific outcome in a
group of patients, such as diabetics, as a means of establishing and justifying a budget.

 Performance Budget is a technique of presenting the budget of the Ministry in terms of

functions, programmes, and activities. It correlates the physical and financial aspects of the
individual items, contained in the budget so as to provide for a fuller review of the budget.

 By providing an indicator of the relationship between estimated inputs and the expected

 outputs as an integral part of the budget, it acts as a tool for management and as an
instrument for evaluation of performance.

 A programme represents a segment of a function and while an activity represents the

division of a programme into homogeneous type of works.

 The core functions of the Department are promoting exports and organising, developing and
regulating the foreign trade. (The function of the Directorate General of Foreign Trade
(DGFT), the executive arm of the Department, is implementation of the foreign trade polices
laid down by the Government.)

 Performance budgeting is generally understood as a system of presentation of public

expenditure terms of functions, programmes, performance units, viz. activities projects,
etc., reflecting primarily, the governmental output and its cost.

 It is essentially a process which brings out the total governmental operations through a
classification by functions, programmes and activities. Through suitable narrative statements
and workload data that form an integral part of the presentation, it indicates the work done,
proposed to be done and the cost of carrying these out.

 The main thrust of performance budgeting has been on providing output-oriented budget
information within a long range perspective so that resources could be allocated more
efficiently and effectively.

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 Its emphasis is on accomplishment rather than on the means of accomplishment. The
purpose of government expenditure is more important than the object of expenditure under
performance budgeting.

 Thus performance budgeting is a programme of action for any given year with specific
indicators regarding tasks, the means of achieving them and the cost of achieving them. It
tries to define the physical and financial aspects of each programme and activity and thereby
establish the relationship between output and inputs.

 Performance budgeting has to operate within the framework of clearly defined objectives
which are to be achieved through successful implementation of various programmes and
activities undertaken by the concerned agency.

 Performance budgeting, therefore, involves the development of more refined management

tools, such as work measurement, performance standards, unit costs, etc.

Objectives: Performance budgeting seeks to:

correlate the physical and financial aspects of programmes and activities;

ii) improve budget formulation, review and decision-making at all levels of management in
the government machinery;

iii) facilitate better appreciation and review by the legislature;

iv) make possible more effective performance audit;

v) measure progress towards long-term objectives as envisaged in the plan; and

vi) bring annual budgets and developmental plans together through a common language.

Components of Performance Budget

The performance budgets have certain vital ingredients that need to be constantly kept

in view:

i) a programme and activity classification that represents the range of work of each

organisation;

ii) a framework of specified objectives for each programme;

iii) a stipulation of the targets of work or achievement; and

iv) suitable workload factors, productivity and performance ratios that justify financial

requirements of each programme.

STEPS IN PERFORMANCE BUDGETING

Four basic steps are involved in the introduction of performance budgeting:

i) Establishing a meaningful classification of public expenditure in terms of functions,

654
 the establishment, improvement and extension of activity schedules for all measurable
activities of the government;

iii) the establishment of work output, employee utilisation, standard or unit costs by

objective methods, i.e. bringing the system of accounting and financial management into
accord with the classification; and

iv) the creation of related cost and performance recording and reporting system.

 The important requirement for performance budgeting is a programme of action for any
given year with specific indications regarding the tasks, the means of achieving them and the
costs of achieving them. This is important even in traditional budgeting process.

 The distinction, however, is that under performance budgeting the organisations are
compelled to think of their future activities not merely in terms of financial plans but in
terms of the results, work assignment and organizational responsibilities.

 It isnormally held that in the context of planningfor economic growth, planning is a thinking
process and budgeting is a doing process. Since the physical and financial aspects go
together and the programme structure is expected to be the same, performance budgeting
facilitates the functional integration of the thinking and doing process.

 The formulation of programmes for achieving the organisationuL goals is an important task
in the budgetary process. A programme is a segment of an important function and represents
a homogeneous type of work.

 These programmes of work need to be developed for meeting the short-term plans, medium-
term plans and long-term plans and involve formulation of schemes, laying down their
targets, measuring the financial costs and benefits.

 The programme has to be assessed in the light of financial and economic factors i.e.
ensuring adequate resources for the programme so chosen and examination of the impact of
the proposed outlays on the economy as a whole through cost-benefit analysis.

 Complex programmes are divided into sub-programmes to facilitate execution in specific

areas. Each programme or sub-programme further consists of many activities which are
shown in the respective budgets.

For example immunization programme is a programme under the function 'health'. As each
programme has many activities, provision for storage of vaccines could be an activity under
the programme.

 The real commencing point in the budgetary process is allocation of resources. In the
conventional system primary emphasis is laid on the previous level of allocations and
spendings and no emphasis is laid on its performance in terms of its objectives and the
programme of action that it has set out for itself for the next year.

 Under performance budgeting the primary agency prepares the budget, submits its
requirements as per programme classification.
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 It indicates its past activities, their costs, the activities to be taken up during the next year,
the results expected and the pattern of assignment of responsibilities. The very basis of the
performance budgeting is commitment to achievement and the awareness of accountability.
The budget so prepared is reviewed at higher level and resources are allocated keeping in
view the priorities of the proposal.

 Some times due to financial constraints resources may not be available in full and a cut has
to be imposed. However, this may be done in full awareness of the implications of the cut on
the programme.

 Under performance budgeting, the programme classification and the rationale behind it
indicate a group of choices with their priorities, already'made. This minimises the
dislocational effect of cuts and ensures a better identification of their impact on programme
achievement.

 Resource allocation is followed by budget execution. Budget execution must ensure

achievement of objectives and for that the following budgetary and managerial
considerations must be kept in view:

i) Communication of the grants to the various subordinate agencies well in time

) Ensuring the initiation of action for implementing the schemes provided for in the budget

iii) Overseeing the regular flow of expenditures

iv) Prevention of cost over-runs; and

v) Time phased plan for expenditure and work.

The final stage in the performance budgeting process is appraisal and evaluation.

 Under the existing system evaluation of the physical achievements in certain sectors is being
undertaken by the Programme Evaluation Organisation.

 Under performance , budgeting, each programme would lend itself to an evaluation by the
agency concerned, even before it is undertaken by an outside organisation.

 The important ,aspect is that evaluation should, as far as possible, follow the completion of a
programme and the administration should be enabled to formulate its future course of action
in the light of results obtained.

 Types of Budget Models

 TRADITIONAL MODELS

 Incremental Budgeting

 Incremental budgeting is the oldest and most common approach used in higher education. It
uses the same budget from one year to the next, allowing only minor changes in revenue
levels and resource distribution. These increases or decreases in budget are represented by a
percentage or a dollar amount. This approach is simpler, easier to understand and apply, and

656
 more flexible than other approaches. Some weaknesses are that it is based more on inputs
than on outputs or outcomes, and is slow to adapt to changing conditions.

 Formula Budgeting

 Formula budgeting is a procedure for estimating future budgetary requirements by using

relationships between program demands and costs.

 It is a method that calculates the amount of funding a program requires by applying selected
measures of unit costs to selected output measure.

 Primarily, it has been used at the state level as a method for public institutions to prepare
their appropriation requests. Some strengths are that it provides an equitable distribution of
funds among institutions, and budget requests are more uniform and easier to prepare,
making it easier for institutions to communicate with state legislatures.

 The weaknesses with formula budgeting are that formulas are typically enrollment-driven,
which may cause problems when enrollment drops, formulas do not deal with issues of
quality very well, and new programs and other innovations are discouraged because the
formulas are based on historical relationships.

 Program Budgeting

 Program budgeting was one of the first attempts to develop a more output-oriented approach
to budgeting. It has been defined as a method in which budgets are created for specific
programs or activities, rather than departments, and each program’s budget is apportioned
among the several departments that contribute to the program’s activities.

 Zero-Base Budgeting

 Whereas incremental budgeting assumes that this year’s budget provides the base from
which next year’s budget is developed, zero-base budgeting assumes there is no prior year
base. Therefore, each activity and program must be re-justified each year.

 RECENT DEVELOPMENTS

 Performance Budgeting

 This is an approach States use to allocate budgets to state universities. In performance

budgeting funds are allocated to public campuses based on selected measures of
performance. If a state school achieves a certin performance level it is allocated designated
amount.

 Responsibility Center Budgeting

 Responsibility Center Budgeting is similar to Performance Budgeting except it is used for

budgeting at the institutional level rather than state. The basic idea is that all costs and
income generated by each college, faculty, or department are attributed to that unit, appear in
its budget, and are under its control. Incentives are created and barriers removed to allow
each academic unit to increase income and reduce costs according to its own academic plans
and priorities.

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 Advantages and Disadvantages.

 The major strength is that it provides incentives for entrepreneurship and rewards
performance. It highlights areas that are not earning enough revenues to cover their costs.
The weaknesses are that it is often short-term oriented and requires significant information
technology resources. It is safe to say that each institution that has adopted RCB has
modified it to reflect its own instructional character.

 Activity Based Budgeting

 With an Activity Based Budgeting model various activities are identified. They can be
instructional activities, research activities, service activities, and support activities. It is very
similar to program budgeting where the program is the activity. The costs and outputs of the
activities are budgeted and activity rates computed. These rates can be compared to the rates
at benchmark institutions. The emphasis is on reducing the cost per unit of output while
meeting a set level of quality.

 For example, the cost per credit of nursing instruction could be budgeted and compared to
other benchmark programs.

AUDIT

 INTRODUCTION TO FISCAL AUDIT

Audit was originally confined to ascertaining whether the accounting party had properly
accounted for all receipts and payments on behalf of his principal, and was in fact merely a
cash audit. Modern audit not only examine cash transactions, but also verify the purpose to
which the cash transactions relate. Audit

Audit is, therefore, an examination of accounting records undertaken with a view to

establishing whether they correctly and completely reflect the transactions to which they
purport to relate.

 Audit is an instrument of financial control.

 In its relation to commercial transactions, it acts as a safeguard on behalf of the proprietor

against extravagance, carelessness or fraud on the part of proprietors’ agents or servants in
the realization and utilization of his money or other assets and it ensures on the proprietors
behalf that the accounts maintained truly represent facts, and that expenditure has been
incurred with due regularity and propriety.

 The agency employed for this purpose is called 'an auditor'.

Government auditing

 Audit forms an indispensable part of the financial administration and is one of the important
organs necessary to ensure the sound functioning of a Parliamentary Democracy.

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  It is the main instrument to secure accountability of the Executive to the Legislature.

 Audit assists Parliament/Legislature in exercising its financial control over the Executive, to
ensure that funds voted by the Parliament/Legislature have been utilized for the purpose
intended and the funds authorized to be raised through taxation and other measures have
been assessed, collected and credited to the Government properly.

The primary function of audit is to verify the accuracy and completeness of accounts to
secure that all revenue and receipts collected are brought to account under the proper head,
that all expenditure and disbursements are authorized, vouched and correctly classified and
the final account represents a complete and a true statement of the financial transactions it
purports to exhibit.

It is the function of audit to verify that financial rules and orders satisfy the provisions of
Law and or otherwise free audit objections and the rules & orders are properly applied.

Audit control

State Audit is the main instrument to secure accountability of the lower formation in the set
up to the Administration and of the Administration to the Legislature in the area of financial

administration.

Fiscal accountability

This includes fiscal integrity, full disclosure and compliance with applicable laws and
regulations.

Managerial accountability

It is concerned with efficiency and economy in the use of public funds, property, personal
and other resources.

Program accountability To check whether Government programs and activities are

achieving the objective established for them with due regard to both costs and results.

Objectives of audit:

Overall objectives of audit are aimed:

a) To detect error and fraud in accounts

b) To prevent commission of errors and frauds

c) To enable timely finalization of accounts

d) To make the public know the state of affairs of the Institution

To achieve the above objectives in respect of Government audit, it has to be ensured that:

(i) There is provision of funds for the expenditure duly authorized by a competent authority.

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(ii) The expenditure is in accordance with a sanction properly accorded and is incurred by an
officer competent to incur it.

(iii) (iii) Payment has been made to proper person and duly acknowledged so that a second
claim on the same account is impossible.

(iv) (iv) The charge is correctly classified.

(v) (v) In the case of audit or receipts (1) the sums due are regularly recovered and checked
against demand and (2) sums received are duly brought to credit in the accounts.

(vi) (vi) In the case of audit of stores and stock where a priced account is maintained stores are
priced with reasonable accuracy and rates fixed are reviewed from time to time.

(vii) (vii) That the numerical balance of stock materials is reconciled with the total of value of
balance in accounts.

(viii) (viii) Expenditure conforms to the following general principles of standards financial
property viz:

(1) the expenditure is not prima-facie more than the occasion demands and that every
Government servant exercises vigilance in respect of expenditure as his own money;

(2) no authority exercises its power of sanctioning expenditure to pass an order which will
be directly or indirectly to its own advantage;

(3) public moneys are not utilized for the benefit of a particular person or section of
community unless:

a) the amount of expenditure involved is insignificant or;

b) the expenditure are in pursuance of a recognized policy or custom and

c) the amounts of allowance such as traveling allowance are not on the whole a source of
profit to the recipients.

Function and spirit of Audit

Audit forms an indispensable part of the financial system and is one of the important organs
necessary to ensure the sound functioning of a parliamentary democracy. It is the main
instrument to secure accountability of the executive to the Legislature.

. Functions of Audit

The primary function of Audit is to verify the accuracy and completeness of accounts, to
secure that all revenue and receipts collected are brought to account under the proper head,
that all expenditure & disbursement are authorized, vouched and correctly classified and the
final account represent a complete and true statement of the financial transactions it purport
the exhibit. Its broad aim is to safeguard the financial interest of the taxpayer.

Spirit of Audit

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 In audit under insistence on trifling errors and technical irregularities which are of no
consequence to the finances of the Government should wherever possible be avoided and
more time and attention devoted to the investigation of really important and substantial
irregularities with the object not only on securing rectification of particular irregularity but
also ensuring regularity and propriety in similar cases for the future.

Efficiency-cum-Performance Audit

 Before independence, Government audit was mostly confined to check individuals,

transaction against provision of funds, rules or orders or sanction or propriety of
expenditure.

 These methods are quite effective and fruitful in detecting improper, irregular, extravagant
,wasteful and uneconomic expenditure.

 But after independence, the pattern of Government expenditure, its nature and dimension
underwent rapid change in the wake of increasing Government expenditure on development
and welfare activities.

 The security of individual transaction was felt quite inadequate.

 It become necessary and essential for audit to ascertain whether the various department
programs and accordingly been developed to meet the changing requirements.

 This audit involves review of performance of a scheme in terms of the goals and objectives.

Economy is the practical systematic management of the affairs of a scheme of project with
minimum operating cost for carrying out its functions and responsibilities.

Efficiency

Efficiency is the accomplishment of assigned goals, production targets or other specific

programs, objectives in a systematic manner with minimum operating cost without
detracting from the level, quality or timing of the services to be provided.

Effectiveness

Effectiveness is the adoption of a course of action which assures achievement of objects at

the lowest reasonable cost and in a practical manner within an agreed time frame.

Development of Audit Plan

A specific audit plan is chalked out in advance indicating the guidelines for investigation
marking out the offices to be visited and the time allotted for completing the review.
Necessary format and questionnaire are also prepared for collection of important data
relating to the various aspects of the scheme from the field offices.

Review proper

The approach of audit is systematic methodical, logical and rational. The review always
commences with an in-depth study of files in the offices in the concerned administrative
department and heads of department. While scrutinizing the records, audit is to see whether

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 1) the objectives of the project have been well defined and are in conformity with the
accepted policies and decisions of the Government

2) programmes have been drawn up in accordance with these objectives and are being
implemented by specific and well defined procedures

3) a good monitoring/management information system exists for collecting reliable data and
whether the date is effectively utilized to improve organization or remedial deficiencies with
utmost speed.

Systems of Audit

The system of audit can be broadly classified into two viz. central audit and local audit.

Central Audit

The systems of Central audit is confined to the offices of Accountant General (Audit)
located in the State Capital. Central Audit is based on the Accounts, vouchers schedules and
other documents submitted to him by various disbursing authorities like the Treasuries, PW
Divisions, Forest Divisions as also the copies of sanction endorsed to the AG's by the
various sanctioning authorities.

The following are the duties and functions carried out in Central Audit.

Audit of sanction and agreements

b) Audit of vouchers and monthly accounts

c) Recording of the objections in the objection book and issue of the objection memos and
pursuance with the concerned departments

d) Scrutiny and certification of finance and appropriation accounts Central Audit is by and
large regularity and propriety.

Local Audit Inspection

 The major portion of the original records namely the initial accounts and other books or
papers on which the accounts so rendered are based are retained in the offices where they
originate.

 To enable him to assure himself of the accuracy of the original data on which the accounts
and his audit work are based, the Accountant General has authority to inspect any offices of
Accounts which is under the control of the State Government including treasuries and such
offices responsible for the keeping of initial or subsidiary accounts.

 The object of local audit is to audit the initial or subsidiary accounts.

 The object of local audit is to audit the initial accounts maintained properly, the financial
rules are properly observed, whether the accounts are accurate and complete according to the
prescribed rules for the audit of expenditure and receipts of the Government.

Advantages of nursing audit

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1. Can be used as a method to measurement in all areas of nursing.

2. Seven functions are easily understood.

3. Scoring system is fairly simple.

4. Results easily understood.

5. Assesses the work of all those involved in recording care

6. May be a useful tool as part of a quality assurance program in areas where accurate records
of care are kept .

Disadvantages of nursing audit

1. Appraises the outcomes of the nursing process so it is not useful in areas where the nursing
process has not been implemented.

2. Many of the components overlap. If making analysis difficult.

3. Is time consuming

4. Requires a team of trained auditors.

5. Deals with a large amount of information .

6. Only evaluates record keeping it only serves to improve documentation not nursing care.

COST EFFECTIVENESS

INTRODUCTION:

With the increased interest in containing health care costs, economic issues in nursing are
receiving much greater attention in recent years. Because nurses belong to the largest health
care profession and are thus in a position to influence health care costs, it is essential that all
nurses understand basic concepts of economics and fiscal (money)management.

Meaning of cost effectiveness

The desired end product of a careful fiscal planning is cost effectiveness.

Cost –effectiveness does not mean inexpensive; it means getting the most for your money,
or that the product is worth the price. Buying a very expensive piece of equipment may be
cost-effective if it can be shown that sufficient need exists for that equipment and that it was
the best purchase to meet the need at that time. Cost –effectiveness takes into account factors
such as anticipated length of service, need for such a service, and availability of other
alternatives.

ECONOMICS OF CARING:

Fiscal responsibility concerns a two fold responsibility: first to the patient and second to

the employing institution. It is defined as the duty / obligation of the nurse to allocate

1) financial resources of the patient maximize health benefit to the patient and 2) financial
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 resources of the employer maximize organizational cost effectiveness.

FISCAL RESPONSIBILITY TO THE PATIENT:

A nurse needs to understand the costs of care and different reimbursement systems
because this will effect the development of a plan of care. When creating a discharge plan
for a patient, it is essential that a nurse understand the health care resources the patient
requires and how they will be paid. It is also important that nurses engage in early discharge
planning, beginning from the process of admission or even before admission. It is also
important; nurses understand that fiscal responsibility for clinical practice is a responsibility
shared with all other health care disciplines.

FISCAL RESPONSIBILITY TO THE EMPLOYING INSTITUTION:

Nurses also have a responsibility to the institution or agency where they are employed.
The most important way a nurse is fiscally responsible is by providing quality patient care.
Nurses also have an obligation to use the resources of the institution wisely. The most costly
health care resource that nurses allocate is their time. Nurses also need to understand
prospective payment; the hospital is paid a set amount for the care of a patient with a certain
condition or surgery. Another way that nurses practice fiscal responsibility is by accurately
documenting the patient’s condition. This must include the severity of the patient’s illness as
well as the plan of care.

Can health care cost be contained, nursing’s responsibility & trends affecting the rising
costs of health care:

INTRINSIC FACTORS:

i) characteristics of the population

ii) Demand for health care

iii) Employer- paid health insurance

iv) Consumer participation

EXTRINSIC FACTORS:

i) Availability of technology

ii) Providers of health care

iii) Financing

Workforce costs NURSES RESPONSIBILTY:

Health care has as its aim as the well being of the individual and family at an optimal
level of health. Within this broader framework, the individual and the family have primary
responsibility for maintaining health with support from health care specialists. Consumer
are to be educated and nurse have the expertise to provide this education. Nurse can unite,
with a common concern for health care for people at affordable cost, the capacity to join
with consumer to create such change and thereby heal themselves.

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 Cost effectiveness of computerization in nursing practice and administration

computerization in nursing practice:

 Documentation

 Nursing audit

 Lab investigations

 Drug administration

 Diagnostics

 Policy manuals

 Research

 Job appraisal

 Planning nursing care

 Dietary planning

 Pharmacy

 Drug auditing

 Health care planning

 Curriculum planning

 In-service education

 Quality assurance

COST EFFECTIVENESS ANALYSIS (CEA):

These applications tend to be circumscribed and usually related to financial services

(such payroll, billing and purchasing) and to ancillary services (such as laboratory,
pharmacy, or central supply). When one can document that, all things taken into account, a
specific computer system can perform units of service at the same or less cost than any
alternative method, then the computer system can be said to be cost effective.

COST-BENEFIT ANALYSIS (CBA):

Fully documenting the costs of development, implementation and operation of a system

along with its real and perceived benefits and comparing these with alternative ways of
achieving the benefits constitute cost benefit analysis (CBA).

Differences between CBA and CEA

 Many studies claim to be CBAs, but are in fact CEAs .

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 CEA calculates the direct financial cost of reaching specific outcome/output levels and
requires one other alternative for comparison .

 CBA compares all benefits to all costs and can "stand alone." If the benefit/cost ratio
exceeds 1, the program is socially valuable .

 CBA typically prospective and used for major capital investments

 CEA typically retrospective and useful for evaluating discrete interventions

 CBA a macro (societal) view.

 CEA a micro view of program activities, outputs, or outcomes.

Core ideas for this session

 Both CBA and CEA examine the costs of producing net outcomes

 CBA really only makes sense when applied to assessing the net value of achieving social
outcomes. In other words, CBA measures the full (social) costs of the full (social) benefits
resulting from an intervention.

 CEA measures the financial cost of producing a specific net outcome

 Evaluation analysis most usefully focuses on the cost-effectiveness of activities, outputs, and
immediate outcomes

CBA and CEA compared

Net change to welfare of all stakeholders value in $

CBA ----->
Social cost ($)

Activities/outputs/outcomes (actual changes – not $)

CEA ----->
Direct program cost ($)

Scope of CEA and CBA

CBA must translate all outcomes and impacts into a money equivalent
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 The CBA equation divides the total dollar value of benefits by the total dollar value of costs

 Desirable programs have a high benefit/cost ratio (or low cost/benefit ratio)

 Many outcomes are difficult to value (increasing the life span arising from health
investments)

Cost-effectiveness analysis

Advantages of CEA

 Because CBA compares the welfare among stakeholders, methods to translate welfare into a
common denominator (i.e., money) strike many as artificial .

 For this reason, CEA is conceptually and operationally simpler. It is also more applicable to
evaluation and performance measurement of public programs .

 When a cost-benefit study is specified, a cost-effectiveness study is most often what is really
desired.

CEA aligns with value-for-money auditing

CEA can be aligned with value-for-money concepts and the results chain

Economy the unit cost of an activity

Efficiency the unit cost of an output

Effectiveness the unit cost of an outcome

Aligning CEA to the results chain

CEA / CBA and the results chain

CEA (cost of producing a unit...)

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 Focus on the amount of activity, output, or outcome. CBA value of outcomes to society.

(Net value to all stakeholders including program participants and non-participants, tax
payers, etc.)

Cost economy, efficiency, effectiveness along the results chain

Cost Economy Cost Efficiency

Cost to complete activities (E.g., Staff time per Cost per output (E.g., Cost per
client assessed, delivery of intervention...) parent trained, cost per trainee)

CEA moving along the results chain

The key is to identify and enumerate immediate outcomes:

 Success in athletic competition (medals)

 Increase in number of hours worked (active labor market program)

 Reduced incidence of hospital adverse incidents ("mistakes")

 Reduced waiting times for diagnosis

 Reduced use of social assistance (active labor market program, welfare reform)

 Diversion of clients from in-person to electronic service (e.g., electronic tax filing)

Measuring efficiency

 Activities should be discrete and measurable (e.g., staff years):

 Processing grant applications

 Consulting with applicants/clients

 Preparing media

 Costing should be allocated by activity

The transition from CEA to CBA: ---The GAIN model

"Hybrid" analyses allow a cost-effectiveness calculation to incorporate many of the features

of a cost-benefit model

Application of the GAIN model to Taking Charge!

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 Costs "Benefits"

Income assistance
Reduced SA payments because of
payments during
earned income of clients
training

Training
allowances Reduced SA due to shorter time on
+ +
(books, special welfare by clients
needs)

Cost of training
Increased taxes from employment
+ (personnel, +
earnings
contracts)

= Total costs = Total benefits

CEA AND NURSING SYSTEMS:

 It is difficult to evaluate the cost effectiveness of automated systems in the practice settings
because computer applications in nursing practice (with the possible exception of public
health and community health agency systems) are not circumscribed.

 The three most frequently retrieved categories were physician’s orders, medications, and lab
test results, in that order.

 For this reason there are no nursing information, systems per se, because to develop a
clinical information system in an institutional environment for the exclusive use of nurses
would be impractical.

CBA AND NURSING SYSTEMS:

 The administrators of the clinical center of the National Institute of Health (NIH) approved
the CBA methodology for evaluating the hospital wide information system (another
Technical system) in use at the clinical center.

 For the cost-benefit analysis, the researchers employed in innovative technique. They
gathered together benefit- assessment panels representing physicians, nurses, and
administrators at the clinical center.

 These panels estimated the relative benefits of alternative information systems, system
vendors and other sources provided the cost data for the alternative systems.

 In this study, the alternative systems were hypothetical systems with varying levels of
automation, from the stand-alone ancillary service system to the totally automated hospital
system with research and data management capabilities.

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 The findings were” the Medical Information System (MIS) provides greater benefits than
less automated alternatives, that the value of the benefits it provides exceeds the costs of the
system, and that the net value (i.e., value minus cost) of MIS is greater than that of less
automated alternatives.

IMPLICATION FOR NURSING PRACTICE:

Health care services provided by nurses include:

i) Health promotion

ii) Illness prevention

iii) Diagnosis

iv) Treatment

v) Rehabilitation

COST EFFECTIVENESS OF CONTINUING EDUATION:

Rapid advances in health related scientific and technological knowledge, changing social
attitudes, attitudes, and expanding practice opportunities require nurses to regularly enhance
and update their knowledge and skills.

PROSPECTIVE ANALYSIS:

Used prospectively, CEA helps administrators make judgement about the desirability
of a given course of action as compared with other courses of action that would compete for
the same funds and resources.

The analysis comprises the following steps:

i) Identification of goals and objectives to be achieved.

ii) Identification of feasible courses of action for achieving goals and objectives.

iii) Identification and measurement of costs of each alternative and cost of benefits
foregone by choosing one alternative (e.g.,opportunity costs).

iv) Development of models that trace out the potential impact of each alternative.

v) Setting of a criterion involving both cost and benefits that will identify the preferred
alternative.

RETROSPECTIVE ANALYSIS:

To develop the needed history for using CEA as a planning tool, a modified version of the
above steps can be applied to past programs and, in limited way, to current programs.

COST SIDE OF THE RATIO:

Continuing education costs may be analyzed in terms departmental costs associate with
program, program production or in terms of total departmental costs. Shipp describes three

670
types of labors costs associated with continuing education departments; direct, indirect, and
unassigned.

Direct labor costs are those incurred when someone is paid for work.

A work sampling approach may be useful for identifying the approximate percentage of time
the continuing education director, secretaries, and others designed to the department spend
on program and non program related activities. That portion of administrative time that is
program related is assigned to indirect labor while the non program – related time is
charged to departmental overhead, also called unassigned labor.

OVERHEAD:

Two kinds of overhead need to be considered: departmental and institutional .

Overhead refers to costs originating outside the department that are charged back as the
department’s share of the general organizational costs.

NON DEPARTRMENTAL COSTS:

Continuing education programs also generate non departmental labor costs when
employers either absorb the costs of labor or cover replacement or premium pay for
continuing education participants.

METHODOLOGICAL PROBLEMS:

Basically, there are two methodological problems that plague continuing education
evaluators: 1) adequate specification of outcomes: and 2) problems of measurement.

1. specification of outcomes:

The first problem is the identification of outcome hierarchies.

The second problem in identification of objectives is the handling of multiple outcomes.

2. problems of measurement:

The first, and perhaps most formidable problem in measuring continuing education
outcomes, is the identification of useful data. The data come in three forms.

1.Monetarily quantifiable.

2. Non monetarily quantifiable but measurable in terms of such things as rates of

occurrence, time, knowledge acquisition, satisfaction.

The second measurement problem lies in the statistical analysis of non monetarily
quantifiable data.

APPROPRIATENESS OF GOALS:

Appropriate objectives need to be paired with appropriate teaching and reinforcement

techniques. If the objective is to change clinical behavior, the program design must go
beyond knowledge acquisition.

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 COST EFFICIENCY:

Efficiency looks at process: were the objectives met in a way that cost as little as
possible? Questions of efficiency should be part of part of a prospective cost analysis.

Improving efficiency may mean:

 Getting better results for the same cost

 Getting the same results for a lower cost

 Getting better results for a lower cost

APPLICATION OF COST EFFECTIVENESS ANALYSIS:

Goals must be achievable with available resources and must reflect organizational
mission. The first step in prospective analysis is crucial. The next three steps, identification
of 1) alternatives, 2) costs, and 3) benefits associated with each, are based on historical data
and on educated guesses that have been informed by those data.

The last step is setting a decision criterion.

THEORIES RELATED TO BUDGETING

11.1. Lewin’s change theory :

The Planned Change Process

The basic concepts of the change process were outlined by Lewin. A successful change
involves three elements:

(1) unfreezing

(2) moving, and

(3) refreezing

Lewin’s theory of change used ideas of equilibrium within systems.

unfreezing

refreezing moving

Elements of successful change

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Unfreezing

Unfreezing the existing equilibrium involves motivating others for change. The change agent
must loosen, or “unfreeze,” the forces that are maintaining the status quo. This involves
increasing the perceived need for change and creating discontent with the system as it exists.
If individuals do not see a need for change, they are not likely to be motivated or ready for
change and may even hinder change. Assessment of readiness for change is critical in this
phase.

Moving

During the moving phase, the change agent identifies plans, and implements strategies to
bring about the change. The change agent must do all that is possible to reduce restraining
forces and strengthen driving forces. It is critical that the change agent continue to work to
build trust and enlist as many others as possible. The more ownership there is in the change,
the more likely the change will be adopted. Timing is also important during this phase.

People need time to assimilate change; therefore, the change agent must allow enough time
for people to redefine how they view this change cognitively.

Refreezing

During the refreezing phase, the change agent reinforces new patterns of behavior brought
about by the change. Institutionalizing the change by creating new policies and procedures
helps to refreeze the system at a new level of equilibrium. Refreezing has occurred when the
new way of doing things becomes the new status quo.

11.2.Lippitt’s Phases of Change

Lippitt’s Phases of Change Theory (1958) is built on the Lewin’s model.

He extended the model to include seven steps in the change process. Lippitt’s model focuses
more on the role of the change agent than on the evolution of the change process.
Communication skills, team building, and problem solving are central to this theory. The
participation of key personnel, those most affected by the change, and those most critical in
673
promoting the change is essential to the success of the change effort (Noone, 1987). The
seven steps of Lippitt’s phases of change are:

Step 1: Diagnosis of the Problem

The person or organization must believe there is a problem that requires change. The change
agent helps others see the need for change and involves 174 Skills for Being an Effective
Leader key people in data collecting and problem solving. The ideal situation exists when
both the organization and the change agent recognize and accept the need for change.

Step 2: Assessment of the Motivation and Capacity for Change

Determine if people are ready for change. Assess the financial and human resources. Are
they sufficient for change? Analyze the structure and function of the organization. Will it
support the change, or does there need to be organizational redesign? This process is
essentially defining the restraining and driving forces for change within the organization.

Step 3: Assessment of the Change Agent’s Motivation and Resources

This step is crucial to achieving change. The change agent (either an individual or a team)
must count the personal cost of change. The change agent must be willing to make the
commitment necessary to bring about the planned change. He or she must have the energy,
time, and necessary power base to be successful. The change agent may take on the role of
leader, expert consultant, facilitator, or cheerleader, but whatever role is assumed, the
change agent must be willing to see the change through.

Step 4: Selection of Progressive Change Objectives

The change is clearly defined in this step. Establish the change objectives. Develop a plan of
action; include specific strategies for meeting the objectives. Decide how to evaluate the
change plan and final result.

Step 5: Implement the Plan

It is critical to remain flexible during implementation. If resistance is higher than

anticipated, slow down. Give others a chance to catch up. On the other hand, if all is going
well and the momentum is good, keeps the plan moving ahead.

Step 6: Maintenance of the Change

During this phase the change is integrated into the organization. It is becoming the new
norm. In this phase, the role of the change agent is to provide support, positive feedback and,
if necessary, make modifications to the change.

Step 7: Termination of the Helping Relationship

The change agent gradually withdraws from the role and resumes the role of member of the
organization (Lippitt, Watson, & Wesley, 1958).

Havelock’s Model

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Havelock’s Six Step Change Model (1973) is another variation of Lewin’s change theory.
The emphasis of this model is on the planning stage of change. Havelock’s model asserts
that with sufficient, careful, and thorough planning, change agents can overcome resistance
to change. Using this model, essential to the success of change is inclusion. It is imperative
that the change agent encourage participation at all levels. This follows the assumption that
the more people are part of the plan, the more they feel responsible for the outcome, and the
more likely they will work to make the plan succeed.

The planning stage of Havelock’s model includes:

(1) Building a relationship;

(2) diagnosing the problem; and

(3) Acquiring resources.

(4) Choosing the solution

(5) Gaining acceptance.

(6) Stabilization and renewal (Havelock, 1973).

ROGERS’ DIFFUSION OF INNOVATION

Everett Rogers (1983) developed a diffusion theory, as opposed to a planned change theory.
It is included with change theories because it describes how an individual or organization
passes from “first knowledge of an innovation” to confirmation of the decision to adopt or
reject an innovation or change. Rogers defined diffusion as “the process by which
innovation is communicated through certain channels over time among the members of a
social system”. Rogers’ framework emphasizes the reversible nature of change. Initial
rejection of change does not mean the change will never occur. Likewise, the adoption of
change does not ensure its continuation.Rogers’ five-step innovation/decision-making
process is:

Step 1: Knowledge

The decision-making unit (individual, team, or organization) is introduced to the innovation

(change) and begins to understand it.

Step 2: Persuasion

The change agent works to develop a favourable attitude toward the innovation (change).

Step 3: Decision

A decision is made to adopt or reject the innovation.

Step 4: Implementation/Trial

The innovation is put in place. Reinvention or alterations may occur.

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Step 5: Confirmation

The individual or decision-making unit seeks reinforcement that the decision made was
correct. It is at this point that a decision previously made may be reversed.

ROLE OF THE NURSE ADMINISTRATOR IN BUDGETING:

Budget required for the Nursing Department should be co-operative activity of he nursing
superintendent and her/his associates including the supervisors. It is prepared under the
direction and supervision of the administrator or financial officer designated by him. The
administrator supplies special forms to guide the budget. The budget request may be broken
down to the different units, e.g. salaries, supplies , equipments and other purchase
requirements

Budget of nursing unit is an expressive tool, i.e. expression of the what to do within a given
time. The administration of nursing unit has certain specific functions in the preparation of
budget request for programmed planning, estimating the cost, justification of request and for
administration of budget in nursing unit.

The steps of planning budget for nursing unit is as follows:

1. assistance of her/his subordinate- nursing administrator requires the assistance of

nursing superintendents and nursing supervisors to present the needs of the coming within
the specified data and confer with those who presented such need.

2. review of the budget – nursing administrator should review the budget appropriation and
actual expenditure of the current year.

3. ascertain change – he/ she requires to ascertain whether any change contemplated such
as opening new facilities for patients changes in department etc. which in turn effects of
Nursing Department .

Preparing requirements – he/she should prepare requirements with the assistance of their
subordinate officials for the coming year from the supplied information by them .

Summary of new needs – he/ she should prepare a summary of new needs and requirements
both personnel and material with the proper data supports of the requirements.

Submitting to institutional administrator: budget should be submitted to the administrator

of the institute / hospital for review , decision and to incorporate into the master budget
required for the hospital . In any change made by either the administrator or the committee
on budget, report should be furnished to her to be used in the control of expenditure .

A copy of the nursing department appropriation is sent to the director after adaptation of the
budget. These statements generally proved the budget for the period and difference between
the budget appropriation and actual expenditure.

These reports should be kept reviewed by the director and her associates and if expenditure
exc The responsibilities of nursing administration in budget includes the following :

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1. Participation in planning budget.

2. Consult and take assistance of his/ her subordinates in determining the needs of the unit for
ensuring year on the basis of information received.

3. Request sufficient funds to suggest a sound programme such as to provide for developing
programme provision , expansion of programme to attract and hold qualified staff to provide
for expansion of physical facilities, supplies, equipment, for improving instruction ( schools
and college) and also to carry out adequate functions of the institution.

4. Submit budget request with justification with proposed expenditure. The administrator
defines her/ his budget so that nursing unit will have enough money to conduct programme
effectively. Money must be available to allow experimentation also

5. When the budget is allotted, the administrator should support the budget . he / she should
interpret the subordinates, any changes that may affect instruction services for the adopted
budget. She / he secures for the adapted budget. Once the budget is adapted, it is the
responsibility of the administrator to see that expenditure should not exceed the
appropriation made.

6. Since the Nurse Administrator also is responsible for budget, she/he should cover the routine
budget control.

Roles:

He or she:

1. Is visionary in identifying or forecasting short term unit needs, thus inspiring proactive
rather than reactive fiscal planning.

2. Is knowledgeable about political, social and economic factors that shape fiscal planning in
health care today.

3. Demonstrates flexibility in fiscal goals setting in a rapidly changing system.

4. Anticipates, recognises and creatively problem-solves budgetary constraints.

5. Influences and inspires group members to become active in short and long range fiscal
planning.

6. Recognises when fiscal constraints have resulted in an inability to meet the organizational or
unit goals and communicates this insight effectively, following the chain of command.

7. Ensures that client safety is not jeopardized by cost constraints.

Functions:

1. Identifies the importance of, and develops short and long range fiscal plans that reflect unit
needs.

2. Articulates and documents unit needs effectively to higher administrative levels.

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3. Assess the internal and external environment of the organisations in forecasting to identify
driving forces and barriers of fiscal planning .

4. Demonstrates knowledge of budgeting and uses appropriate techniques .

5. Provide opportunities for subordinates to participate in relevant fiscal planning.

6. Co-ordinates unit level fiscal planning to be congruent with organisational goals and
objectives.

7. Accurately assesses personnel needs using predetermined standards or an established patient

classification system.

8. Co-ordinates the monitoring aspects of budget control.

9. Ensures that documentation of clients need for services rendered in clear and complete to
facilitate organisational reimbursement

LEADERSHIP AND MANAGEMENT BEHAVIOURS :

Leadership behaviours:

 Determines resource requirements for the group

 Guides a visionary justification of resources.

 Analyzes expenditures

 Uses creativity to strategize and negotiate for the group’s resource needs.

 Motivates the group to increase budgetary knowledge

 Influences the group to find innovative ways to do things better.

 Find new sources for resources .

 Creates a financially savvy work environment.

Management behaviours:

 Plans the budget

 Organizes the needed resources

 Organizes budget justification

 Implements the unit budget and budget processes

 Controls expenses

 Determines resource requirements within organizational constraints .

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 Evaluates technology

 Motivates subordinates to learn about budgeting

Overlap areas:

 Determines resource requirement

 Motivates expanded knowledge about financial aspects

 Manage expenditures.

 Budget in academic settings:

Tradition and status often supersede documented need in academic settings .leaders of
nursing programs may not always be able to obtain the monies needed to maintain quality
programs and grow. A budget can be a crucial tool that documents and quantifies program
needs and how the program contributes to the overall college or university .

CHAPTER - -IX
volantine

Fiscal planning Audit, cost effectiveness, cost accounting.

INTRODUCTION:

AUDIT

The term 'audit' is commonly associated with accounting, auditing consists of careful
checking and investigation to see that all phases of the accounting for financial matters are
being conducted according to established procedures and practices. Auditing is not only
concerned with the handling of money but is also involved with proper inventory control,
proper payment for goods purchased and checking whether the goods paid for are actually
received. Audit seeks to investigate all practices related to the accounting for material
personnel or any activity that involves expenditure.

Nurses are practicing caring in an environment where the economics and costs of health care
permeate discussions and impact decision. ---Marian C. Turkel.

The trouble with a budget is that it‘s hard to fill up one hole without digging another- ---Dan
Bennett

Scarce resources and soaring healthcare costs have strained all healthcare delivery systems.
There has never been a time when healthcare organizations needed to operate more
efficiently or be more aware of cost containment.

Cost containment refers to effective and efficient delivery of services while generating
needed revenues for continued organizational productivity. Cost containment is the
responsibility of every healthcare provider, and the viability of most healthcare
organizations today depends on their ability to use their fiscal resources wisely.

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It is critical that unit managers have expertise in managing costs. An essential feature of
fiscal planning is responsibility accounting, which means that each of an organization’s
revenues, expenses, assets, and liabilities is someone’s responsibility.

DEFINITION :

Montgomery defined, "auditing as a systematic examination of the books and records of

business of other organizations in order to ascertain or verity and to report open the facts
regarding this financial operations and the results thereon."

Spicer and Pegler have defined audit as, such an examination of the books, accounts and
vouchers of business as will enable the auditor to report, whether he is satisfied that the
balance sheet is properly drawn up so as to give a true and fair view of the state of affairs of
business and that the profit and loss. Account gives a true and fair view of the profit for the
financial period according to the best of information and explanation given and as shown by
the books, and if not, to report in what respect he is not satisfied.

R.K.Mautzauditing as, being concerned with the verification of accounting determining the
accuracy and reliability of accounting statements and reports.

Human resource audit refers to an examination and evaluation of policies, procedures and
practices to determine its effectiveness. It measures the effectiveness of personnel
programmes and practices as well as determines what should or should not be. One in future.

5.INTRODUCTION TO FISCAL AUDIT:

Audit was originally confined to ascertaining whether the accounting party had properly
accounted for all receipts and payments on behalf of his principal, and was in fact merely a
cash audit. Modern audit not only examine cash transactions, but also verify the purpose to
which the cash transactions relate.

5.1.Government auditing

Audit forms an indispensable part of the financial administration and is one of the important
organs necessary to ensure the sound functioning of a Parliamentary Democracy. It is the
main instrument to secure accountability of the Executive to the Legislature.

Audit assists Parliament/Legislature in exercising its financial control over the Executive, to
ensure that funds voted by the Parliament/Legislature have been utilized for the purpose
intended and the funds authorized to be raised through taxation and other measures have
been assessed, collected and credited to the Government properly.

The primary function of audit is to verify the accuracy and completeness of accounts to
secure that all revenue and receipts collected are brought to account under the proper head,
that all expenditure and disbursements are authorized, vouched and correctly classified and
the final account represents a complete and a true statement of the financial transactions it
purports to exhibit.

It is the function of audit to verify that financial rules and orders satisfy the provisions of
Law and or otherwise free audit objections and the rules & orders are properly applied.

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 5.2. Audit control :

State Audit is the main instrument to secure accountability of the lower formation in the set
up to the Administration and of the Administration to the Legislature in the area of financial

Administration.

Fiscal accountability -This includes fiscal integrity, full disclosure and compliance with
applicable laws and regulations.

Managerial accountability - It is concerned with efficiency and economy in the use of public
funds, property, personal and other resources.

Program accountability - To check whether Government programs and activities are

achieving the objective established for them with due regard to both costs and results.

6. THE ESSENTIALS FEATURES OF AUDITING

The essentials features of auditing are

* Critical review of the systems and procedures in an organization.

* Making such tests and enquires as the auditor may consider necessary to form an opinion.

* Expressing to form an opinion

* Ensuring that all necessary aspects have been taken into account.

7. PURPOSE OF AUDIT

The Purpose of auditing includes:

 Examination of the books of accounts and records with a view to test the arithmetical
accuracy and correctness in recording of transactions and their reliability.

 Verify that the balance sheet and profit and loss account are drawn in conformity with the
accounts and records.

 Ascertain that proper accounting principles and procedures and management policies are
followed.

 Ensures that book of accounts and records as required by law are kept.

 Report on the balance sheet as to whether it reflects the true and fair state - of affairs of the
institution and that the profit or loss of the institution.

 Inspect all the documents, records and books of accounts of the institution and express
opinion on matters required by the statistics.

8. SUBSIDIARY OBJECTIVES:

8.1. Overall objectives of audit are aimed:

a) To detect error and fraud in accounts.

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 b) To prevent commission of errors and frauds.

c) To enable timely finalization of accounts.

d) To make the public know the state of affairs of the Institution.

8.2. The Subsidiary objectives of audit are:-

 Detection and prevention of Errors.

 Detection and prevention of Frauds

I. Detection and prevention of errors

Generally, the term error refers to the unintentional mistakes in financial information such as
mathematical or clerical mistakes by oversight or misinterpretation of accounting policies. It
can be classified as.

Clerical errors

 Error of commission

 Error of omission

 Compensatory errors

Errors of Principle

Errors of Principle refer to the treatment of transactions in the books of account against the
accepted principles of accounting for e.g. Treatment of revenue expenditure as capital
expenditure and vice-versa of posting transactions to wrong class of revenue accounts etc.

II. Detection and prevention of Frauds

Fraud is an intentional misrepresentation or false representations of a fact Fraud is

committed with mischievous motivation of disappearing money and goods or both.

It can include Manipulation and falsification o accounts. Misuse of funds and other
properties of the properties of the stock and distraction of records.

To achieve the above objectives in respect of Government audit, it has to be ensured that:

(i) There is provision of funds for the expenditure duly authorized by a competent authority.

(ii) The expenditure is in accordance with a sanction properly accorded and is incurred by an
officer competent to incur it.

(iii) Payment has been made to proper person and duly acknowledged so that a second claim
on the same account is impossible.

(iv) The charge is correctly classified.

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(v) In the case of audit or receipts (1) the sums due are regularly recovered and checked
against demand and (2) sums received are duly brought to credit in the accounts.

(vi) In the case of audit of stores and stock where a priced account is maintained stores are
priced with reasonable accuracy and rates fixed are reviewed from time to time.

(vii) That the numerical balance of stock materials is reconciled with the total of value of
balance in accounts.

(viii) Expenditure conforms to the following general principles of standards financial

property viz:

(1) The expenditure is not prima-facie more than the occasion demands and that every
Government servant exercises vigilance in respect of expenditure as his own money;

(2) No authority exercises its power of sanctioning expenditure to pass an order which will
be directly or indirectly to its own advantage;

(3) Public moneys are not utilized for the benefit of a particular person or section of
community unless:

a) The amount of expenditure involved is insignificant or;

b) The expenditure are in pursuance of a recognized policy or custom and

c) The amounts of allowance such as traveling allowance are not on the whole a source of
profit to the recipients.

9. FUNCTIONS AND SPIRIT OF AUDIT

Auditing is concerned with the verification and examination of the books of accounts. The
functions of audit are.

Ascertain the systems of accounting, internal control and management pattern of the
organization.

Conduct a test check of the system of the internal control find out its soundness.

Collect all the evidences in support of the transactions and find out whether the transaction
entered in the books of accounts reflect the true nature of the transactions.

Check the arithmetical accuracy of the records

Verify the assets and liabilities and ensure that the assets are valued properly.

Examine that all statutory requirements are completely.

Spirit of Audit

In audit under insistence on trifling errors and technical irregularities which are of no
consequence to the finances of the Government should wherever possible be avoided and
more time and attention devoted to the investigation of really important and substantial

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irregularities with the object not only on securing rectification of particular irregularity but
also ensuring regularity and propriety in similar cases for the future.

10. BASIC PRINCIPLES OF AUDIT:

The important principle of audit includes the following.

Integrity, Objectivity and Independence:

The auditor should be straight forward, honest and sincere in his approach to his
professional work. He must be fair and must not allow prejudice or bias to override his
objectivity. He should be maintaining an impartial attitude.

Confidentiality:

The auditor should respect the confidentiality of information acquired in the course
of his work and should not disclose any such information to the third party without specific
authority there is legal or professional duty to disclose.

Skills and competence:

The audit should be performed and report prepared with due professional care by
persons who have adequate training, experience and competence in auditing.

Work performed by others:

When the auditor delegates work to assist" nts or uses work performed by other auditors and
experts, he will continue to Be responsible for his opinion on the financial information.

Documentation:

The auditor should document matters which are important in providing evidence that
the audit was cared out in accordance with the basic principles.

Planning:

The auditor should plan his work to enable him to conduct an effective audit an
efficient and timely manner. Plans should be based on knowledge of the client's Business.

Audit evidence:

The auditor should obtain sufficient appropriate audit evidence through’ the
performance of compliance and substantive procedures to enable him to draw reasonable
conclusions therefore on which to base his opinion on the financial, information.

Accounting system and internal control:

Management is responsible for maintaining an adequate accountings system

incorporating various internal controls to the extent appropriate to the size and nature of
institution. The auditor should reasonably assure himself that the accounting system is
adequate and that all the accounting information which should be recorded has intact been
recorded.

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 Audit conclusion and reporting:

The auditor should review and assess the conclusion drawn from the audit evidence
obtained and from his knowledge of the client as his basis for the expression of his opinion
on the financial information.

11. TYPES OF AUDIT

Audit can be classified into two categories

 Statutory audits

 Non-statutory audits.

11.1. Statutory Audits:

A Statutory audit means an audit which is compulsory by any state or law. Such an audit is
to be conducted by an independent qualified auditor. A statutory auditor is appointed
according to the norms laid down by law. The following audits fall in the category of
statutory audits.

Financial audit:

In India, audit of financial accounts of joint stock companies public and private, is
mandatory under the companies Act 1956. Financial audit can be described as an
independent examination of books and vouchers of a business or undertaking to enable the
auditor to satisfy whether the accounts are properly drawn up to exhibit a true and fair view
of the state of affairs of the company.

Special audit:

Under Section 233-A • of the companies Act 1956, the Central government may at
any time by order, direct special audit of the accounts of a company, either by auditor of the
company, itself or by another qualified chartered accountant.

Cost audit:

Cost audit critical review undertaken for the purpose of Verification of the correctness of
cost accounts and Checking that cost accounting plan is adhered to.

Tax audit:

Sec. 44 AB of the Income Tax Act 1961 provides for compulsory audit of accounts by a
charted accountant. Where In case of a business - total sales, turnover or gross receipts in
any previous year exceed 40 lakhs and In case of a profession - gross professional receipts in
any previous year exceed Rs. 10 lakhs.

11.2. Non-statutory audits :

Management audit:

It is an examination, review and appraisal of the various policies and actions of the
management
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Efficient audit:

It consists of appraisal of performance to determine whether the plan has been executed
efficiently. Efficiency audit ensure the application of the basic economic principles.

Property audit:

It is an audit of such actions and plans of the management which have a bearing on the
finances and expenditure of the concern.

Internal audit:

This is independent appraisal activity within organization for the review of accounting,
financial and other operations as a basic service to management. Internal audit may be
carried out by the employees of company or some outside agency may engaged to carry out
internal audit.

Social audit: Social audit is independent assessment to determine, the extent to which the
activities of an enterprises are beneficial and contribute to the social at large.

Audit may be classified into five categories. Different types of audit are as follows:

I. Audit on the basis of organizational structure of the business. '

II. Classification of audit on the basis of Degree of independence.

III. Classification of audit on the basis of the conduct of audit.

IV. Classification of audit for specific objectives.

V. New Generation Audits. I Statutory Audit

Certain institutions and enterprises are established by statutes. Audit of these institutions is
carried out compulsorily under the provisions of the statute or Law of Audit of the accounts
of these institutions is termed as Statutory Audit. The following are the undertakings
(Governed by different laws) in which case audit is compulsory.

1. Joint stock companies under Companies Act.

2. Banking Companies governed by Banking Regulation Act 1949.

3. Insurance companies .

Co-operativesocietiesregisteredunderdifferentstateCo-operativeSocieties.
PubliccharitablecompaniesregisteredundervariousreligiousandotherendowmentsAct.

Generallytherulesandregulationsforauditareprescribedbyrespectiveact(i.e.Company
Act,BankingCompanyAct,etc.)Relativeactlaysdownindefinitetermsthenature,scopeand
extentofauditaswellasqualifications,rightsanddutiesoftheauditors.

1. CompanyAudit

InIndia,theauditofaccountofjointcompaniesiscompulsoryundertheCompanies
Act(IndianCompaniesActof1913andCompaniesActof1956)
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TheCompaniesActand subsequentamendmentshavecaused.tremendouschangesin
theoutlookofcompanyaudit.Therightsandduties,powersscopeoftheauditorsissubjectto
changeaccording to the social development . The shouldbeaqualifiedauditoraslaid
downundersection226oftheCompaniesAct1956.

2. TheAuditofTrustAccounts

Trustiscreatedforthebenefitofsameinstitutions,widowsminorsetc.andforthe
benefitofweakerandhelplesspersons.TrustiscreatedbyaTrustDeed.

TheTrusteeslookaftertheproperty,collecttherentofproperty,dividendsasshareetc.
anddistributetheincometothebeneficiariesaccordingtothetermsofTrustDeed.

Thetrusteesareresponsibleformaintainingofthebooksofaccounts.Somedishonest
trusteeshavemisappropriatedlargesumsoftrustmoneywithouttheknowledgeofthe
beneficiaries.Sameofthetrusteesthemselvesdonotknowhowtokeeptheaccount.Theyare
alsoignorantoftrustlaws.Theymaintaintherecordattheirownwillandfancy.Sometrustees
willfullymanipulatetheaccounts.

Thebeneficiariessuchaswidowsandminorsarenotina
positiontohaveaccesstobookofaccountsandevaluateitsresults.VeryoftentheTrusteewill
misleadthebeneficiarieswhentheyarequestioned.Inseveralcases,Trusteespresentno
accountsuntiltheyareforcedtodoso.Sotoavoidmisappropriationofmoneyandfraudulent
manipulationoftrustaccountsspecificprovisionismadeintheTrustDeedfortheappointment
ofauditorstochecktheaccountsoftrusts.

InsomestatesinIndia,PublicTrustActshavebeen
enactedtoprovideforstatutoryorcompulsoryauditofaccountsofthetrustbyqualifiedauditors.
TheIndianTrustActhasalsomadeauditoftrustaccountscompulsory.BombayPublicTrust
Act1950,TheaccountsofPublictrusthavebeenenactedwhichprovideforcompulsoryaudit
ofaccountsoftrustbyCharteredAccountants.

3. StatutoryAuditofotherInstitutions

Certaincorporatebodiesareformedunderstatutesandmakecompulsoryauditofthe
accountsofthesebodiesfortheirrespective.StatuteorActtheaccountsofcorporatebodies
likebankingcompanies,electricitysupplycompanies,

Insurancecompanies.ReserveBankofIndia,IndustrialFinanceCorporations,K.S.R.TC.
etc.Corporatepublicbodiesarerequiredtobeauditedbyqualifiedauditor.

The Government undertakings usually deal with large amount of public money, therefore the
job auditor becomes all more significant. He has to see that revenues by these corporations
are not wasted or miss appropriated by the authorities concerned.

The duties, powers and liabilities of auditors of these bodies are laid down by the relevant
statutes under which they are formed.

4. Statutory Audit of Co-operative Societies

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 A Co-operative society is formed under the provision of Co-operative Act 1912. This act is
further amended by various states Governments. In Kerala State Co-operative Act of 1969
the accounts of co-operative institutions are maintained as per Co-operative Act and
regulations.

Audit of accounts of these co-operative institutions is compulsory. Co-operative department

of the state is the authority for conducting audit. The registrar of co-operative societies
(Audit) appoints auditors to the co-operative societies.

From the point of view of audit, co-operative societies are classified in A.B.C.D. and E.
classes according to the standard of efficiency of management. It is the auditor, who after
examining all the aspects awards the classification. The auditor has to submit the audit
report to the Registrar.

II. Private Audit or General Audit

Private audit refers to the audit of accounts of private business enterprises such as sole
trader, partnership firms, and Private individuals. It is not compulsory to audit the accounts
private enterprises but it is left to the discretion of the owner. The private business houses
have their own professional arrangements for audit and to protect the interest of owners.
There arethree types of such institutions.

 Sole trader

 Partnership

 Private individuals

1. Private Audit of Accounts of Sole Traders

The conduct of audit of sole trader is optional and not compulsory by law. The sole trader
appoints the auditor under an agreement. By this agreement the auditor must get clear
instructions in writing from his client as to what he is expected to do. The scope, nature and
duties of auditor will depend upon the agreement.

If the auditor is appointed to prepare the accounts or income tax returns of the client the
auditor acts as accountant, not an auditor. Thus the auditor is not liable for their failure to
discover the misappropriations of cash by the employees of the client.

2. Private Audit Accounts of Partnership

Audit of accounts of Partnership is not compulsory but it is optional. It is done with the
interest of partners. It is better to get the accounts of the firm audited by a qualified auditor.
It helpstoavoidfuturedisputebetweenpartners.Theauditofpartnershipisperformedunder
PartnershipDeedifitprovidesforit.Themanagementonthemutualagreementbetween
partnersandhimselfappointstheauditor.Theserights,dutiesandliabilitiesoftheauditorare
alsodefinedinthemutualagreementinwriting.Thepartnersmayaskhimtodofullauditora
partialaudit.Theauditorofthefirmhastosubmitinauditreportstothepartnerswhohave
appointedhim.Thereisalsonospecificformofthereport.

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Theaimofapartnershipauditistoverifythefinalaccountandtodetectandprevent
errorsandfraud.Heshouldseethattheaccountsareproperlymaintainedandareinaccordance
withtheprovisionofpartnershipdeedoract.Thepartnersofafirmrecognizetheadvantages of
scientific audit.

3. Auditof Institutions (Non Profit Institutions)

Therearecertaininstitutionsworkingnotforearningprofits.Theyarenon-profit
organizationslikehospitals,schools,colleges,associations,clubsandlibrarieswhohavelarge
receiptsandhugeexpenditure.Itisnotcompulsorytogettheiraccountsaudited.Itisnecessary
toaudittheaccountstoassurethemembersthattheaccountsaremaintainedproperly.

This helpsthantodetectfraudsandirregularitiescommittedbytheofficebearersandemployees.It
furtherhelpsthemforobtaininggovernmentgrantandotherassistanceonthebasisofaudited
accounts.

III. Government Audit

Governmentauditmeansauditofaccountsofgovernmentdepartmentandoffices:
Governmentcompaniesandgovernmentstatutorycorporations.

Governmentauditisanimportantmeansofensuringpublicaccountability.Italsoacts
asatoolforfinancialcontrol.Inawaygovernmenttodayarethelargestenterprises.Auditof
financialtransactionsoftheGovernment.Thereforeitassumesspecialimportance.

TheauditofaccountsgovernmentdepartmentofficesareundertakenbytheComptroller
andAuditorGeneralofIndia.Thereisaseparatedepartmentforperformingauditinthename
ofAccountsandAuditDepartment.TheComptrollerandAuditorGeneralofIndiaisassisted
bydifferentofficialsatvariouslevels.

Thegovernmentauditisprovidedforbylaw.Articles149oftheConstitutionofIndia.
Thedutiesandliabilitiesofauditorsarenotdefinedbystatutes.Theauditorsworkaccording to
thedepartmentrulesandinstructions.Governmentauditisacontinuousaudit,aslargenumber
oftransactionswithhugesumofpublicmoneyisinvolvedinit.

1. Audit of Government Department and Office

TheauditofaccountsofGovernmentdepartmentsandofficesiscarriedoutbythe
ComptrollerandAuditorGeneralofIndiaandhisstaff.TheauditofUnionGovernmentis
performedbytheComptrollerandAuditorGeneralofIndiaandhisstaff.Theauditreportof the
sameissubmittedtoPresidentofIndia,whowillthensendittobothhousesoftheParliament.
TheauditreportrelatingtotheaccountoftheStateGovernmentshouldbesubmittedtothe
StateGovernorsconcernedwhowillthusforwardittothestatelegislature.

2. Audit of Government Companies

AGovernmentcompanyisoneinwhichatleast51%ofthepaidupcapitalisheldby
CentralGovernmentorStateGovernmentorbothStateandCentralGovernment.A subsidiary
companyisalsotreatedasaGovernmentCompany.

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Theauditof theaccountsofthesecompaniesorcorporationsisstatutoryunderCompanies
Act.TheauditofaccountofGovernmentcompaniesisconductedbytheCharteredAccountant
appointedbyComptrollerandAuditorGeneralofIndiaastherecommendationbytheCompany
LawBoard.

TheauditorofthesecompaniesshouldsubmitareporttotheComptrollerandAuditor
General.Thisreportisthenplacedbeforetheshareholders'annualgeneralmeeting.

3. Audit of Corporations

TheCorporationlikeLifeInsuranceCorporationofIndia,ReserveBankofIndia,Food
CorporationofIndia,etc.,arestatutorycorporations.Auditoftheaccountsofthesecorporations
iscompulsory.TheauditisentrustedwithCharteredAccountant.Theduties,rightsandliabilities
oftheauditorofthesecompaniesareexplainedintheAct.

Differences between Govt. Audit and Commercial Audit (Private Audit)

Govt. Audit Commercial Audit

1 AuditforGovt.Departments,Offices, 1Private,Commercialconcerns.
. .

PublicGovt.CorporationsandGovt.
companies.

2 Auditiscompulsory. 2Optional.
.

* 3. AuditisconductedbyComptrollerand 3ProfessionalAuditors.
.

AuditorGeneralofIndiaandhisstaffor

professionalCharteredAccountant

approvedbyComptrollerandAuditor

General.

4 ItisacontinuousAudit. 4Auditisdoneperiodicallyafterafixed
. .

period.

5 DisbursingDepartmentoftheGovt.Office 5Thecashpaymentdepartmentisnot
. .

isresponsibleforapartofauditwork. concernedwiththeauditwork.

690
 6 PreliminaryAuditofbillsismadeby 6Thecashiermakespaymentonlyandno
. .

TreasuryOfficerorDisbursingOfficerwho preliminaryaudit".

makespaymentonbehalfoftheGovt.

Departments.

II. Classification of audit on the basis of degree of independence

1. Independent Audit

Independentauditisalsoreferredasexternalaudit.Theauditofaccountofthefirmis
conductedbyindependentprofessionallyqualifiedauditors.Itisconductedtoprotecttheinterest
ofproprietorsandthirdparties.Theauditworkisdoneperiodicallyafterafixedperiodi.e.,
normallyayear.

2. Internal Audit

Internalauditingisasignificanttypeofaudit,whichinvolvesasystematicexamination
ofrecords,systemsandproceduresandoperationsofanorganizationasaservicetothe management.

III. Classification of audit according to the method or on the basis of the conduct pudit
or practical point of view

Auditmaybeconductedunderdifferentformsinwhichauditisoftenconductedpractically
bythebusinesshouses.Thenatureofauditdependsonthenatureofbusinessandthepurposes;
ofaudit.Theimportantclassificationisasfollows:

(1) Continuous Audit or Running Audit or Detailed Audit

Continuousauditisastatutoryaudit.Thisauditisdonebyprofessionallyqualifiedauditors .

InthewordofSpicerandPegler,"Acontinuousauditisoneweretheauditor'sstaffs
occupiedcontinuouslyontheaccountsofthewholeyearroundortheauditorattendsatintervals
fixedorotherwiseduringthecurrencyofthefinancialyearandperformsaninterimaudit".

InthewordsofJ.R.Batilibol,"Acontinuousordetailedauditinvolvesadetailed
examinationofallthetransactionsbytheauditorattendingatregularintervals,sayweakly
fortnightlyormonthly.duringthewholeperiodoftrading.

Theabovedefinitionrevealsthatinacontinuousaudit,auditorcarriesouttheprocessof
auditcontinuouslythroughouttheaccountingperiodatintervalsfixedbyhim.Thecheckingof
accountsgoesonsimultaneouslywiththepreparationthereof.Theauditorisconstantlyengaged
incheckingtheaccountsduringthewholeperiod.Howevertheworkofverificationofassessandliabi
litiesisleftoveruntilthepreparationofbalancesheet.

Continuousauditisnecessaryonlyforbigbusinesshousesandnotsmallfirms.

continuous audit is applicable in the case of the following the business.

 Wherebusinessisverylarge
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 Wherethebusinessrequiresmonthlyfinalaccountsforpublication,etc....

 Inconcernslikebanks,railways,etc...wherefinalaccountsarepresentedimmediately
afterthecloseof theaccountingperiod.

 Wherebusinesshasnosatisfactorysystemofinternalcheckinoperation.

 Wherevolumeissameareverylarge.

 Wherethecompaniesrequirestodeclaresinterimdividend

2. Final Audit or Completed Audit or Periodical Audit or Annual Audit

Thefinalaudittakesplaceonlyaftertheendofthetradingperiodwhenallthetransaction
forthewholeyeararecompletelyrecordedandbalanced.Atradingonprofitlossaccountsand
balancesheethavebeenprepared.Theauditorcarriesashisauditworktillitiscompleted.The
auditorgetsholdofthebooksofaccounts,documentvouchers,billandfillfactsrelating the
accountingperiodunderreview.Inthistypeofaudit,theauditorvisitshisclientonlyonceina
yearandtheauditworkiscommandedandcompletedinasingleuninterruptedsession.

Firmstowhichfinalauditissuitable

Thisformofauditisveryusefulandconvenienttosmallerbusinesshouses.Forbig
businesshousescontinuousauditismoresuitable.Wheretransactionsarenumeroushencefinal
accountscannotbepreparedatthecloseofthefinancialyear.

3. BalanceSheetAudit

Balancesheetauditisofrecentorigin.Theterm'BalancesheetAudit'isanAmerican
contribution.ThistypeofauditismorepopularinUSA.ItisrarelyusedinIndiaandother countries.

InBalancesheetAudittheauditorverifiesthebalancesheetitemssuchas.Capital,
liabilities,reservesandprovisions,assetsandotheritemsgiveninthebalancesheet.Theauditor
checksonlythosedocuments,whicharerelatedtotheitemsgiveninthebalancesheet.This
typeofauditisnotaimedatcheckingprofitandlossaccountandothersimilartransactions.

Balancesheetauditisdescribedas"PracticalAudit".ItisinthenatureofExamination
offinancialstatement.Itistreatedasabrieftermofaudit.TheBalancesheetauditwillbe
moreextensivelyusedinfuture.

4. InterimAudit

Itisatypeofaudit,whichisconductedinbetweenthetwoannualaudits.Theobjectof
interimauditistofindoutinterimprofitandtodeclareinterimdividend.

5. OccasionalAudit

Occasionalauditissuitabletosoletradersandpartnershipformofbusiness.Ifthe
soletraderorpartnerdesirestoconductanauditforaspecialobjectonspecialoccasionthis
typeofauditiscalledoccasionalaudit.

6. PartialAudit

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 Partialauditisatypeofaudit,whichiscarriedoutinrespectofaspecifiedaspectofthe
looksofaccountsof thebusiness.Underthisaudit,auditorisonlyapartofaccountsasinstructed
bytheclient.Thusitiscalledpartialaudit.Intheauditreport,auditormayspecificallymention
thathehasconductedonlypracticalauditasperdirectionoftheclient.Practicalauditisnot
permittedinthecaseofjointstockcompanies.

7. StandardAudit

Thisisatypeofauditrarelyconductedinbusinessfirms.Underthistypecertainitems
ntheaccountsarethoroughlyscrutinizedandanalyzedtestcheckingisalsoappliedinthetype
ifaudit.

AuditinginDepth

Inlargefirmsthereislargenumberoftransactionsandhavingagoodinternalcheck
andinternalcontrolsystemoperating.Theauditorisnotpossibletoverifyeachandevery
transactionindetails.Theauditorselectsfewtransactionsandapplythoroughscrutinisingof
thetransactions,i.e.,fromoriginalentrytofinalentryofthetransactionatvariousstages.The
auditorexaminesthesystemappliedinthebusinesstransactionisstrictlyfollowedandsee
whetheraneffectiveinternalcheckandcontrolsystemapplied.Thistechniqueiscalledauditing
indepth.Theauditorshouldresorttodepthauditingonlywhenheissatisfiedwiththeefficiency
ofinternalchecksystemprevailsintheundertaking. IV. Classification of Audit According to
Special Objectives

Thisclassificationismadeaccordingtospecialobjectives.Theyare:

 ManagementAudit

 CostAudit

 CashAudit

 Specialaudit

 OperationAudit

 EfficiencyAudit

 DetailedAudit

 ProprietyAudit

 PerformanceAudit

 RegulatorAudit

ManagementAudit:

ManagementAudithasarecentorigin.ThetermManagementAudit
haditsorigininUnitedStatesofAmerica.ItisanewstarinthehorizonofAudit:InIndia,the
managementaudithasgainedmomentumamongthecorporatemanagementintherecentyears.
Today,theworldovertheeconomicsisliberalizing;thestatecontrolintrade,Commerceand
industryetc.isgivingawaytomarketforces.Modernbusinesshasbecomesolarge,sophisticated
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 andcomplicated.Modernmanagementofthesefirmsistobecharacterizedbyprofessionalism
andchallenge.

Todayprevailsmostofthisunhealthysituationsthatareattributabletothebusiness
defectsorganisationalstructure,ineffectiveandinefficientdecision-makingandtardyexecution
ofexistingpoliciesandprogrammes.Thetopmanagementandexecutivesatmiddleorlower
levelsalsomakeitimperativetothinksomeinternalcontrolsystem.Itshouldbeatoolfor
evaluationofthemethodsandperformanceinallareasoftheenterprisethatisManagement Audit.

CostAudit:

Costauditingiscompulsorytothesecompanies,whichareengagedin
manufacturing,processingandminingactivities[u/sof209 (d)]ofCompaniesAct.Butu/s233
BofCompaniesAct,specifythatothercompanieswillengagecostaudit,whichwerespecifically
beenworkedtodoso.Costauditisconductedby'CostAccountant'onlywithinthemeaningof
thecostandworksAccountantsAct1959.

CashAudit:Cashauditisatypeofauditunderwhichonlycashtransactionsareaudited.

Thereceiptandpaymentofcashareverifiedwithsupportingdocumentslikevouchers,receipts,
counterfoils,correspondencedocuments,minutesbooks,contractagreementetc....

Thecashaudithascertainlimitationsandrestrictions.Thecashauditormentionsthis
limitationinhisauditreport.Inoldendaysauditwasconfinedasauditofcash.

4. SpecialAudit:

AspecialauditisatypeofauditconductedbytheCentralGovernmentfor
somespecialobjectives.Undersection233Aof theCompaniesAct1956theCentralGovernment
isempoweredtoappointaspecialauditorinthecaseofcompaniesundercertaincircumstances.
Thecircumstancesare:

 Themanagementofthe.companyisnotinproperformandmaycauseseriousdamageto
tradeandindustryandtheshareholderofthecompany.

 Whenthefinancialpositionof thecompanyisconstantlydeteriorating.

 Whenthecompanyisnotbeingmanagedaccordingtosoundbusinessprinciples.

 ThecentralGovernmentmayappointspecialaudit.Thepersonwhoconductsthe
specialauditiscalledspecialauditor.ThespecialauditormustreporttotheCentralGovernment.
Theremunerationof thespecialauditorisdecidedbytheCentralGovernmentandispaidbythe
concernedcompany.

5. OperationAudit:

Operationauditisthepartofmanagementaudit.Itisusuallyconducted
byexternalauditorknownas"ManagementConsultingServices".Thistypeauditalsois
performedbyinternalauditors.

The objectives of operational audit:

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 Improvingtheefficiencyoftheoperations

 Fullerutilisationofmanpowerandplant

 Increaseprofitabilityofthefirm

 Tocreategoodwill

Under thistypeaudit,theauditorscrutnisesbothfinancialandnon-financialactivitiesof thefirm.

EfficiencyAudit:

Thistypeauditisconductedforthepurposeofincreasingefficiencyof the
firm.Italsoaimedatreapingmaximumprofitfromexistingsituations.Thusefficiencyauditis
anaidtomanagement.

DetailedAudit:

Adetailedauditisreferredascontinuousauditorrunningauditorcomplete
audit.Underthistypeofaudit,theauditorchecksindetailallbooksofaccountswithregular
intervals.Detailedcheckingmaybedonethroughapplyingtestchecking.

ProprietyAudit:

Proprietyauditisapartofmanagementaudit.Itistreatedashighformof
audit.Underthistypeofauditneedsclosesecurityofcontracts,analysisofprojectestimates,
manpowerrequirementsandtheirproperutilisationpricingpolicyandsellingpolicyandevaluation
ofperformancewithtarget.

Theaimofproprietyauditistoguaranteethevalidityandproprietyofallthemajor
transactionsandcontractsbytheconcernsareitsbestinterest.Theproprietyauditorhasto
certifytheminhisauditreport.

PerformanceAudit:

Performanceauditisapartofmanagementaudit.Undertheaudit
auditorhasevaluatetheperformanceoftheconcernwithpredeterminedtargetandto&
whetherthefirmisyieldingtheresultwhichareexpected.

RegulatoryAudit:

Regulatoryauditisconductedbyprivatebusinessfirms.The main
objectofthisauditistoseewhethereverytransactionisapprovedandsanctionedbycompetent
authority.Thetransactionsaremadeasperlaw.Underthusaudittheauditorissuesacertificate
thattheaccountsgiveatrueandfairviewofthefinancialpositionofthecompany.

SocialAudit

Socialauditisnowreceivingworldwideacclaimandisdeclaredallovertheworld
adevisetomeasurethebenefits(contributions)madebyanenterprisetothesociety.

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 InthewordsofBauer,"theconceptofsocialauditisavisionthatatsomefuturetime
corporationswillassesstheirsocialperformanceinassystematicamannerastheynowassess
theirfinancialperformance".

Anumberofresearcheshavebeenconductedtodesignaccountingsystem,which
measuresthesocialperformancesof theindustrial,andbusinessorganizations.Mostofto
studiesanditsproposalsaimedatmeasuringthetotalperformancecontributedbytheundertaking
withregardstopubliccontribution,education,medicaltreatment,socialwelfareprotection
environmentproductorservicecontributions.

Theseareallsocialobligations,whichareunlikelegalobligations,whicharefulfilled
compulsoryaccordingtolaw.Itisatypeofvoluntaryeffortsonthepartof theindustrialists and
businessmentosolvethesocialproblems.Thechangesinthesocial,economical,politicalandenviro
nmentalarenasforced
businessenterprisestoperformsocialresponsibility.Socialaudithasreceivedaworldwideacceptan
ce.Suchanauditreportwouldberequiredbothforpublicreportingandforintense
managementpurpose.Thesocialauditcommitteeanalysestheperformanceofindustrial
undertakingindischargingsocialobligations.

12. METHODS OF AUDIT:

The method of audit refers to the extent of work to be performed and/or the manager
of its execution. Generally, the methods audit includes as follows,

Continuous audit

Final audit

Periodical audit

Balance sheet audit

Interior audit

Continuous audit:

Continuous audit is on in which the audit staff is engaged checking of the accounts during
the which year. Thus, continuous audit is conduct either throughout the year or at fixing
periodical internals.

Merits of Continuous audit:

 Errors can be discovered earlier rectified immediately with the result that the effect of the
errors need may be carried out for a longer period/time.

 The continuous attendance of the auditor creates moral check among staff and lessens the
possibility and committing frauds.

 Since the audit is carried out throughout the year, there is sufficient time for the detailed and
exhaustive checking of the accounts.

 The auditor can perform his duties without strain.

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 Demerits:

 continuous audit involves good deal of time.

 It is expensive.

Final audit:

Final audit is otherwise known as complete audit. It is commonly understand as an audit

which is carried out after the close of the accounting year. Final audit begins when the
accounting for the period ends. The auditor visits his clients only once a year to conduct the
audit.

Advantages:

 The cost of the audit will be comparatively less.

 The time consumed will be less

 The auditor can make the audit report without any difficult.

Demerits:

 The errors are found only after close of accounting period

 There is sufficient time for the accounting staff to manipulate the accounts

Periodical audit:

Periodical audit refers to the audit at periodical intervals.

During each visit the auditor completes his work up to the period of next visit. This enables
the auditor to complete his audit soon after the close of accounting year.

Balance sheet audit:

This audit consists mainly of the verification of each of the teams in the balance
sheet. Naturally, the verification of each of each item in the Balance sheet leads to complete
examination of the different items of expenditure and their allocation into capital and
revenue. Under balance sheet audit the work commences from the balance sheet working
back to the books of prime entry and documentary evidence.

Balance sheet audit closely corresponds to the method of ascertaining the profit on the basis
of single entry book keeping systems.

Interior Audit:

Interior audit is one where the auditor conducts the audit for a part of the accounting year. It
is an audit conducted at a particular data within the accounting period. The audit is carried
out for a specified purposed.

Efficiency-cum-Performance Audit

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 Before independence, Government audit was mostly confined to check individuals,
transaction against provision of funds, rules or orders or sanction or propriety of
expenditure.

 These methods are quite effective and fruitful in detecting improper, irregular, extravagant ,
wasteful and uneconomic expenditure.

 But after independence, the pattern of Government expenditure, its nature and dimension
underwent rapid change in the wake of increasing Government expenditure on development
and welfare activities.

 The security of individual transaction was felt quite inadequate.

 It become necessary and essential for audit to ascertain whether the various department
programs and accordingly been developed to meet the changing requirements.

 This audit involves review of performance of a scheme in terms of the goals and objectives.

 Economy is the practical systematic management of the affairs of a scheme of project with
minimum operating cost for carrying out its functions and responsibilities.

Efficiency

Efficiency is the accomplishment of assigned goals, production targets or other specific

programs, objectives in a systematic manner with minimum operating cost without
detracting from the level, quality or timing of the services to be provided.

Effectiveness

Effectiveness is the adoption of a course of action which assures achievement of objects at

the lowest reasonable cost and in a practical manner within an agreed time frame.

Development of Audit Plan

A specific audit plan is chalked out in advance indicating the guidelines for investigation
marking out the offices to be visited and the time allotted for completing the review.
Necessary format and questionnaire are also prepared for collection of important data
relating to the various aspects of the scheme from the field offices.

Review proper

The approach of audit is systematic methodical, logical and rational. The review always
commences with an in-depth study of files in the offices in the concerned administrative
department and heads of department. While scrutinizing the records, audit is to see whether

1) The objectives of the project have been well defined and are in conformity with the
accepted policies and decisions of the Government

2) Programmes have been drawn up in accordance with these objectives and are being
implemented by specific and well defined procedures

698
 3) a good monitoring/management information system exists for collecting reliable data and
whether the date is effectively utilized to improve organization or remedial deficiencies with
utmost speed.

Systems of Audit

The system of audit can be broadly classified into two viz. central audit and local audit.

Central Audit

The systems of Central audit is confined to the offices of Accountant General (Audit)
located in the State Capital. Central Audit is based on the Accounts, vouchers schedules and
other documents submitted to him by various disbursing authorities like the Treasuries, PW
Divisions, Forest Divisions as also the copies of sanction endorsed to the AG's by the
various sanctioning authorities.

The following are the duties and functions carried out in Central Audit.

a) Audit of sanction and agreements

b) Audit of vouchers and monthly accounts

c) Recording of the objections in the objection book and issue of the objection memos and
pursuance with the concerned departments

d) Scrutiny and certification of finance and appropriation accounts Central Audit is by and
large regularity and propriety.

Local Audit Inspection

 The major portion of the original records namely the initial accounts and other books or
papers on which the accounts so rendered are based are retained in the offices where they
originate.

 To enable him to assure himself of the accuracy of the original data on which the accounts
and his audit work are based, the Accountant General has authority to inspect any offices of
Accounts which is under the control of the State Government including treasuries and such
offices responsible for the keeping of initial or subsidiary accounts.

 The object of local audit is to audit the initial or subsidiary accounts.

 The object of local audit is to audit the initial accounts maintained properly, the financial
rules are properly observed, whether the accounts are accurate and complete according to the
prescribed rules for the audit of expenditure and receipts of the Government.

13. TECHNIQUES OF AUDITING :

* Techniques of auditing are the processes and the plan of work of the auditor to collect
evidences and review them to satisfy himself of the correctness of the financial operations
and its result. The process includes.

* The auditor makes physical examination of the assets, satisfies himself about the existence
of the assists and in case certain assets and their utilization.
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* Obtains conformation of the statements and certificated made available to him.

* Examines the documentary evidence with the transactions

* Scans the books of accounts in detail to satisfy that all transactions are correctly and
completely entered into the books.

* Makes queries to important officials through tactful questions and correlate his answer.

* Analyses the financial statements and works out ratios to understand the relationship
between different items of expenditures, incomes and other financial operations and
compares them with the previous period for any large variation.

* Uses the system of flow chart to find out the control operation and various systems involved
in the business.

* Adopts different types of ticks in the course of examination of the accounts with a view of
maintaining the secrecy in the examination of books.

* Carries out test checks by following sampling methods to verify soundness of the internal
control and the system of accounting in vogue.

* Issues questionnaires to satisfy himself of the adequacy of internal control in existence in the
business.

* Gets confirmation of certain commitments of the business from the authorities, obtains
statements of cash balance, debtors balance, creditors balances and bank reconciliation
statements.

* Verifies the organizational structure of the business with reference to flow of authority
delegation of powers etc.,

14. AUDIT COMMITTEE:

Before carrying out an audit, an audit committee should be formed, comprising of a

minimum of 5 members who are interested in quality assurance, are clinically competent and
able to work together in a group.

It is recommended that each member should review not more than 10 patients each month
and that the auditor should have the ability to carry out an audit in about 15 minutes. If there
are less than 50 discharges per month, then all the records may be audited, if there are large
number of records to be audited, then an auditor may select 10 percent of discharges.

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Audit
cycle

Measure
selected topic
Review
Review The against
standards standard
Audit
Implement Cycle Identify
action gaps
Decide
action
15. QUALITIES OF AN AUDITOR:

An auditor must possess certain qualities to perform his duties efficiently. These qualities
will help him of smooth conduct of audit and maintain the high tacticians of the professions.

Knowledge of accountancy and the commercial law:

Auditor has to check the books of accounting and satisfy that they reveal the true and fair
view of the state of affairs of the business. Hence, he should know the principles of
accounting of transactions and the different ways in which the accounts are maintained.

Honesty and integrity :

The auditor certificates are taken as true and the profession is recognized for its morale and
honesty. The social recognition to the profession, is such that the public looks forward to his
with confidence for his report on business

Skill and tact:

An auditor often has to act with care and skill to elicit informal from his clients and
the accounting staff of the business and to satisfy about the truthfulness of the transaction.
He may have to ask questioning such a way that the staff may not be prejudiced or opposed
to answering them. Hence tact is required.

Patience and perseverance:

An audit tor must have utmost patience in carrying out his duties. He must hear his clients
fully He should have firm conviction of his actions.

Ability to work hard:

Auditor should be witching to undertake hard work and evidence interest in his work.

701
Ability to maintain secrets:

Auditor while dealing with the books of accounts d his clients may come across information
which needs to be maintained secret. The auditor must possess and develop the quality of
maintaining secrecy client's affairs.

Knowledge of Report writing:

The observations and finding of the auditor are to be written in the form of a report and sent
to the client for information. The report is to be written in a concise form and in an under-
stand able language, free from ambiguity and contradictions. At the sometime, his opinion is
to be given in clear terms. Hence the auditor should know as to how to write a report.

Common sense:

Above all these qualities, an auditor must possess common sense. He must have
practical wisdom and act with presence of mind. He should act in a rational manner should
exercise constant vigilance.

16. BENEFITS OF AUDITING IN HOSPITALS

Benefits to the patients: Better service is given to the patient because when comes, is kept
on the highest plane of efficiency. The attending physician leaves nothing undone that will
contribute to patient's early recovery.

Benefits to the physician: The clinical conferences increase the efficiency of individual
physician. They provide the much needed continued medical education of the physicians as
they are closer to new techniques of therapeutic and surgery. A good clinical conference
tends to eliminate unfriendliness and jealousies by affording an opportunity for the exchange
of viewpoints. So, the medical audit therefore serves to response the physician to his best of
all times.

Benefits to the Hospitals : There are three distinct advantages to the hospital. The medical
staff conferences are helpful in monitoring the professional work revealing weakness and
strengths thereby ensuring constant improvement. The medical audit gives the comparison
comparable institutions possible. All these contribute in improvement of hospital image b/
generating fetching of confidence in the community.

17. NURSING AUDIT:

Nursing audit may be defined as a detailed review and evaluation of selected clinical records
in order to evaluate the quality of nursing care and performance by comparing it with
accepted standards. To be effective a nursing audit must be based on established criteria and
feedback mechanism that provide information to providers on the quality of care delivered.
To evaluate quality nursing care regularly, many staff nurses do indeed welcome
opportunity to develop criteria, to review nursing care retrospectively and concurrently, and
to discover methods of achieving higher levels of quality nursing care.

17.1. Definition:

According to Elison "Nursing audit refers to assessment of the quality of clinical nursing".

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 According to GosterWalfer Nursing Audit is an exercise to find out whether good nursing
practices are followed.

The audit is a means by which nurses themselves can define standards from their point of
view and describe the actual practice of nursing.

17.2. Purposes of Nursing Audit

 Evaluating Nursing care given,

 Achieves deserved and feasible quality of nursing care,

 Stimulant to better records,

 Focuses on care provided and not on care provider,

 Contributes to research.

17.3. Methods of Nursing Audit

There are two methods:

17.3.1. Retrospective view - this refers to an in-depth assessment of the quality after the
patient has been discharged, have the patients chart to the source of data.

Retrospective audit is a method for evaluating the quality of nursing care by examining the
nursing care as it is reflected in the patient care records for discharged patients. In this type
of audit specific behaviors are described then they are converted into questions and the
examiner looks for answers in the record. For example the examiner looks through the
patient's records and asks :

Was the problem solving process used in planning nursing care?

Whether patient data collected in a systematic manner?

Was a description of patient's pre-hospital routines included?

Laboratory test results used in planning care?

Did the nurse perform physical assessment? How was information used?

Were nursing diagnosis stated?

Did nurse write nursing orders? And so on.

17.3.2. The concurrent review : This refers to the evaluations conducted on behalf of
patients who are still undergoing care. It includes assessing the patient at the bedside in
relation to pre-determined criteria, interviewing the staff responsible for this care and
reviewing the patients record and care plan

17.4. Advantages of Nursing audit:

Can be used as a method of measurement in all areas of nursing,

Seven functions are easily understood,

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Scoring system is fairly simple

Results easily understood

Assesses the work of all those involved in recording care

May be a useful tool as part of a quality assurance programme in areas where accurate
records of care are kept.

17.5. Disadvantages of the Nursing audit:

Appraises the outcomes of the nursing process, so it is not so useful in areas where the
nursing process has not been implemented.

Many of the components overlap making analysis difficult

Is time consuming

Requires a team of trained auditors

Deals with a large amount of information

Only evaluates record keeping. It only serves to improve documentation, not nursing care.

17.6. Types of Nursing audit:

Prospective audits are future oriented and attempt to identify how future performance will be
affected by current performance. The audits most frequently used in quality control include
outcome, process and structure audits.

Outcome audit

Outcomes are the end results of care the changes in the patients health status and can be
attributed to the delivery of health care services, outcome audits determine what results if
any occurred as result of specific nursing intervention for clients. These audits assume the
outcome accurately and demonstrate the quality of care that was provided.

Example: Outcomes traditionally used to measure quality of hospital care include mortality
its morbidity, and length of hospital stay.

Process audit

Used to measure the process of care or how the care was carried out, process audit task
oriented and focus on whether or not practice standards are being fulfilled.

These audits assume that a relationship exists between the quality of the nurse and quality of
care provided.

Structure audit:

Monitors the structure of setting in which patient care occurs, such as the finances, nursing
services, medical records and environment. This audit assumes that a relationship exists
between quality care and appropriate structure.

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These above audits can occur retrospectively concurrently and prospectively.

2. COST ACCOUNTING

18. INTRODUCTION:

There is a competition everywhere. There is a struggle for existence in every field. This is
true in the field of business also. Every business unit needs to carry on its activities in the
most efficient manner. Accounting plays an important role in the efficient and successful
running of business.

There are three branches of accounting. They are financial accounting, management
accounting and cost accounting. Financial accounting is the traditional form of accounting.
It is concerned with the recording of day-to-day transactions of the business in the proper of
account. The objective is to prepare profit and loss account and balance sheet. Management
accounting refers to the accounting for management . It relates to the use of financial and
cost data in the task of managerial decision making.

Financial accounting is really inadequate for manufacturing enterprises. Manufacturing

enterprises. Manufacturing enterprises require a specialised branch of accounting. This
specialised branch of accounting is known as cost accounting.

18.1.MEANING AND DEFINITION OF COST;

The term “cost “ carries different meanings. But in cost accounting it is used in special
sense. Cost may be defined as the monetary value of all sacrifices made to achieve an
objective. It refers to resources spent for producing a product or rendering a service or
attaining any other objective.

The resources may be tangible ( machinery , materials, vehicles etc.) or intangible (wages ,
salaries, rent, power etc. )

Cost is defined as “the amount of expenditure (actual or notional ) incurred on or attribute to

a specified thing or activity”.

-I.C.M.A., London.

18.2. DEFINITION OF COSTING:

Costing is defined as, “the technique and process of ascertaining the cost”.

-I.C.M.A, London

18.3. MEANING AND OF COST ACCOUNTING

Cost accounting is the process of determining and accumulating the cost of product or
activity. It is a process of accounting for the incurrence and the control of cost. It also covers
classification, analysis, and interpretation of cost. In other words, it is a system of
accounting, which provides the information about the ascertainment, and control of costs of
products, or

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 services. It measures the operating efficiency of the enterprise. It is an internal aspect of the
organisation.

Cost Accounting is accounting for cost aimed at providing cost data, statement and reports
for the purpose of managerial decision making. The Institute of Cost and Management
Accounting, London defines “Cost accounting is the process of accounting from the point at
which expenditure is incurred or committed to the establishment of its ultimate relationship
with cost centres and cost units.

In the widest usage, it embraces the preparation of statistical data, application of cost control
methods and the ascertainment of profitability of activities carried out or planned”. Costing
includes “the techniques and processes of ascertaining costs.” The ‘Technique’ refers to
principles which are applied for ascertaining costs of products, jobs, processes and services.
The `process’ refers to day to day routine of determining costs within the method of costing
adopted by a business enterprise.

Costing involves “the classifying, recording and appropriate allocation of expenditure for the
determination of costs of products or services; the relation of these costs to sales value; and
the ascertainment of profitability”.

In management accounting, cost accounting establishes budget and actual cost of operations,
processes, departments or product and the analysis of variances, profitability or social use of
funds.

Managers use cost accounting to support decision-making to cut a company's costs and
improve profitability. Costs are measured in units of nominal currency by convention.

Cost accounting can be viewed as translating the Supply Chain (the series of events in the
production process that, in concert, result in a product) into financial values.

The nurse manager or administration may function as an intermediary between the

personnel or pay -all department and the staff, in matters regarding wages and pay checks.
The nurse manager is responsible for business communications representing the nursing
unit’s staffing and budgetary needs.

18.4. ORIGINS

 Cost accounting has long been used to help managers understand the costs of running a
business.

 Modern cost accounting originated during the industrial revolution, when the complexities
of running a large scale business led to the development of systems for recording and
tracking costs to help business owners and managers make decisions.

 In the early industrial age, most of the costs incurred by a business were what modern
accountants call "variable costs" because they varied directly with the amount of production.
Money was spent on labor, raw materials, power to run a factory, etc. in direct proportion to
production.

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 Managers could simply total the variable costs for a product and use this as a rough guide
for decision-making processes.

 Some costs tend to remain the same even during busy periods, unlike variable costs which
rise and fall with volume of work. Over time, the importance of these "fixed costs" has
become more important to managers.

 Examples of fixed costs include the depreciation of plant and equipment, and the cost of
departments such as maintenance, tooling, production control, purchasing, quality control,
storage and handling, plant supervision and engineering. Managers must understand fixed
costs in order to make decisions about products and pricing.

 For example: A company produced railway coaches and had only one product.

 To make each coach, the company needed to purchase $60 of raw materials and
components, and pay 6 laborers $40 each.

 Therefore, total variable cost for each coach was $300. Knowing that making a coach
required spending $300, managers knew they couldn't sell below that price without losing
money on each coach.

 Any price above $300 became a contribution to the fixed costs of the company. If the fixed
costs were, say, $1000 per month for rent, insurance and owner's salary, the company could
therefore sell 5 coaches per month for a total of $3000 (priced at $600 each), or 10 coaches
for a total of $4500 (priced at $450 each), and make a profit of $500 in both cases.

18.5. SCOPE OF COST ACCOUNTING

The terms ‘costing’ and ‘cost accounting’ are many times used interchangeably. However,
the scope of cost accounting is broader than that of costing. Following functional activities
are included in the scope of cost accounting:

1. Cost book-keeping: It involves maintaining complete record of all costs incurred from
their incurrence to their charge to departments, products and services. Such recording is
preferably done on the basis of double entry system.

2. Cost system: Systems and procedures are devised for proper accounting for costs.

3. Cost ascertainment: Ascertaining cost of products, processes, jobs, services, etc., is the
important function of cost accounting. Cost ascertainment becomes the basis of managerial
decision making such as pricing, planning and control.

4. Cost Analysis: It involves the process of finding out the causal factors of actual costs
varying from the budgeted costs and fixation of responsibility for cost increases.

5. Cost comparisons: Cost accounting also includes comparisons between cost from
alternative courses of action such as use of technology for production, cost of making
different products and activities, and cost of same product/ service over a period of time.

6. Cost Control: Cost accounting is the utilisation of cost information for exercising control.
It involves a detailed examination of each cost in the light of benefit derived from the

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 incurrence of the cost. Thus, we can state that cost is analysed to know whether the current
level of costs is satisfactory in the light of standards set in advance.

7. Cost Reports: Presentation of cost is the ultimate function of cost accounting. These
reports are primarily for use by the management at different levels. Cost Reports form the
basis for planning and control, performance appraisal and managerial decision making.

18.6. OBJECTIVES OF COST ACCOUNTING

* Cost accounting will be part of total management plan for all level of hospital personnel and
will he used between hospital and regulator or third-party payer.

* Nurse Manager well develops clear cost- accounting Objectives with the hospital
administrator and other associate administrators.

* Nurse Managers will use various objectives pertaining to the methodology of cost
accounting they will include methods for measuring the industry of severity of illness as
well as case mix a patients.

* It is also important to have objectives and method for measuring performance or outcome
against standards.

* These standard will include short-term expenses related to use of all resources. Information
will be relayed to all managers to particularly cost-center manager.

* Nurse manager will also have objectives and method to make maximal use of variable costs.
They can be controlled more easily through staffing methodologies.

* All this objectives for cost according need to be co-ordinate with and other affected
department if they are tohe effective in controlling costs.

* Cost accounting in important to cost management as it describes cost behavior.

There is a relationship among information needs of management, cost accounting objectives,

and techniques and tools used for analysis in cost accounting.

Cost accounting has the following main objectives to serve:

1. Determining selling price,

2. Controlling cost

3. Providing information for decision-making

4. Ascertaining costing profit

5. Facilitating preparation of financial and other statements.

1. Determining selling price

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The objective of determining the cost of products is of main importance in cost accounting.
The total product cost and cost per unit of product are important in deciding selling price of
product. Cost accounting provides information regarding the cost to make and sell product
or

services. Other factors such as the quality of product, the condition of the market, the area of
distribution, the quantity which can be supplied etc., are also to be given consideration by
the management before deciding the selling price, but the cost of product plays a major role.

2. Controlling cost

Cost accounting helps in attaining aim of controlling cost by using various techniques such
as Budgetary Control, Standard costing, and inventory control. Each item of cost [viz.
material, labour, and expense is budgeted at the beginning of the period and actual expenses
incurred are compared with the budget. This increases the efficiency of the enterprise.

3. Providing information for decision-making

Cost accounting helps the management in providing information for managerial decisions
for formulating operative policies. These policies relate to the following matters:

(i) Determination of cost-volume-profit relationship.

(ii) Make or buy a component

(iii) Shut down or continue operation at a loss

(iv) Continuing with the existing machinery or replacing them by

improved and economical machines.

4. Ascertaining costing profit

Cost accounting helps in ascertaining the costing profit or loss of any activity on an
objective basis by matching cost with the revenue of the activity.

5. Facilitating preparation of financial and other statements

Cost accounting helps to produce statements at short intervals as the management may
require. The financial statements are prepared generally once a year or half year to meet the
needs of the management. In order to operate the business at high efficiency, it is essential
for management to have a review of production, sales and operating results. Cost accounting
provides daily, weekly or monthly statements of units produced, accumulated cost with
analysis.

Cost accounting system provides immediate information regarding stock of raw material,
semi-finished and finished goods. This helps in preparation of financial statements.

18.7. FUNCTION OF COST ACCOUNTING

1. Cost of findings: Analyzing and finding costs of products, services, process operations
and in nursing practice is an important function of cost accounting.

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 2. Costing out nursing services: It also help the nurse managers and hospital administration
to charge the nursing services.

3. Profit Determination: Cost accounting data facilitate profit of income determination at

any time of the year for managerial information.

4. AID to budgeting: Cost accounting in framing budgets, since it supplies historical costs
on the best of which budgetary cost are projected into the future.

5. Cost control: He also help to reduce the cost of operation in nursing service in hospital
offering close charges on purchasing, store keeping and handling of supplies equipment in
nurse service.

18.8. RESPONSIBILITIES OF THE NURSE MANAGER:

The nurse manager by understanding systems like patient classification systems, staffing
and scheduling well be able to provide cost-effective patient care.

Risk Management and insurance cost

The hospital staffs are taught to be concerned about the safety of the environment- for the
such of both staff the chart safety campaigns cautions the workers about potential electrical
hazard.

Various types of spells on the floor improper disposal of needed and danger of cumulative
exposure to radiation.

The insurance policies are based on calculation in volume the average no and types of claims
processed and the average expected dollar payment needed to pay the insured or the
beneficiary for any for any loss.

18.8. DIFFERENCE BETWEEN FINANCIAL ACCOUNTING ANDCOST

ACCOUNTING

After studying financial accounting and cost accounting, you can understand the difference
between these two accounting systems. Therefore, difference between financial accounting
and cost accounting is as follows:

Differences between financial accounting and cost accounting

Basis Basis Financial Accounting Basis Financial Accounting Cost

Financial Cost accounting accounting
Accounting
Cost
accounting

Objective It provides information about It provides information of

the financial performance and ascertainment of cost to control cost
financial position of the and for decision making about the
business. cost.

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Nature It classifies records, presents It classifies records, presents and
and interprets transactions in interprets in a significant manner the
terms of money. material, labor and overheads cost.

Recording of It records historical data. It also records and presents the

data estimated budgeted data. It makes
use of both the historical costs and
pre-determined costs.

Users of The users of financial The cost accounting information is

information accounting statements are used by internal management at
shareholders, creditors , different levels.
financial analysts and
government and its agencies
etc.

Analysis of It sows the profit loss of the It provides the details of cost and
costs and organisation. profit of each product, process ,job,
profits contracts, etc.

Time period Financial statements are Its reports and statements are
prepared for a definite period , prepared as and when required.
usually a year.

Presentation A set format is used for There are not any set formats for
of presenting financial presenting cost information.
information information.

In spite of the above differences, both financial and cost accounting are in agreement
regarding actual cost data and product costing analysis. Values of stock and cost of goods
produced and sold are the main examples. For the preparation of the position statement,
financial accountant receives the necessary data from the cost accountant.

18.9. IMPORTANCE OF COST ACCOUNTING

The limitation of financial accounting has made the management to realize the importance of
cost accounting. The importance of cost accounting are as follows:

18.9.1. Importance to Management

Cost accounting provides invaluable help to management. It is difficult to indicate where the
work of cost accountant ends and managerial control begins. The advantages are as follows :

Helps in ascertainment of cost

Cost accounting helps the management in the ascertainment of cost of process, product, Job,
contract, activity, etc., by using different techniques such as Job costing and Process costing.

Aids in Price fixation

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By using demand and supply, activities of competitors, market condition to a great extent,
also determine the price of product and cost to the producer does play an important role. The
producer can take necessary help from his costing records.

Helps in Cost reduction

Cost can be reduced in the long-run when cost reduction programme and improved methods
are tried to reduce costs.

Elimination of wastage

As it is possible to know the cost of product at every stage, it becomes possible to check the
forms of waste, such as time and expenses etc., are in the use of machine equipment and
material.

Helps in identifying unprofitable activities

With the help of cost accounting the unprofitable activities are identified, so that the
necessary correct action may be taken.

Helps in checking the accuracy of financial account

Cost accounting helps in checking the accuracy of financial account with the help of
reconciliation of the profit as per financial accounts with the profit as per cost account.

Helps in fixing selling Prices

It helps the management in fixing selling prices of product by providing detailed cost
information.

Helps in Inventory Control

Cost furnishes control which management requires in respect of stock of material, work in
progress and finished goods.

Helps in estimate

Costing records provide a reliable basis upon which tender and estimates may be prepared.

18.9.2. Importance to Employees

Worker and employees have an interest in which they are employed. An efficient costing
system benefits employees through incentives plan in their enterprise, etc. As a result both
the productivity and earning capacity increases.

18.9.3. Cost accounting and creditors

Suppliers, investor’s financial institution and other moneylenders have a stake in the success
of the business concern and therefore are benefited by installation of an efficient costing
system. They can base their judgement about the profitability and prospects of the enterprise
upon the studies and reports submitted by the cost accountant.

18.9.4. Importance to National Economy

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An efficient costing system benefits national economy by stepping up the government
revenue by achieving higher production. The overall economic developments of a country
take place due to efficiency of production.

18.9.5. Data Base for operating policy

Cost Accounting offers a thoroughly analysed cost data which forms the basis of
formulating policy regarding day to day business, such as:

(a) Whether to make or buy decisions from outside?

(b) Whether to shut down or continue producing and selling at below cost?

(c) Whether to repair an old plant or to replace it?

18.10. LIMITATIONS OF COST ACCOUNTING

Like other branches of accounting, cost accounting is not an exact science but is an art which
has developed through theories and accounting practices based on reasoning and common
sense. Cost accounting is a normative science. Even though cost accounting is highly useful,
it suffers from the following limitations :

The limitations of cost accounting are as follows:

Cost accounting lacks uniformity . different organisations prepare cost records in different
methods and forms. As a result cost results of different organisations are not comparable.

Cost accounting has only a limited use in projecting future costs. It provides data for
arriving at decisions. It does not offer solutions to a problem.

Cost accounting is only one of the means of achieving cost control and improvement of
efficiency. It does not by itself achieve these objectives.

Computation of cost depends on the purpose .cost computed for one purpose may not be
suitable for some other purposes .

Cost accounting system is applicable only to manufacturing and service units. It is not
suitable to trading concerns.

Cost accounting system is more complex because a number of steps are involved in
ascertaining costs.

Cost accounting is based on assumptions and presumptions. Hence it is not accurate.

It is expensive because analysis, allocation and absorption of overheads require considerable

amount of additional work.

The results shown by cost accounts differ from those shown by financial accounts.
Preparation of reconciliation statements frequently is necessary to verify their accuracy. This
leads to unnecessary increase in workload.

It is unnecessary because it involves duplication of work. Some industrial units are

functioning efficiently without any costing system.
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Costing system itself does not control costs. If the management is alert and efficient, it can
control cost without the help of the cost accounting.

18.11. ACTIVITY-BASED COSTING

Activity-based costing (ABC) is a costing model that identifies activities in an organization

and assigns the cost of each activity resource to all products and services according to the
actual consumption by each: it assigns more indirect costs (overhead) into direct costs.

In this way an organization can precisely estimate the cost of its individual products and
services for the purposes of identifying and eliminating those which are unprofitable and
lowering the prices of those which are overpriced.

In a business organization, the ABC methodology assigns an organization's resource costs

through activities to the products and services provided to its customers. It is generally used
as a tool for understanding product and customer cost and profitability. As such, ABC has
predominantly been used to support strategic decisions such as pricing, outsourcing and
identification and measurement of process improvement initiatives.

According to Ray H. Garrison and Eric W.Noreen, there are six basic steps required
toimplement an ABC system:

1. Identify and define activities and activity pools

2. Directly trace costs to activities (to the extent feasible)

3. Assign costs to activity cost pools

4. Calculate activity rates

5. Assign costs to cost objects using the activity rates and activity measures previously
determined

6. Prepare and distribute management reports

18.12. FINANCIAL STANDARDS AND RESPONSIBILITY ACCOUNTING

In an era of retrenchment in the hospital industry, professional nurses will be asked to

reduce waste while they will be expected to maintain high Standards of care, the will also of
care, they will also he expected to compare treatment expenses with classical benefits. This
will mean making efficient decision has these. One way nurse can do this is through system
of responsibility accounting.

According to McRullers and schroides, a responsibility accounting system for making

efficient decision has these characteristics.

1. DECISION USE FULNESS - information must be relevant and reliable.

2. TIMELINESS – The information can be available to the decision maker before it

capacity to economize expenditure.

Favorable/Benefit ratio : The benefit desired from the information must exceed the cost of
collecting, maintaining and processing it.
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Understandability : information content must be intelligible to those who must handle it
and be presented in a form they can grasp.

Relevance : The information collected must actually make a difference in decisions to be

made.

Reliability :Information should faithfully represent what it passports to represent.

Verifiability :Agreement among independent measures using the same measurement

method can demonstrate content validity to referents.

3. MATERIALITY : Information magnitude has a significant impact on resources of the

unit or the organization as a whole.

Comparability and consistency: Current information can be compared with similar

information about the same unit for another period of time.

Neutrality : Accounting methods should be free from bias towards a predetermined result.

Predictive value and feed back value: The information should be able to help pediatric
confirm expectations. Like all other characteristics of quality control a system of
responsibility accounting needs pertinent standards.

The cost of nursing care

i) To determine the cost of nursing care several factors should be considered. Nursing
charges should be quantifiable. A patient acuity system can be used for this purpose. The
patient acuity acuity system usually separates patients unit four or five levels of nursing
care. Charges are set by level and will be negotiated with third party pay us. Non-nursing
task are reassigned to ensure that the charges for nursing care relict the actual cost of
providing such cost.

ii) A second method a costing nursing is determining the share of total hospital cost
attributable to nursing.

18.13. ADVANTAGES OF COST ACCOUNTING:

The primary advantage of cost accounting is that, data accumulated through this method
will enable the head nurse or supervisor to assess the cost of each additional demand
imposed upon her responsibility.

1. Financial data obtained through this method will enable the nurse manage to identify
interaction between different types of expenditures in nursing service.

2. It also provided data which shows the need for addition of removal of employees from
patriotic unit.

3. It enables the nurse manages to identify popular nursing service programs that received
children pending in the forms of voluntary time contributors by professional.

18.14.DISADVANTAGES OF COST ACCOUNTING:

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 1. Primary disadvantage of cost accounting are that, it is excluding different to associate
some cost with particular program.

2.It is difficult for the manage to interpret or the cost a nursing care program output in terms
of improved health or enhanced quality of life for patient served.

18.15.APPLICATIONS FOR NURSE MANAGER

The following list of hints can be helpful to assist the nurse manager.

 Monitor the use of equipment and supplies.

 Work with staff to identify changing resource requirement.

 Complete forms on time and justify requisites for resources.

 Keep current with technological advances and trends.

 Communicate with other departments and parties involved in the budgeting.

 Engage in continuing education related to financial management responsibility.

 Become familiar with the approach to budgeting and the budgeting policies, procedures used
by the agency.

 Ensure that quality of care measurable don’t become last process and procedures used by the
agency.

 Ensure that quality of care measures do not become lost in the process.

18.16. CONTRIBUTING FACTORS IN RISING HEALTH CARE COST

Many factors contribute to the rising cost of health care.

1. Price of new technology

One important factors in cost increase in the price of new technology new more
sophisticated and treatment devices are developed each year. The rising cost of technology
affects every area of the health care field, from the cardiac care unit to laboratory.

2. Construction of new facilities

 An increasing population needs a greater number of facilities, and the construction of new
care facilities also contribute to response cost.

 In addition existing facilities after require modification.

 More space is needed for new technologies both at bed side and many departments.
Computer system is used more often for documentation of care.

 Besides computers that enable documentation to be done at the point of case disease the
amount of time required for paper world, they also have other facilities like fire safety
infection control measures and protection against environmental hazards.

 These factors combine to make ‘per bed’ cost increasingly expensive.

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3. Higher survival rates leading to greater need for costly intensive or long-term care

The average length of hospital stay for standard diagnosis has decreased steadily. The
typical client in today’s hospital is discharged rapidly to convalescence at home in long
term care facility leaving behind only the acutely ill. Many clients who would have did
quickly in each year live through a crisis but require long and intensive care. This is turn
requires more intensive observation and care and use of more specialized equipment.

4.Growing population of elderly adults requiring health care

The population as a whole is growing order and statistically elderly have an increased
incidence of all chronic illness. A greater percentage of the population require health care on
a register basis and many depend a medication, treatment and therapies for continuing
functioning.

5.Rise in salaries for health care workers

Until recently, the salaries of health worker were for below those of the general society.
To remedy this for a time salaries of health care workers rose more rapidly than the general
information rate.

6.High costs of drug and health related equipment.

Companies that manufacture health related devices and drug reportedly have some of
the highest profits in any industry. These companies justify their profits as appropriate
relative to the risk and cost involved in research and development. However some cities
believe these companies take advantage of the public dependence on their products. For,
example, recent evidence indicates that drug companies spend more an advertising they do
on research.

7. Lack of competition

Lack of competition in the health care field is one factor that many contribute to
higher cost. Although physicians continue to be primary gate keepers in the system, the
advent of other primary care providers, such as nurse practitioner and nurse midwives, has
offered alternate and less costly for many routine problem and for normal child birth
process. There has been opportunity for these to operate in collaborative rather than
dependence or subordinate roles.

8. Prospective payment

A prospective payment is a reimbursement amount for a procedure a that has been

determined in advance of the provision of service. The pre determined amount is paid
amount without regard to actual cost in individual’s situation. Prospective payment in based
on fluid reimbursement amount for a major illness or acuity category.

Prospective payment is designed to provide an incentive for hospitals to control costs.

Another advantage to payers in a prospective payment system is that costs are predictable.
The system transfers the rests from payer to the provider.

9. Diagnosis related group (DRG)

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 The major change in the method of payment for health care services began on
October

1 st 1983 when the feudal government stopped using a fee for service reimbursement
system for medicare and introduced a prospective payment system using (DRG) to
determine the payment of each person adult to the hospital. This change was designed stop
the spiraling costs of Medicare and to correct equivalent that made the cost of care in one
facility very different from those in another facility.

3 . COST EFFECTIVENESS

19.INTRODUCTION:

The term cost-effectiveness has become synonymous with health economic evaluation and
has been used (and misused) to depict the extent to which interventions measure up to what
can be considered to represent value for money. Strictly speaking, however, cost-
effectiveness analysis is one of a number of techniques of economic evaluation, where the
choice of technique depends on the nature of the benefits specified.

Cost-effectiveness analysis has been defined by the National Institute for Health and
Clinical Excellence (NICE) as an economic study design in which consequences of different
interventions are measured using a single outcome, usually in ‘natural’ units (for example,
life-years gained, deaths avoided, heart attacks avoided or cases detected).

Alternative interventions are then compared in terms of cost per unit of effectiveness. In
cost–utility analysis the benefits are expressed as quality-adjusted life-years (QALYs) and
in cost–benefit analysis in monetary terms. As with all economic evaluation techniques, the
aim of cost effectiveness analysis is to maximise the level of benefits – health effects –
relative to the level of resources available.

With the increased interest in containing health care costs, economic issues in
nursing are receiving much greater attention in recent years. Because nurses belong to the
largest health care profession and are thus in a position to influence health care costs, it is
essential that all nurses understand basic concepts of economics and fiscal (money)
management.

Cost-effectiveness analysis compares the costs and health effects of an intervention to assess
the extent to which it can be regarded as providing value for money. This informs decision-
makers who have to determine where to allocate limited healthcare resources.

It is necessary to distinguish between independent interventions and mutually exclusive

interventions. For independent interventions, average cost-effectiveness ratios suffice, but
for mutually exclusive interventions, it is essential to use incremental cost-effectiveness
ratios if the objective – to maximise healthcare effects given the resources available – is to
be achieved.

Cost-effectiveness ratios should be related to the size of relevant budgets to determine the
most cost-effective strategies.

Cost–utility analysis is the approach required by the National Institute for Health and
Clinical Excellence, and other assessment agencies (for example, the Scottish Medicines
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Consortium and the All Wales Medicines Strategy Group), to determine the relative cost-
effectiveness of therapeutic interventions.

All cost-effectiveness analyses should be subjected to sensitivity analysis, which should be

included as part of the reporting ofthe findings.

Cost-effectiveness is only one of a number of criteria that should beemployed in

determining whether interventions are made available.

Issues of equity, needs and priorities, for example, should also form part of the decision-
making process.

Care should be exercised in interpreting cost-effectiveness studies to ensure that all

underlying assumptions have been made explicit and the context and perspective of the
study are adequately reported.

19.1.MEANING OF COST EFFECTIVENESS

The desired end product of a careful fiscal planning is cost effectiveness.

Cost –effectiveness does not mean inexpensive; it means getting the most for your money,
or that the product is worth the price. Buying a very expensive piece of equipment may be
cost-effective if it can be shown that sufficient need exists for that equipment and that it was
the best purchase to meet the need at that time. Cost –effectiveness takes into account factors
such as anticipated length of service, need for such a service, and availability of other
alternatives.

19.2.ECONOMICS OF CARING:

Fiscal responsibility concerns a two fold responsibility: first to the patient and second to

the employing institution. It is defined as the duty / obligation of the nurse to allocate

1) financial resources of the patient maximize health benefit to the patient and 2) financial

resources of the employer maximize organizational cost effectiveness.

19.3.FISCAL RESPONSIBILITY TO THE PATIENT:

A nurse needs to understand the costs of care and different reimbursement systems
because this will effect the development of a plan of care.

When creating a discharge plan for a patient, it is essential that a nurse understand the
health care resources the patient requires and how they will be paid. It is also important that
nurses engage in early discharge planning, beginning from the process of admission or even
before admission. It is also important ,nurses understand that fiscal responsibility for clinical
practice is a responsibility shared with all other health care disciplines.

19.4.FISCAL RESPONSIBILITY TO THE EMPLOYING INSTITUTION:

Nurses also have a responsibility to the institution or agency where they are employed.
The

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most important way a nurse is fiscally responsible is by providing quality patient care.
Nurses

also have an obligation to use the resources of the institution wisely. The most costly health

care resource that nurses allocate is their time. Nurses also need to understand prospective

payment, the hospital is paid a set amount for the care of a patient with a certain condition or

surgery.

Another way that nurses practice fiscal responsibility is by accurately documenting the

patient’s condition. This must include the severity of the patient’s illness as well as the plan
of care.

Can health care cost be contained, nursing’s responsibility & trends affecting the rising costs
of health care;

INTRINSIC FACTORS:

characteristics of the population

Demand for health care

Employer- paid health insurance

Consumer participation

EXTRINSIC FACTORS:

Availability of technology

Providers of health care

Financing

Workforce costs

19.5. NURSES RESPONSIBILTY:

Health care has as its aim as the well being of the individual and family at an optimal
level of health. Within this broader framework, the individual and the family have primary
responsibility for maintaining health with support from health care specialists. Consumer
are to be educated and nurse have the expertise to provide this education. Nurse can unite,
with a common concern for health care for people at affordable cost, the capacity to join
with consumer to create such change and thereby heal themselves.

Cost effectiveness of computerization in nursing practice and administration

computerization in nursing practice:

Documentation

Nursing audit

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 Lab investigations

Drug administration

Diagnostics

Policy manuals

Research

Job appraisal

Planning nursing care

Dietary planning

Pharmacy

Drug auditing

Health care planning

Curriculum planning

In-service education

Quality assurance

19.6. COST EFFECTIVENESS ANALYSIS (CEA):

These applications tend to be circumscribed and usually related to financial services

(such payroll, billing and purchasing) and to ancillary services (such as laboratory,
pharmacy, or central supply). When one can document that, all things taken into account, a
specific computer system can perform units of service at the same or less cost than any
alternative method, then the computer system can be said to be cost effective.

19.7. COST-BENEFIT ANALYSIS (CBA):

Fully documenting the costs of development, implementation and operation of a system

along with its real and perceived benefits and comparing these with alternative ways of
achieving the benefits constitute cost benefit analysis (CBA).

19.8. DIFFERENCES BETWEEN CBA AND CEA

 Many studies claim to be CBAs, but are in fact CEAs .

 CEA calculates the direct financial cost of reaching specific outcome/output levels and
requires one other alternative for comparison .

 CBA compares all benefits to all costs and can "stand alone." If the benefit/cost ratio
exceeds 1, the program is socially valuable .

 CBA typically prospective and used for major capital investments

 CEA typically retrospective and useful for evaluating discrete interventions

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 CBA a macro (societal) view.

 CEA a micro view of program activities, outputs, or outcomes.

Core ideas for this session

 Both CBA and CEA examine the costs of producing net outcomes .

 CBA really only makes sense when applied to assessing the net value of achieving social
outcomes. In other words, CBA measures the full (social) costs of the full (social) benefits
resulting from an intervention.

 CEA measures the financial cost of producing a specific net outcome .

 Evaluation analysis most usefully focuses on the cost-effectiveness of activities, outputs, and
immediate outcomes.

CBA and CEA compared

Net change to welfare of all stakeholders value in $

CBA ----->
Social cost ($)

Activities/outputs/outcomes (actual changes – not $)

CEA ----->
Direct program cost ($)

19.9. SCOPE OF CEA AND CBA

CBA must translate all outcomes and impacts into a money equivalent

The CBA equation divides the total dollar value of benefits by the total dollar value of costs

Desirable programs have a high benefit/cost ratio (or low cost/benefit ratio)

Many outcomes are difficult to value (increasing the life span arising from health
investments)

19.10. COST-EFFECTIVENESS ANALYSIS

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 ADVANTAGES OF CEA

 Because CBA compares the welfare among stakeholders, methods to translate welfare into a
common denominator (i.e., money) strike many as artificial .

 For this reason, CEA is conceptually and operationally simpler. It is also more applicable to
evaluation and performance measurement of public programs .

 When a cost-benefit study is specified, a cost-effectiveness study is most often what is really
desired.

CEA aligns with value-for-money auditing

CEA can be aligned with value-for-money concepts and the results chain

Economy the unit cost of an activity

Efficiency the unit cost of an output

Effectiveness the unit cost of an outcome

Aligning CEA to the results chain

CEA / CBA and the results chain

CEA (cost of producing a unit...)

 Focus on the amount of activity, output, or outcome. CBA value of outcomes to society.

 (Net value to all stakeholders including program participants and non-participants, tax
payers, etc.)

Cost economy, efficiency, effectiveness along the results chain

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 Cost Economy Cost Efficiency
Cost to complete activities (E.g., Staff time Cost per output (E.g., Cost per
per client assessed, delivery of intervention...) parent trained, cost per trainee)

CEA moving along the results chain

The key is to identify and enumerate immediate outcomes:

 Success in athletic competition (medals)

 Increase in number of hours worked (active labor market program)

 Reduced incidence of hospital adverse incidents ("mistakes")

 Reduced waiting times for diagnosis

 Reduced use of social assistance (active labor market program, welfare reform)

 Diversion of clients from in-person to electronic service (e.g., electronic tax filing)

Measuring efficiency

 Activities should be discrete and measurable (e.g., staff years):

 Processing grant applications

 Consulting with applicants/clients

 Preparing media

 Costing should be allocated by activity

19.11. THE TRANSITION FROM CEA TO CBA: ---THE GAIN MODEL

"Hybrid" analyses allow a cost-effectiveness calculation to incorporate many of the features

of a cost-benefit model

Application of the GAIN model to Taking Charge!

Costs "Benefits"

Income Reduced SA payments because of

assistance earned income of clients
payments during

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 training

Training
allowances Reduced SA due to shorter time on
+ +
(books, special welfare by clients
needs)

Cost of training
Increased taxes from employment
+ (personnel, +
earnings
contracts)

= Total costs = Total benefits

19.12. CEA AND NURSING SYSTEMS:

It is difficult to evaluate the cost effectiveness of automated systems in the practice settings
because computer applications in nursing practice (with the possible exception of public
health and community health agency systems) are not circumscribed.

The three most frequently retrieved categories were physician’s orders, medications, and lab
test results, in that order.

For this reason there are no nursing information, systems per se, because to develop a
clinical information system in an institutional environment for the exclusive use of nurses
would be impractical.

19.13.CBA AND NURSING SYSTEMS:

The administrators of the clinical center of the National Institute of Health (NIH) approved
the CBA methodology for evaluating the hospital wide information system (another
Technical system) in use at the clinical center.

For the cost-benefit analysis, the researchers employed in innovative technique. They
gathered together benefit- assessment panels representing physicians, nurses, and
administrators at the clinical center.

These panels estimated the relative benefits of alternative information systems, system
vendors and other sources provided the cost data for the alternative systems.

In this study, the alternative systems were hypothetical systems with varying levels of
automation, from the stand-alone ancillary service system to the totally automated hospital
system with research and data management capabilities.

The findings were” the Medical Information System (MIS) provides greater benefits than
less automated alternatives, that the value of the benefits it provides exceeds the costs of the
system, and that the net value (i.e., value minus cost) of MIS is greater than that of less
automated alternatives.

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 19.14.IMPLICATION FOR NURSING PRACTICE:

Health care services provided by nurses include:

* Health promotion

* Illness prevention

* Diagnosis

* Treatment

* Rehabilitation

19.15. COST EFFECTIVENESS OF CONTINUING EDUATION:

Rapid advances in health related scientific and technological knowledge, changing social
attitudes, attitudes, and expanding practice opportunities require nurses to regularly enhance
and update their knowledge and skills.

19.16. PROSPECTIVE ANALYSIS:

Used prospectively, CEA helps administrators make judgement about the desirability
of a given course of action as compared with other courses of action that would compete for
the same funds and resources.

The analysis comprises the following steps:

 Identification of goals and objectives to be achieved.

 Identification of feasible courses of action for achieving goals and objectives.

 Identification and measurement of costs of each alternative and cost of benefits foregone by
choosing one alternative (e.g.,opportunity costs).

 Development of models that trace out the potential impact of each alternative.

 Setting of a criterion involving both cost and benefits that will identify the preferred
alternative.

19.17. RETROSPECTIVE ANALYSIS:

To develop the needed history for using CEA as a planning tool, a modified version of the
above steps can be applied to past programs and, in limited way, to current programs.

COST SIDE OF THE RATIO:

Continuing education costs may be analyzed in terms of departmental costs associate

with program, program production or in terms of total departmental costs. Shipp describes
three types of labors costs associated with continuing education departments; direct,
indirect, and unassigned.

Direct labor costs are those incurred when someone is paid for work.

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A work sampling approach may be useful for identifying the approximate percentage of time
the continuing education director, secretaries, and others designed to the department spend
on program and non program related activities. That portion of administrative time that is
program related is assigned to indirect labor while the non program – related time is
charged to departmental overhead, also called unassigned labor.

OVERHEAD:

Two kinds of overhead need to be considered: departmental and institutional .

Overhead refers to costs originating outside the department that are charged back as the
department’s share of the general organizational costs.

NON DEPARTRMENTAL COSTS:

Continuing education programs also generate non departmental labor costs when
employers either absorb the costs of labor or cover replacement or premium pay for
continuing education participants.

METHODOLOGICAL PROBLEMS:

Basically, there are two methodological problems that plague continuing education
evaluators: 1) adequate specification of outcomes: and 2) problems of measurement.

1. specification of outcomes:

The first problem is the identification of outcome hierarchies.

The second problem in identification of objectives is the handling of multiple outcomes.

2. problems of measurement:

The first, and perhaps most formidable problem in measuring continuing education
outcomes, is the identification of useful data. The data come in three forms.

1.Monetarily quantifiable.

2. Non monetarily quantifiable but measurable in terms of such things as rates of

occurrence, time, knowledge acquisition, satisfaction.

The second measurement problem lies in the statistical analysis of non monetarily
quantifiable data.

APPROPRIATENESS OF GOALS:

Appropriate objectives need to be paired with appropriate teaching and reinforcement

techniques. If the objective is to change clinical behavior, the program design must go
beyond knowledge acquisition.

19.18. COST EFFICIENCY:

Efficiency looks at process: were the objectives met in a way that cost as little as
possible? Questions of efficiency should be part of part of a prospective cost analysis.

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Improving efficiency may mean:

Getting better results for the same cost .

Getting the same results for a lower cost .

Getting better results for a lower cost.

19.19. APPLICATION OF COST EFFECTIVENESS ANALYSIS:

Goals must be achievable with available resources and must reflect organizational
mission. The first step in prospective analysis is crucial. The next three steps, identification
of 1) alternatives, 2) costs, and 3) benefits associated with each, are based on historical data
and on educated guesses that have been informed by those data. The last step is setting a
decision criterion.

The assessment of cost-effectiveness is an essential component in determining whether a

therapy is approved for reimbursement and for formulary inclusion. Health technology
assessment agencies such as NICE place considerable weight on the relative cost
effectiveness of therapies in making their judgments. NICE requires the use of cost–utility
analysis, in which the outcome measure is expressed as a QALY, and which enables
comparisons to be made across therapeutic areas – using the QALY as the ‘common
currency’. In cost–utility analysis the ICER therefore becomes the cost per QALY gained
and can be compared with those of other interventions, or with a notional threshold value of
what is considered to represent cost-effectiveness .

Cost-effectiveness analysis (or cost–utility analysis) is far from being a precise science, and
there is often considerable uncertainty associated with the findings and wide variation
around the estimate generated. For example, one of the early technology appraisals
undertaken by NICE was on interferon beta and glatiramer acetate for the treatment of
multiple sclerosis. Estimates of the cost-effectiveness varied enormously due to differing
assumptions relating to the duration of treatment, the number, severity and impact on quality
of life (QoL) of relapses that occurred, and the extent to which progression was
compromised by the interventions.

It is therefore imperative that the assessment of cost-effectiveness should be subjected to a

sensitivity analysis to enable decision-makers to be fully aware of the range of possible
eventualities.

19.20. Promoting the Value and Cost-Effectiveness of Nursing

ICN Position:

Evidence shows that nursing is a cost effective yet often undervalued and underutilized
health care resource.

Nurses must clearly articulate and demonstrate the value and cost-effectiveness of nursing
and nursing outcomes to consumers, other health providers and policy-makers at all levels.

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They must also be able to negotiate and advocate for the resources needed to provide safe
care.

Nurses have a responsibility to engage in research and develop innovative models of care
delivery that will contribute evidence of nursing effectiveness to planning, management and
policy development.

Nursing education, especially management and leadership development programmes, must

help nurses become skilled and articulate in demonstrating the value and cost effectiveness
of nursing to the health services. Nursing education institutions, and where relevant nursing
regulatory bodies, should regularly review curricula to ensure the inclusion of content
related to the value and cost effectiveness of nursing.

National nurses’ associations have an important role in helping determine and influence
health and public policy that promotes cost effectiveness and quality of care.

National nurses associations must develop strategies to actively promote the participation of
nursing in health service decision-making, nursing and health research, and health and
public policy development. This requires developing and supporting strategies for the
preparation of nurse leaders who are skilled and articulate, and able to demonstrate as well
as promote the value and cost effectiveness of nursing to the health services.

Nurses must assert their professional involvement in policy formulation at all levels.

With rising health needs and health care costs, which includes costs associated with the
provision of nursing services, nurses must take the initiative in defining, examining and
evaluating the health outcomes and costs of their activities.

Nurses, especially nurse leaders, must have a good understanding of the purpose and nature
of health care reform, and the contribution nursing can make at all levels of health care
delivery, and in planning, management and policy development for health care services.
Where health care reform is in its planning stages, nurse leaders must play a leadership role
in policy development related to the appropriateness, nature and purpose of health reform.

ICN and member associations can assist nursing to develop the capacity for dealing
with cost-effectiveness in health care, by:

Promoting the role of nursing as a core resource in cost-effective care and as a critical
contributor to decision making on healthcare spending;

Offering nurses educational opportunities to gain knowledge of political skills, economic

principles, budgeting and resource use and cost-effectiveness in health;

Supporting leadership and management development that includes the role of nurses in
resource management, decision-making and policy development;

Promoting and supporting research and evaluation that links and validates costing
methodologies to nursing and health outcomes;

encouraging the development of database systems that permit comparison of outcomes

across settings to best approaches to care and the most effective design of nursing systems;

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 Facilitating information dissemination and interactive networking on cost-effectiveness
research, cost-saving strategies and best practice standards;

Establishing professional networks with relevant stakeholders, to foster collegial

collaboration and exchange of ideas and information aimed at promoting quality and cost
effectiveness;

Promoting equity in terms and conditions of service for nurses, to recognize and support
their role in promoting cost effectiveness and quality of care in multi-disciplinary settings.

ROUND III
CHAPTER- X - B.BHAGYALAKSHMI
NURSING INFORMATICS: TRENDS, USES OF COMPUTER IN HOSPITALS &
PATIENT RECORD SYSTEM
Access to health care services is a matter of concern in any developing society. Particularly among
rural communities where mortality and morbidity rates are high, health care delivery is a
challenging task. Most establishments of health care systems do not completely ensure access and
utilization of the facilities to the general public.

The other side of the issue is the service provider. Health care service providers also need
information on the general health conditions and also the patient’s health records for effective
service deliver. Use of information technology can help both the public and the health care services
provider to create a better healthy society.

Information technology facilitates health care providers to collect, store, retrieve and transfer
information electronically. Health information technologies are being adopted to improve patient
safety, increase the quality of care, reduce costs and strengthen and advance public health. Nursing
informatics as a branch of health information technology integrates nursing science, computer
science and information science to manage and communicate essential data about the patients to
health care providers for better quality decision making and care.

Nursing informatics is the integration of computer science and information systems into the practice
of nursing. It aims to boost the efficiency of data management and communication in the healthcare
field, and in so doing, is revolutionizing the field of nursing. The following resources are finks to
nursing organizations, catalogs of nursing schools, and articles detailing the development of this
dynamic new field of nursing informatics

MEANING OF INFORMATICS -
 Informatics is derived from the word informatique, which refers to the computer milieu.
 It is a new science that encompasses computers and their application in all the health
sciences and professions.

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  Nursing informatics is a branch of informatics particularly concerned with nurses' use of
computer technology and the management of information that facilitates nursing practice
and enhances nursing knowledge
It focuses on this field of technology as it affects the nursing profession.

DEFINITION OF NURSING INFORMATICS -

Nursing informatics is a specialty that integrates nursing science, computer science, and
information science to manage and communicate data, information, and knowledge in nursing
practice (Craves and Corcoran, 1989)

Nursing Informatics is a specialty that integrates nursing science, computer science and information
science to manage and communicate data, information and knowledge in nursing practice. Nursing
Informatics facilitates the integration of data, information, knowledge to support patients, nurses
and other providers in their decision making in all roles and settings. This support is accomplished
through the use of information structures, information processes and information technology.
(ANA, 2001)

“Nursing Informatics (NI) is the application of computer science and information science to
nursing. NI promotes the generation, management and processing of relevant data in order to use
information and develop knowledge that supports nursing in all practice domains” (Canadian
Nurses Association National Working Group, 2001)

From this definitions,

 Nursing Informatics is a multidisciplinary science practice

 Nursing Informatics is not equated with generic term informatics because it is specific to
nursing and nursing practices and inclusion of nursing science domain
 Nurses specializing in Nursing Informatics employ their nursing science knowledge to mold,
provide direction to and influence the design of nursing information system.
 Nursing informatics is not about computers but rather the core elements derived from
computers – data, information and knowledge to ensure the output that meets the needs of
patient and nursing science.

GENERAL PURPOSES:

To Supports and improve the care of the patients

ToFacilitates communication between the client, specialist and the nurses
To assist in making the contributions of nursing visible in the medical record and assist the
nurse by providing decision support tools.
Tointegrates the work of different health care givers
ToImproves knowledge of the nurses and develop the skills in using the information and
communication technologies
ToImproves leadership qualities of a nurse through better knowledge and decision making as
they collaborate with the others.
To saves the time
To Inform the client about the health, health care facilities and their needs so that there is a
better health
To access information from any location and contributes to the better care.
731
 To Reduces traveling time and cost effective
To Reduces the space for saving the health and administrative records.

AREAS OF FOCUS IN NURSING INFORMATICS:

This includes the following:

 Technology: nurses use any type of information technology in delivering nursing care or
in the process of educating nursing students. This includes the use of technology or
computer systems to store, process, display, retrieve and communicate health care
information quickly in the health care setting.
Eg:

o Administering nursing services and resources

o Managing the delivery of client and nursing care
o Linking research resources and findings to nursing practice
o Applying educational resources to nursing education.
 Nursing theory: Nursing informatics began to combine nursing theory and informatics.
Without a well articulated theoretical basis to guide the gathering data, it will be
meaningless data. There is a need for common definitions, standardized nursing
language, and criteria of organization of data.
 Function: The function of nursing informatics to manage and process data to help nurses
enter, organize and retrieve needed informaion. Although technology forms the
foundation of informatics the nurse’s ability to use that technology is the real test of the
system’s effectiveness.
In reality, nursing informatics includes all three of these areas – technology, nursing theory and
function. However, the field of information has become so large that it is difficult for any one
person to be an expert in all three areas.

NURSING INFORMATICS MODELS:

Models or frameworks help clinicians understand how concepts are structured and
operationalized. Four meta-structures or over arching concepts are used in informatics theories and
sciences.

 Data, information and knowledge

 Science underpinning nursing informatics
 Concepts and tools from information science and computer science
 Phenomena of nursing
o Data are discrete entities that are described objectively without interpretation.
o Information is data that have been interpreted, organized or structured.
o Knowledge is synthesized information.

Turley’s Model:

Dr. James Turley suggested the addition of cognitive science to the definition of Nursing
Informatics. Cognitive domain provides important understanding to guide the design of information
system software, helping to create system that are increasingly more useful and more effective in
supporting decision making by clinicians.
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Understanding the processes employed in structuring knowledge, representing knowledge and
employing knowledge in decision making; recall and perception are important dimensions in the
practice and application of informatics nursing, information and computer science and adds
cognitive domain.

Turley’s Model suggests that nursing science is the foundation on which the other three sciences
rest.

He also suggests that it is the intersection of the cognitive, information, computer science that
constitutes nursing informatics. Without the needs and context of nursing science, nursing
informatics has no purpose.

This model has advantage of flexibility – ie the model can be translated to other health care science
disciplines by changing the foundational domain.

Graves & Corcoran model of transformation of data to knowledge:

Graves & Corcoran, 1989 identified and formalized the relationship between the three
entities. As data are transformed into information and information into knowledge, increasing
complexity requires greater application of human intelligence. The circles overlap in these three
concepts because the concepts are blurred, and there are multiple feed back loops.

Nurses are processors of information. They use informatics to mange and communicate data,
information and knowledge to support patients, nurses and other providers in making decisions.

Informatics assists them in storing clinical data, translating clinical data into information,
linking clinical data and knowledge and aggregating clinical data.

733
 The sciences underpinning nursing informatics are nursing science, information science and
computer science. They are used to manage and process nursing data, information and knowledge
to facilitate the delivery of health care. Informatics nursing specialists often collaborate with other
informaticists and may borrow concepts from many sources, including linguistics, cognitive
science, engineering and a variety of others as needed.

The tools and methods derived from computer and information sciences include information
technology structures, management and communication. Information technology includes computer
hardware, software, communication and network technologies. Human computer interaction and
ergonomics concepts are fundamental to the informatics nursing specialist. Ergonomics focuses on
the design and implementation of the equipment related to human use.

The meta-concepts of nursing are nursing, person, health and environment. Decision
making involves these four concepts; nurses must make numerous decisions with important
implications for quality of life and well being of individuals, family, communities. Nurses depend
on data that have been transformed into information to determine interventions.

Staggers, Thompson &Happ’s Patient centered informatics model: (PCIM, 1999)

This is an interdisciplinary framework to guide clinicians and systems developers. This

model enables the users to evaluate the influencing factors in designing and implementing clinical
systems. Influencing factors may be delivery methods, knowledge bases and supporting
technologies.

Advantage:

 PCIM can be applied in the planning and integration of informatics system.

 It supports education and research by enabling technology assessment and critical thinking
 This is the only model that describes the relationship with other discipline in planning and
using information technologies.

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TRENDS IN INFORMATICS
TELEHEALTH:

Telehealth is the delivery of health-related services and information via telecommunications

technologies. Telehealth delivery could be as simple as two health professionals discussing a case
over the telephone, or as sophisticated as using videoconferencing between providers at facilities in
two countries, or even as complex as robotic technology.

Clinical uses of telehealth technologies

 Transmission of medical images for diagnosis (often referred to as store and forward
telehealth)

 Groups or individuals exchanging health services or education live via videoconference

(real-time telehealth)

 Transmission of medical data for diagnosis or disease management (sometimes referred to as

remote monitoring)

 Advice on prevention of diseases and promotion of good health by patient monitoring and
followup.

 Health advice by telephone in emergent cases(referred to as teletriage)

Nonclinical uses of telehealth technologies

 Distance education including continuing medical education, grand rounds, and patient
education

 Administrative uses including meetings among telehealth networks, supervision, and

presentations

 Research on telehealth

735
  Online information and health data management

 heathcare system integration

 asset identification, listing, and patient to asset matching, and movement

 overall healtcare system management

 patient movement and remote admission

Telemedicine:

Telemedicine is a rapidly developing application of clinical medicine where medical information is

transferred through the phone or the Internet and sometimes other networks for the purpose of
consulting, and sometimes remote medical procedures or examinations.

Telemedicine may be as simple as two health professionals discussing a case over the telephone, or
as complex as using satellite technology and video-conferencing equipment to conduct a real-time
consultation between medical specialists in two different countries. Telemedicine generally refers to
the use of communications and information technologies for the delivery of clinical care.

Telepathology:

Telepathology is another common use of this technology. Images of pathology slides may be sent
from one location to another for diagnostic consultation. Dermatology is also a natural for store and
forward technology (although practitioners are increasingly using interactive technology for
dermatological exams). Digital images may be taken of skin conditions, and sent to a dermatologist
for diagnosis.

Teleradiology:

The sending of images like x-rays, CT scans, MRI may be within a building, between two buildings
in the same city or from one location to another to anywhere in the world is known as tele-
radiography.

For this process to be implemented, three essential components are required, an image sending
station, a transmission network, and a receiving / image review station. The most typical
implementation are two computers connected via Internet. The computer at the receiving end will
need to have a high-quality display screen that has been tested and cleared for clinical purposes.
Sometimes the receiving computer will have a printer so that images can be printed for
convenience.

The teleradiology process begins at the image sending station. The radiographic image and a
modem or other connections are required for this first step. The image is scanned and then sent via
the network connection to the receiving computer.
DIGITAL PHOTOGRAPHY
Digital photography is just more than shooting and transferring the images in your
computers and it is being increasingly utilized to capture and share medical information and
knowledge with increasing speed and better accessibility.
736
 In clinical practice the availability of digital cameras has made recording, viewing, storing
and forwarding the data and images much easier. The clinical specialties that deal with
dermatology, otolaryngology and ophthalmology, plastic and cosmetic surgery can make innovative
and improved applications with the use of digital photography
Video conference: conferencing
The other widely used technology, two-way interactive television (IATV), is used when a 'face-to-
face' consultation is necessary. The patient and sometimes their provider, or more commonly a
nurse practitioner or telemedicine coordinator (or any combination of the three), are at the
originating site. The specialist is at the referral site, most often at an urban medical center.
Videoconferencing equipment at both locations allows a 'real-time' consultation to take place.

The technology has decreased in price and complexity over the past five years, and many programs
now use desktop videoconferencing systems. There are many configurations of an interactive
consultation, but most typically it is from an urban-to-rural location. It means that the patient does
not have to travel to an urban area to see a specialist, and in many cases, provides access to specialty
care when none has been available previously.
Almost all specialties of medicine and in nursing have been found to be conducive to this kind of
consultation, including
 psychiatry,
 internal medicine,
 rehabilitation,
 cardiology,
 pediatrics,
 obstetrics
 gynecology
 neurology and
 Nursing.

There are also many peripheral devices which can be attached to computers which can aid in an
interactive examination. For instance, an otoscope allows a physician to 'see' inside a patient's ear; a
stethoscope allows the consulting physician to hear the patient's heartbeat.

Many health care professionals involved in telemedicine are becoming increasingly creative with
available technology. For instance, it's not unusual to use store-and-forward, interactive, audio, and
video still images in a variety of combinations and applications. Use of the Web to transfer clinical
information and data is also becoming more prevalent. Wireless technology is being used for
instance, in ambulances providing mobile telemedicine services.

Telenursing:
Telenursing refers to the use of telecommunications technology in nursing to enhance patient care.
It involves the use of electromagnetic channels (e.g. wire, radio and optical) to transmit voice, data
and video communications signals. It is also defined as distance communications, using electrical
or optical transmissions, between humans and/or computers

Applications:

737
  Telelnursing applications are available in the home, hospital, through telenursingcentres and
through mobile units. Telephone triage and home care are the fastest growing applications
today.

 In home care nurses use systems that allow home monitoring of physiologic parameters,
such as blood pressure, blood glucose, respiratory peak flow, and weight measurement, via
the Internet.

 Through interactive video systems, patients contact on-call nurses any time and arrange for a
video consultation to address any problems; for example, how to change a dressing, give an
insulin injection or discuss increasing shortness of breath. This is especially helpful for
children and adults with chronic conditions and debilitating illnesses, particularly those with
cardiopulmonary diseases.

 Telenursing helps patients and families to be active participants in care, particularly in the
self-management of chronic illness. It also enables nurses to provide accurate and timely
information and support online. Continuity of care is enhanced by encouraging frequent
contacts between health care providers and individual patients and their families.

E-HEALTH:

E-health is a client-centered World Wide Web-based network where clients and health care
providers collaborate through ICT mediums to research, seek, manage, deliver, refer, arrange, and
consult with others about health related information and concerns (Moody, 2005; Conte, 1999).

IT facilitates the transmission of health care information without regard to location; it

contributes to the trend toward boundary-less delivery of both health information and health care.

e- Learning:

E- Learning stands for electronic learning. It is a formalized teaching and learning system
specifically designed to be carried out remotely by using electronic communication.

E- Learning commonly referred to the intentional use of net worked information and
communication technology in teaching and learning.

These also termed as online learning, virtual learning, distributed learning, network and web
based learning.

Advantages:

It is less expensive to support

Less expensive to produce

It is not constrained by geographic considerations

It is more flexible in terms of time

It can be delivered virtually any where

738
 The number of students is never limited by the size of the class room

The teacher is able to monitor student progress

The individual learning can be easily realized.

Importance of E-Learning in Nursing:

o Enables learning at any time and any where

o The observation of demonstration with use of animation and narration with music is
most direct message to the student, it is very effective method of learning

o Ensuring that professional staffs have access to up to date information on which to

base their practice.

o Speeding up an easing, access to service for patients.

o Improves student’s psychomotor skills by using a virtual environment with the use of
simulations.

o For lecturer it improves students learning, good interactive, and involvement of

students for the best learning

o It clarifies each scientific principles by appropriate illustrations.It correlates theory

and practice.

Popular E- Learning technologies:

 Voice-based technology such as CD and MP3 recordings or web casts

 Video technology such as instructional videos, DVDs and interactive video

conferencing

 Computer based technology delivered over the Internet or Corporate Intranet.

POINT-OF-CARE TECHNOLOGY LIGHTENING THE LOAD

Bedside or point-of-care nursing technology was first pioneered in the 1980s. The initial drawback
was the often prohibitive cost of buying and installing personal computers (PCs) for each patient
room. But lower prices and better designs (including smaller mobile units) have now made point-of
care technology a cost-effective option for many health care facilities.

Today's point-of-care systems don't require that every room be hardwired for a computer. Instead,
state-of-the-art systems use wireless radio frequency technology so nurses can use mobile units
throughout the coverage area. The technology is advanced enough to withstand significant external
radio interference. Security sophistication has also grown, preventing unauthorized people from
gaining access to the system.

The most advanced point-of care systems include a tablet PC, an embedded wireless radio with an
internal antenna, and a barcode reader that doubles as a pen tether-a versatile tool that can be used
739
for scanning or writing. Staff nurses can use the bar-code reader to scan the patient's ID tag and
medication labels before drug administration, and then use the pen like component to enter data into
the system.

One point-of-care system features a locking-docking station that allows you to mount the computer
in hallways or patient rooms for ready access. The docking station charges the battery and protects
the device from theft by demanding a valid security code. (A manual lock overrides the security
lock if power fails.) An optional keyboard allows you to use the computer when it's in the docking
station.

Some software applications are more effective when used with a large, high-resolution screen and a
keyboard or powerful bar-code scanner. One point-of-care provider handles this challenge by
offering a large-screen notebook PC with a wireless radio, a standard mouse, a keyboard, and a bar-
code scanner that can be used at a distance without touching the object being scanned. These
components are mounted on a cart that adjusts from standing to seated heights, which is useful for
bedside admission or extended charting sessions. A security lock reduces the risk of theft, and a
keyboard splash cover protects it from fluid spills.

BED SIDE SYSTEM:

A bedside system implies a computer terminal installed in each client’s room or next to each
bed will improve productivity and quality of care due to:

o Better integration of medical and nursing information.

o Information is registered immediately after care so that better documentation

o Better integrity – error or incompleteness is prevented by the fact that fewer

transcription errors occur resulting in a more accurate charting.

o Better quality assurance.

PERSONAL DIGITAL ASSISTANTS:

PDAs (personal digital assistants) have been quickly embraced by the healthcare community
because they are a portable and convenient way to bring reference materials to the point of patient
care. They are also increasingly used to collect a wide variety of patient data.

E-MAIL AND INTERNET:

The internet has become a valuable resource for communicating with colleagues and
professional organizations, researching clinical information and educating consumers about health
resources and information.

With internet facility countries in the globe have shrinked and come together in rendering
efficient health delivery system.

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 Implementing the intra and internet based capabilities can translate into immediate value in
improved patient/practitioner relationship and improved access to domain specific information and
knowledge for both patient and practitioner.

Waiting and appointment time for treatment, management are reduced.

Less cost and improved quality and no disparity in care.

Intranet technology could be applied in health care deliver network comprised of health
institutions within the same city.

Uses for professionsls:

Online text books provide current and updated medical and nursing news. Online
subscriptions also could be available to graduates who then could always have a current text at their
fingertips.

Online journals, magazines and world library are available to those institutions that have
paid the large amounts of money required to maintain the service. A nurse who lives hundreds of
miles from a traditional library now truly can search the literature and download articles without
ever leaving the computer.

Online discussions allow the students to discuss the topic and thoughtfully reply the
questions posed by the faculty or other students. The need to prepare the topic beforehand and the
faculty make participation in discussions and guide the students and evaluate the student’s response.

Most courses provides group learning opportunity including group chat and group drop
boxes where students working on a group project can keep their project online for others to view
and update. Online examination and evaluation is also possible for different online courses and for
job placement.Many professional organizations maintain a Web site containing information about
the organization. Many include policy statements and lists of publications. Continuing education
units can be obtained via the World Wide Web to help nurse remain current and retain licensure.

Eg: the Nursing Network (www.nursingnetwork.com) is a site that lists education courses, position
vacancies, conferences and other pertinent information.

www.mursingworld.orgprovide professional information and access to experts in specific

areas o interest.

Disease specific web sites publish clinical information for both the consumer and the
professional. www.oncoLink provides information about cancer.

Uses for consumers:

Consumers are more knowledgeable about health care through use of internet. Clients are
better informed than they were in the past.

741
 Preventive and wellness services are available electronically through articles, chat groups
and health risk assessment surveys posted on consumer Web sites.

Clients can now purchase medications over web, in lower cost.

There are the sites (Healthfinder) which links the user with on-line government publications,
clearing houses, databases, websites, support and self help groups as well as the government
agencies and non profit organizations that produce reliable information for the public. The goal of
this information source is to help consumers make better choices about their health and human
services needs for both themselves and their families.

NURSING INFORMATICS STANDARDS OF PRACTICE:

It is closely related to the nursing process. That is,

 Assessing the needs of the patient and individuals

 Develops a plan of care based on careful prioritizing of nursing diagnosis

 Implementation of planned care

 Assessed and evaluated according to the patient’s responses to the plan.

 Data collections during evaluation are thoughtfully analyzed and appropriate modifications
are made to the plan of care.

Focus of Nursing Informatics standards of practice includes:

1. Identify the Issue or problem

Assessment of systems problems as identified b a group of clinical practitioners;

identification of the problems, opportunities and constraints; and description of the
outcomes the group desires to achieve.

Prepare a project charter and initial project plan based on assessed problems,
opportunities and directives of the project.

Define business requirements of a new system

Define the desired functional requirements or activities and services of the new system.

2. Identify alternatives

Analyze requirements in terms of data, processes, interfaces, etc, the system will require.

Analyze possible solutions in terms of technical, operational, economic and timeline

feasibility.

Prepare solution recommendation(s) for discussion with the users

3. Choose and develop a solution

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 Select a solution in collaboration with users

Create a project plan, which include timelines, dependencies, evaluation milestones and
evaluation metrics

4. Implement the solution

Implement programming of the solution

At defined intervals, evaluate the developing solution in collaboration with users

Implement the fully completed solution

5. Evaluate and modify

Evaluate solution with evaluation metrics

Implement programming and workflow modifications in response to feed back.

Evaluate solution after completion of programming modifications to determine further

needs or issues.

NURSING INFORMATICS AS A SPECIALITY:

Nursing Informatics is now recognized as a nursing specialty for which a registered nurse (RN) can
receive certification.

The catalog of the American Nurses Credentialing Centre (ANCC) states that the nursing
informatics practice encompasses the full range of activities that focus on the methods and
technologies of information handling in nursing.

It includes the development, support and evaluation of applications, tools, processes and structures
that assist the practice of nurses with the management of data in direct care of patients/clients.

The work of an informatics nurse can involve any and all aspects of information systems,
including theory formulation, design, development, marketing, selection, testing, implementation,
training, maintenance, evaluation and enhancement.

COMPETENCY REQUIRED:

Three competency levels includes both knowledge and skills required to:

 Use Information And Communication Technologies To Enter, retrieve and

manipulate data- technical competencies;

 interpret and organize data into information to affect nursing practice- utility
competencies; and

 combine information to contribute to knowledge development in nursing – leadership

competencies(Hebert, 1999)
743
Level of Expertise:

a) beginner, entry or user level

b) intermediate or modifier level and
c) advanced or innovator level of competency.

Technical Competencies

Technical competencies are related to the actual psychomotor use of computers and other
technological equipment. Specific nursing informatics competencies include the ability to use
selected applications in a comfortable and knowledgeable way. It is important that nurses feel
confident in their use of computers and software in the practice setting, especially at the bedside, in
order to be able to attend to the client at the same time.

COMPUTER APPLICATIONS
All three levels of competencies - users, modifiers and innovators need to develop a working
knowledge of the following computer programs and processes:

1. Word processing

2. Keyboarding

3. Spreadsheets

4. Presentation Graphics

5. Databases (simple to complex)

6. Desktop Publishing

7. World Wide Web

8. E-mail programs

9. Expert data systems

10. Multimedia

11. Telecommunication devices

12. Nursing information systems

13. Hospital information systems

14. Periphereals (printers, CD-ROMS, DVD)

Utility Competencies

Utility competencies are related to the process of using computers and other technological
equipment within nursing practice, education, research and administration. Specific nursing
informatics competencies include the process of applying evidenced based practice, critical
thinking, and accountability in the use of selected applications in a comfortable and knowledgeable

744
way.
Leadership Competencies

Leadership competencies are related to the ethical and management issues related to using
computers and other technological equipment within nursing practice, education, research and
administration. Specific nursing informatics competencies include the process of applying
accountability, client privacy and confidentiality and quality assurance in documentation in the use
of selected applications in a comfortable and knowledgeable way.

Barriers to achieving NI competencies in the workplace include:

 restricted access to training and training systems for nurses and nursing students,
 few leaders and educators with NI skills,
 limited empirical support for the contributions ICT can or will realistically make to nursing
and patient outcomes"

ROLES OF INFORMATICS NURSES:

 project manger
 consultant
 educator
 researcher
 product developer
 decision support/ outcomes manager
 policy developer
 chief information officer
 entrepreneurs/ innovator

ISSUES RELATED TO INFORMATION TECHNOLOGY:

ETHICAL CONCERNS:

Confidentiality, security and privacy are great concern in use of technology. (ANA, 2001).

The concepts of autonomy, empowerment, accountability and respect for the individual hold
true for the practice of nursing informatics. Nurses have an ethical duty to protect patient
confidentiality and have moral code to maintain privacy in maintaining patient records.

The expansion of guidelines for the ethical development of Internet sites has been ongoing
since 1996 by Health on the Net Foundation.

The American Accreditation Health Care Commission (2001) is also developing an

accrediting process for health care web sites.

CONFIDENTIALITY OF MEDICAL RECORDS AND DATA:

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 There are many laws addressing confidentiality and patient privacy. Example: Health
Insurance Portability and Accountability Act.

DATA INTEGRITY:

Data integrity instills trust with controls that avoid incomplete or inaccurate entry of data. It
is linked to data bases; it also refers to ensuring that data are entered correctly and that there are data
quality management procedures in place. The correctness of patient information is always essential.
The quality of data input into the computer is critical to ensuring quality output.

CARING IN A HIGH TECH ENVIRONMENT:

According to Rinard, Introduction of new technology leads to transformation of nursing.

The author attributes the massive waves of technological change and related funding in health care
delivery over time in part to the deskilling (substitution of less trained people) and fragmentation of
nursing tasks.

According to Ball et al, caring is an essential part of the provision of health. When
technologies are introduced, informatics nurses may be the architects and bridges to improved
patient outcomes.

The three issues – ethics, confidentiality and caring are important in a high tech environment
as the expansion of information technologies continues at a rapid place.

USES OF COMPUTERS:

FOR THE PATIENTS:

For patients, these systems can:

Provide more accurate data about the patient’s health file, both for his usage or for the
health care provider’s.
Enable a closer follow up for elderly and patients with chronic diseases.
Facilitate access to specialists.
Provide remote medicine without the costs, time consumptions and patient exhaustion of
traveling.
Decrease the end-costs for the patient while provided by a high quality health care.
Provide simple but valuable explanation for the disease, precautions, treatment and
complications, in a simple interactive way (images, videos), answering the patient’s
questions and providing psychological support.
Studies have shown that when primary health care was provided remotely, people were
“able to ask more questions, felt better informed, less anxious and more confident.
FOR THE PHYSICIAN:

The system provides a more professional work environment, scheduling time and
regulating the work.

They will have easy access to medical sources and records, easy search and adequate
information about their patients;
This provides a better physician-patient relationship and a more specific management.
746
 Physicians will be able to recognize the pattern of their work, the reliability of drug
regimes they prescribe, risk prediction and disease prognosis for particular patients.
The standardization of guidelines and the usage of clinical prediction rules [derived from
the patient case] assist the physician to improve the expected outcomes.
Teleconsultation, CME, virtual conferences, up-to-date materials will all be a matter of
minutes.
They will also have more secure medicolegal coverage, through predefined working
protocols. Overall increase in work efficiency “Do less for more”.

FOR THE HEALTHCARE ORGANIZERS:

Provide efficiency, real costs and enable fast error detection and management.
Allow wide scale biostatistical studies through the nation-wide health records, providing
evidence-based medical facts at relatively low costs.
Allow wide-scale screening tests in a controlled fashion with accurate results and low
costs. [Primary prevention]
Serve as a hot-line network in disasters, reorganizing teams and minimizing “paralysis”
that occurs in such conditions.
Enable communication between all health departments, conferences, seminars etc.
Enable high-quality medical services in rural areas and peripheries at low costs.
Decrease total health costs at many levels [decreasing errors, travel costs,
communication costs, preventing diseases, remote education] and shifts more resources
towards the patient and community, without decreasing health service quality and
probably improving it.
Help deal with staff shortages or requests for improving working lives (like working
from home).
Could help in moving towards services that are better coordinated, promote equity and
patient independence and adhere to government targets on national and international
levels.
USES FOR THE PHARMACIST:

Provides data about the available drugs, and the demand

Helps for inventory taking
Helps to order the drug as per the need and the demand
Estimate the cost of the drugs easily
A computerized drug reference system gives details of all brands of drug in the local
market, their constituents, indications and contra indication, side effects, drug
interaction, etc
The patient’s allergies are immediately notified and give an alarm when it was
prescribed.

USE OF COMPUTERS IN CLINICAL NURSING PRACTICE:

a) Admission, Discharge and Transfer (ADT)

ADT system allows Nurses to obtain basic biographical information on clients before they arrive to
the unit.
747
When a discharge or transfer is entered in the computer, all the appropriate departments (Eg:
dietary, house keeping, pharmacy) are automatically notified, thus, saving the Nurses from many
phone calls. Information about beds and a client's location on the unit is also readily available.

b) Nursing Documentation:

Nursing assessments, clients' care plans, medication, administration records, nursing notes and
discharge plans are some of the forms of Nursing documentation that are computerized.
Computerized documentation has many advantages. It is typed and therefore legible. The computer
can be programmed to identify the data and time of all entries as well as the initials or the name of
the person making the entry.

The computer can store standard nursing care plans in a format determined by the institution, to
be used by Nurses as the basis for developing individualized client care plan.

The computer is often programmed to automatically print a list of medication to be administered at

pre determined times, during the day. A Nurse using a printout for a particular client, administers
the medication and then charts it on the computer (If the medication is not charted and given within
a specified time after the scheduled time, the computer prints a reminder that the medication is over
due).

Computer can perform drug dosage calculation faster and more accurately. Nurses' notes can be
entered quickly by choosing statements, appropriate for a particular client from multiple pre
programmed choices.

USE OF COMPUTERS IN NURSING EDUCATION.

COMPUTER ASSISTED INSTRUCTION

Computer is a useful tool in Education because it allows for an individual a self paced learning.
Computed Assisted Instruction (CAI) is a method of teaching that involves interaction between the
learner and the computer. The computer takes on the role of a teacher.

Dozens of software programs help nursing students and nurses learn and demonstrate learning.
These have been created by individuals, educational institutions, technology companies or print
publishers.

There are three different types of CAI programmes:

a) Drill and Practice: It is the most common and least complex type of CAI. A learner is presented
with a series of questions or problems about materials that have already been learnt. Drug dosage
calculation, intravenous drip rate calculation and medical terminology and abbreviations are some.
of the topics that drill and practice CAT is well suited for.

b) Tutorial Programs: Display new materials that are similar to programmed instructions.
Tutorials present information and provide the learner the feed back.

748
c) Simulations : Present before learners the 'real - life' situations that are designed to assist learners
in developing problem solving and decision making skills in a safe environment. Interactive Video
Instruction (IAV) can provide learners with "true -to - life" simulation. IAV combines CAI with a
videotape or videodisc player so that video pictures as well as graphics can be incorporated in the
design of the software.

Nursing programs require computerized libraries, faculty members use technological

teaching strategies in the classroom and for outside assignments as well as demonstrating and using
applications in clinical rotations, and academic record keeping is facilitated by database programs.

LITERATURE ACCESS AND RETRIEVAL

In addition to searching lists of documents, actual complete publications and materials are available
in computerized formats. These include medical textbooks, the full text of journals, drug
references, digitized x-rays or scans and graphics including clip art. Through the Internet and world
wide web, both classis and the most current information can be found on any topic. Users can
access statistics form the centers for Disease Control and Prevention, census data and National
library of medicine.

CLASSROOM TECHNOLOGY

Most new educational buildings are wired to accommodate technology. For the faculty6, projectors
and liquid crystal display (LCD) panels that allow computer screens to be displayed to the entire
classroom are becoming standard. These enhancements allow faculty to use the full text, video, and
audio capabilities of computers instead of overhead transparencies, slides or writing on the board.

DISTANCE LEARNING

The student receives course materials, communicates with the faculty & other students and submits
assignments completely through the mail, phone or fax, e-mail, website and electric drop box (a
server folder accessible from the Internet).

TESTING

The computer is ideal for conducting certain types of learning evaluations. Surveys can be
completed online, including anonymous questionnaires. The students answers can be scored
electronically and over all exam results analyzed quickly.

STUDENT AND COURSE RECORD MANAGEMENT

Very useful for maintaining results of students grades or attendance using spread sheets.

For faculty – can scan student exam answer sheets directly into a grade book on the computer –
calculate percentages, sort student scores in order and print results for both students and faculty.

All student records – name, addresses, courses taken, grades and all other pertinent student data are
present in computer. Students can able to sign up for classes, check their tuition bills and see their
transcripts on computer terminals on campus or from anywhere that has a computer with internet
access.

749
COMPUTERS IN NURSIG ADMINISTRATION

Administrators can use the human resources database (demographic and salary data, licensed or
certified health care personnel & health requirements-TB testing, hepatitis, immunization, etc) to
communicate with employees, examine staffing pattern and create budget projections.

Computers are useful tools for Nurse Administrators. A number of computer programmes are
designed to assist Nurse Administrators.

Computerized patients' classification system can be used to assign Nursing staff based on how
severely ill clients are. Clients are assessed on a number of criteria and their abilities or need for
nursing care are rated. A client's total rating score indicates how much Nursing care the client
requires.

Computerized inventory system keeps track of supplies received and disbursed. They can also be
integrated with the client billing system. General computer application software such as word
processing, electronic spread sheets and data based management system help Nurse Administrator
to prepare reports and letters, create budgets and maintain personnel records and mailing lists.

Computers can calculate daily the number of Nurses needed on each unit, computer can be used to
schedule Nurses' days off so that an optional number of Nurses are working at one time.

MEDICAL RECORDS MANAGEMENT

It is expensive to keep records and not able to access. Computerized medical records help to
provide information about presenting diagnosis, diagnosis related groups, most expensive cases,
length of stay or total number of days, etc.

FACILITIES MANAGEMENT

Heating, air, conditioning, ventilation and alarm systems are computer controlled. In security
services , it is used to scan identification cards, bar codes or magnetic strips permit only authorized
personnel. It can also used for inventory purposes.

BUDGET & FINANCE

This saves time and cost in maintaining clerical bills.

Standards, pathways, key indicators and other vital data which are used in computer helps to
maintain quality assurance.

COMPUTER IN NURSING RESEARCH

PROBLEM IDENTIFICATION

The computer can be useful in locating current literature about the problem and related concepts. A
search of existing documents and e-mail to colleagues may help define the problem.

LITERATURE REVIEW

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The increase in availability of full text journal articles on line has made the electronic literature
search process even more productive.

RESEARCH DESIGN

At design stage the investigator determines whether the study will uses a qualitative or quantitative
approach, what instruments will be used to collect data, and the types of analyses that will be carried
out on the data to answer the research questions. Computers help to select design and instruments
to test.

DATA COLLECTION ANALYSIS

Computer helps to create forms like informed consent document, a tool to collect demographic data,
and recording forms for research variables. Calculations that are formerly time consuming and
complex can now be done by computer programs quickly and accurately.

RESEARCH DISSEMINATION:Many journals now require that manuscripts submitted for

publication include both hardcopy & electronic versions. With rapid growth of e-mail, authors can
also send an article or data to interested persons instaneously.

Nursing programs require computerized libraries, faculty members use technological

teaching strategies in the classroom and for outside assignments as well as demonstrating and using
applications in clinical rotations, and academic record keeping is facilitated by database programs

USES OF COMPUTERS IN THE HOSPITALS AND IN THE COMMUNITY:

Physician order entry:

It is an automated physician order entry system, enable appropriate providers (physicians and in
some states nurse practitioners) to enter, edit, schedule, track and discontinue treatment and
diagnostic services electronically.

In this way, orders can be checked against patient allergies, interactions with other
medications or tests, dosage levels and standards of practice for the institution.

With computerized physician order entry, adverse events and costs may be reduced and
length of patient stay may be shortened.

Clinical Information System :( CIS)

Clinical Information System is a collection of software programs and associated hardware that
supports the entry, retrieval, update and analysis of patient care information and associated clinical
information related to patient care.

Clinical information system involve any system that is used in patient care and may not be
nursing information system. However, these systems are generally associated with the nursing
information system in hospitals, such as a laboratory or medication administration system. Many
nursing areas benefit from unique information system some these areas include surgery, infection
control, labor and delivery, enterostomal therapy, oncology, mental health, orthopedics,
neonatology and intensive care. CIS can be used to improve the quality of care while enhancing the
environment and reducing cost long term. Many CIS are designed in modular form, providing

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flexibility to the organization. General nursing information system has multiply programs
comprising a module that is used to perform various clinical task, educational, and management
functions. The modules may vary between vendors and software developers but may include
medical history, patient assessment, documentation, nursing care plan, medication administration,
dietary information, patient education, on going daily care, vital signs, graphic sheet information,
reports, nursing progress notes, discharge planning and other tasks that nurses perform on a daily
basis. Clinical nurses can use CIS to provide quality patient care. These systems provide a
mechanism for capturing data that can be used to formulate treatment plans and evaluate trends.
Technology along with clinical information system continues to change the work environment and
improve the quality of work life for nursing.

A CIS can be patient focused or departmental.

Patient focused system – automation supports patient car processes. Typical applications found in a
patient focused system include order entry, results reporting, clinical documentation, care planning,
and clinical pathways. As data are entered into the system, data repositories are established that can
be accessed to look for trends in patient care.

Departmental system – evolved to meet the operational needs of a particular department such as the
laboratory, radiology, pharmacy, medical record or billing. Early systems often were stand- alone
systems designed for an individual department. A major challenge facing clinical information
system developers is to integrate these stand-alone systems to work with one another and now it
allows integrated patient focused system.

Advantage:

 Health care is delivered whether hospital, clinic, patient home or provider’s office
 Provides high level decision support
 It is a mechanism for patient centered care
 It provides integration to ensure coordination of care across patient conditions, services and
setting over time.

Wireless and Portable Devices:

Wireless and Portable devices are bringing patient records and provider services to the point of care.
This enables to access the patient information anywhere and at any time. The location of patient
care at home, in an office, in a church, in a community center or in a hospital makes wireless and
portable devices an attractive vehicle for documentation and record access.

One type of device is the personal digital assistant. It allows nurses wireless access to
patient records and reference databases such as Medcalc and ePocrates.

RNpalm.com is a website dedicated to mobile computing for nurses.

Computer Based Patient Record: (CPR)

The ideal CPR also called Electronic Patient Record or Electronic Medical Record (EPR) will
support users with reminders and alerts, clinical decision – support system and links to medical
knowledge.

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 Electronic Health record will include all information about an individual’s lifetime health
status and health car maintained electronically. It permits much more data to be captured,
processed, and integrated which results in broader information than paper record.

EHR focus the individual’s health both wellness and illness.

It focuses the health data about the person across his or her lifetime, including facts,
observations, interpretation, plans, actions and outcomes.

Health data include information on allergies, history of illness and injury, functional status,
diagnostic studies, assessments, orders, consultation reports and treatment records.

Health data also include wellness information such as immunization history, behavioural
data, environmental information, demographics, health insurance, administrative data for care
deliver process and legal data such as informed consents.

The who, what, when and where of data capture also identified.

Advantage:

 Provides quality measurements and clinical outcome data to support the analysis of patient
problems.
 Integrated online CPR type information system allows ready access to electronic patient
records via web browser.
 This enables a clinician in the emergency room to access patient records via the web.
 This reduces the time for intervention and treatment, saving money and improving patient
conditions.
 Improves communication, increased completeness of documentation and reduction in error
Disadvantage:

 High cost in buying an electronic system and converting from a paper system
 Employees may have problems adapting to the new system
 Decisions must be made about who can enter data and when the entries should be made.
 Legal and ethical issues involving privacy and access to client information.
Guidelines and Strategies for safe computer charting:

The American Nurses Association, the American Medical Record Association and the
Canadian Nurses Association offer the following guidelines:

 Never give your personal password or computer signature to anyone, including another
nurse in the unit, a float nurse, or a doctor.
 Don’t leave a computer terminal unattended after you have logged on
 Follow the correct protocol for correcting errors. To correct an error after storage, mark the
entry “mistaken entry” add the correct information and date and initial the entry. If you
record information in the wrong chart, write “mistaken entry – wrong chart” and sign off.
 Never create, change, or delete records unless you have specific authority to do so.
 Make sure that stored records have back up files – an important safety check. If you
inadvertently delete part of the permanent record, type an explanation into the computer file
with the date, time, and your initials and submit an explanation in writing to your manager.

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  Don’t leave information about a patient displayed on a monitor where others may see it.
Keep a log that accounts for every copy of a computerized file that you’ve generated from
the system.
 Never use e-mail to send protected health information unless it has been encrypted to protect
it from unauthorized access.
 Follow the agency’s confidentiality procedures for documenting sensitive material, such as a
diagnosis of acquired immunodeficiency syndrome or human immuno deficiency virus
infection.

HOSPITAL INFORMATION SYSTEM:

Patient Registration

This function of Hospital Management Information System deals with registering the new
Patient either for OPD or IPD and giving unique Identification Number to the Patient. This number
is unique through out the System for identifying the patient.

The patient can be registered either at IPD Front Office or at OPD Reception. The OPD or
IPD identification number is also created for each separate visit of the patient. This is also a part of
registering patient. IPD/OPD ID is used for tracking of medical records of the patient for that
particular OPD visit or IPD admission. All the medical record of the patient are identified by
combination of numbers i.e. Patient ID and OPD/IPD ID. The numbers gives flexible search in
terms of finding patient's History Record.

OPD / IPD Investigation Cases

This Module of Hospital Management System deals with all kinds of Investigations suggested
by Doctors. The function enables the entry of Investigations /Procedures for a particular patient. The
entered investigations are rooted through the Billing/Cash office and once the patient pays for the
Investigations the entries of the same goes to respective Diagnostics Center. This flow is not

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compulsory of IPD patients since the Billing for IPD patients is done at the time of Discharge.
Investigation requisition is created and printed with function and the same is available at respective
diagnostics center for preparation of Reports.

IPD ADMISSION AND WARD ALLOCATION

This function Patient IPD Admission gives facility to process patient admission and allocate
Bed to patient. System identifies the patient as new IPD patient or internal referred from hospital
OPD/CMO. This function gives information on vacant beds in a Hospital. Occupancy status on that
particular position can be found out while allocating the Bed. The main function Patient Admission
facilitates admitting the patient according to requirement, considering the type of admission and the
patient condition. The admission of the patient can be direct / Referred from a consultant / Hospital.
The category of the patient can be Company, Self, Government Schemes, Insurance, MLC
depending on that the admission procedure is completed. Once the patient is admitted in the
Hospital the Room charge starts from the time of Admission. The case paper of the patient is printed
from the system and is send to the respective Nursing Station. Once the Admission of the patient is
completed the IPD Identification Number is created by the system for that particular Admission of
Patient. The IPD Admit Card is also printed along with the Case Paper. The system informs with
Audio Visual alert to the respective Nursing Station about admission of the patient under them and
to prepare Room for patient. In case of MLC, system stores the details of the Police Station, Name
of the official informed about Medical Legal Case.

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PATIENT SHIFTING

This function of Hospital Management System facilitates to Shift patient from one Room to
other inside the Hospital.

With this facility patient’s actual position can be updated on line so that the internal functions
such as Billing, Investigations, Surgery are planned. The position of the patient is very important
since all the charges like Surgery. Procedures, Investigations are related to Room Category.

DEPOSITS, ADVANCES, REFUNDS, DISCOUNTS AND CONCESSIONS

This function of Hospital Management System facilitates all kind of financial transactions
from the patient. Function plays vital role in payment recovery from patients time to time during the
stay.

The Advances from the patient depends on the Type of Admission and the Patient category
is prompted by the System. The Interim Bill vs. Advances ratio is also maintained to carry out
recovery planning.

Advances and the deposits accepted by the Billing/Cash counter are directly posted into
Accounts.

Refund cases are considered for excess Advances from the Patient. The Accounts Official
authorizes this transaction and then refund is processed. In case of Company category patient the
ration analysis between Interim Bill and the Authority letter amount by the company is compared
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for further action.

If patient is to be given Discounts then the authorized person authorizes the Amount and
the discount is processed. The discount categories are flexible and can be changed by the
administrator. This facilitates easy way to keep track on the discounts and concession.
Reports

Following are the main reports / outputs

DIAGNOSTIC CENTRES

This enables to get patient’s investigation, procedure record from different Locations.
EX;IPD,OPD,Casualty.

It covers Laboratory System for Pathology, Radiology, Cardiology, Neurology, and

Chest Medicine. The prescriptions given by the Doctors are routed through billing system to
respective DiagnosticCenters.

Pathology

 Comprehensive On-line Laboratory Reports

 Fast Entry of Results

 Enables Doctors to see the Results On-Line from any Location at any time

 Up-to-date status about request

 Provision for templates of Input of test Results

Radiology

 CT Scanning-Direct Capturing of CT Scanned images &Easy reporting facility

 MRI-Easy reporting

 X-Rays-Direct Capturing of X-Ray images

Sonology

 Sonography Reporting

 Capturing of Images

Cardiology

 ECG Notes

 BLOOD BANK

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  Donors data entry

 Details of Donors such as Name, Address, Contact Numbers, Blood group are
maintained in the system through Donors data entry.

 The details can be printed as and when required. The mailing list from the
available data of donors can be printed for Correspondence.

 Investigation Data Entry: Various tests details are stored in the system for as per rules
of Blood Bank.

 Maintains data of tests: Tests data details required for Blood Bank records are stored
into the system with specific results on HIV, HB details.

 Facilitates component level administration of the blood units: Keeps track of

distribution / disposal of the whole blood and the components

 System Signals the expiry dates of components. Such report can be printed for
reference from the system to manage the shortcomings.

Reports

 Blood Stock Register

 Donor register as per FDA requirements

 Investigation Report

 Blood Issue Register

 Demographic data of Donors

STORES

This facilitates accounting of General Purchases, Stock Items, Tenders and Generation of
Stores related transactions such as Receipts, Issues, Different Order levels, Spare Parts. This
will also facilitate for replenishment of Stock.

Functions

 Vouchers generation for Issue, Receipts, Returns and Adjustments

 Inventory Control and Stores Accounting

 Vendor History / Appraisal

 Preparation of Purchase Orders

 Inquiries for Stock Level / Vendor / Items

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  Inquiries for Quantity available / ordered / to be ordered

 Inventory ABC Analysis

 Trend Analysis for Purchase price / Consumption

 Conversion of Units for Receipts, Issue and Consumption

 Automatic weighted average stores pricing of stocks and issues

 Automatic reminder system for placing orders and follow ups

 Billing from Vendors

REPORTS

 Item Listing

 Item Issue and Return List

 Receipt Registers

 Issue and Return Summaries

 Purchase Orders Listing

 Purchase Orders

 Inquiry Reports

 MIS Reports

 Slow, Fast Moving Items

 Location wise Stock statement

 Daily GRN Register

 Purchase per Vendor During the Year

 Tender Preparation

 Lowest Selected Tenders with Approved Rates

 Lowest Selected Tenders Item wise, Vendor wise

 Purchase Register

 Issue of items during the Patients Stay

COSTING

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Hospital activity has philanthropic mission to render services to alleviate human suffering on
priority basis. Service to the humanity, utmost efforts to save the precious life remains guiding
principle.

Still the cost reports provide the management important tools to ensure this mission on long-term
basis.

In the normal course, the cost is a relevant factor to ensure the efficient management. At a point of
time, management would like to know the cost of the services and utilities provided to ensure timely
control to avoid disastrous situation. It may provide the clue and guidelines for revisions or
restructuring. A proper analysis of the costs on regular basis then becomes unavoidable.

Functions

 Classification of Cost Centers

 Deciding the tests, services ad the technical details for allocating

material, technical labor and rational method for allocating other
overheads.

 Reporting method for extraordinary cost.

 Wherever feasible, fix standards of cost to keep regular watch on the

actual

 Method of analysis of the contribution of the various activities to

ensure long term survival kit for the Hospital

Reports

 Department wise Income / Expenditure Statement

 Service / Test wise cost report

 Per bed cost

 Comparisons of general services cost like Electricity, Water, waste

disposal etc.

PAYROLL AND ADMINISTRATION

The Payroll & Personnel module deals with Pay (and deduction) calculation, printing of
salary slip, salary certificates, and PF statements, Gratuity Statement and provides a
monthly analysis. It deals with the maintenance of employee Attendance / Overtime
details. It also reports on absenteeism, leave encasements etc. The Personnel & Payroll
department is responsible Employee Related Activities like appointing the staff,
maintaining the employee database, Fixing allowances and deductions, Leave
entitlements, Leave sanctions, Loan, Termination Process, Maintenance of Hospital
documents, Insurance details, Tenancy Contracts and Vehicle Registration etc.

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Function

 Creation of Master Data

 PF Calculation

 Loans and Advances

 Employee Time Sheet

 Employee Work Allocation

 Pay Calculations

 Performance based incentives planned

Reports

 Employee Listing

 Loans and Advances

 Listing and Summaries

 P ay Slips

 Employee IT Reports

 Incentive Summary

SYSTEM SECURITY

The Security and Administration module deals with controlling the access to the
information available in the application. It deals with the user level security to the different
modules/functions. User defined error messages and help messages are also maintained and
customized in this module.

The User Manager module basically deals with security through controlling the
access to the information available in the application. Any user associated with a user
group can access only those screens for which the user group has rights. It also deals with
the System Related Activity like User Monitor, Creating User Group Master, User Master
and view the User Group Lookup of employee database, Maintenance of company
documents, User defined error message, Generating Daily Statistical Summary

Function

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  Group Creation

 User Creation

 Assigning User writes

 User Authentication

MEDICAL TRANSCRIPTION

Medical transcription, also known as MT, is an allied health profession, which deals in the
process of transcription, or converting voice-recorded reports as dictated by physicians and/or other
healthcare professionals, into text format.

History

The evolution of transcription dates back to the 1960s. The method was designed to assist in the
manufacturing process. The first transcription that was developed in this process was MRP, which is
the acronym for Manufacturing Resource Planning, in 1975.

However, transcription equipment has changed from manual typewriters to electric typewriters to
word processors to computers and from plastic disks and magnetic belts to cassettes and endless
loops and digital recordings.

Today, speech recognition (SR), also known as continuous speech recognition (CSR), is
increasingly being used, with medical transcriptionists and or "editors" providing supplemental
editorial services, although there are occasional instances where SR fully replaces the MT. Natural-
language processing takes "automatic" transcription a step further, providing an interpretive
function .

Many MTs now utilize personal computers with electronic references and use the Internet not only
for web resources but also as a working platform. Technology has gotten so sophisticated that MT
services and MT departments work closely with programmers and information systems (IS) staff to
stream in voice and accomplish seamless data transfers through network interfaces. In fact, many
healthcare providers today are enjoying the benefits of handheld PCs or personal data assistants
(PDAs) and are now utilizing software on them for dictation.

The medical transcription process

When the patient visits a doctor, the doctor spends time with the patient discussing his medical
problems, including past history and/or problems. The doctor performs a physical examination and
may request various laboratory or diagnostic studies; will make a diagnosis or differential
diagnoses, then decides on a plan of treatment for the patient, which is discussed and explained to
the patient, with instructions provided.

After the patient leaves the office, the doctor uses a voice-recording device to record the
information about the patient encounter. This information may be recorded into a hand-held cassette
recorder or into a regular telephone, dialed into a central server located in the hospital or

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transcription service office, which will 'hold' the report for the transcriptionist. This report is then
accessed by a medical transcriptionist, it clearly received as a voice file or cassette recording, who
then listens to the dictation and transcribes it into the required format for the medical record, and of
which this medical record is considered a legal document.

The next time the patient visits the doctor, the doctor will call for the medical record or the patient's
entire chart, which will contain all reports from previous encounters. The doctor can on occasion
refill the patient's medications after seeing only the medical record, although doctors prefer to not
refill prescriptions without seeing the patient to establish if anything has changed.

Curricular requirements, skills and abilities

 High school diploma , plus range of 1 to 3 years' experience that is
directly related to the duties and responsibilities specified, and
dependent on the employer (working directly for a physician or in
hospital facility).

 Knowledge of medical terminology.

 Above-average spelling, grammar, communication and memory

skills.

 Ability to sort, check, count, and verify numbers with accuracy.

 Skill in the use and operation of basic office equipment/computer;

eye/hand/foot coordination.

 Ability to follow verbal and written instructions.

 Records maintenance skills or ability.

 Good to above-average typing skills.

Basic MT knowledge, skills and abilities

 Knowledge of basic to advanced medical terminology is essential.

 Knowledge of Anatomy and Physiology.

 Knowledge of disease processes.

 Knowledge of Medical Style and Grammar.

 Average verbal communication skills.

 Above-average memory skills.

 Ability to sort, check, count, and verify numbers with accuracy.

 Demonstrated skill in the use and operation of basic office

equipment/computer.

 Ability to follow verbal and written instructions.

 Records maintenance skills or ability.

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  Above-average typing skills.

 Knowledge and experience transcribing (from training or real report

work) in the Basic Four work types.

 Knowledge of and proper application of grammar.

 Knowledge of and use of correct punctuation

Duties and responsibilities

 Accurately transcribes the patient-identifying information such as
name and Medical Record or Social Security Number.

 Transcribes accurately, utilizing correct punctuation, grammar and

spelling, and edits for inconsistencies.

 Maintains/consults references for medical procedures and

terminology.

 Keeps a transcription log.

 Foreign MTs may sort, copy, prepare, assemble, and file records and
charts (though in the United States (US) the filing of charts and
records are most often assigned to Medical Records Techs in
Hospitals or Secretaries in Doctor offices).

 Distributes transcribed reports and collects dictation tapes.

 Follows up on physicians' missing and/or late dictation, returns

printed or electronic report in a timely fashion (in US Hospital, MT
Supervisor performs).

 Performs quality assurance check.

 May maintain disk and disk backup system (in US Hospital, MT

Supervisor performs).

 May order supplies and report equipment operational problems (In

US, this task is most often done by Unit Secretaries, Office
Secretaries, or Tech Support personnel).

 May collect, tabulate, and generate reports on statistical data, as

appropriate (in US, generally performed by MT Supervisor).

ADMINISTRATIVE INFORMATION SYSTEMS:

Administrative information system include a wide varied of systems that work to maintain
information used in the daily operation of an organization. These include financial system, HR
system, Non clinical patient system such as registration and scheduling systems, and even nursing
administrative system that nurse leaders use.

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 Information system that are classified as administrative systems involve any operation that is
not directly linked to hands- on patient care. Operations may include non-clinical patient activities,
medical record activities, business and accounting activities, and some nursing management tasks.
Non clinical patient activities may involve such tasks as patient scheduling, admission, discharges,
transfer, census functions, bed assignments and other non-clinical activities association with the
patient. Medical records procedures include master patient index functions, abstracting
(diagnosis/procedure/and coding), transcription, and correspondence. Business and accounting
function may include patient insurance verification, billing, accounts payable, accounts receivable,
cash processing, maintenance activities, and other business operations. Nursing management tasks
may involve budget projections, employee records( annual skills and educational updates,
evaluations, staffing), and other management activities required for daily operations by nurse
lesders

PATIENT RECORD SYSTEM

INTRODUCTION

Record is an account of something, written to perpetuate knowledge of events. Records and

reports are indispensable aids to all who are responsible for giving the best possible service to
individuals, families and to the community. Good reports are time savers. They prevent duplication
of work, decrease errors and efficiency level of the staff in giving nursing care. They provide a
sense of security and confidence to the nurse in doing her work.

DEFINITION

It is a written communication that permanently documents information relevant to a client’s

healthcare management.

FEATURES OF GOOD RECORDING AND REPORTING

ACCURACY

Information should be correct. All information should be correct to correct to prevent

serious mistakes in giving continued nursing care. Use of correct spellings and the institution s
accepted abbreviation and symbols ensure accurate interpretation of information. Always complete
a descriptive entry in the client’s record with an accurate signature .Do not use nick names.

CONCISENESS

Use of few words as possible to give the necessary information.

THOROUGHNESS

Even a concise record or report must contain complete information about client.

UP –TO- DATE

Recording should be done on time. A definite time and routine for the reporting makes for more
efficient management of the word. Delay in recording can result in serious omissions and delay the
needed care.

ORGANIZATION
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Communicate all information in a logical format or order.

CONFIDENTIALITY

The nurse is the legally and ethically obliged o keep information pertaining to client’s illness
and treatment as confidential.

OBJECTIVITY

Presentation of facts and not personal feelings, to give a true picture.

MAIN PURPOSES OF KEEPING RECORDS

 Communication
 Aids to diagnosis
 Education
 Assessment
 Documentation of continuity and justification of case
 Research
 Auditing
 Legal documentation
 Individual case study.
TYPES OF RECORDS

 Patient clinical records

 Individual staff records
 Ward records
 Administrative records with educational value.
TECHNOLOGIES OF MEDICAL RECORDS

COMPUTERIZATION

The degree of computerization varies from hospital to hospital depending on the resources available
and computer culture prevalent. Starting from the basic R–ADT (Registration – Admission
Discharge Transfer) module, computerization has been progressively applied to various registers
and indexes ( particularly the patient master index, coding of diseases, operation and delivery
register ), compilation of statistics, chart location and tracking system, generation of laboratory and
other reports, word processors applications for discharge summaries and medical reports, scanning
of inactive records, risk assessment, etc.

MICROFILMING

Storage of medical records on microfilm achieves almost 98 percent saving in filing space and filing
equipment, reduces paper handling, and protects records against loss, theft and manipulation.
However the costs associated with photographing, storing, reading and printing micro- records are
high. Microfilming is therefore cost-effective only if the records are relatively inactive and if they
are to be maintained for over 15 years.

COMPUTERIZED PATIENT RECORD SYSTEM

CPRS-Adverse Reaction Tracking

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 This module has options for data entry and validation, supported references for use by
external software module, and the ability to report adverse drug reaction data to food and drug
administration (FDA)

FEATURES

 Document patient allergy and adverse drug reaction data

 Alerts the pharmacy and therapeutic committee each time the signs/symptoms are modified
for patient reaction
 Allows for configuration of allergy files
 Allows for editing and verification of reaction data
 Contains an online reference guide
CPRS-Authorization/Subscription Utility (ASU)

Authorization/subscription utility provides methods for identifying who is authorized to perform

various actions on clinical documents. These actions include signing, co-signing and
amending.(discharge summary, progress notes, etc.,)

CPRS- Clinical Reminders

Clinical reminders package is a valuable aid in patient treatment. Reminders assist clinical
decision-making and educate providers about appropriate care. Electronic clinical reminders also
improve documentation and follow-up, by allowing providers to easily view when certain tests or
evaluations were performed and to track and document when care has been delivered. They can
direct providers to perform certain tests or other evaluations that will enhance the quality of care for
specific conditions

CPRS- Consult/Request Tracking

The consult/request tracking package provides an efficient way for clinicians to order
consultations and procedures from other providers or services within the hospital system, at their
own facility of another facility. It also provides a framework for tracking consults and reporting the
results. It uses a patient’s computerized patient record to store information about consult requests

CPRS- Problem List

Problem list is used to document and track a patient’s problems. It provides the clinician
with a current and historical view of the patient’s health care problems across clinical specialties
and allows each identified problem to be traceable through the system in terms of treatment, test
results, and outcome

CPRS- Health Summary

Health summaries can be printed or displayed for individual patients or for groups of
patients. The data displayed coves a wide range of health-related information such as demographic
data, allergies, current active medical problems and laboratory results

Features:

 Vital signs
 Clinical reminders problem list
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  System radiology
 Dietetics scheduling
 Discharge summary social work
 Inpatient medications spinal cord dysfunction
 Laboratory system surgery
 Mental health
I. ADVANTAGES
 Complete and accurate patient data
 More easily archived
 Standardized and customized reporting
 Legible
 More accurate patient data, less chance of error
 Document set maintained
DISADVANTAGES

 Increased costs to startup, maintain, train and upgrade

 Computer literacy required-fear of computers
 Confidentiality, privacy and security difficult to guarantee

CHAPTER- X CATHERINE.R
NURSING INFORMATICS: NURSING RECORDS & REPORTS, MANAGEMENT
INFORMATION &EVALUATION SYSTEM, E-NURSING, TELE-NURSING,
TELEMEDICINEELECTRONIC MEDICAL RECORDS

NURSING RECORDS AND REPORTS

INTRODUCTION:
Record is an account of something, written to perpetuate knowledge of events. Records and
reports are indispensable aids to all who are responsible for giving the best possible service to
individuals, families and to the community. Good reports are time savers. They prevent
duplication of work, decrease errors and show efficiency level of the staff in giving nursing care.
They provide a sense of security and confidence to the nurse in doing her work.
Hospitals deal with the life and health of their patients. Good medical care relies on well-trained
doctors and nurses and on high-quality facilities and equipment. Good medical care also relies
on good record keeping. In a hospital, head nurse is responsible for keeping both administrative
and educational records. Some administrative and educational records.

RECORD:
A record is a written communication that permanently documents information relevant to a
client’s health care management. A record is a clinical, scientific, administrative and legal
document relating to the nursing care given to the individual, family or community. It is a
practical and indispensable aid to the doctor, nurse and paramedical personnel in giving the best
possible service to the clients.

REPORT:
It is an oral or written information about a patient by one member of the health team to another.
A report summarizes the services of the person or personnel and of the agency.

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PUPOSES OF REPORT AND RECORD KEEPING:
Facilitate communication
Promote good nursing care
Meet professional and legal standards
Aids to diagnosis
Education
Assessment
Documentation of continuity and justification of case
Research
Auditing
Legal documentation
Individual case study
CHARACTERISTICS OF GOOD RECORDING & REPORTING:
1. ACCURACY:
Information should be correct. All information should be correct to prevent serious mistakes in
giving continued nursing care. Use of correct spellings and the institution’s accepted
abbreviation and symbols ensure accurate interpretation of information. Always complete a
descriptive entry in the client’s record with an accurate signature. Do not use nick names.
2. CONCISENESS:
Use as few words as possible to give the necessary information.
3. THOROUGHNESS:
Even a concise record or report must contain complete information about a client.
4. UP-TO-DATE:
Recordings should be done on time. A definite time and routine for the reporting makes more
efficient management. Delay in recording can
result in serious omissions and delay the needed care.
5. ORGANIZATION:
Communicate all information in a logical format or order.
6. CONFIDENTIALITY:
The Nurse is legally and ethically obliged to keep information pertaining to client’s illness and
treatment as confidential.
7. OBJECTIVITY:
Presentation of facts and personal feelings, to give a true picture.
PRINCIPLES OF RECORD WRITING:
 Nurses should develop their own method of expression and form in record writing.
 Records should be written clearly, appropriately and legibly.
 Records should contain facts based on observation, conversation and action.
 Select relevant facts and the recording should be neat, complete and uniform
 Records are valuable legal documents and so it should be handled carefully, and accounted
for.
 Records systems are essential for efficiency and uniformity of services.
 Records should provide for periodic summary to determine progress and to make future
plans.
 Records should be written immediately after an interview.
 Records are confidential documents.
VALUES AND USES OF RECORDS:

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 Record provides basic facts for services. Records show the health condition as it is and as
the patient and family accepts it.
 Provides a basis for analyzing needs in terms of what has been done, what is being done,
what is to be done and the goals towards which means are to be directed.
 Provides a basis for short and long term planning.
 It prevents duplication of services and helps follow up services effectively.
 Helps the nurse to evaluate the care and the teaching which she has given.
 It helps the nurse organize her work in an orderly way and to make an effective use of time.
 It serves as a guide to professional growth.
 It enables the nurse to judge the quality and quantity of work done.
 Records help them to become aware of and to recognize their health needs. A Record can be
used as a teaching tool too.
 Record serves as a guide for diagnosis, treatment and evaluation of services.
 It indicates progress
 It may be used in research
 The record helps identify families needing service and those prepared to accept help.
 It enables him to draw the nurse’s attention towards any pertinent observation he has made.
 The record helps the supervisor evaluate the services rendered, teaching done and a person’s
actions and reactions.
 It helps in the guidance of staff and students – when planned records are utilized as an
evaluation tool during conferences.
 It helps the administrator assess the health assets and needs of the village or area.
 It helps in making studies for research, for legislative action and for planning budget.
 It is legal evidence of the services rendered by each worker.
 It provides a justification for expenditure of funds
TOOLS FOR DOCUMENTATION:
There are many tools used for client(patient) documentation, including
worksheets and kardexes,
client care plans,
flow sheets and checklists,
care maps,
clinical pathways and
Monitoring strips.
These tools may be written or electronic in format.

Worksheets and kardexes:

Nurses use worksheets to organize the care they provide, and to manage their time and multiple
priorities. Kardexes are used to communicate current orders, upcoming tests or surgeries, special
diets or the use of aids for independent living specific to an individual client. If a paper format is
used, entries may be erasable as long as the assessment, nursing interventions carried out and
the impact of these interventions on client outcomes are documented in the permanent health
record. When the kardex is the only documentation of the client’s care plan, it is kept as part of
the permanent record.

Client care plans:

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Care plans are outlines of care for individual clients and make up part of the permanent health
record. Care plans are written in ink (unless electronic), up-to-date and clearly identify the needs
and wishes of the client.
Nursing care plan
The documents of the care plan will have space for:
— Patient/client needs and problems.
—nursing diagnoses will be documented.
— Planning to set care priorities and goals. Goal-setting should follow the SMART system, i.e.
the goal will be specific, measurable, achievable and realistic, and time-oriented.
— The care/nursing interventions needed to achieve the goals.
— An evaluation of progress and the review date. This might include evaluation notes,
continuation sheets and discharge plans. In some care areas you might record progress using a
Kardex system along with the care plan.
— Reassessing patient/client needs and changing the care plan as needed.

Flow sheets and checklists:

Flow sheets and checklists are used to document routine care and observations that are recorded
on a regular basis (e.g., activities of daily living, vital signs, intake and output). Flow sheets and
checklists are part of the permanent health record, and can be used as evidence in legal
proceedings. Symbols (e.g., check marks) may be used on flow sheets or checklists as long as it
is clear who performed the assessment or intervention and the meaning of each of the symbols is
identified in agency policy.

Nursing assessment sheet:

The nursing assessment sheet contains the patient’s biographical details (e.g. name and age), the
reason for admission, the nursing needs and problems identified for the care plan, medication,
allergies and medical history.

Care maps and clinical pathways:

Care maps and clinical pathways outline what care will be done and what outcomes are expected
over a specified time frame for a “usual” client within a case type or grouping. Nurses
individualize care maps and clinical pathways to meet clients’ specific needs (e.g., by making
changes to items that are not appropriate). If the status of clients varies from that outlined on the
care map or clinical pathway at a particular time period, the variance is documented, including
the reasons and action plan to address it.

Monitoring strips:
Monitoring strips (e.g., cardiac, fetal or thermal monitoring; blood pressure testing) provide
important assessment data and are included as part of the permanent health record.

Vital signs:
The basic chart is used to record temperature, pulse, respiration and possibly blood pressure.
Sometimes the patient’s blood pressure is recorded on a separate chart. Basic charts may also
have space to record urinalysis, weight, bowel action and the 24-hour totals for fluid intake and
output. More complex charts, such as neurological observation charts, are used for recording

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vital signs plus other specific observations, which include the Glasgow Coma Scale score for
level of consciousness, pupil size and reaction to light, and limb movement.

Fluid balance chart:

This is often called a ‘fluid intake and output chart’ or sometimes just ‘fluid chart’. It is used to
record all fluid intake and fluid output over a 24-hour period. The amounts may be totalled and
the balance calculated at 24.00 hours (midnight), or at 06.00 or 08.00 hours. Fluid intake
includes oral, nasogastric, via a gastrostomy feeding tube, and infusions given intravenously etc.
Fluid output from urine, vomit, aspirate from a nasogastric tube, diarrhea, fluid from astoma or
wound drain are all recorded .

Medicine/drug chart:
A basic medication record will contain the patient’s biographical information, weight,
history of allergies and previous adverse drug reactions. There will be separate areas on the
chart for different types of drug orders. These include:
— drugs to be given once only at a specified time, such as a sedative before an invasive
procedure.
— drugs to be given immediately as a single dose and only once, such as adrenalin
(epinephrine) in an emergency.
— drugs to be given when required, such as laxatives or analgesics (pain killers)
— drugs given regularly, such as a 7-day course of an antibiotic or a drug taken for longer
periods (e.g. a diuretic or a drug to prevent seizures). All drugs, except a very few, are ordered
using the British Approved Name, and the order (or prescription) will include the dose, route,
frequency (with times), start date and sometimes a finish date. There is space for the signature of
the nurse giving the drug and, in some cases, the witness.

Informed consent:
Responsibility for making sure that the person or the parents of a child have all the information
needed for them to give informed written consent rests with the health practitioner (usually a
doctor or nurse) who is undertaking the procedure or operation. This information will include:
— information about the procedure/operation
— the benefits and likely results
— the risks of the procedure/operation
— The other treatments that could be used instead
—The patient/parent can consult another health practitioner
—The patient/parent can change their mind.

Incident/accident form:
Any non-routine incident or accident involving a patient/client, relative, visitor or member of
staff must be recorded by the nurse who witnesses (sees) the incident or finds the patient/client
after the incident happened. Incidents include falls, drug errors, a visitor fainting or a patient
attacking a member of staff in any way. An incident/accident form should be completed as soon
as possible after the event. Careful documentation of incidents is important for clinical
governance (continuous quality improvement, learning from mistakes and managing risk, etc.)
and in case of a complaint or legal action.

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The following points provide you with some guidance:
— be concise, accurate and objective
— record what you saw and describe the care you gave, who else was involved and the person’s
condition
— do not try to guess or explain what happened (e.g. you should record that side rails were not
in place, but you should not write that this was the reason the patient fell out of bed)
— record the actions taken by other nurses and doctors at the time
— do not blame individuals in the report
— always record the full facts.

TYPES OF RECORDS REQUIRED IN HOSPITALS:

Patient Casenotes:
Patient casenotes form the largest and most complex series of records required in a
hospital.Casenotes are created or written when a patient comes into contact with any member of
the medical staff. Notes may also be created to record contact with nurses, physiotherapists and
others involved in patient care. Casenotes include patient histories, diagnostic test results and
temperature, blood pressure and other charts, as well as records of operations and other forms of
treatment. In most hospitals, the notes about each patient are kept together in one file bearing the
patient’s name and other personal details. The file may also contain referral letters from health
centres or family doctors and other documents relating to the patient’s condition

CASE NOTE FILE DESIGN AND CONTENT:

The construction of the casenote file should resemble that described in the module Organising
and Controlling Current Records. Because hospital files are often handled by many people in a
day, in busy wards and clinics, it is important that papers do not become detached or
disorganised. Therefore, secure fasteners are essential to hold hospital patient notes in their
original order. Inert plastic fasteners are recommended, since metal clips or staples can be
physically damaging.

The File Cover

The design of the file cover for patient casenotes will differ in some respects fromdesigns used
in civil service agencies. The hospital name should be printed, or stamped, on the cover; some
hospitals also print the word ‘Confidential’. It is also necessary to include on the front of the
cover

It may also be desirable to allocate space for

X-rays
X-ray films are large-size photographic records produced for diagnostic purposes in response to
a request from a clinician. They form part of a patient’s case history, but because of their size

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they cannot be kept in the files containing the casenotes. X-rays are usually filed separately,
according to a unique identifying number that is linked with the patient’s name.

Pathological Specimens and Preparations

Specimens taken from patients (such as plasma, serum, bodily fluids, swabs, wettissue or whole
blood samples) and the preparations made from them for pathologicalexamination and diagnosis
are also part of a patient’s case history.

Patient Indexes and Registers

One or more indexes should be maintained, either in traditional card index form orelectronically,
containing the names and other appropriate details about the hospital’s patients. A single central
index containing data about all its patients may be known as the ‘master patient index’. This
index serves as a finding aid for the patient casenotes and may also provide location information
for X-rays and other diagnostic documentation. In addition to providing access to the casenotes
and related documents, the index forms an important record in its own right. In some hospitals
local indexes may also be maintained in individual departments.

Pharmacy and Drug Records

The prescription and supply of drugs generates a variety of records, including pharmacy stock,
ordering and dispensing records, requests for drugs from wards and departments, drug
administration records and prescriptions for individual patients.

Central Administrative Records

The hospital administrator’s files will reflect the implementation of policy and also the
hospital’s day-to-day activities in so far as they need his or her direction.

Nursing and Ward Records

The office of the chief nurse will generate record like: correspondence meeting records,, reports,
minutes of meetings, staff records and so on. The chief nurse may be expected to keep copies of
any rules and procedures issued for nursing staff or for patients: these are important records,
though unlikely to be bulky.

In the wards, records may be produced in larger quantity. Wards may maintain their own
admission registers, in addition to the hospital’s central record of admissions and discharges.
Property and linen books may be used to provide a record of any possessions received into
custody when patients are admitted and to document their return to the patient or his or her
representative on discharge or death. Nurses may be required to write activity reports, typically
in a book kept on the ward for inspection by their managers, and they may also keep records of
nursing care for their own and their colleagues’ use. As noted above, drug records should also
be maintained in each ward.

RECORDS MAINTAINED IN COMMUNITY SETTINGS:

In community settings the health care agency maintains certain records under following
headings:
1. Forms , case cards and registers:
 Family and village record

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  Eligible couple and child register.
 Sterilization and IUD register.
 MCH card/ register
 Child card / register
 Birth and death register
 Subcentres/PHC/clinic registers
 Stock and issue registers
 Reports of blood stain of malaria and filarial
 Malaria parasite positive case registers and others.
 Family records.
2. Diaries
 Diaries of heath worker (male and female)
 Diaries of health assistants.
3. Return
 Monthly report of health workers
 Compilation report of health assistants.
 PHC monthly report.
REGISTERS
It provides indication of the total volume of service and type of cases seen. Clerical assistance
may be needed for this. Registers can be of varied types such as immunization register, clinic
attendance register, family planning register, birth register and death register.
Cumulative or continuing records
 This is found to be time saving, economical and also it is helpful to review the total history
of an individual and evaluate the progress of a long period. (e.g.) child’s record should
provide space for newborn, infant and preschool data.
 The system of using one record for home and clinic services in which home visits are
recorded in blue and clinic visit in red ink helps coordinate the services and saves the time.
Family records
 The basic unit of service is the family. All records, which relate to members of family,
should be placed in a single family folder. This gives the picture of the total services and
helps to give effective, service to the family as a whole.
 Separate record forms may be needed for different types of service such as TB, maternity
etc. all such individual records which relate to members of one family should be placed in a
single family folder.
Educational Records
The officers, boards and committees of medical and nursing schools will produce their own
records: minutes, correspondence, reports and so on. Autonomous schools will also produce the
usual range of finance, personnel, estates and accommodation records.The school may issue an
annual report and a calendar or handbook setting out details of courses. Records relating to the
students themselves — for example, applications, study records, examination results, payment
of fees, records of attendance, prizes and scholarships — will also be generated.

Financial and Personnel Records

Like other institutions, hospitals produce financial records, which in a paper-based system
generally comprise series of accounts such as ledgers and cash books together with supporting
documents (invoices, delivery notes, purchase orders, receipts) and payroll records. Hospitals
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are likely to be required to produce estimates of income and expenditure, to provide annual
account statements and to record all financial transactions for the purposes of accountability and
for internal and external audit. In hospitals responsible for their own personnel functions, files
for current and former staff are kept. There may be separate series for administrative, medical
and nursing staff. It may also be necessary to keep separate records relating to recruitment,
staffing structures, remuneration schemes and so on. Some hospitals also keep details of
individual staff on index cards, in registers, on microfilm or fiche, or in electronic databases.

REPORTING:
Reports can be compiled daily, weekly, monthly, quarterly and annually. Report summarizes the
services of the nurse and/ or the agency. Reports may be in the form of an analysis of some
aspect of a service. These are based on records and registers and so it is relevant for the nurses
to maintain the records regarding their daily case load, service load and activities. Thus the data
can be obtained continuously and for a long period.A report , whether oral or written , should be
concise ,including pertinent information but no extraneous details. In addition to change-of –
shift reports and telephone reports , reporting also includes the sharing of information or ideas
with colleagues and other health professionals about the aspect of a clients care. Examples
include the care plan conference and nursing rounds.
PURPOSES OF WRITING REPORTS
 Show the kind and quantity of service rendered over to a specific period.
 Show the progress in reaching goals.
 As an aid in studying health conditions.
 As an aid in planning.
 Interpret the services to the public and to other interested agencies.
 Communicate specific information to a person or group of people
TYPES OF REPORTS:
CHANGE –OF-SHIFT REPORTS:
A change –of-shift is a report given to all nurses on the next shift. Its purpose is to provide
continuity of care for clients by providing the new caregivers a quick summary of clients
needs and details of care to be given.
Change–of-shift reports may be written or given orally, whether face to face exchange or by
audiotape recording . The face to face reports permits the listener to ask questions during
the report; written and tape –recorded reports are often briefer and less time consuming.
Reports are sometimes given at the bedside, and the client as well as the nurses may
participate in the exchange of information .

TELEPHONE REPORTS:
Health professionals frequently report about a client by telephone . Nurses inform
physicians about a change in a client ‘s condition ; a radiologist reports the results of an X-
ray study; a nurse may report to a nurse on another unit about a transferred client .
A nurse receiving a telephone report should document the date and time , the name of the
person giving the information , and the subject of the information received and design the
notation.

CARE PLAN CONFERENCE:

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A care plan conference is a meeting of a group of nurses to discuss possible solutions to certain
`problems of a client, such as inability to cope with an event or lack of progress towards goal
attainment. The care plan conference allows each nurse an opportunity to offer an opinion about
possible solutions to the problem. Other health professionals may be invited to attend the
conference to offer their expertise . For example; a social worker may discuss the family
problems of a severely burned child , or a dietician may discuss the dietary problems of a client
who has diabetes.

NURSING ROUNDS:
Nursing rounds are procedures in which two or more nurses visit selected clients at each clients
bedside to
 Obtain information that will help plan nursing care.
 Provide clients the opportunity to discuss their care.
 Evaluate the nursing care the client has received.
During rounds, the nurse assigned to the client provides a brief summary of the client’s nursing
needs and the interventions being implemented.

INCIDENT REPORTS
Agencies often have policies that require nurses to complete incident reports following unusual
occurrences, such as medication errors or harm to clients, staff or visitors. Regardless of whether
incident reports are used, nurses have a professional obligation to document the actual care
provided to an individual in the client’s health record. Incident reports are administrative risk
management tools to track trends and patterns about groups of clients over time. Incident reports
are to be used for quality assurance not punitive purposes.

RECORDS-LEGAL PROTECTION FOR NURSES:

 Follow the procedures and policies of the employing agency.
 Build and maintain good reports with the clients
 Always check the identity of a client to make sure it is the right client
 Observe and monitor the client accurately.
 Communicate and record significant changes in the clients condition to the physician.
 Promptly and accurately document all assessment and care given
 Be alert when implementing nursing interventions and give each task your full attention and
skill.
 Perform procedures correctly and appropriately.
 Make sure the correct medication are given in the correct dose , by the right route , at the
scheduled time and to the right client.
 When delegating nursing responsibilities make sure that the person who is delegated a task
understands what to do and that the person has the required knowledge and skill.
 Protect clients from injury.
 Report all incidents involving clients.
 Maintain your own clinical competence .For students this demands study and practice
before caring for clients. For graduate nurses it means continued study to maintain and
update clinical knowledge and skills.

USE OF TECHNOLOGY FOR DOCUMENTATION:

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Technology may be used to support client documentation in a number of ways. If technology is
used, the principles underlying documentation, access, storage, retrieval and transmittal of
information remain the same as for a traditional, paper-based system. These new ways of
recording, delivering and receiving client information, however, pose significant challenges for
nurses, particularly with respect to confidentiality and security of client information. It is
important that nurses be supported by agencies in resolving these issues through clear policies
and guidelines and ongoing education

ELECTRONIC DOCUMENTATION:
A client’s electronic health record is a collection of the personal health information of a single
individual, entered or accepted by health care providers, and stored electronically, under strict
security.

Guidelines for nurses using electronic health records are as follows:

 Never reveal or allow anyone else access to your personal identification number or password
as these are, in fact, electronic signatures; inform your immediate supervisor if there is
suspicion that an assigned personal identification code is being used by someone else;
change passwords at frequent and irregular intervals (as per agency policy);
 choose passwords that are not easily deciphered;log off when not using the system or when
leaving the terminal;maintain confidentiality of all information, including all print copies of
information;shred any discarded print information containing client identification;locate
printers in secured areas away from public access;retrieve printed information
immediately;protect client information displayed on monitors (e.g., use of screen saver,
location of monitor, use of privacy screens);use only systems with secured access to record
client information; andonly access client information which is required to provide nursing
care for that client; accessing clientinformation for purposes other than providing nursing
care is a breach of confidentiality.

FAXTRANSMISSION:
Facsimile (fax) transmission is a convenient and efficient method for communicating
information between healthcare providers. Protection of client confidentiality is the most
significant risk in fax transmission and special precautions are required when using this form of
technology.

Guidelines for protecting client confidentiality when using fax technology to transmit
client information are as follows:
 locate fax machines in secured areas away from public access;
 check that the fax numbers and/or fax “distribution lists” stored in the machine of the sender
are correct prior to dialing;
 carefully check activity reports to confirm successful transmission;include cover sheet
warnings indicating the information being transmitted is confidential; also request
verification that, in the event of a misdirected fax, it will be confidentially and immediately
destroyed without being read;
make a reasonable effort to ensure that the fax will be retrieved immediately by the intended
recipient, or will be stored in a secure area until collected;
shred any discarded faxed information containing client identification; and

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advocate for secure and confidential fax transmittal systems and protocols.

ELECTRONIC MAIL
The use of e-mail by health care organizations and health care professionals is becoming more
widespread as a result of its speed, reliability, convenience and low cost. Unfortunately the
factors that make the use of e-mail so advantageous also pose significant confidentiality,
security and legal risks. E-mail can be likened to sending a postcard. It is not sealed, and may be
read by anyone. Because the security and confidentiality of e-mail cannot be guaranteed, it is not
recommended as a method for transmission of health information.

TELENURSING:
Agencies such as health units, hospitals and clinics increasingly use telephone advice as an
efficient, responsive and cost-effective way to help people care for themselves or access health
care services Nurses who provide telephone care are required to document the telephone
interaction. Documentation may occur in a written form (e.g., log book or client record form) or
via computer. Standardized protocols that guide the information obtained from the caller and the
advice given are useful in both providing and documenting telephone nursing care. When such
protocols exist, little additional documentation may be required.

Minimum documentation includes the following:

 date and time of the incoming call (including voice mail messages);
 date and time of returning the call;
 name, telephone number and age of the caller, if relevant (when anonymity is important, this
informationmay be excluded); and
 reason for the call, assessment of the client’s needs, signs and symptoms described, specific
protocol or decision tree used to manage the call (where applicable), advice or information
given, any referrals made,agreement on next steps for the client and the required follow-up.
Telenursing is subject to the same principles of client confidentiality as all other types of
nursing care.

COMPUTER-BASED PATIENT-RECORD
Patient record commonly referred to as the patient’s chart or medical record is entered in the
computer for communication purpose. The patient record is an amalgam of all the data acquired
and created during a patient’s course through the health-care system
NURSES REPONSIBILITY IN MAINTAINING RECORDS
The patient’s record must provide an accurate, current, objective, comprehensive, but concise,
account of his/her stay in hospital. Traditionally, nursing records are hand-written. Do not
assume that electronic record keeping is necessary.
 Use a standardised form. This will help to ensure consistency and improve the quality of the
written record. There should be a systematic approach to providing nursing care (the nursing
process) and this should be documented consistently. The nursing record should include
assessment, planning, implementation, and evaluation of care.
 Ensure the record begins with an identification sheet. This contains the patient’s personal
data: name, age, address and so on. All continuation sheets must show the full name of the
patient.
 Ensure a supply of continuation sheets is available.

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 Date and sign each entry, giving your full name. Give the time, using the 24-hour clock
system. For example, write 14:00 instead of 2 pm.
 Write in dark ink (preferably black ink), never in pencil, and keep records out of direct
sunlight. This will help to ensure they do not fade and cannot be erased.
 On admission, record the patient’s visual acuity, blood pressure, pulse, temperature, and
respiration, as well as the results of any tests.
 State the diagnosis clearly, as well as any other problem the patient is currently
experiencing.
 Record all medication given to the patient and sign the prescription sheet.
 Record all relevant observations in the patient’s nursing record, as well as on any charts,
e.g., blood pressure charts or intraocular pressure phasing charts. File the charts in the
medical notes when the patient is discharged.
 Ensure that the consent form for surgery, signed clearly by the patient, is included in the
patient’s records.
 Include a nursing checklist to ensure the patient is prepared for any scheduled surgery.
 Note all plans made for the patient’s discharge, e.g., whether the patient or carer is
competent at instilling the prescribed eye drops and whether they understand details of
follow-up appointments.
Writing tips
 Ensure the statements are factual and recorded in consecutive order, as they happen. Only
record what you, as the nurse, see, hear, or do.
 Do not use jargon, meaningless phrases, or personal opinions (e.g.,“the patient’s vision
appears blurred” or “the patient’s vision appears to be improving”). If you want to make a
comment about changes in the patient’s vision, check the visual acuity and record it.
 Do not use an abbreviation unless you are sure that it is commonly understood and in
general use. For example, BP and VA are in general use and would be safe to use on records
when commenting on blood pressure and visual acuity, respectively.
 Do not speculate, make offensive statements, or use humour about the patient. Patients have
the right to see their records!
 If you make an error, cross it out with one clear line through it, and sign. Do not use sticky
labels or correction fluid.
 Write legibly and in clear, short sentences.
 Remember, some information you have been given by the patient may be confidential.
Think carefully and decide whether it is necessary to record it in writing where anyone may
be able to read it; all members of the eye care team, and also the patient and relatives, have a
right to access nursing record.

E-NURSING
INTRODUCTION
Increasingly rapid advances in information and telecommunications technology are
revolutionizing life and business around the world. The impact is being felt in the health sector
with many new applications of these technologies. Telemedicine is essentially the use of both
information technology and telecommunications to provide health services or support health
service provision over a distance.
Information technology refers to a system utilized to retrieve, manage, process, and disseminate
information by means of telecommunication. Telecommunication is the transmission of

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 information from one site to another. Use of equipment to transmit information in the form of
signs, signals, words, or pictures by cable, radio or other systems. Information and
communication technology have changed the way the nurses share among themselves the
information they study.
So nurse manager have to equip their knowledge providing health care information to their
clients through the websites for health promotion and chronic disease.

Definition
E- Nursing incorporates the information communication technology into the nursing to speed up
the nursing process and to aid quality of care.
Definition of e-learning
E- Learning stands for electronic learning. It is a formalized teaching and learning system
specifically designed to be carried out remotely by using electronic communication.
E- Learning commonly referred to the intentional use of net worked information and
communication technology in teaching and learning.
These also termed as online learning, virtual learning, distributed learning, network and web
based learning.
Nurses all around the world have risen to the challenge of new technology. Today, the nurses
work in a variety of E-Health programs such as tele-triage.
PURPOSES OF E-NURSING:
To enhance nurses to benefit from all developments in information, communication and
technology,
To improve nursing and client outcomes.
Educational products available for e-learning:
Up to date inventory of educational programs, educational institutions, workshops and conferences
Online databases, journals, text books
Tutorials providing basic computer skills, search and appraisal training
Online courses, including self directed learning modules in specific areas of practice
Current information on timely topics, best practices, competencies
24 hours helpline
Popular E- Learning technologies:
 Voice-based technology such as CD and MP3 recordings or web casts
 Video technology such as instructional videos, DVDs and interactive video conferencing
 Computer based technology delivered over the Internet or Corporate Internet.

E- Learning Modalities/Types:
 Individualized self paced e-learning online: it refers to situations where an individual learner
is accessing learning resources such as a database or course content online via an Internet.
 Individualized self paced e-learning offline: it refers to situations where an individual learner
is using learning resources such as a database or a computer assisted learning package
offline. Eg: a learner working alone off a hard drive, a CD or DVD.
 Group based e-learning synchronously: it refers to situations where groups of learners are
working together in real time via an intranet or the internet. Eg: real time video conference
or text based conference.

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  Group based e-learning asynchronously: It refers to situations where groups of learners are
working over an Intranet or the Internet where exchanges among participants occur with a
time delay. Eg: on line discussions via electronic mailing lists.
Strategic directions given by Canadian Nurses Association for e-nursing:
 Access
 Competencies
 Participation
Access:
The nurses should seek an appropriate technology and incorporate them into daily practice
The health care organizations also should acknowledge this need and take necessary steps to
facilitate connectivity
Competencies:
Development and ongoing use of ICT skills are key to improve nurses competencies
ICT competencies should be included in the undergraduates and graduate nursing curricula
ICT competencies are included in continuing education
Participation:
Nurses play an increased role in development of ICT solutions
By communicating changes and needs in their practice settings they can ensure the right ICT
tools are selected and implemented for maximum patient benefit.
Role of educator in e-learning:
Learning Management System is a software application or web based technology used to plan,
implement, and assess a specific learning process. It provides an instructor with a way to create
and deliver content, monitor student participation and assess student performance.

Preparation of E- content:
Planning own E-Learning Course:
Create a storyboard before writing the content that is drawing blocks on a page that
represents the frames (pages/screens) of the course
If not story board, prepare an outline of the material.
Consider the objectives of the course, the delivery method of materials, kind of authorsing
software used before writing.
E-Learning content:
An authorsing tool can ensure the unified content development process. The author is to care
not only about the content, but also about the design and the technical side of the project. It
requires programming skills from the author to allow the user to quickly insert active elements
into the text.
A good content should have the following:
It should be easily understand by the audience
A good way is to write in the second person
Use simple or compound sentence structures
Avoid clauses and appositives
Use common contractions
Do not use pronouns where they could lead to confusion
Avoid using multiple adjectives before a noun
Follow one writing style
Keep your fonts simple.

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Avoid extra characters like dash, comma, exclamation marks, uppercase, etc
Use tables only where there is an absolute necessary.
Use hyperlinks
Make use of pictures and include written description of that image
Use animation to illustrate examples.
Use narration if possible. Use of direct message to student is more effective
Make interaction facilities like hypermedia, simulations video conferencing
The learning content is to be based on appropriate and current learning resources
The course is to be motivational and challenging
The learning material is to be accurate and clearly presented
The appropriate level of instruction is to be provided
The downloadable and printable materials are to be available
The tests for knowledge control are to correspond to the subject and contain no mistakes.
Composing tests for knowledge control:
A test is usually introduced to estimate the student’s skills, to see how well he or she has
worked with the learning material.
Types of tests include:
Multiple choices, True/false, Essay, Matching, Ordering, Fill in the blank, Multiple answers,
Drag and drop
Tips for good tests:
Do not ask about what you did not mention in the course
State your question correctly
Make a question that contains only one interrogative sentence
Where the student is to pick only one correct answer, only one answer must be correct
Follow the rules for good writing
Give your student enough time to read the question and all the possible answers twice
slowly.
Distributing E-Learning Materials:
There are different ways to deliver e-learning materials to the user.
 Integrating the e-learning materials to an LMS
 Publishing the E-learning course on the web
 Recording the e-learning materials on CDs
 Providing the printed version of the e-learning course
Advantages:
 Less expensive to produce
 It is not constrained by geographic considerations
 It is more flexible in terms of time
 It can be delivered virtually any where
 The number of students is never limited by the size of the class room
 The teacher is able to monitor student progress
 The individual learning can be easily realized.
Barriers to e-nursing/e-learning:
 Lack of comfort and knowledge about the computers and the Internet
 Lack of access to computer and Internet at work or at home
 Lack of appropriate hardware/software, internet access
 Lack of IT training

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 Lack of support and time from administration to use ICT as part of nursing practice

TELEMEDICINE
INTRODUCTION:
The term ‘telemedicine’ derives from the Greek‘tele’ meaning at a distance and the present
word medicine which itself derives from theLatin ‘midair’ meaning healing. Telemedicine is a
phrase first coined in the 1970”s by Thomas bird, referring to health care delivery where
physicians examined distant patients through the use of telecommunication technologies.
Telemedicine is the use of medical information exchanged from one sight to another via
electronic communications for the health and education of the patient or healthcare provider and
for the purpose of improving patient care. Telemedicine includes consultative, diagnostic, and
treatment services.
It is the process of using communication through audio and video to convey or exchange notes
about a patient with a doctor oralso from one medical professional to another. it is not restricted
to one single place and actually can take place between two remote sites located anywhere in the
country.
Definition of telemedicine:
Telemedicine can be defined as, the use of modern information technology, especially two- way
interactive audio/video telecommunications, computers, and telemetry to deliver health services
to remote patients and to facilitate information exchange between primary care physicians and
specialists at some distance from each other. (Telemedicine: Theory and Practice).

OBJECTIVES OF THE TELE MEDICINE:

 To make high quality healthcare available to traditionally under privileged population
 To Save the time wasted by both providers and patients in travelling from one geographic
location to another to avail services on time
 To Reduce costs of medical care
TERMINOLOGIES OF TELEMEDICINE:
 Asynchronous: This term is sometimes used to describe store and forward tramissions of
medical images or informations because the tranmissions typically occurs in one directions
in time.
 Bandwidth: A Measure of the information carrying capacity of a communication channels
;apratical limit to the size,cost, and capability of a Telemedicine service.
 Broadband: Communications (e.g.,broad television , microwave, and satellite)capable of
carrying a wide range of frequencies : Refers to transmissions of signals in a frequency-
modulated fashion, over a segment of the total bandwidth available, thereby permitting
simultaneous transmissions of several messages.
 Codec: Acronym for coder-decoder. This is the videoconferencing device
(e.g..Polycom.Tandberg.Sony, Panasonic, etc.)that converts analog video and audio signals
to digital video and audio code and vice versa.
 Compressed video: Video images that have been processed to reduce the amount of
bandwidth needed to capturethe necessary information so that the information can be sent
over a telephone network.
 Digital Imaging and Communication in Medicine (D1COM): A standard for
communications among medical imaging devices.

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 Electronic Data Interchange (EDI): The sending and receiving of data directly between
trading partners without paper or human intervention.
 Encryption:The rearrangement of the "bit" stream of a previously digitally encoded signal in
a systematic fashion to make it unrecognizable until restored by the necessary authorization
key.
 Firewall:Computer hardware and software that block unauthorized communications between
an institution's computer network and external networks.
 H.320:This is the technical standard for videoconferencing compression standards that allow
different equipment to interoperate via Tl or ISDN connections.
 H.323:This is the technical standard for videoconferencing compression standards that allow
different equipment to interoperate via the Internet Protocol .
 .H324:This is the technical standard for video conferencing compression standards that
allow different equipment to in interoperate via plain old telephone services (pots)
 Health Level 7 Data communications Protocol (HL-7): Defines standards for transmitting
billing, hospital census, order entries, and other health-related information.
 Interactive Video/Television:This is analogous with video conferencing technologies that
allow for two-way, synchronous, interactive video and audio signals for the purpose of
delivering telehealth, telemedicine or distant education services.
 Integrated services Digital Network (ISDN):This is a common dial-up transmission path for
videoconferencing. Since ISDN services are used on demand by dialing another ISDN
based device, per minute chares accumulate at some contracted rate and then are billed to the
site placing the call.
 ISDN Basic Rate Interface(BRI): This is and ISDN interface that provides 128k of
bandwidth for videoconferencing or simultaneous voice and data services.
 ISDN Primary Rate Interface(PRI): This is an channels ISDN interface standard that
operates using 23, 64k channels and one 64k data channel, with the proper multiplexing
equipment the ISDN PRI channels can be selected by the user for a video call.
 Internet Protocol(IP): IP is par of the protocols describing the software that tracks the
Internet address of outgoing and incoming messages. Most of today’s videoconferencing dev
ices have the capability to use IP as a video protocol
 Multiplexer (MUX): A device that combines multiple inputs (ISDN PRI channels or ISDN
BRI) into an aggregate signal to be transported via a single transmission path.
 Multipoint control Unit (MCU):A device that can link multiple videoconferencing sites into
a single videoconference . An MCU is also often referred to as a bridge.
 POTS: Acronym for Plain Old Telephone Service.
 Router: This is a device that interfaces between two networks or connects sub-networks
within a single organization. It routes network traffic between multiple locations and it can
find the best route between any two sites.
 Switch:A switch in the videoconferencing world is an electrical device tat selects the path of
the video transmission.
 Synchronous:This term is sometimes used to describe interactive video connections because
the transmission of information in both directions is occurring at exactly the same period.
 Telehealth and Telemedicine:Telemedicine and telehealth both describe the use of medical
information exchanged from one site to another via electronic communications to improve
patients health status. Although evolving, telemedicine is sometimes associated with direct
patient clinical services and telehealth sometimes associated with a broader definition of

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 remote healthcare and is sometimes also perceived to be more focused on other health
related service.
Principles of telemedicine:
 provide and support health care when distance separates the participation
 It employs communication and computer technology as a substitute for face to face contact
between provider
 Encompass potential preventing and education/learning application
 Delivers areas to high level care
Applications In Different Forms:
 Information exchange between Hospitals and Physicians.
 Networking of group of hospitals, research centers.
 Linking rural health clinics to a central hospital.
 Videoconferencing between a patient and doctor, among members of healthcare teams.
 Training of healthcare professionals in widely distributed or remote clinical settings.
 Instant access to medical knowledgebase, technical papers etc.

Specialties:
Telemedicine covers a growing number of medical specialties such as:-
 Cardiology.
 Home Care.
 Radiology.
 Emergency Care.
 Surgery.
 Dermatology.
 Psychiatry.
 Oncology.
 Pathology.
 Ophthalmology.
 Hematology.
 E.N.T.
 Nephrology.
 Pre hospital Care.

Growth of Telemedicine Applications:

 2001: Tele-radiology –still images.

 2002: Tele-cardiology – Moving images.
 2003: Tele-pathology, Tele-ophthalmology.
 2004: Tele-oncology, Tele-surgery.

Types of telemedicine:

Store and forward : details related to medical data ,images ,videos, audios and reports are
collected and transmitted to the medical expert for diagnosis.

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 Interactive telemedicine/ services: telephonic conversation , home visits and online interaction
between the client and the expert with an activities like review of history , physical examination
, assessments and check- ups are carried out.
Remote monitoring: also called self testing or self monitoring technique with lots of
technological devices and electrical interaction instruments ,the medical professionals can
monitor the patients .
Telemedicine services:
Primary care and specialists referral services: provide consultation with a patient or a
specialist assisting the primary care physician
Remote patient monitoring: uses devices to remotely collect and send data for interpretation
Consumer medical and health information : Uses internet and Wireless devices for consumer
to obtain specialized health information and on-line discussion groups to provide peer –to –
peer support.
Medical education: provide continuing medical education credits for health professionals and
special medical education seminars for targeted group[s in remote locations.
Major areas of telemedicine technology adopted…

Telemedicine In India:
o Existing system limited only to private hospital.
o APPOLO Group of Hospitals.
o RN Tagore cardiac Hospital, Calcutta.(Asia Heart Foundation).
o No Telemedicine system for public health care.
o Corporate Sectors Offering telemedicine Systems.
o Online Telemedicine Systems, Ahmadabad.
o WIPRO GE.
o SIEMENS.

The elements of the network :

 The Patient End
 The Specialist End
 The Communication Link
The Patient End:
The patient end has to prepare an electronic file of the patient’s history and his radiological and
pathological reports. The patient end must therefore have the facility to prepare these reports and

787
convert these into an electronic record. To convert the patient record into an acceptable
Telemedicine file, a Telemedicine software package has to be used. This software package must
follow certain standards (like DICOM 3 and HL-7) for processing the patient files. Thus, the
hardware requirement at the patient end includes various medical equipment like ECG, X-
Ray/MRI, Scanner, Ultrasound etc., interfaced with a computer which has the Telemedicine
software for preparing and transferring the patient file

The Specialist end:

The specialist end has to receive the patient file and display the patient records satisfactorily on
the monitor in order to enable the specialist doctor make a diagnosis. The specialist doctor
should be able to write down his diagnosis and his recommendation for the line of treatment and
send it back to the patient end.
The above process of receiving the records, examining and sending back the diagnosis and
recommended line of treatment can be done in an “offline” mode, i.e. without the patient and
specialist simultaneously being present and talking to each other. This is known as “offline”
consultation.
For receiving and opening the electronic file the specialist end will need software on its
computer which is inter-operable with the software of the patient end. This is required so that
the specialist end computer can decode the file coded by the patient end
However, “online” consultation would also be possible if the patient along with the treating
doctor at the patient end talk to the Specialty through a “teleconferencing system” also made
part of the Telemedicine system and the communication link. If “online” consultation is not
required the teleconferencing element (consisting of camera and additional bandwidth) could be
eliminated.

The Communication Link:

The Communication link is like a pipeline connecting two sources of information. The speed
and quality of flow will depend upon the “bandwidth” available. The link could be a simple
telephone line (providing 64 Kbps) Internet or ISDN line (provides 128 or 384 Kbps) or fiber
optic on satellite link, depending upon requirement, availability, operational acceptability and
cost. From experience, it is seen that generally 384 Kbps connectivity is found acceptable. This
is the norm in many Telemedicine networks abroad. can have better reliability. However, the
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operational cost could be high depending upon the bandwidth used and the duration of usage.
Availability of fiber optic connectivity can be a limitation especially in remote areas. The
availability of OFC connectivity in India has improved substantially in urban areas and big
towns but it is not available in small towns and beyond.
Satellite based connectivity has the advantage of being available in the remotest part of the
country. Normally, a Very Small Aperture Terminal network (VSAT Network) would be used
to provide this connectivity. The bandwidth can be selected as per requirement. These networks
have the disadvantage of higher costs but have much higher reliability and availability especially
in rural areas and small towns. There are situations like islands, or remote hilly terrain, border
areas, where no other communications link is available and satellite link is the only answer.
The VSAT networks too can be of different types employing different configurations (Star or
Mesh) and different access or connectivity protocols. These features significantly affect the
costs, and performance of the system.
Satellite terminals can also be mounted on vans and be made “Transportable”. Such vans can
visit rural areas, establish connectivity, and provide consultation from a specialty end and then
move on to another location.
EXAMPLE: ISRO’s network in Andaman Nicobar Islands proved to be a vital link during the
recent TSUNAMI DISASTER. Medical advises were regularly given to heavily devastated Car
Nicobar islands through Telemedicine node installation at GB pant hospital, Port Blair.During
his scheduled visit to A&N islands to monitor relief and rehabilitation activities, the Hon’ble
Minister of Home Affairs, ShriShivrajPatil, also visited the telemedicine node at PHC,
Campbell bay and had an online interaction with specialist doctors of Port Blair hospital through
videoconferencing. It may be noted that Ca mpbell Bay PHC is the farthest and remotest
PHC of the country.

Type of connectivity:
Point-to-Point communication:
In networking, the Point-to-Point Protocol (PPP), is a data link protocol commonly used to
establish a direct connection between two nodes over terrestrial and satellite link e.g.
SGPGIMS, Lucknow is connected to the medical colleges of Orissa through point to point
connectivity via satellite link and District Hospital, Rae Bareli via fiber optic cable network.
Point-to-multipoint communication:
It is a term that is used in the telecommunication field which refers to communication which is
accomplished via a specific and distinct type of multipoint connection, providing multiple paths
from a single location to multiple locations e.g. two District Hospitals of Uttaranchal state are
linked to SGPGIMS via ISDN link
Equipments used:
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Hardware:
 PC, Intel P4 3.0 Ghz (dual core), HT/915G/512 MB DDR2, 160 GB SATA HDD/ DVD
ROM/LAN/ Graphic Card With 256 MBVRAM, Two USB ports
 Ethernet port17” TFT-LCD Monitor
 Keyboard
 Mouse
 Multimedia Speaker
 Headphone & Mic.
 Web Camera
 Laser Printer
 UPS – 1KVA
Software:
 Windows Vista OS
 MS Office (latest Prof. Edition) application software
 Customized Telemedicine Software
VSAT
Router, Dish antenna, Modem, DAMA unit
Terrestrial
Media Converter, Router, STM, Power back up for one hour, 6 U RacK
Uses of telemedicine :
General:
 Local doctor can treat without having to leave his/her place
 Cost- reduction on each patient reduce the burden on government bodies
 Makes specialty care more accessible to underserved populations
 Video consultations can alleviate travel and associated costs and open up possibilities for
continuing medical education or training for isolated or rural health practitioner.
People :
 Interaction with specialist doctor
 Practical, safe , time-saving and cost effective
 Immediate access to medical; specialists for second opinion
 Quality health care at one’s doorstep
 Early diagnosis and treatment
 “video say it all “- more advantageous than voice –only – communication
Doctors:
 effective use of medical and technological resources
 Updating medical knowledge in various specialities through periodic referrals
 Continuing medical education
 Global medical community at the desktop
 Enhanced doctor –patient relationship
Tertiary care institution:
 Expansion of market share
 Training for health care professionals
 Organizational expansion of services
 Expansions of tertiary care network
 Providing support for review cases thereby enhancing the reputation.
Barriers to telemedicine:

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 Lack of health infrastructure and services.
 Shortage of computer
 Out flow of doctors
 Lack of training facilities with regard to the application of information and communication
technology in medicine. Terms like HIS, RIS, PACS etc are unheard of by the medical/healthcare
community.
 Virtually no exposure to the applications of ICT in curriculum of medical colleges.
 Inadequate communication services to facilitate telemedicine in most of the cities but the situation is
rapidly improving.
Issues in telemedicine:
Physician/Patient Acceptance
 Physicians and patients have unique technological resources available to improve the patient-
physician relationship. It has been found that patients have no difficulty in accepting telemedicine
program.
 However, some resistance is seen amongst doctors. Doctors in government sector tend to look upon
telemedicine as an additional duty or workload. Therefore, there is need to weave telemedicine into
the routine duties of the doctors. The private doctors sometime fear that telemedicine is likely to
reduce their practice. They need to realize that this technology enhances their reach and exposure
and is only likely to increase their practice further.
 Availability of Technology at a Reasonable Cost:
 It is myth that to establish a telemedicine platform is an expensive. The basic system needs
hardware, software and telecommunication link. In all the areas there is a significant reduction in
the prices. Most of these costs are well within the reach of most of the hospitals, and can be
recovered by nominal charge to the patients and students in case of tele-education which would be
much less than the physically traveling.
 Accessibility:
 Although information technology has reached in all corner of the country but the accessibility of
people living in remote and rural area to the nearest health center (PHCs, CHCs or district hospital)
may not be easy due to poor infrastructure of road and transport. It may be possible that the
available telemedicine system in the health centers may not function because of the interruption in
power supply.
 Reliability:
 Some healthcare professionals has doubt about the quality of images transmitted for tele-
consultation and tele-diagnosis. In tele-radiology, telepathology, tele-dermatology the quality of
image (color, resolution, field of view, etc) should be international standards to avoid any wrong
interpretation and mis-diagnosis. The delay in transmission of data may be of critical importance in
tele-mentoring and robotic surgery
 Funding/ Reimbursement Issues:
 There should be a format to calculate the investment and recurring cost of the telemedicine system.
The insurance companies have to decide whether the cost of tele-healthcare should be reimbursed or
not
 Lack of Trained Manpower:
 Telemedicine is a new emerging field; there is lack of training facilities with regards to application
of IT in the field of medicine. Most of the healthcare and IT professionals are not familiar with the

791
 terms commonly used in telemedicine such as HIS, EMR, PACS, etc. Telemedicine is also not the
part of course curriculum of medical schools.
 Legal & Ethical:
 Telemedicine technology has been proved and established and its advantages and benefits are well
known but still many healthcare professionals are reluctant to engage in such practices due to
unresolved legal and ethical concerns.
 Privacy and Security Concerns:
 There are many issue that should be considered regarding the security, privacy and confidentiality
of patient data, in telemedicine consultations How are patients’ rights of confidentiality of their
personal data ensured and protected How to ensure security of the data and restrict its availability to
only those for whom it is intended and who are authorized and entitled to view it? How to prevent
misuse and even abuse of electronic records in the form of unauthorized interception and/ or
disclosure?

Management role:
Planning:
Role of central coordinating body:
 It is desirable to have a central coordinating body for telemedicine development at the national or
regional level for establishing national standards to ensure technological compatibility of projects
throughout the country.

Review of local and national infrastructure

 Local telecommunication services like person to person voice communication, fax, internet and e-
mail, etc is necessary for establishing telemedicine.

Needs analysis/consultation with end users

 The needs analysis should involve talking to a number of potential end users about the planned
service , the objectives of the service, potential impact on the health of the community and degree of
support expected from health workers.

Staff capabilities
 Staff capabilities to use the proposed technology must be assessed. If they are comfortable only they
will integrate the technology into their work habits.
 Technical support
 The close availability of technical support is critical. Problems as basic as locating switches, loose
connections or using software can often cause major frustration to users in the early stages.

Technology selection
 The application of the technology need to be identified and all categories of staff who will be
involved with the project be given the opportunity to test - drive the possible choices. This includes
clinical, technical and administrative staff.
 A number of vendors should be surveyed regarding available technology and its suitability and
verification of capabilities of equipment is done with technology consultants.
 Cost benefit analysis
 A cost benefit analysis should be done prior to making the final decision to proceed costs and
benefits should be identified and quantified.
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 Implementation:
Project management
 A project manager should be appointed to oversee the implementation of project. He should review
the progress of the project and solve the problems and arrange for ongoing promotional activities
like staff training.

Staff Training and support

 All staff will need training in the new technology. This should include formal training sessions,
supervision when using new technology until confident with the equipment, provision of
appropriate manuals and checklists, and ready availability of support when they start using the
technology on their own.

Evaluation
 Evaluation is designed to assess the degree to which the project has successfully achieved its goals
and objectives and the factors which contributed to the success or failure of the project.

OTHERS:
National standards and strategies
 Telemedicine development also requires the adoption of standards either national or international
standards or strategies to allow ready and free communication between health facilities.

TELENURSING
Definition
Telenursing refers to the use of telecommunications technology in nursing to enhance patient
care. It involves the use of electromagnetic channels (e.g. wire, radio and optical) to transmit
voice, data and video communications signals. It is also defined as distance communications,
using electrical or optical transmissions, between humans and/or computers
Telenursing, the delivery of nursing care and services using telecommunications, increases
access to nursing care interventions for clients in remote or distant locations (Chaffee, 1999;
Helmlinger&Milholland, 1997; Yensen, 1996).
Telenursing is a component of telehealth that occurs when nurses meet the health needs of
clients, using information, communication and web-based systems. It has been defined as the
delivery, management and coordination of care and services provided via information and
telecommunication technologies (CNO, 2005).
Technologies used in telenursing may include,
 Telephones (land lines and cellphones)
 Personal digital assistants (PDAs)
 Facsimile machines (faxes)
 Internet
 Video and audio conferencing
 Teleradiology
 Computer information systems
 Telerobotics

Principles:
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 These guidelines are based on the principles of telenursing, which state that effective telenursing
should:
 Augment existing healthcare services
 Enhance optimum access arid, where appropriate and necessary, provide immediate access to
healthcare services
 Follow position descriptions that clearly define comprehensive, yet flexible roles responsibilities
 Improve and/or enhance the quality of care
 Reduce the delivery of unnecessary health services
 Protect the confidentiality/privacy and security of information related to nurse-client interactions
Types:
Telephone nursing:
Telephone nursing is the use of the nursing process to provide care to patients over the
telephone (AAACN, 1997). First used by nurses in the late 1800s, the telephone is now used to
deliver an extraordinary variety of nursing care and services nationwide.
Telephone triage is the largest and most recognized component of telephone nursing. Telephone
triage, a staple in nursing, is considered the forerunner of telemedicine (Connors, 1997; Pond,
2000). In addition to telephone triage, telephone nursing services include advice and
information, appointments and referrals, symptom management, demand management, and
disease management.
The role of telephone nursing has become increasingly central to the delivery of cost-effective,
quality care for disease management populations (Bleich, 1998; NCSBN, 1997).
According to Bleich (1998), to best manage disease progression, a concurrent patient/provider
relationship is essential, ideally provided by telephone nursing. Telephone nursing therefore has
significant potential in improving disease management outcomes. In other settings, it is effective
in reducing health care costs, improving access to care, and increasing satisfaction with care.
Sub specialty of telenursing - telephone triage:
The more applicable subspecialty of telenursing is the telephone 'triage".
Definition:
Telephone triage is defined as the management of patient health concerns and symptoms via
telephone interaction (telecommunications) by the "advice nurses it is thus an aspect of
telenursing. It can also be considered an aspect of telemedicine and telehealth utilizing an older
form of technology.
Telephone triage nurses have a range of titles: advice nurse, telepractitioners, telenursing,
telepractice nurse or consulting nurses.Telenurse practice in a range of settings, from large
medical call centers, physician's offices, clinics, hospices, college health centers, disease
management call centers, poison centers and emergency departments.
Uses of telephone triage:
Triage means a sorting out. Telephone triage nurses utilize protocols orguidelines, in paper or
electronic format to help sort symptoms, from chest pain tochicken pox.
Telephone triage involves ranking clients' health problem according to their urgency, educating and
advising clients, and making safe, effective, and appropriate dispositions all by telephone.

Telehomecare
Telehomecare, which incorporates the principles of telehealth into the home care setting, is not
specific to nursing. However, within nursing, home health nurses use technology to provide

794
services in the home which enhance the efficiency and the quality of care (Milholland, 1995;
Short &Saindon, 1998; Stricklin, Jones, & Niles, 2000; Warner, 1998).
Telehomecare services such as discharge follow-up, cost-effective assessments and
interventions, education, and supportive care can both empower clients and improve outcomes
(Borchers&Kee, 1999; Frantz, 2000; Short &Saindon, 1998).
According to Frantz (2000), the combination of telehomecare and disease management offers
additional opportunities to improve outcomes and decrease costs, allows the nurse more
effective management of large caseloads, and provides seamless, individualized, ongoing care
within the home for patients with high-profile, high-cost diseases.
Scope of Practice, Liability and Risk Management:
The practice of nursing, as defined in the Registered Nurses Act (2006), is broad and
encompasses diverse roles and settings for nursing practice, including telenursing. Registered
nurses who practice telenursing must have a valid and current Nova Scotia nursing license and,
as in any context of practice, provide services that are consistent with their legislated scope of
nursing practice (i.e., as outlined in various policy documents such as the Registered Nurses
Act, the College's Standards for Nursing Practice, CNA's Code of Ethics, and various College
guidelines and position statements). Nurses" practice should also reflect agency guidelines,
other relevant acts such asPIPEDA and the Protection of Persons in care Act, and. where
applicable, clinical protocols.
Nurses providing services via telenursing that fall outside the legislated scope of practice of
nursing should contact the College to determine if their practice contravenes the RN Act or other
legislation such as the Medical or Pharmacy acts. In some cases, nurses may receive direction on
how to acquire the authority to perform specific services (e.g., to perform a delegated medical
function).
Registered Nurse's practicing tele-nursing be concerned about liability and risk
management:
Whether nurses engage in e-health, internet-based .practice or other technologies, they will face
new and constant challenges, including potential issues of liability. Although a lack of legal
precedents creates uncertainty about liability in telehealth clearly defined accountabilities will
be key to dealing with several recognized categories of liability, including those related to:
 health professionals involved
 specific technologies/applications used
 organizations or institutions involved
 Human resources and training
Nurses providing care via telehealth also need to be involved in the development and
documentation of risk management plans and related policies.
Risk management in terms of telehealth could include ensuring the security and integrity of
relevant websites, with the use of disclaimers being of particular importance. Disclaimers on
websites and/e-mail messages help define accountabilities and minimize liability. For example,
if a registered nurse has created a website to assist in the delivery of nursing services, a
disclaimer might indicate that the nurse is not accountable for sites which may be linked to
her/his site. While the nurse could, and should, ensure that all links or endorsed sites are
credible, the sites to which her/his site are linked could also be linked to non-credible sites from
which clients could receive misleading or inaccurate information that may be harmful when
followed.

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 The following questions may prove helpful to nurses in developing their own websites and
evaluating the trustworthiness of others:
 Is the resource credible? (e.g.. is the author/organization name clearly stated? is the
author/organization an accredited authority?)
 Is the content suitable? (e.g., is there enough information or detail?)
 Is the resource timely? (e.g.. is the information reviewed and/or updated on a regular basis?)
 Is there clear and adequate disclosure? (e.g., is the author's/organization's interest and' .or mandate
in developing and sharing the information clear? are commercial links sponsorships stated?)
 Is there a clear caution statement? (e.g., does the site offer a clear statement that health information
should not be taken as health advice or a substitute, where applicable'? if fees are charged for
services are they clearly noted and explained?)
 Does the website have a security certificate to validate its authenticity?

Liabilities protection an issue in telenursing:

Face-to-face interactions are still considered to be the best way to ensure accurate
communications between nurses and clients (CNPS, 1997). Given this, the importance of
developing policies to support safe, competent, compassionate and ethical' telenursing cannot be
overstated. Examples of further policy development and/or practices needed to help reduce
liability risks include:
 Using consistent tools to collect data (see CNPS infoLaw Telephone Advice)
 Using evidence-based, protocol-driven software or data to support telenursing
 Consulting other care providers when appropriate (e.g., "when in doubt, check it out")
 Employers generally provide insurance protection for registered nurses. However, liability
protection is provided by CNPS, for nurses who hold active-practicing status with a member
association of CNPS and who are practicing nursing in accordance with their provincial
nursing legislation (the College of Registered Nurses of Nova Scotia is a member
association). The need for additional liability protection for nurses practicing telenursing
depends on a number of factors, such as the:

Types of technology to be used (e.g., Internet)

Services to be provided (e.g., expanded scope of practice)
Location of the clients (e.g., outside of Canada)
Employment status of the registered nurse (e.g., self-employed).
RNs practicing or considering practicing telenursing are encouraged to discuss liability issues
with their employers, legal counsel, and/or CNPS. Legal, ethical and regulatory issues
Telenursing are fraught with-legal, ethical and a regulatory issue, as it happens with telehealth
as a whole. In many countries, interstate and inter country practice of telenursing is forbidden
(the attending nurse must have a license both in her state/country of residence and in the
state/country where the patient receiving telecare is located). Legal issues such as accountability
and malpractice, etc. are also still largely unsolved and difficult to address.
Competencies are required to safe telenursing practice:
In general, the competencies required in telenursing practice mirror the competencies required
of all registered nurses (e.g., clinical competence and assessment skills in the nurses" area of
practice; an understanding of the scope of service being provided). However, registered nurses
practicing telenursing should also possess:

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 Personal characteristics (e.g., positive attitude, open-mindedness towards technology and
good people skills) that will facilitate their involvement and advance the telehealth program
 Knowledge and ability to navigate the technology system and environment (e.g.. the
knowledge and skill to properly operate hand-held cameras, videoconferencing equipment,
computers, etc.)
 An understanding of the limitations of the technology being used (e.g.. able to determine if
vital signs are being monitored accurately by specific equipment)
 The ability to recognize when telehealth approaches are not appropriate for a clients, needs
(i.e.. not 'reasonably" equivalent to any other type of care that can be delivered lo the client.,
considering the specific context, location and timing, and relative availability of traditional
care), includes assessment of a client's level of comfort with telehealth
 Ability to modify clients" care plans based on above noted assessments " awareness of client
risks associated with telehealth and willingness to develop back-up plans and safeguards
 Knowledge, understanding and application of telehealth operational protocols and
procedures
 Competent enhanced communication skills
 Appropriate video/telephone behaviours Awareness ofthe evidence base for their practice
and areas of practice in need of research
 The ability to deliver competent nursing services by regularly assessing their own
competence, identifying areas for learning, and addressing knowledge gaps in relation to the
area of practice and relevant decision-based software and technology.

Nurse needs specialized preparation or education for telenursing:

As is the case for all registered nurses, those providing telehealth services should have the
necessary education and competencies to provide safe, competent, compassionate and ethical
care. The required amount/type of formal education and on-the-job training will depend on the
nature of the telehealth service offered. In light of the evolving nature of telehealth services
there is a need for continuing education/professional development in this area, and already
certificate programs in telehealth are becoming more common in Canadian universities and
colleges
Pronsand con of telenursing:
Proponents of telenursing think it increases public access to health services, especially for
people living in rural areas and those with compromised health status. These individuals also
propose that telenursing will decrease waiting times, reduce unnecessary visits to emergency
rooms and physicians' offices, enable clients to leave hospitals sooner or stay at home longer
before becoming institutionalized, and potentially reduce costs for public travel and professional
overhead expenses. Another benefit cited includes the immediacy of information provided to
clients to help them meet their healthcare needs.
In addition to healthcare professionals in rural areas valuing telehealth, clients have reported
decreased isolation as a positive aspect of being able to access health services in their
communities via technology It (telehealth) is .especially useful in cases of elderly and
chronically ill clients who need to be nursed at home and are remotely located". Promoting the
availability of communication technologies may also help attract healthcare professional to rural
or underserved areas as this will enable them to access other healthcare providers through
mechanisms such as videoconferencing and the Internet (American Nurses Association, 1999).

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Evaluations of telehealth projects in various aspects of nursing (e.g. education, administration,
clinical practice) have had positive results. For instance, applications of telehealth in education
have shown the potential to bring interactive education, potentially rich in visual content, to
audiences dispersed over immense geographical areas in a logistical and cost-effective manner
that could not have been achieved through any other means. This evaluation also demonstrated
that from an administrative perspective the avoidance of travel for in-person meetings is more
than just a matter of convenience and cost savings: it is essential for conducting the business of
health care in a safe and responsible manner. In fact, telehealth is considered to be so effective
that in 1997 the World Health Organization announced that it has become part of their "health
for all" strategy and should be made available to all people (World Health Organization. 1997)
Alternatively, opponents to telehealth fear the absence of direct hands-on assessments or face-
to-face interactions will diminish the quality of health care and increase liability risks. Concerns
have also been expressed in relation to the potential for agencies to reduce healthcare
expenditures by replacing face-to-face encounters with connections in telehealth technologies
even in situations when personal contacts would be deemed to be in the best interests of a client
(e.g.. need for more emotional support, therapeutic (ouch). Other potentially negative impacts
raised in relation to telehealth include;
Likelihood of technology failures
Increased risk to the security and confidentiality of clients health information
Potential for health providers to step outside their scopes of practice
Inability (increased difficulty) to provide clients with information to allow them to make in
informed decisions about whether to give or refuse consent
Responsibilities of employers to ensure personnel have the necessary competencies
Ethical dilemmas in telenursing
Studies have reported different kinds of ethical dilemmas that nurse’s encounter in their daily
practice
Autonomy versus beneficence
Within telenursing it is not unusual that the caller is not the actual patient, but a close relative. It
may be a parent calling on behalf of a sick child or a wife calling for her husband. The ethical
dilemma telenurses can experience in the latter situation is a conflict between the patient’s
autonomy and the relative’s, as well as the nurse’s, ambition to do help the patient. Hence, the
principles of autonomy and beneficence are in conflict. The nurse always strives to speak to the
patient herself, but when that is not possible she has to walk a fine line between help and
respect.
Integrity and documentation
One aspect several telenurses experience as ethically troubling is that the encounter over the
phone is “faceless” which makes it difficult for the nurse to “read” the patient through body
language and face expressions. This means that decisions must be based only on the verbal
information the caller chooses to reveal. Further, the nurse can never be fully sure of the caller’s
identity, in spite of the fact that the caller gives a name and a social security number. This raises
the ethical question of how to ensure the caller’s integrity within telenursing.
One way to handle this dilemma is by being restrictive about information on previous illness
and calls. Furthermore, a telenurse should be cautious when sensitive information is to be
documented, For example, when calls concern psychiatric illness or venereology/gynaecology.
On such occasions, a telenurse may just note ‘referral’ in the record, which is a correct but not
very informative notation.

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 Priority setting and the healthcare organisation
As a telenurse can be described as being both a healthcare adviser and a “gate-keeper”, priority
setting is part of the day-to-day work in telenursing. Priorities should be made according to a
platform consisting of three ethical principles, namely:
 The principles of human dignity
 Need and solidarity
 Cost-efficiency.
Responsibility and information
Ethical dilemmas in telenursing can also occur due to the nurses’ obligation to inform the
patient and at the same time avoid giving too much information that might overwhelm the
patient and make him/her deny the symptoms. Here, the ethical demand of presenting honest
information to the patient might clash with the principle of non-maleficence.
An example of a situation that may create this dilemma is when a patient calls in for what she
believes is a small problem, needing only some advice on self-care, while the nurse apprehends
that the symptoms described are signs of a serious illness. The telenurse feels that she cannot
confront the caller with the truth too abruptly, but she must at the same time try to make the
caller realize the severity and urgency of the symptoms. As one nurse describes it, this is
“walking a fine line, both ethically and as a fellow human being”
Ethical competence building in telenursing
As ethical dilemmas occur frequently in telenursing the question of ethical competence building
in this context is urgent. Nurses’ individual qualities, as well as the organisational climate, are
important aspects to address in this discussion. Ethical competence is both an individual and an
organisational responsibility in the healthcare system. In order to be able to identify if a
dilemma is truly ethical in nature, as well as to be able to judge and act upon it, high ethical
competence is needed among nurses.
One way to achieve this could be to work with so called ethics rounds, i.e., a form of
institutionalized, interprofessional ethics discussions. In addition to the increased ethical
competence that might come out of such ethics rounds, a decrease in moral uncertainty and
moral distress might also follow.
Guidelines for telenursing( Australian nursing and midwifes council)
Nurses and midwives practicing in telenursing shall be registered nurses or midwives.
Enrolled nurses involved in telenursing need to be under the supervision of a registered
nurse or midwife.
Nurses and midwives practicing telenursing are personally responsible for ensuring that their
nursing and/or midwifery skills and expertise remain current for their practice.
Nurses and midwives who are practicing telenursing in Australia are expected to practice
within the framework of the ANMC National Competency Standards for Registered Nurses,
National Competency Standards for the Midwife, the ANMC Code of Professional Conduct
for Nurses in Australia, Code of Ethics for Nurses in Australia and other relevant
professional standards.
Nurses and midwives have a duty to inform consumers of their name, qualification and
registration status. Consumers may wish to confirm registration status with the relevant
nursing and midwifery regulatory authority.

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 Nurses and midwives should inform consumers of the telehealth process including other
persons/professionals who may be participating or present in the telehealth consultation; and
obtain consent before proceeding.5
Nurses and midwives in telenursing have a duty to provide privacy and confidentiality in all
interactions.
Nurses and midwives must comply with government and institutional policies relating to
privacy, confidentiality, informed consent, information security and documentation during
the provision of telenursing care. Nurses and midwives are required to document all
interactions during the telenursing consultation
Nurses and midwives practicing in telenursing should be aware of both the evidence base for
their practice and the areas of practice in need of research.
Nurses and midwives practicing telenursing should engage in evaluation of their practice in
relation to issues of quality, safety and patient outcomes.
Enquiries regarding a nurse or midwife’s registration status or complaints about practice can
be made to the relevant nursing and midwifery regulatory authority with which the nurses
registered
Telenursing practice guidelines
It is well recognized that assessments and the ongoing collection and analysis of relevant data
are required to promote and support the sustainability of telehealthprograms, in addition, there is
a need to establish clinical outcomes evaluations and indicators. However, it is important to note
that the identification and measurement of these indicators will be partially dependent on the
telehealth service being used/ evaluated.
Application
 One of the most distinctive telenursing applications is home care. For example, patients
who are immobilized, or live in remote or difficult to reach places.citizens who have chronic
ailments, such as chronic-obstructive, pulmonary disease, diabetes, congestive heart disease
or disabilitating diseases., such, as neural degenerative diseases (Parkinson's disease,
Alzheimer's disease. ALS).etc.. May stay at home and be "visited" and assisted regularly by
a nurse via videoconferencing, internet, videophone, etc. Still other applications of home
care are the care of patients in immediate post-surgical situations, the care of wounds.
ostomies, handicapped individuals, etc. In normal home health care, one nurse is able to visit
up to 5-7 patients per day. Using telenursing, one nurse can"visit"12-16 patients in the same
amount of time.

 A common application of telenursing is also used by call centers operated by managed care
organizations, which are staffed by registered nurses who act as, case managers or perform
patient triage, information and counseling as a means of regulating patient access and flow
and decrease the use of emergency rooms.
 Telenursing can also involve other activities such as patient education, nursing
teleconsultations, examination of results of medical tests and exams,andassistance to
physicians in the implementation of medical treatment protocols.
 Clinical information can be shared with other professional colleagues including national and
international experts.
 A common application of telenursing is also used by managed care organizations which are
staffed by registered nurses who act as case managers or perform patient triage, information

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 and counseling as a means of regulating patient access and flow and decrease the use of
emergency rooms.
 Telenursing can also involve other activities such as patient education, nursing
teleconsultations, and examination of results of lab tests and assistance to physicians in the
implementation of medical treatment protocols.

ELECTRONIC MEDICAL RECORD

Definition
Electronic Health record will include all information about an individual’s lifetime health status
and health care maintained electronically. It permits much more data to be captured, processed,
and integrated which results in broader information than paper record.
o Electronic medical records (EMR), this is a longitudinal record of personal health and
healthcare "from cradle to grave".
o It combines information about patient's contacts with primary health care as well as subsets
of information about hospitalizations [secondary and tertiary healthcare].
o The term electronic patient record refers to records of patient healthcare provided
periodically by one institution [a hospital for example]. It represents the classical file for
every patient admitted to a hospital.

The 2003 IOM Patient Safety Report describes an EMR as encompassing :

 "A longitudinal collection of electronic health information for and about persons
 Immediate electronic access to person- and population-level information by authorized users;
 Provision of knowledge and decision-support systems [that enhance the quality, safety, and
efficiency of patient care] and
 Support for efficient processes for health care- delivery." [IOM 2003)

The 1997 Institute of Medicine report: The Computer-Based Patient Record: An Essential
Technology for Health Care provides the following more extensive definition:
"A patient record system is a type of clinical information system, which is dedicated to
collecting, storing, manipulating, and making available clinical information important to the
delivery of patient care. The central focus of such systems is clinical data and not financial or
billing information. Such systems may be limited in their scope to a single area of clinical
information (e.g., dedicated to laboratory data), or they may be comprehensive and cover
virtually every facet of clinical information pertinent to patient care (e.g.. computer-based
patient record systems)." [IOM. 1997]
The eight core capabilities that EHRs should possess are:
Health information and data. Having immediate access to key information - such as patients'
diagnoses, allergies, lab test results, and medications - would improve caregivers' ability to
make sound clinical decisions in a timely manner.
Result management. The ability for all providers participating in the care of a patient in
multiple settings to quickly access new and past test results would increase patient safety and
the effectiveness of care.
Order management.The ability to enter and store orders for prescriptions, tests, and other
services in a computer-based system should enhance legibility, reduce duplication, and improve
the speed with which orders are executed.

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Decision support.Using reminders prompts, and alerts, computerized decision-support systems
would help improve compliance with best clinical practices, ensure regular screenings and other
preventive practices, identify possible drug interactions, and facilitate diagnoses and treatments.
Electronic communication and connectivity.Efficient, secure, and readily accessible
communication among providers and patients would improve the continuity of care, increase the
timeliness of diagnoses and treatments, and reduce the frequency of adverse events.
Patient support.Tools that give patients access to their health records, provide interactive
patient education, and help them carry out home-monitoring and self-testing can improve
control of chronic conditions, such as diabetes.
Administrative processes. Computerized administrative tools, such as scheduling systems,
would greatly improve hospitals' and clinics' efficiency and provide more timely service to
patients.
Reporting.Electronic data storage that employs uniform data standards will enable health care
organizations to respond more quickly to federal, state, and private reporting requirements,
including those that support patient safety and disease surveillance."
The electronic health record has been continually expressed as an evolvement of health record-
keeping. Because it is electronic, this means of recordkeeping has been both supported and
debated in the health professional community and within the public realm.
Health information managers are charged with the protection of patient privacy and are
responsible for training their employees in the proper handling and usage of the confidential
information entrusted to them. With the rise of technology's importance in healthcare, health
information managers must remain competent with the use of information databases that
generate crucial reports for administrators and physicians
Contrast with paper-based record
Paper based records are still by far the preferred method of recording patient information for
most hospitals and practices in the U.S. The majority of doctors still find their ease of data entry
and low cost hard to part with. However, as easy as they are for the doctor to record medical
data at the point of care, they require a significant amount of storage space compared to digital
records. In the US, most states require physical records be held for a minimum of seven years.
The costs of storage media, such as paper and film, per unit of information differ dramatically
from that of electronic storage media. When paper records are stored in different locations,
collating them to a single location for review by a health care provider is time consuming and
complicated, whereas the process can be simplified with electronic records. This is particularly
true in the case of person-centred records, which are impractical to maintain if not electronic
(thus difficult to centralise or federate). When paper-based records are required in multiple
locations, copying, faxing, and transporting costs are significant compared to duplication and
transfer of digital records. Because of these many "after entry" benefits, federal and state
governments, insurance companies and other large medical institutions are heavily promoting
the adoption of electronic medical records.
One study estimates electronic medical records improve overall efficiency by 6% per year, and
the monthly cost of an EMR may (depending on the cost of the EMR) be offset by the cost of
only a few "unnecessary" tests or admissions.
However, the increased portability and accessibility of electronic medical records may also
increase the ease with which they can be accessed and stolen by unauthorized persons or
unscrupulous users versus paper medical records as acknowledged by the increased security
requirements for electronic medical records included in the Health Information and Accessibility

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Act and by recent largescale breaches in confidential records reported by EMR users. Concerns
about security contribute to the resistance shown to their widespread adoption.
Handwritten paper medical records can be associated with poor legibility, which can contribute
to medical errors. Pre-printed forms, the standardization of abbreviations, and standards for
penmanship were encouraged to improve reliability of paper medical records. Electronic records
help with the standardization of forms, terminology and abbreviations, and data input.
Digitization of forms facilitates the collection of data for epidemiology and clinical studies.
In contrast, EMRs can be continuously updated. The ability to exchange records between
different EMR systems would facilitate the co-ordination of healthcare delivery in non-affiliaied
healthcare facilities. In addition, data from an electronic system can be used anonymously for
statistical reporting in matters such as quality improvement, resource management and public
health communicable disease surveillance.
Legal status
Electronic medical records, like medical records, must be kept in unaltered form and
authenticated by the creator. Under data protection legislation, responsibility for patient records
(irrespective of the form they are kept in) is always on the creator and custodian of the record,
usually a health care practice or facility. The physical medical records are the property of the
medical provider (or facility) that prepares them. This includes films and tracings from
diagnostic imaging procedures such as X-ray, CT, PET, MRI, ultrasound, etc. The patient,
however, according to HIPAA, has a right to view the originals, and to obtain copies under law.
Technical features
Using an EMR to read and write a patient's record is not only possible through a workstation but
depending on the type of system and health care settings may also be possible through mobile
devices that are handwriting capable. Electronic Medical Records may include access to
Personal Health Records (PHR) which makes individual notes from an EMR readily visible and
accessible for consumers.
Event monitoring
Some EMR systems automatically monitor clinical events, by analyzing patient data from an
Electronic Health Record to predict, detect and potentially prevent adverse events. This can
include discharge/transfer orders, pharmacy orders, radiology results, laboratory results and any
other data from ancillary services or provider notes.
Components of an EHR

EHR focus the individual’s health both wellness and illness.

It focuses the health data about the person across his or her lifetime, including facts,
observations, interpretation, plans, actions and outcomes.
Health data include information on allergies, history of illness and injury, functional status,
diagnostic studies, assessments, orders, consultation reports and treatment records.

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 Health data also include wellness information such as immunization history, behavioural data,
environmental information, demographics, health insurance, administrative data for care deliver
process and legal data such as informed consents.
Who, what, when and where of data capture also identified.
Advantage:
 Provides quality measurements and clinical outcome data to support the analysis of patient
problems.
 Integrated online CPR type information system allows ready access to electronic patient records via
web browser.
 This enables a clinician in the emergency room to access patient records via the web.
 This reduces the time for intervention and treatment, saving money and improving patient
conditions.
 Improves communication, increased completeness of documentation and reduction in error
 Simultaneous access from multiple locations: CPR has a great advantage over the paper-based
record since it can be accessed from multiple locations within the health care facility.
 Legibility: documentation in a CPR is more legible because it is recorded as printed text rather than
as hand writing, and it is better organized because software display end on the input.
 Variety of views on data: with the current computer technology, data can be displayed in many
different formats e.g. laboratory data can be displayed as numerical figures or graphical
representation against time (flow sheets).
 Support of structured data entry: this usually results in collection of more reliable and more
complete data.
 Decision support: CPRs commonly supports both decisions related to the diagnosis of a disease on
the basis of individual data, and decision related to the therapy on the basis of the available data
evidence.

Support to Clinical Epidemiological Research: CPR systems are used in epidemiological

researches in three ways.
i. As a sampling tool, where patients are selected from a trial population using the
existing database.
ii. As a data collection tool, where certain specific clinical data of the selected sample
need to be retrieved.
iii. as a registration tool, when the CPR system has the capabilities to register data that
are used for research project, it assists the researcher in professional data
management (Bemmel et al., 1997).

Health technology in the hospital

Systems for admission, discharge, transfer
- A patient’s entry into health care always involves registration at the providing facility.
- Registration information is needed by all care providers.
- It was this need that supported the development of registration systems as one of the first
information systems is to be used in health care.
- Information collected through registration should be electronically transmitted to all user
who need the data.
- Electronic transmittal assures that uniform data exist at all locations.
- Also, electronic transmittal decreases the risk of errors associated with duplicate data.
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- Registration system assigns a unique identifier to all patients, which has been called the
medical record number.
- To access patient records at different sites of care, users must have a way to link all medical
record numbers within an enterprise to obtain a longitudinal record of care received by the
patient.

Order Communication Systems

- Order communication systems automate the processing of clinical orders to the providing
departments.
- Traditionally, order entry systems have been transcription based, which allow for clerical
entry of physician order from paper charts.
- Support of clinical order entry through use of graphical user interface (GUI) orders.
- GUI uses pull-down menus, dialog boxes, pictures or icons, file folders, and other on-screen
aids to allow user to navigate the system operations.
- GUI orders allow users to easily enter new orders or modify existing orders at any time,
from any system function, during patient record review.
- When the order management system sends an order to an automated ancillary system, the
order is electronically placed directly into the ancillary system, without intervention of
department staff.
- Orders transmitted to ancillary departments that are not automated are usually sent via
message to the department printer.
- The most commonly automated ancillary systems are laboratory, radiology, and pharmacy

Test Result Reporting

- After tests are reported by the service department, the results should be made accessible to
all system users.
- To facilitate review, results should be presented in results display and results storage.
- Results display: Test results are accessible for on screen display.
- The list is usually presented in reverse chronological order.
- Results storage: Results are stored in the system’s database.
- Two ways of access to results; by direct access into the source system or by query into the
source system
- Ancillary and clinical system results can also be stored in a clinical data repository.
- Use of a common data repository for all clinical systems allows users to access information
from one location.
- Also eliminates or decreases duplication of data entry, and usually enhances performance.
External Access to Multisourced Data
- External access is generally less efficient.
- Often, institutions that have very effective internal is lack effective linkages to patient data
at other sites of care.
- Hospital based caregivers can usually access results from any automated hospital based
system.
- Older Methods of Access: clinicians have compensated for a lack of access to patient
information by phoning for the data and writing it down
- This method is less than desirable because it is time consuming and holds considerable
potential for errors.

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- With the proliferation of fax, which provide clinicians with paper copies of patient data from
alternate sites of care, access to information has improved.
- However, faxes still present a problem, in that access requires that the site be open when the
information is needed.
- When caregivers cannot access data, they must determine if test results can wait or if repeat
testing is needed.

Electronic Methods of Access and the Master Patient Index

- The real value of collecting data electronically is assuring access to all users at the time of
need.
- Access to records should be available regardless of the location of the user or the record.
- Preferred solutions for access to multisource data include the use of:
- Data repositories: Which store data from multiple systems and allow users, based on security
clearance, to access the data.
- Data repositories:Which store data from multiple systems and allow users, based on security
clearance, to access the data.
- Networks: Which link computers with link computers within the same general physical area,
and wide area networks which create links over large geographic areas.
- Community health information networks: Which are clinical messaging networks that
provide patient data form multiple sites across defined geographic areas.
- Master patient indexes (MPIs): Which is a cross-referencing mechanism for identification
and access of patient data from multiple sources.
- It supports health care organizations with multiple and changing sources of patient
identification and registration.

Common objectives for MPI include:

a) Providing a fast, reliable, thorough, enterprise wide patient search capability.
b) Assisting in the prevention of duplicate patient entries in a network.
c) Detecting duplicate patient entries and providing facilities for review and correction of these
exceptions.
d) Accepting registration, case, and member input from multiple sources.
e) Cross-referencing entries from multiple data sources.
f) Storing patient demographics, insurance, and other data.
g) Providing a source for network wide unique patient identifiers.

Central Scheduling Systems

- It was developed to facilitate patient scheduling through one or more department within an
institutions or an enterprise.
- Central scheduling departments schedule both inpatients and outpatients for exams, tests,
and other procedures.
- Central scheduling systems give institutions a distinct competitive edge in the marketplace.
- Also place an increasingly important role in patient satisfaction outcomes.
- Central schedulers have access to identified department patient schedules and coordinate
scheduling of patient test.
- At the same time, schedulers assure that exams are appropriately sequenced.

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 - In addition, that patients are expedited throughmultiple departments and/ facilities in the
shortest time possible.
- Patient have one stop scheduling and are assured that test are appropriately sequenced.
- Central scheduling department staff assures that patients receive appropriate instructions
required for test.
- Some unique issues of a central scheduling systems include:
- Departmental ownership and control of schedules: Scheduling departments frequently
believe that only the servicing department can appropriately schedule patients.
- Staffing concerns: When scheduling staff are centralized, participating departments need to
contribute to the full-time equivalent component of the new centralized scheduling
department.
- The goal of computerized patient records is to use automation to provide users concurrent
data analysis, and appropriate warnings and alerts.
- Fully functional automated systems improve patient care, clinical outcomes, and caregiver
productivity.

Advantages :
Replace paper-based medical records which can be incomplete, fragmented (different parts in
different locations), hard to read and (sometimes) hard to find. Provide a single, shareable, up to
date, accurate, rapidly retrievable source of information, potentially available anywhere at any time.
Require less space and administrative resources.
Potential for automating, structuring and streamlining clinical workflow.
Provide integrated support for a wide range of discrete care activities including decision support,
monitoring, electronic prescribing, electronic referrals radiology, laboratory ordering and results
display.
Maintain a data and information trail that can be readily analyzed for medical audit, research and
quality assurance, epidemiological monitoring, disease surveillance.
Support for continuing medical education

Disadvantages:
High cost in buying an electronic system and converting from a paper system
Employees may have problems adapting to the new system
Decisions must be made about who can enter data and when the entries should be made.
Legal and ethical issues involving privacy and access to client information.

Barriers:
Widespread implementation of EMRs has been hampered by many perceived barriers including:
Technical matters (uncertain quality, .functionality, ease of use, lack of integration with other
applications,
Financial matters - particularly applicable to non-publicly funded health service systems (initial
costs for hardware and software, maintenance, upgrades, replacement, ROI)
Resources issues, training and re-training; resistance by potential users; implied changes in working
practices.
Certification, security, ethical matters; privacy and confidentiality issues
Doubts on clinical usefulness

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Incompatibility between systems (user interface, system architecture and functionality can vary
significantly between suppliers' products)

Guidelines and Strategies for safe computer charting:

The American Nurses Association, the American Medical Record Association and the Canadian
Nurses Association offer the following guidelines:
 Never give your personal password or computer signature to anyone, including another
nurse in the unit, a float nurse, or a doctor.
 Don’t leave a computer terminal unattended after you have logged on
 Follow the correct protocol for correcting errors. To correct an error after storage, mark the
entry “mistaken entry” add the correct information and date and initial the entry. If you
record information in the wrong chart, write “mistaken entry – wrong chart” and sign off.
 Never create, change, or delete records unless you have specific authority to do so.
 Make sure that stored records have back up files – an important safety check. If you
inadvertently delete part of the permanent record, type an explanation into the computer file
with the date, time, and your initials and submit an explanation in writing to your manager.
 Don’t leave information about a patient displayed on a monitor where others may see it.
Keep a log that accounts for every copy of a computerized file that you’ve generated from
the system.
 Never use e-mail to send protected health information unless it has been encrypted to protect
it from unauthorized access.
 Follow the agency’s confidentiality procedures for documenting sensitive material, such as a
diagnosis of acquired immunodeficiency syndrome or human immunodeficiency virus
infection.
Technical standards
Though there are few standards for modern day EMR systems as a whole, there are many
standards relating to specific aspects of EMRs. These include:
HL7 - messages format for interchange between different record systems and practice
management systems.
ANSI XI2 (EDI) - A set of transaction protocols used in the US for transmitting virtually any
aspect of patient data.
CEN - CONTSYS (EN 13940), a system of concepts to support continuity of care.
CEN - EHRcom (EN 13606), a standard for the communication of information from EHR
systems.
CEN - HISA (EN 12967), a services standard for inter-system communication in a clinical
information environment.
DICOM - a standard for representing and communicating radiology images and reporting
Conclusion
The practice of telemedicine,telenursing – through transmission of digitized data, audio, video
and images – is getting popular all over the world as it provides unavailable access to tertiary
level specialist healthcare even in geographically remotest areas without displacement of the
patient, physician or the equipment. It is not only cost-effective to the patient but cost-beneficial
to the society also. More and more doctors and patients are resorting to the use of telemedicine
due to its advantages of convenience and cost-saving. The practice of telemedicine, however,
has brought with it several complicated issues. These issues involve not only healthcare workers
and consumers but the society, technologists and the lawmakers also.
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 CHAPTER-XI HEMAPRIYA

Leadership: Concepts, Types Theories

INTRODUCTION:

Leadership has probably been written about, formally researched and informally discussed more
than any other single topic. Leadership still remains an unexplainable phenomenon. It is known to
exist and to have tremendous influence on human performance, but its inner workings and specific
dimensions cannot be precisely spelled out.
No organization can succeed without good leadership. Whether it is business, trade, or education,
competent leaders are needed to show the way and provide support and encouragement to
employees. The process of selecting suitable leaders, therefore, is crucial to the efficiency and
success of the entire organization. True leaders show qualities that demonstrate character and
integrity, and they are more concerned with leading by good example than with commanding and
coercing those under their authority. The objective of leadership is to gain the respect of
employees, so that their loyalty is guaranteed.
In an organization wherever an individual has subordinates , he may acts as a leader . The
efforts of Subordinates are to be channelized in the right direction .As leader they are not only
responsible for directing their followers but also responsible for the attainment of goals of
the organization .
Definition

Leadership is interpersonal influence exercised in a situation and directed through communication

process, towards the attainment of a specific goal or goals.
(L.M.Prasad, 2006)
Leadership is the process of influencing and supporting others to work enthusiastically towards
achieving objectives.
(BarnardKeys, 1990)
Leadership refers to the relation between an individual and group around some common interest
and behaving in a manner directed or determined by leader.
(Encyclopedia of Social
Sciences)

Leadership is defined as influence, that is the are a process of influencing people so that they will
strive willingly and enthusiastically toward the achievement of group goals.
- Heinz Weihrich and K.
Harold

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 “The Lifting of man’s visions to higher sights, the raising of man’s performance to higher
standard, the building of man’s personality beyond its normal limitations”.
Peter Drucker
Every group of people that performs near its total capacity has some person as its head who is
skilled in the art of leadership. This skill seems to be a compound of at least four major ingredients.

1. The ability to use power effectively and in a responsible manner.

2. The ability to comprehend that human beings have different motivation forces at different times
and in different situation‘s.
3. The ability to inspire and
4. The ability to act in manner that will develop a climate conducive to responding to and arousing
motivations.

CONCEPT OF LEADERSHIP:

Leadership is the use of non-coercive influence to shape the group‘s or organization goal‘s,
motivate behavior towards the achievement of those goal‘s and help define group or organization.
As a property, leadership is the set of characteristics attributed to Individual‘s who are perceived to
be leader‘s. Thus leader‘s are people who can influence the behaviors of other‘s without having to
rely on force, leader‘s are people whom others accept as leader‘s.
Leadership is an important aspect of managing. The ability to lead effectively is one of the Key‘s
to being effective manager. The essence of the leadership is followership. In other word‘s it is the
willingness of people to follow that makes a person a leader. Moreover, people tend to follow those
whom they see as providing a means of achieving their own desires, wants and needs.
FEATURES OF LEADERSHIP

1. Leadership is a continuous process of behaviors, it is not one-shot activity.

2. Leadership may be in terms of relations between a leader and his followers which arise out of
their functioning for common goals.
3. By exercising his leadership, the leader tries to influence the behavior of individuals or group of
individuals around him to achieve common goals.
4. The followers work willingly and enthusiastically to achieve these goals.

IMPORTANCE OF LEADERSHIP
Leadership is an important factor for making any type of organizations successful. The importance
of good leadership can be discussed as follow;
i) Motivating employees:
Motivation is necessary for work performance, higher the motivation, better the performance. A
good leader, by exercising his leadership, motivates the employees for high performance.
ii) Creating confidence:
A good leader may create confidence in his followers by directing them, giving them advice and
getting through them good results in the organization.

iii) Building morale:

810
Morale is expressed as attitude of employees towards organization, management and voluntary co-
operation to offer their ability to the organization. High morale leads to high productivity and
organization stability.
TYPES OF LEADERSHIP
According to the personal research board of the Ohio university, there are five types of leadership,
these are:
a. The Bureaucrat Leadership : Who sticks to routine, appease his superiors, and avoid his
subordinates.
Bureaucratic leaders work "by the book." They follow rules rigorously, and ensure that their staff
follows procedures precisely. This is a very appropriate style for work involving serious safety
risks (such as working with machinery, with toxic substances, or at dangerous heights) or where
large sums of money are involved (such as handling cash).

b. The diplomat leadership : Who, is opportunistic and exploits people. He generally rouses
distrust.
c. The autocrat leadership : Who is directive and expects objects obedience; His subordinates to
be antagonistic to him.
Autocratic leadership is an extreme form of transactional leadership, where leaders have absolute
power over their workers or team. Staff and team members have little opportunity to make
suggestions, even if these would be in the team's or the organization's best interest.
A leader who want to run the organization all by himself. A leader think that his followers
donot have much ability to do a job effectively .so he avoids discussion with his followers
regarding job completion.
d. The expert leadership
The leader, who is concerned only with his own field of specialization. He treats his subordinates
as fellow-workers.
e. The quarter back : The leader, who identifies himself with his subordinates even at risk of
displeasing his superiors.
f.Intellectual leadership : A leader wins the confidence of his followers by his intelligence
.Generally the advice of a leader is sought in big business concerns . He excels as a leader
because he use his superior knowledge.
g. Liberal leadership : A leader is one who permits his followers to do their job homesoever
they want to do. The liberal leader would not exercise any influence over his followers and
vice versa .The liberal leader has low maturity followers , he is not able to make his followers
, he is not able to make his followers understand what , how , when and where to perform.
h. Democratic leadership : A Leader acts according to the wishes of his followers . The leader
frame the policy or procedure according to the opinion of the majority of his followers . He acts
as a representative of his followers to management .
I . Institutional leadership : A leader exercise his power over his followers because of his
positioned held in the organizational hierarchy .The leader can control the activities of his
followers in order to achieve the objectives.
J . Inducing leadership: The leader is one who influences his followers with his personality and
persuades them to join him in doing a work. He loved and is loved by his followers .
k. Paternal leadership : An individual who has become the leader in the place of his father as
leader has close relationship with his followers and comes to their rescues ever so often .
paternal leader has job maturity followers only.

811
L . Creative leadership: The leader is one who encourages his followers to suggest new ideas,
thought or ways. He controls his followers just like other leaders and makes them to achieve the
specific goals.
THEORIES OF LEADERSHIP:
The oldest view of leadership considered it a birth right. Kings and queens ascended to thrones
because of custom. Kings begot kings and became king leader.
Individuals in formal leadership roles were accepted without questions. This is similar to the
―great man theory which states the great leaders are born with the ability to lead, influence and
direct others. Under this perspective leaders may not be developed, but researcher given a number
of theories to explain leadership and its development.
Some of leadership theories are:-
1. Great man theory or Charismatic theory
2. Trait theory
3. Behavioral theory
4. Situational theory or Contingency theory
5. New theory of leadership
6. Path –goal theory of leadership

1. Great Man Theory or Charismatic Theory

The Plato explained in Republic some insight of leadership. Subsequent studies based on the
insights suggested that a leader is born and is not made.
A leader has some charisma which acts as influencer. Charisma is a Greek word meaning ―Gift‖.
Thus charisma is a god gifted attribute in a person which make him a leader irrespective of the
situations in which he works. Charismatic leaders are those who inspired followers and have major
impact on their organization through their personal vision and energy.

Characteristics of charismatic leaders

followers

Basic assumptions

qualities.

e enhanced through education and training.

Further, since these qualities are of personal nature, these cannot be shared by others.

influence.

Implication
Charismatic leadership have importance to explain transformational leaders who inspires his
followers through vision and energy, while other theories discuss more about transaction leaders,
who determine what subordinates need to do achieve objective and help them.
Limitations

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A charismatic leader may fail in the changed situation thus the situational variable play their own
role in determining leadership effectiveness.

2. Trait Theory
Under the influence of the behaviorist psychological thought, researcher accepted the fact that
leadership traits are not completely inborn can also be acquired through learning and experience.
Ralph M. Stogdill (1974) suggested the trait theory after evaluation of various traits suggested by
the researchers.
Trait is defined as ―relatively enduring quality of an individual. Various trait theories have
suggested these traits in a successful leader‖.
 Physical and constitutional factors (Height, Weight, Physique, Energy, Health, Appearance)
 Intelligence
 Self confidence
 Sociability
 Will
 Dominance

The current research on leadership traits suggests that some factors do help differentiate leaders
from non-leaders. Various traits that needed for leadership can be classified into innate and
acquirable traits.
A. Innate qualities
These qualities which are possessed by various individuals since their birth. These qualities are
natural often known as God-gifted. On the basis of such qualities, it is said that ―Leaders are born
and not made‖. These qualities cannot be acquired by the individuals. The major innate qualities
are:-
a) Physical features
Physical features of a man are determined by heredity factors. Heredity is the transmission of the
qualities from ancestor to descendant through a mechanism lying primarily in the chromosomes of
the germ cells. To some extent, height, weight, physique, health and appearance are important for
leadership.
b) Intelligence
For leadership level of intelligence is required. Intelligence is generally expressed in terms of
mental ability. Intelligence to a great extent, is a natural quality in the individuals because it is
directly related to brain.
B. Acquired qualities
These are qualities of leadership are those which can be acquired and increased through various
processes. Many of these traits can be increased through training program. Following are the major
qualities essential for leadership.
a) Emotional stability
A leader should have high level of emotional stability. He should be free from bias, is consistent in
action and refrains from anger. He is self confident and believes that he can meet most situations
successfully.
b) Human relations

813
A successful leader should have adequate knowledge of human relations that, is how he should
deal with human beings. Since an important part of a leader‘s job is to develop people and get their
voluntary cooperation knowledge of people and their relationship to each other.
c) Empathy
Empathy relates to observing the things or situation from others point of view. The ability to look
at things objectively and understanding them from others point of view is an important aspect of
successful leadership.
d) Objectivity
Objectivity implies that what a leader does should be based on relevant facts and information. He
must assess these without any bias or prejudice.
e) Motivating skill
Not only a leader is self motivated but he has requisite quality to motivates his followers. Though
there are many external forces which motivate a person for higher performance, there is inner drive
in people also for motivation to work.
f) Technical skills
The leading of people requires adherence to define principles which must be understood and
followed for greater success. The ability to plan, organize, delegate, analyze, seek advise, make
decision, control and win cooperation requires the use of important abilities which constitute
technical competence of leadership.
g) Communicative skills
A successful leader knows how to communicate effectively. Communication has great force in
getting the acceptance from the receivers of communication. A leader uses communication
skillfully for persuasive, informative and stimulating purposes. Normally, a successful leader is
extrovert as compared to introvert.
h) Social skills
A successful leader has social skills. He understands people and knows their strengths and
weakness. He has the ability to work with people and conducts himself so that he gains their
confidence and loyalty and people cooperate willingly with him.
Implications of the theory
The two very implications are:-
 The theory emphasis that a leader requires some traits and qualities to be effective.
 Many of these qualities may be developed in individuals through training and development
programmes.

Limitations
1. Generalization of traits-
There are problems in identification of traits which may relevant for a leader to be effective in all
situations.
2. Applicability of traits-
The limitations that hinder the full application of trait theory in practice, is that leadership as a
process of influence reflects in leaders behavior and not his traits.

3. BEHAVIORAL THEORY
Behavioral theory of leadership given by Lewin K. Lippitt (1953) emphasis, that strong leadership
is the result of effective role behavior. Leader ship shown by a person‘s acts more that by his traits.
For a leader to operate effectively, groups need some one to perform two major functions

814
I. Task related functions
It is problem solving functions related to providing solution to the problems faced by the group, in
performing jobs and activities.
II. Group related functions
It is also called as social functions, related to actions of mediating disputes and ensuring that
individuals feel valued by the group.
An individual who is able to perform both roles successfully would be an effective leader. These
two roles may require to different sets of behavior from the leader, known as leadership styles.
Leadership behavior may be viewed in two way: functional and dysfunctional. Functional behavior
influence followers positively and includes such as setting clear goals, motivating, building team
spirit etc. Dysfunctional behavior may be inability to accept employee‘s ideas so it is unfavorable
to the followers and denotes ineffective leadership.

Implications of the theory

Behavioral theory of leadership has some important implications for managers. They can shape
their behavior which appears to be functional and discard the behavioral which appears to be
dysfunctional.
Limitations
 A particular behavior may be functional at a point of time but it may be dysfunctional at
another point of time. Thus the time elements will be a decider of the effectiveness of the
behavior and not the behavior itself.
 Effectiveness of leadership behavior depends on various factors which are not in the leader
but external to him like nature of followers and the situations under which the leader‘s
behavior takes place. These factors have not been given adequate consideration.

4. SITUATIONAL THEORY
Situational leadership theory also known as contingency theory given by Paul Hersey and Ken
Blanchard was first time applied in 1920 in the armed forces of Germany with the objectives to get
good generals under different situations.
The prime attention in situational theory of leadership is given to the situations in which leadership
is exercised. There for, effectiveness of leadership will be affected by the factors associated with
the leader and factors associated with the situation.
The various factors affecting leadership effectiveness may be broadly be classified into two major
categories: Leader‘s behavior and situational factors. The combination of these factors determines
leadership effectiveness.

815
Factors affecting leadership effectiveness
A. Leader’s behavior
Leader‘s behavior is affected by two variables. Leader‘s characteristics and his hierarchical
position in the organization
I. Leader’s characteristics
An individual‘s behavior is influenced by intelligence and ability, his characteristics like his
personality, attitudes, interest, motivation and physical characteristics such as age, sex and physical
features. Thus the behavior of the leader is also influenced by all these factors. All these factors are
internal to leader.
II. Leader’s hierarchical position
Leader‘s hierarchical position in the organization is important because persons at different levels
face different kind of problems. That affects the degree of participation between superior and his
subordinates in arriving at decisions to solve the problems. Managers at higher levels are more
concerned with long-run complex problems which require more participation in decision making.
Managers at lower levels are more concerned with short run problems involving the daily
operations which may not require high level of participation. The degree of participation affects the
leader‘s behavior.

B. Situational factors
Besides the leader‘s related factors, leadership effectiveness is affected by situational factors are
these factors affect the leader‘s behavior. To the extent, a leader matches the requirement of these
factors, his leadership will be effective. The various situational factors may be group in four
categories.
I. Subordinates characteristics
The subordinate‘s characters are relevant to the effectiveness of leadership such as personality,
attitudes, interest, motivation and physical characteristics such as age, sex and physical features.
II. Leader’s situation
The leader‘s situation in respect to his subordinates is an important factor affecting leadership
effectiveness. There are two main variables which determine the leader‘s situation. Leader‘s
position power and leader subordinate relations. Leader‘s position power helps in influencing
other, while low position power makes the leader‘s task more difficult. Another factor, which is
leader – subordinate relations is based on the classic exchange theory which suggests that there is
two way influences in a social relationship. Thus good followers need to succeed in their own jobs
with the help of the leader while helping their leadership to succeed at theirs. Thus, if the leader
has good subordinates and good relations with them, he is likely to be more effective.
III. Group factors
Various group factors like task design, group composition, group norms, group cohesiveness and
peer group relationship affect leadership effectiveness and performance. If these factors are
favorable, the leader will be effective.
IV. Organizational factors
Organizational factors like organizational climate and organizational culture affect leadership
effectiveness. If these are conductive, the leader will be effectiveness.
Implications of the theory
 It offers clues why a manager who is successful in one situation, fails when there is change
in the situation.

816
  A manager may do better by adopting management practices including leadership which
match with the situational variables.

Limitations
 The theory appears to be good on the surface but become quite complex in practice because
of numerous contingent factors.
 This theory loses the insight of leadership and the leader is overwhelmed by the contingent.

5. NEW THEORY OF LEADERSHIP-

Bennis and Manus (1995) suggest new theory of leadership based on an extensive study of 90
leaders who participated in interview for the purpose of discovering what is common to leadership
and leadership.
The findings of this study concluded that there are four types of human handling skills common to
leaders. The authors elaborate in great detail the specific of these skills and refer to them as
strategies.

A. Strategy – I :- Attention through vision

B. Strategy – II :- Attention through vision
C. Strategy – III :- Attention through vision
D. Strategy – IV :- Attention through vision
Strategy – I
It is the management of attention through vision, refers to the leader‘s ability to create a focus or a
clear picture of an outcome. The leaders who were interviewed were all results oriented. The ideas
they held were very clear in their own minds, making it easy for people to see where they were
going.
Strategy – II
The meaning through communication means that this group of leaders was able to turn its vision
into images that others could understand. These leaders had the ability to translate their ideas into
symbols with real meaning. From this ability, referred to as the management of meaning and the
mastery of communication, leaders are able to inspire by capturing the imagination of others.
Strategy – III
Trust through positioning, refers to the leaders ability to inspire trust in others by contributing to
the organization‘s integrity. This means the leader never loses sight of why the organizational
exists. The leader knows what the organization stands for and what it has to do.
A second component of a leader‘s contribution to the management of trust is the facilitation of
constancy, or staying the course. Like a pilot and an airplane, the leader takes the organization in
the right direction. In this way a leader, through positioning maintains the organization‘s harmony
and purpose but also recognizes the need for change and in congruities and provides for
innovations. It essence the leader provides stability for the organization but also allows for the
necessary changes that provide for organizational growth.
Strategy – IV
The development of self through positive self regard means that the leader leads in a very personal
way. The leader will display a positive self image and especially self respect. This is achieved by

817
the leader recognizing his or her strengths and compensating for weakness while nurturing the
talents and skills that he or she posses.
Implications of the theory-
 Leadership can be learned and cultivated.
 Leaders are not necessary charismatic. In fact, leadership is more than a characteristic and
charisma just may be the result of effective leadership.
 Leadership is not limited to those who reside at the top of the organization. Rather,
leadership opportunities exist at all levels of the organization. It is not so much the exercise
of power but the empowerment of others.

PATH-GOAL THEORY
The path-goal theory of leadership associated most closely with Martin Evan‘s and Robert House
theory of direct extension of the expectancy theory of motivation.
This theory of leadership suggesting that the primary function‘s of a leader are to make valued or
desired reward‘s available in the workplace and to clarify for the subordinate the kind‘s of behavior
that will lead to those reward‘s that is leader should clarify the path‘s to goal attainment.

1. Leader Behavior
The most fully developed version of path goal theory identifies four kinds of leader behavior.
1). Directive behaviour
It is letting subordinates know what is expected of them, giving guidance and direction and
scheduling work.
2) Supportive leader behaviour
It is being friendly and approachable, showing concern for subordinates welfare and treating
member‘s as equal‘s.
3) Participative leader behaviour
It is consulting subordinates, soliciting suggestion‘s and allowing participation in decision making.
4) Achievement – oriented leader behaviour
It is setting challenging goal‘s, expecting subordinates to perform at high level‘s encouraging
subordinates, and showing confidence in subordinates abilities.
In contrast to Fiedler‘s theory, Path-goal theory assumes that leader‘s can change their style a
behaviour to meet the demands of particular situation.
2. Situational Factor’s
Like other situational theories of leadership, Path-goal theory suggest that appropriate leader style
depend‘s on situational factor‘s.
Path-goal theory focuses on the situational factors of the personal characteristics of subordinates
and environmental characteristics of the workplaces.

818
A. Leader’s behavior
Leader‘s behavior is affected by two variables. Leader‘s characteristics and his hierarchical
position in the organization
I. Leader’s characteristics
An individual‘s behavior is influenced by intelligence and ability, his characteristics like his
personality, attitudes, interest, motivation and physical characteristics such as age, sex and physical
features. Thus the behavior of the leader is also influenced by all these factors. All these factors are
internal to leader.
II. Leader’s hierarchical position
Leader‘s hierarchical position in the organization is important because persons at different levels
face different kind of problems. That affects the degree of participation between superior and his
subordinates in arriving at decisions to solve the problems. Managers at higher levels are more
concerned with long-run complex problems which require more participation in decision making.
Managers at lower levels are more concerned with short run problems involving the daily
operations which may not require high level of participation. The degree of participation affects the
leader‘s behavior.
B. Situational factors
Besides the leader‘s related factors, leadership effectiveness is affected by situational factors are
these factors affect the leader‘s behavior. To the extent, a leader matches the requirement of these
factors, his leadership will be effective. The various situational factors may be group in four
categories.
I. Subordinates characteristics
The subordinate‘s characters are relevant to the effectiveness of leadership such as personality,
attitudes, interest, motivation and physical characteristics such as age, sex and physical features.
II. Leader’s situation
The leader‘s situation in respect to his subordinates is an important factor affecting leadership
effectiveness. There are two main variables which determine the leader‘s situation. Leader‘s
position power and leader subordinate relations. Leader‘s position power helps in influencing
other, while low position power makes the leader‘s task more difficult. Another factor, which is
leader – subordinate relations is based on the classic exchange theory which suggests that there is
two way influences in a social relationship. Thus good followers need to succeed in their own jobs
with the help of the leader while helping their leadership to succeed at theirs. Thus, if the leader
has good subordinates and good relations with them, he is likely to be more effective.
III. Group factors

819
Various group factors like task design, group composition, group norms, group cohesiveness and
peer group relationship affect leadership effectiveness and performance. If these factors are
favorable, the leader will be effective.
IV. Organizational factors
Organizational factors like organizational climate and organizational culture affect leadership
effectiveness. If these are conductive, the leader will be effectiveness.
Implications of the theory
• It offers clues why a manager who is successful in one situation, fails when there is change
in the situation.
• A manager may do better by adopting management practices including leadership which
match with the situational variables.

Limitations
• The theory appears to be good on the surface but become quite complex in practice because
of numerous contingent factors.
• This theory loses the insight of leadership and the leader is overwhelmed by the contingent.

Leadership Styles
Introduction
Leadership does not mean dominating the subordinates The leader‘s job is to get work done by
other people, and make people willingly want to accomplish something. So effective leadership
means effective and productive group performance .
Definitions
A. Leader ship:
Leadership is the process of influencing the thoughts and actions of other people (a person r a
group) to attain the desired objectives.
B. Style:
A style is a particular form of a behavior directly associated with an individual.
Or the way in which a leader uses interpersonal influences to achieve the objective of an
organization One should ask why the style of functioning of a leader need to be under stood.
The reasons are;
• A style of leadership affects the health care delivery system.
• A style allows the nurse to interact more productively and more harmoniously to achieve personal
and organizational goals.
Leadership style: Leadership style is how a leader uses interpersonal influence to accomplish
goals of an organization.
Types of Leadership Styles:
 Autocratic style of leadership
 Democratic style of leadership.
 Laissez-faire style of leadership
1. Autocratic style of leadership:
Autocratic leader ship is described as
 Authoritarian leadership
 Directive leadership and the leader is referred to as
 Extreme form of ―Dictator
2. Democratic Leadership Style:

820
A democratic leader ship is described as
 Participative or
 Consultative style of leadership.
3. Laissez-faire leadership style: Also known as
 Permissive
 Free –rein,
 Anarchic,
 Ultra liberal style of leadership
Autocratic leadership
The leader assumes complete control over the decisions and activities of the group.
The authority for decision making is not delegated to persons in lower level positions (centralized
organization)
Personality of the leader:
 Firm personality ,insistent, self assured ,highly directive ,dominating, with or without
intention
 Has high concern for work than for the people who perform the task
 Uses the efforts of the workers to the best possible shows no regard to the interests of the
employees
 Sets rigid standards and methods of performance and expects the subordinates to obey the
rules and follow the same.
 Makes all decisions by himself or herself related to the work & pass orders to the workers
and expect them carry out the orders.
 There is minimal group participation or none from the workers
 Thinks that what he or she plans and does is the best. May Listen to them by not influenced
by their suggestions.
 Has no trust or confidence in the subordinates in turn they fear and feel they have nothing
much in common
 Exercises power ,.manipulates the subordinates to act according to his goals plans and keeps
at the centre of attention.

Advantages & Disadvantages of Autocratic leadership

SL Advantages Disadvantages
NO
1 Efficient in times of crisis, Easy to make Does not encourage the individuals
decision by one person than by group. growth and does not recognize the
And less time consuming potentials, initiative ness and creates
less cooperation among members.
2 It is useful when there is only leader The leader lacks supportive power that
who is experienced having new and results in decisions made with
essential information while subordinates consultation although he may be correct.
are in experienced and new.
3 It is useful when the workers are unsure Inhibits groups participation which
of taking decision and expect the leader results in lack of growth, less job
to tell them what to do. satisfaction can lead to less commitment

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 to the goals of organization

The democratic leadership style:

It is also referred to participative, consultative style of leadership.

1. This style is characterized by a sense of equality ‘among leaders and followers.
 The leader is people oriented
 Focuses on the human aspects
 Builds effective work group
 Togetherness is emphasized

2. Open system of communication prevails

 The group participate in work related decisions. (sharing the thoughts in problem solving)

3. The interaction between the leader and the group is friendly and trusting
 The leader brings the subject to be discussed to the group
 Consults
 Decision of the majority is made and implemented by the entire group
 Makes final decision after seeking input from the total group.
 Therefore the group feels they have important contribution to make, Freedom – ideas
drawn, develop sense of responsibility for the good of the whole.
4. Leader works through people not by domination but by suggestions and persuasions
 The leader motivates the workers to set their own goals, makes their own work plans and
evaluates their own performance.
 Informs the overall purpose and the progress of the organization
5. Performance standards exist to provide guide lines and permit appraisal of workers thus
results in high productivity.

Advantages & Disadvantages of democratic leadership style

Sl.N Advantages Disadvantages
o
1 It permits and encourages all employees to
practice decision making skills.
It takes more time for making the
2 It promotes personal involvement. decisions by the group than by leader
suggestions are welcomed .this results in alone. However the advantages over
greater commitment to work and enhanced weigh the negative outcomes.
job satisfaction

3 Decisions made by the group are more

effective than by the leader alone.
Members may have more information than
the leader

The Laissez –faire Leadership style:

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It is also referred to as Free-Rein, Anarchic, Ultra liberal style of leadership.
The leader gives up all power to the group.
Characteristic features
1. This encourages independent activity by the group members.
 An outsider would not be able to identify the leader in such a group
 The leader exerts little or no influence on the group members.
 There is lack of central direction, Supervision, coordination and control.

2.Group members are free to set their own goals determine their own activities and allowed
to do almost what they desire to do.
 A variety of goals may be set by every individual and it will be difficult to carry out to
accomplish the task by the group easily.

3. This style may be chosen by the leader or it may evolve because ;

 The leader is too weak to exert any influence on the group and
 Attempting to please everyone to feel good.
 And fails to function as an effective leader.
4. This style is effective in highly motivated professional groups.
eg: research projects where independent thinking is rewarded or when the leader feels that the
problem must be solved by the group alone
5. This style is not useful in a highly structured health care delivery system or any institution.
6. The group where there is no appointed leader will fall in to this category.

Advantages & Disadvantages of Laissez –faire Leadership style

SL.NO ADVANTAGES DISADVANTAGES
1 In limited situations creativity may be May lead to instability ,disorganization,
encouraged for specific purposes . eg. inefficiency ,no unity of actions.
highly qualified people plan a new
approach to a problem that need
freedom of action

2 Neither the group nor any one in the group

will feel to be responsible to solve the
problems that may arise.
To try new methods of actions
3 The individual members will lose interest
,initiative and desire for achievement.

Bureaucratic style of leader ship:

In this kind of leadership the leader functions only on lines with rules and regulations. The leader
cannot be flexible and does not like to take any risk out of the rules.

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Example: Defense leaders. They are strictly adhering to the rules and maintain the discipline of
group.
The effective leadership style:
• No one functions always with a particular leadership style.
• No single style is appropriate for all situations.
• At times combination of styles may be most appropriate
Eg: a midway between authoritarian and democratic or between democratic and laissez faire.

“Comparison of leadership styles”

Implications to nursing:
Regardless of the style selected the nurse managers should be aware of the effect of the style
adopted in the hospital ,unit or educational institution ,staff and on the level of work performance.
Effective leadership improves the job performance. And quality on the whole .

LEADER BEHAVIOR AND MANAGER BEHAVIOR

INTRODUCTION
Leadership is a process of influence on a group. It is an important part of a manager‘s job. The fact
that a leader can have an immense-effect on the performance of those under him has been noted for
centuries that while some other officers receive only grading obedience, others are able to inspire
their men to do seemingly impossible and do it willingly.
DEFINITION
Leadership is generally defined simply as influence the art (or) process of influencing people so
that they will strive willingly towards the achievement of group goals.
- Koontz and O‘Donnel
Leadership is the ability to secure desirable actions from a group of followers, voluntarily without
the use of coercion‖.
-Alford & Beathy
CHARACTERISTICS OF LEADERSHIP
• Leadership is a process of influence.
• Leadership is related to situation.

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 • Leadership is the function of stimulation.
• Leadership gives an experience of helping attain the common objectives.
• Employees must be stratified with the type of leadership provided.

FUNCTIONS OF LEADERSHIP

825
i. Determination of goals v. Providing guidance
ii. Organisation of activities vi. Inspiration of employees
iii. Achieving co-ordination vii. Building employees moral
iv. Representation of group viii. Facilitating change

QUALITIES OF LEADERSHIP
Traits of a leader are as follows.
(i) Physical trait
- Sound health - Performs duties
- Good vitality and endurance - Satisfactory

(ii) Psychological traits

- Personal magnerism - Co-operation
- Enthusiasm - Forcefulness
- Ability to inspire - Tactfulness

(iii) Traits of Character

- Integrity
- Self discipline - Physical and moral courage
- Willingness to accept responsibility -Humanism

5. Leader:
5.1 Role of a leader:
a. Group task roles:
1. Initiator – contributor 7. Coordinator
2. Information seeker 8. Orienter
3. Opinion seeker 9. Evaluator-critic
4. Information giver 10. Energizer
5. Opinion giver 11. Procedural technician
6. Elaborator 12. Recorder
b. Group building & maintenance roles:
1. Encourager 5. Standard setter or ego ideal
2. Harmonizer 6. Group observer & commentator
3. Compromiser 7. Follower
4. Expeditor
c. Individual roles:
1. Aggressor 5. Play boy
2. Blocker 6. Dominator
3. Recognition seeker 7. Help-seeker
4. Self-confessor 8. Special help pleader
5.2 Qualities of a leader:
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A. In the opinion of Discount slim
1. Courage 4. Flexibility
2. Willpower 5. Knowledge
3. Judgment 6. Integrity
B. According to George terry
1. Energy 5. Communication skill
2. Emotional stability 6. Teaching ability
3. Knowledge of HR relations 7. Social skill; and
4. Personal motivation 8. Technical competence
C. According to Chester I Burnard
1. Vitality & endurance 4. Stability in behaviour
2. Decisiveness 5. Intellectual ability; and
3. Persuasiveness 6. Knowledge

D. According to Ordway Tead

1. Physical & nervous energy 6. Fairness (justice)
2. Self-confidence 7. Initiative
3. Moral qualities 8. Decisiveness
4. Self sacrifice 9. Dignity and
5. Paternalism(paternal 10. Knowledge of men
affection)
E. According to Nitisdh R. De
1. Physical & nervous energy
2. Endurance and vigour of body & mind
3. Readiness to shoulder responsibilities and effective
4. Unfaltering friendliness and effective
5. Tolerance & patience
6. Sense of fairplay & justice
7. A high degree of integrity
8. Decisiveness & initiative
9. Knowledge of men
10. Ability to face rough weather opposition
F. According to HILL
1. Courage 9. Dignity
2. Self confidence 10. Knowledge of men
3. Moral qualities
4. Self sacrifice
5. Paternalism (paternal affection)
6. Fairness (justice)
7. Initiative
8. Decisiveness
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3. Leaders must be optimistic and see possibilities.
Leaders must be adaptive to the constant change in our society, which “takes a hardiness attitude that
allows [them] to face challenges and adapt all of it in a way that results in alignment.”

4. Leaders must create a culture of candor.

Bennis asserted that such a culture requires integrity, which evolves from a balance of ambition,
competence, and having “a moral compass.” When ambition surpasses competence or overrides one’s
moral compass, for example, integrity is lost, a culture of candor cannot be created, and one cannot be
an effective leader.

5. Leaders must mentor others and acknowledge their ideas and accomplishments.
Bennis said, “Drawing out the leadership qualities [of others] is the way of the true leader.”

6. Good leaders must be in tune to getting results. Bennis shared a conversation he had with Jack
Welch, previous CEO of General Electric. This highly successful corporate manager and leader noted
that “getting.

b. Gender differences
Today there are more women than ever before who are effective leaders, and it is expected that the
number of women leaders, particularly those from minority groups, will continue to increase (Bennis,
Spreitzer, & Cummings, 2003).
There are more women governors, senators, and representatives. There are more women leaders in
sports, science, business, education, and many other fields than ever before. In nursing, women have
always led the profession toward change and development. It is reported that women have different
styles than men in many things, and because of these differences, it is assumed that women are better
at some things (e.g., child-rearing, nursing) and men are better at others (e.g., sales, construction
work).
But when it comes to leadership, the styles of men and women allow both to be successful,
particularly if stereotypical maleness is combined with stereotypical femaleness. A more
androgynous perspective on leadership—one that combines the best of “femaleness” and the best of
“maleness” and draws on the strengths of each style—therefore, is most helpful.
The androgynous leader “blends dominance, assertiveness and competitiveness [often thought to be
“male” characteristics]…with concern for relationships, cooperativeness, and humanitarian values
[often associated with a “female” style]” (Grossman & Valiga, 2005) such a combination is critical in
a world characterized by declining resources and increasing chaos and uncertainty.

a. Gaining power

McClelland and Burnham (1976) determined that power is a definitive aspect of leadership because it
motivates individuals and contributes to their charisma. The concept of power is discussed more fully
in Chapter 13 so it will not be examined in depth here. But it is important to look at power as a
component of leadership.
The two primary sources of power are one’s position in an organization and one’s personal qualities.
McClelland and Burnham (1976) asserted that hierarchical power, or the amount of authority one has

828
in an organization, and the ability to provide rewards or “punishments” to others are used to attain
organizational goals.
They also noted that personal power, deriving from one’s knowledge, competence, and
trustworthiness, or from followers’ respect for and desire to be associated with the leader, are used to
influence others. It is only when one’s personal power is well established that one can exert
transformational leadership.
Transformational leaders with highly developed power are comfortable with themselves, have high
self-efficacy, and empower followers to attain their own goals and, ultimately, the goals of the group
or organization. We are well aware of the many disadvantages of people abusing their power, but
when power is used in the service of others, positive results are realized.
Greenleaf (1977) and Block (1993) used the term stewardship to describe the phenomenon of
directing one’s power toward the service of others, and they asserted that such a quality is essential in
leaders. Stewardship is “the willingness to be accountable for the wellbeing of the larger organization
by operating in service, rather than in control, of those around us” (Block, 1993).
Similar notions of building relationships through nurturing and empowerment, gaining power through
community networking, and leading groups based on values of cooperation were offered by Chinn
(2004). Chinn advocated for building one’s personal power base so that it can be used to enhance the
group’s ability to achieve its goals and realize its vision, thereby using it to fulfill the leader role.

d. Becoming a nurse leader

Nurses need to view themselves as leaders, develop their leadership abilities, and embrace the
challenges that face them in health care today (Grossman & Valiga, 2005). In order to become
leaders, however, nurses must learn about leadership in their academic programs (Fagin, 2000),
through on-the-job experiences, through mentors, or through other avenues.
In order to develop their leadership skills, it is imperative for nurses to observe expert leaders, work
hand-in-hand with such individuals, and receive constructive feedback on their performance. Having
a “shadowing,” or preceptor, experience with a leader, for example, allows nursing students to
understand the context of an organization, develop their negotiation skills, think more broadly,
communicate more effectively, collaborate more effectively, and be empowered (Grossman, 2005).
Personal involvements, immersion in a situation, learning by doing, and practicing in the clinical
setting with an experienced nurse have been cited as important to learning generally.
They are also strategies to be used to help individuals learn how to be leaders. Bennis and Thomas
(2002) reinforced the notion that in order to become an effective leader an individual must be able to
define her uniqueness or what makes her special. She must then continually grow and increase her
expertise in that unique area so that she can be a leader who influences policy development, evidence-
based practice, and dissemination of new understandings.
Many health-care organizations have leadership programs for their managers and those aspiring to
become managers. Leadership skills can also be learned as part of the professional development of all
nurses. Many professional organizations have leadership institutes and seminars at their annual
conferences.
When the nursing profession realizes that nurses need leadership skills as much as patient care and
management skills and that every nurse, from the entry-level staff nurse to the chief executive nurse,
needs to become an effective leader, we can expect that patient care outcomes will be enhanced and
that nursing will most effectively influence health care.

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H. Over all qualities of a leader
1. Energy
2. Emotional maturity & stability
3. Knowledge of human relations
4. Objectivity
5. Empathy – objectively look
_ respect others
_ Beliefs etcs
6. Personal motivation
7. Communication skill
8. Teaching ability
9. Social skills – understand weak & strong points of employee
10. Technical competence
11. Integrity – morally sound
12. Conceptual skill
13. Moral courage
14. Flexibility of mind
15. Ability to establish proper priorities

I. Fourteen Qualities of a World Leader Manifested in Swami Vivekananda

1. The power of self-realization
2. The power of rishihood (Attracting the power of purity and holiness)
3. Fearlessness based on spiritual strength (The quintessence of the Vedas and Vedanta and all lives
in one word—strength. Strength is felicity, life immortal, weakness is constant strain and misery,
weakness is death.)
4. Power of organizing people with tremendous dynamism and unselfish action
5. Power of faith (faith in self, in God, in Rishis, and the essential divinity of all souls)
6. The power of awakening excellence in others in order to help them rise above competition
7. The power of sacrifice, love and service
8. The power of positive thinking
9. Practical approach to action
10. Releasing human energy through freedom and equality
11. The power of knowledge for unerring decisions
12. The strength of visionary
13. Success by turning all work into worship
14. A harmonious combination of western organization and eastern spirituality
5.3 Leader behaviour:
1. Integrity: the most important requirement; without it everything else is for nothing. Achieve the
company tasks and objectives, while maintaining your integrity, the trust of your people, are a
balancing the corporate aims with the needs of the world beyond.
2. Honesty: Being honest but sensitive in the way that you give bad news or criticism, always doing
what you say you will do - keeping your promises, being firm and clear in dealing with bad or
unethical behaviour, asking for people's views, but remain neutral and objective
3. Humility: Never self-promoting, Fairness - treating everyone equally and on merit.
4. Courage: Encouraging your people to grow, to learn and to take on as much as they want to, at a
pace they can handle.
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 5. Commitment: Taking notes and keeping good records. Having an effective appreciation and
approach towards corporate responsibility, (Triple Bottom Line, Fair Trade, etc), so that the need to
make profit is balanced with wider social and environmental responsibilities. Planning and
prioritizing.
6. Sincerity: Always giving your people the credit for your successes
7. Passion: Having an effective appreciation and approach towards corporate responsibility, (Triple
Bottom Line, Fair Trade, etc), so that the need to make profit is balanced with wider social and
environmental responsibilities.
8. Confidence: Listening to and really understanding people, and show them that you understand
(this doesn't mean you have to agree with everyone - understanding is different to agreeing).
9. Positivity: Always accentuating the positive (say 'do it like this', not 'don't do it like that').
Involving your people in your thinking and especially in managing change. Managing your time
well and helping others to do so too.
10. Wisdom: Being decisive - even if the decision is to delegate or do nothing if appropriate - but be
seen to be making fair and balanced decisions.
11. Determination: Leading by example - always be seen to be working harder and more
determinedly than anyone else. Working hard to become expert at what you do technically, and at
understanding your people's technical abilities and challenges.
12. Compassion: Backing-up and supporting your people
13. Sensitivity: Being very grown-up - never getting emotionally negative with people - no shouting
or ranting, even if you feel very upset or angry. Helping alongside your people when they need it,
Smiling and encouraging others to be happy and enjoy themselves.
14. Relaxing - breaking down the barriers and the leadership awe - and giving your people and
yourself time to get to know and respect each other.
15. Reading good books, and taking advice from good people, to help develop your own
understanding of yourself, and particularly of other people's weaknesses (some of the best books
for leadership are not about business at all - they are about people who triumph over adversity).
LEADERSHIP BEHAVIOUR
There are several theories on leadership behavior. This section focuses on
1. Leadership based on the use of authority.
2. Likert‘s four systems of management.
3. The managerial grid.
4. Leadership involving a variety of styles, ranging from a maximum to a minimum use of power and
influence.

1. Leadership based on use of authority

• Leaders were seen as applying three basic styles. The autocratic leader commands and expects
compliance, is dogmatic and positive, and leads by the ability to with hold or give rewards and
punishment.
• The democratic, or participative, leader consults with subordinates on proposed actions and
decisions and encourages participation from them. This type of leader ranges from the person
who does not take action without subordinates. Concurrence to the one who makes decisions
but consult with subordinates before doing so.
• The free-rain leader uses his or her power very little, if at all, giving subordinates a high degree
of independence in their operations. Such leaders depend largely on subordinates to set their
own goals and the means of achieving them and they see their role as one of aiding the
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 operations of followers by furnishing them with information and acting primarily as a contact
with the groups external environmental.

3. Likert’s four systems of management

Professor Rensis Likert and his associates at the University of Michigan have studied the patterns and
styles of leaders and managers.
Likert has developed certain ideas and approaches important to understanding leadership behavior.
All members of the group, including the manager or leader, adopt a supportive attitude in which they
share in one another‘s common needs, values, aspirations, goal and expectation.
System – 1
As guidelines for research and for the clarification of his concepts, Likert has suggested four system
of management. System 1 management is described as ―exploitive authoritative, its managers are
highly autocratic, have little trust in subordinates, motivate people through fear and punishment and
only occasional rewards, engage in downward communication, and limit decision making to the top.
System – 2
The management is called ―benevolent-authoritative‖, its managers have a patronizing confidence
and trust in subordinates, motivate with rewards and some fear and punishment with rewards and
some fear and punishment permit some upward communication, solicit some ideas and opinions from
subordinates, and allow some delegation of decision making but with close policy control.
System-3
Management is referred to as ―Consultative‖, managers in this system have substantial but not
complete confidence and trust in subordinates, usually try to make use of subordinates, ideas and
opinions, use rewards for motivation with occasional punishment and some participation, engage in
communication flow both down and up, make broad policy and general decision and at the top while
allowing specific decisions to be made at lower level, and act consultatively in other ways.

832
System-4
The management as the most important participativeof all and referred to it as ―Participative -
group‖. System 4 managers have complete trust and confidence in subordinates in all matters, they
always get ideas and opinions from subordinates and constructively used them. They engage in much
communication down and up and with pears, encourage decision making throughout the organization,
and operate among themselves and with their subordinates as a group.
3. The Managerial Grid
A well known approach to defining leadership styles is the managerial grid, developed some years
ago by Robert Blanke and Jane Mociton. Devised a clever device to dramatize this concern. The grid,
has been used throughout the world as a means of training managers and of identifying various
combinations of leadership styles.
Grid dimension
The grid has two dimensions. Concern for people and concern for production. As Blake and Mouton
have emphasized, their use of the phrase, concern for is meant by to convey ―how‖ managers are
concerned about production or ―how‖ they are concerned about people, and not such things as
―how much‖ production they are concerned about getting out a group.
The four extreme styles
Blake and Mouton recognize four extremes of styles. Under the 1.1. Style (referred to as
―improvised management‖) managers concern themselves very little with either people or
production and have minimum. Involvement in their jobs, to al intents and purpose, they have
abandoned their jobs and only mark time or act as managers communication information from
superiors to subordinates.
At the other extreme and the 9.9 managers. Who display in their actions the highest possible
dedication both to people and to production. They are the real ―team managers‖ who are able to
mesh the production needs of the enterprise with the needs of individuals.

Another style is 1.9 management (called ―country club management‖ by some), in which mangers
have little or no concern for production but are concerned only for people. They promote an

833
environment in which every on is relaxed, friendly and happy and no one is concerned about putting
forth co-ordinated effort to accomplish enterprise goals.
At another extreme are the 9.1 managers (some-times referred to as ―autocratic task managers‖),
who are concerned only with developing an efficient operation, who have little or no concern for
people and who are quite autocratic in their style of leadership.
4. Leadership as a continum
The adaptation of leadership styles to different contingencies has been well characterized by Robert
Tannenbaum and Warren H. Schmiolt developers of the leadership continuum concept. They see
leadership as involving a variety at styles, ranging from one that is highly boss centered to one that is
highly subordinates centered. The styles vary with the degree of freedom a leader or manager grants
to subordinates. Thus instead of suggesting a choice etween the two-styles of leadership-authorization
or democratic – this approach offers a range of style, with no suggestion that one is always right and
another is always wrong.
The continuum theory recognizes that which style of leadership is appropriate depends on the leader,
the followers and the situation. The most important elements that may influence a manager‘s style
can be seen along a continum as;
i. The forces operating in the manager‘s personality. Including his or her value system, confidence in
subordinates, inclination toward leadership styles and feelings of security in uncertain situations.
ii. The force in subordinates (such as their willingers to assume responsibility, their knowledge and
experience, and their tolerance for ambiguity) that will affect the manager‘s behaviour.
iii. The forces in the situation, such as organization values and traditions, the effectiveness of
subordinates working as a unit, the nature of a problem and the feasibility of safety delegating the
authority to handle it and the pressure of time.

Fiedler’s Contingency approach to Leadership

Although their approach to leadership theory is primarily one of analysis leadership style, Fred. E.
Fiedler and his associated at the University of illions have suggested a contingency theory of
leadership. The theory holds that people become leaders not only because of the attributes of their
personalities but also because of various situational factors and the interaction between leaders and
group members.
Critical dimensions of the leadership situation;
On the basis of his studies, Fiedler described three critical dimensions of the leadership situation that
help determine what style of leadership will be most effective.
(i) Position power
This is the degree to which the power of a position, as distinguished from others source of power,
such as personality or expertise enables a leader to get group members to comply with directions, in
the case of managers, this is the power arising from organizational authority.
(ii) Task Structure
It tasks are clear (rather than vague and unstructured), the quality of performance can be more easily
controlled and group member can be hold more definitely responsible for performance.
(iii) Leader-member relatives
Since position power and task structure may be largely under the control of an enterprise. It has to do
with their extent to which group members like, trust, and are willing to follow a leader.
Goal-path approach of leadership behaviour
The path-goal theory suggests that the main function of the leader is to clarify and set goals with
subordinates, help them find the best path for achieving the goals, and remove obstacles. Proponents
834
of this approach have studied leaders which in a variety of situations. As stated Robert House, the
theory builds on various motivational and leadership theories of others.
Factors contributing to effective leadership should be considered. These situational factors include
1. Characteristics of subordinates, such as their needs, self-confidence, and abilities.
2. The work environment, including such components, as the task, the reward system and the
relationships with co-workers.
Leader behavior
Leader behavior is categorized into four groups.
1. Supportive leadership : behavior gives consideration to the needs of subordinates, shows a concern
for their well-being and creates a pleasant organizational climate. It has the greatest impact on
subordinates‘ performance when they are frustrated and dissatisfied.
2. Participate leadership allows subordinates to influence the decisions of their superiors and can
results in increased motivation.

3. Instrumental leadership gives subordinates rather specific guidance and clarifies what is expected
of them, this includes aspects of planning, organizing co-ordinating and controlling by the leaders.
4. Achievement – oriented leadership involves setting challenging goals, seeking improvement of
performance, and having confidence that subordinates will achieve high goals.

MANAGER BEHAVIOR
Decision making is a process of identifying and choosing alternative course of action in a manner
appropriate to the demand of the situation. The act of choosing implies that alternative courses of
action must be weighted and weeded out‖.
- Kreitner
Management decision making is a work the manager performs to arrive at a conclusion an judgment.
- Allen

835
 Manager:
Managerial skills:
Management job is different from other jobs. It requires elements of stewardship and commitment to
the purpose. It involves the obligation to make prudent use of human and material resources. It
requires sound judgment to handle complex situation. Further, the nature of the job becomes
increasingly complex at each higher level because of the increase in the scope of authority and
responsibility. Therefore, each higher level requires increased knowledge, broader perspective and
greater skills.
For purpose of analysis, skills required of any manager are classified under three different heads-
technical, human (employee relations skills) and conceptual skills as shown in figure. The exhibit
helps in understanding the levels of management responsibility, the principal skill requirements, and
the extent to which each kind of skill is required at each level.

Top mgt

Middle mgt Technical skills Human skills

Low mgt

Technical skills human skills

Management levels and skills

Managers develop or acquire a range of skills in their jobs. They are briefly described as
follows:
a. Conceptual skills:
This is the ability to think in abstract terms to form images and ideas, to visualize and understand the
future and to discern relations and interactions among the elements of a system and changes therein.
The skills also called design and problem-solving skill, involves the ability;
 To see the organization and the various components of its as a whole;
 To understand how its various parts and functions mesh together; and
 To foresee how changes in any one of these may affect all the others.
Conceptual skills extend to visualizing the relation of the organization to industry, to the
community and to the political, economic and social forces of the nation as a whole and even to
forces which operate beyond the national boundaries. It is the creative force within the organization.
A high degree of conceptual skill helps in analyzing the environment and in identifying the
opportunities and threats. Managements of companies like ITC, Larsen & Toubro, Asian paints, Bajaj
Auto in the private sector and National Dairy Development Board in the public sector, to mention a
few, have amply demonstrated this skill in gaining a competitive edge over their competitors.
b. Analytical skills:
These refer to abilities to proceed in a logical, step – by step and systematic manner, to examine the
various aspects of specific issues and to understand characteristics of a phenomenon.
c. Administrative skills:
They centre on ability to act in pragmatic manner, to get things done by implementing decisions and
plans, to mobilize and organize resources and efforts, to coordinate diverse activities and to regulate
organizational events in an orderly manner.
d. Behavioral or inter personal skills:
836
These skills have to do with the ability to understand people and their problems, needs and feelings,
to get along with them, to interact and communicate with them, to provide leadership, to inspire
confidence.
e. Technical skills:
Technical skills relate to job knowledge and expertise, ability to apply methods and techniques to
work settings, to provide technical guidance and instructions to subordinates. A technical skill refers
to the ability to use the tools, equipment, procedures, techniques and knowledge of a specialized field.
It implies proficiency in a specific field of activity.
Technical skills are most importance for the lower level managers, because by nature their job
involves supervision of the workers. Effective supervision and coordination of the work of the
subordinates, therefore, depends on the technical skill possessed by the lower level manager.
Any supervisor without a sound knowledge of the job cannot make an effective supervisor. Such
supervisors are not respected by the subordinates at the shop floor. The relative importance of the
technical skills as compared to the other skills diminishes as one move up to higher levels of
management.
f. Human skills:
Human skills are primarily concerned with persons, as contrasted with “things”. When a man is
highly skilled in employee relations, he is aware of his own attitudes, assumptions, and beliefs and
recognizes their limitations as well as their usefulness. He accepts, as an important fact of life, the
existence of viewpoints and feelings, different from his own.
Thus, human skill refers to the ability of the manager to work effectively as a group member and to
build cooperative effort in the team he leads. It is the ability to work with, understand and motivate
people. He understands why people behave as they do and is able to make his own behavior
understandable to them. He can foresee their reactions to possible courses of action and, is able to
take their attitudes into account. His skill in working with others is natural and continuous. He does
not apply it in random or in inconsistent fashion. It is a natural ingredient of his every action.
Technical skills and human skill are always in great demand at the lower level of management for it
is there the productive processes and operations are carried out. It is there where you find most of the
people. It is there where the action takes place. The need for conceptual skill is greatest at the top
level of management. Obviously, the top managers are not often involved in the direct application of
specific methods, procedures and techniques, compared to those at the lower echelons of
management.
As evident from the forgoing discussion, at the entry level is not the management job, that is, at the
supervisory level, besides technical skills, you have to acquire human skills and the problem-solving
skills (conceptual). To climb up the organizational ladder, you must not only be good at the skills
required for the present job, but also learn and acquaint yourself with the skills required at the next
level. As result, in the event of promotion to the next higher levels, you wound feel at home and
discharge the responsibilities with ease.
Based on the differences in the type of skills required, organizations assess the training needs of the
managers. Accordingly, appropriate training methods or modules are designed to equip them the
skills require at the respective levels. Although, each of these skills is needed in some degree at every
levels of management, there are successful executives who have no great amount of technical skills.
But they are able to compensate the lack of that skill through superior creative ability and skill in
selecting, planning and effectively motivating subordinates who are strong in technical skills.
6.2 Functions of managers

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The functions of managers provide a useful framework for organizing management knowledge.
The functions of management, as noted earlier, are: planning, organizing, staffing, leading and
controlling.

1. Planning
Planning involves selecting missions and objectives and the actions to achieve them. It requires
decision making that is, choosing future courses of action from among alternatives. There are
various types of plans, ranging from overall purposes and objectives to the most detailed
actions to be taken, such as ordering a special stainless steel bolt for an instrument or hiring
and training workers for an assembly line. No real plan exists until a decision—a commitment
of human or material resources or reputation—has been made. Before a decision is made, there
is no real plan; all that exists is a planning study, an analysis, or a proposal.

2. Organizing the work

People working together in groups to achieve some goal must have roles to play. The roles are
similar to that of actors in a drama; each role is well-defined and structured. Normally the chief
executive in the organization decides what people at different levels should perform as a part of
their role and ensures that people contribute in a specific way to the group effort. The concept
of a "role" implies that what people do has a definite purpose or objective; they know how their
job objectives fits into group effort, and they have the necessary authority, tools and
information to accomplish the task.
This can be seen in as simple a group effort as setting up camp on a cycle expedition. Everyone
could do anything he or she wanted to do, but activity would almost certainly be more effective
and certain tasks would be less likely to be left undone if one or two persons were given the job
of gathering firewood, others the assignment of getting water, some the task of starting a fire,
after the job of cooking and so on.

3. Organizing the assignment

Organizing involves establishing a structure of roles for people to fill in an organization and
ensuring that all the tasks necessary to accomplish goals are assigned to people who can do
those best. Imagine what would have happened if such assignments had not been made in the
program of flying the special aircraft Voyager around the globe without stopping or refueling.
The purpose of an organization structure is to help in creating an environment for human
performance. It is, then, a management tool and not an end in and of itself. Although the
structure must define the tasks to be done, the roles so established must also be designed in the
light of the abilities and motivations of the people available.
Designing an effective organization structure is not an easy managerial task. Many problems
are encountered in making structures fit situations, including both defining the kind of jobs
that must be done and finding the people to do them.

4. Staffing
Staffing involves the process of filling positions in the organization structure. This is done by
identifying workforce requirements; inventorying the people available; and recruiting,
selecting, placing, promoting, appraising, planning the careers of, compensating and training or
otherwise developing both candidates and current jobholders to accomplish their tasks
effectively and efficiently. This subject is dealt with in Part 4 of this book.
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5. Leading
Leading is the influencing of people so that they will contribute to the organization and group
goals. Predominantly, it is concerned with the interpersonal aspect of managing. All managers
would agree that their most important problems arise from people—their desires and attitudes,
their behavior as individuals and in groups—and that effective manager also need to be
effective leaders. People tend to follow only such leaders who offer a means of satisfying their
own needs, wishes and desires. In other words, leading involves motivation, leadership styles
and approaches, and communication. The essentials of these issues are dealt with in Part 5 of
this book.

6. Controlling
Controlling is the measuring and correcting of activities of subordinates to ensure that events
conform to plans. It measures performance against goals and plans, shows where negative
deviations exist, and, by putting in motion actions to correct deviations, helps ensure
accomplishment of plans. Although planning must precede controlling, plans are not self-
achieving. Plans guide managers in the use of resources to accomplish specific goals; then
activities are checked to determine whether they conform to the plans.
Control activities generally relate to the measurement of achievement. Some means of
controlling, like the budget for expense, inspection records and the record of labor-hours lost,
are generally familiar. Each measures and each shows whether plans are working out or not. If
deviations persist, correction is indicated. But what is corrected? Activities, through persons.
Nothing can be done about reducing scrap, for example, or buying according to specifications,
or handling sales returns, unless one knows who is responsible for these functions. Compelling
events to conform to plans means locating the persons who are responsible for results that
differ from planned action and then taking the necessary steps to improve performance. Thus,
outcomes are controlled by controlling what people do.
7. Coordination, the Essence of Managership
Some authorities consider coordination to be a separate function of the manager. It seems more
accurate, however, to regard it as the essence of managership, for achieving harmony among
individual efforts made towards the accomplishment of group goals. Each of the managerial
functions is an exercise contributing to coordination.
Even in the case of a church, individuals often interpret similar interests in different ways, and
their efforts towards mutual goals do not automatically mesh with the efforts of others. The
central task of the manager is, therefore, to reconcile differences in approach, timing, effort or
interest and to harmonize individual goals to contribute to organization goals.

Social responsibility of Managers

For most business organizations, social responsibility is a way of life. Social responsibility entails all
such activities ranging from providing safe products and services to giving a portion of the company's
profits to welfare organizations with a philanthropic perspective.
Social responsibility of a business is also viewed as conducting its operations in a free and fair
manner by discharging its commitment towards different segments of its operational environment
such as shareholders, consumers, employees, creditors, the government, competitors and the general
public as explained below:
(a) Responsibility towards shareholders—A business enterprise has the responsibility to provide fair
return on capital to the shareholders. The firm must provide them regular, accurate and full infor-
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mation about the working of the enterprise in order to fulfill and encourage their interest in the affairs
of the company.
(b) Responsibility towards consumers—The management has to provide quality products and
services to the customers at reasonable prices. It should consider customer's suggestions and also plan
its services more effectively through consumer satisfaction surveys, which focus on unfulfilled
customer expectations.
(c) Responsibility towards employees—Good working conditions motivate workers to contribute
their best. It is the responsibility of the management to recognize their unions and respect their right to
associate with a union of their choice. The management has to provide a fair deal to employees by
planning for social security, profit sharing, growth and development, employee promotions, grievance
settlement machinery and employee welfare.
(d) Responsibility towards creditors—The business has to repay the loans it has taken from the finan-
cial institutions, as per the repayment schedule. Also, it should inform the creditors about the
developments in the company from time to time. The business firm has to live up to the ethical and
moral expectations of its creditors by fulfilling its commitments.
(e) Responsibility towards the government—The business firm has to pay its taxes and be fair in its
endeavors. It should also support the government in community development projects.
(f) Responsibility towards suppliers—Companies such as Maruti Udyog, Hero Cycles and Escorts
are classic examples that show how best vendors (suppliers) can be nurtured to grow. Vendors set up
ancillary industries around these industries tc respond to the needs of the main plants. Their computer
systems are integrated to the information systems of the main plant. They get seed capital and other
infrastructural support which ensures that the material supplies are not disrupted at any stage and at
any cost.
(g) Responsibility towards competitors—A business firm should always maintain the highest ethical
standards and maintain cordial relations with each of its competitors, which is a critical and sensitive
segment.
(h) Responsibility towards general public—Business units has a tremendous responsibility
towards the general public to support the cause of community development. Most of the companies
maintain public relations departments exclusively to maintain good relations with the community.

Manager development process and training

Before specific training and development programs are chosen, three kinds of needs must be
considered. The needs of the organization include such items as the objectives of the enterprise, the
availability of managers, and turnover rates. Needs related to the operations and the job itself can be
determined from job descriptions and performance standards. Data about individual training needs
can be gathered from performance appraisals, interviews with the jobholder, tests, surveys, and career
plans for individuals. Let us look more closely at the steps in the manager development process,
focusing first on the present job, then on the next job in the career ladder, and finally on the long-term
future needs of the organization. The steps in manager development are depicted in
Present Job
Manager development and training must be based on a need analysis derived from a comparison of
actual performance and behavior with required performance and behavior. Such an analysis is shown
in Fig. 13.2. A district sales manager has decided that the selling of 1000 units is a reasonable
expectation, but the actual sales are only 800, 200 units short of the sales target. Analysis of the
deviation from the standard might indicate that the manager hicks the knowledge and skills for
making a forecast and that the conflicts among subordinate managers hinder effective teamwork. On
840
the basis of this analysis, training needs and methods for overcoming the deficiencies are identified.
Consequently, the district sales manager enrolls in courses in forecasting and conflict resolution.
Furthermore, organization development efforts are undertaken to facilitate cooperation among
organization units.

Next Job
As shown in Fig. 13.1, a similar process is applied in the identification of the training needs for the
next job. Specifically, present competency is compared with the competency demanded by the next
job. For instance, a person who has worked mainly in production may be under consideration for a
job as a project manager. This position requires training in functional areas such as engineering,
marketing, and even finance. This systematic preparation for a new assignment certainly is a more
professional approach than simply thrusting a person into a new work situation without training.
Future Needs
Progressive organizations go one step further in their training and development approach; they
prepare for the more distant future. This requires that they forecast what new competencies will be
demanded by changing technology and methods. For example, energy shortage may again occur, and
this requires that managers be trained not only in the technical aspects of energy conservation but also
in energy-related long-range planning and creative problem solving. These new demands—created by
the external environment — have to be integrated into enterprise training plans which focus on the
present and the future. These plans are contingent not only on the training needs but also on the
various approaches to manager development that are available.

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PROBLEM SOLVING
It is a part of decision making. A systematic process that focuses on analyzing a difficult situation,
problem solving always includes a decision making step.

CRITICAL THINKING
Critical thinking, sometimes referred to as reflective thinking s related to evaluation and has a broader
scope than decision making and problem solving. Components of critical thinking include reason and
creative analysis.
- Pesut & Herman

CHARACTERISTICS OF DECISION MAKING AND CRITICAL THINKING

The basic characteristics of decision making and critical thinking are enumerated below.

1. It is a process of choosing a course of action from among the alternative course of action.
2. It is a human process involving to great extent the application of intellectual abilities.
3. It is the end process preceded by deliberation and reasoning.
4. It is always related to the environment. A manger may take one decision in a particular set of
circumstances and another in a different set of circumstances.
5. It involves a time dimension and a time lag.
6. It always has a purpose. Keeping this in view, there may just be a decision not to decide.
7. It involves all actions like defining the problem and probing and analyzing the various alternatives
which take place before a final choice is made.

DECISION MAKING AND PROBLEM SOLVING PROCESS

Different decision making procedures are required in different situations depending on the nature of
the problem, environment, internal and external, time and cost. Each decision making process
involves the following steps, known as element of decision making.
Elements of decision making and problem solving process
1. Identification of problem situation
2. Definition of problem situation
3. Specification of objectives
4. Collection of data
5. Developing alternative course of action
6. Evaluation of alternative course of action
7. Selecting appropriate techniques
8. Implementation of decision

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1. Identification of problem
The process of decision making starts with the discovering of the problem for which internal and
external situations are analysed. The problem may relate to an area of an operation or may related to
the external environment. Along with location of the problem, its basic nature is ascertained as to
whether it calls for a strategic operational, major or minor, and long and short-term decision.
2. Definition of problem
Once the problem has been perceived, the manger proceeds to analyze it to determine its nature. Here,
the manager has to clearly define the problem. A well defined problem is half-solved. The efficiency
of the decision making process and its quality depends on clear definition of the problem which is a
difficult task because the real problem may be quite different from what it appears.
The problem situation has to be defined and described interms of its origin, scope, symptom causes,
importance, gravity, intensity and ramifications. Defining a problem is a time consuming job and the
manager may prefer to define its strategic and critical components.
3. Specification of objectives
The decision making process does not work in isolation. It has certain objectives. Decisions are
directed towards the achievement of objectives. The managers are expected to prepare a statement of
the objectives which may be quantitative and qualitative and serve as a yardstick for measuring and
evaluating the efficiency and effectives of various alternative course of action, particularly, the one,
chosen or solving the problem. For example, the company facing the problem of cut throat
competition may achieve the objectives of survival or maintenance of market share by solving the
problem.
Collection of Data
Required, relevant and reliable information has a very important role in decision making. Information
is required not only for uncovering and defining the problem but is equally useful for other involved
in the process. The required information is gathered from internal and external sources to provide a
factual framework to managers. Availability and reliability of information is a critical input for
decision making.
5. Developing alternative course of action
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After defining a problem and collecting information, a manager has to developed alternative solution.
The process of decision making becomes relevant and meaningful and challenging exercise for
managers, only I they have may more alternatives to be examined for making a final decisions.
Alternative solutions may not be obvious and apparent. It is the duty of the managers quickly by
reference to experience and expertise and others may be generated through research and analysis,
creative thinking and innovativeness.
6. Evaluation of Alternative course of Action
The objectives of decision making is to choose an alternative that will provide the greatest amount of
wanted and the smallest of unwanted consequences. Each alternative is evaluated to satisfy the
objectives of the managers. The probable consequence of alternatives can be estimate through
forecasting and other devices. An alternative should be thoroughly evaluated in term of risk, time
consumed, efficiency and resource position. While choosing an alternative, both quantitative and
qualitative factors should be taken into account.
7. Selection of Appropriate Alternatives
Here, the final choice is made by screening and conducting a critical evaluation to eliminate the large
number of alternatives. But, for the final choice, the mangers have to rely on experience, skill and
judgment and feasibility, acceptability, practicability and simplicity of the alternative choice. Various
organizational plans, policies, rules, basic philosophy of management and other human factors are
given due weightage.
8. Implementation of the decision
Implementation of decision implies series of actions and utilization of resources. To implement
decision, necessary structural administrative and logistic arrangements are made such as delegation of
authority, allocation of resources, assignment of activities and installation of controlling mechanism.
To secure maximum co-operation commitment and acceptance for implementing decision, the
concerned employees are taken into confidence or involved in process.

TECHNIQUES OR BASIS FOR DECISION MAKING AND CRITICAL THINKING

The selection of an appropriate technique depends upon the judgement of decision making following
techniques of decision making and critical thinking are generally employed of decision making and
critical thinking are generally employed.
1. Intuition
Decision making by intuition is characterized by inner feeling of the person. He takes a decision as
per the dictates of his conscious. He thinks about the problem and an answer is found in his mind.
The decision maker had his own preferences, influences, psychological makeup and these things play
a vital role in taking a decision. The past knowledge, training and experience of the decision maker
plays an important role in intuitive decisions.
2. Facts
Facts are considered to be the best basis of decisions making. A decision based on facts has its roots
in factual data. Such decisions will be sound and proper. The increasing use of computer has helped
in systematic analysis of data. The information had become a major tool in managerial decision
making.
3. Experience
Past experience of a person becomes a good basis for taking decisions. When a similar situation arises
the manager can rely on his past decisions and takes similar decisions. The person sees and
understands. Things in terms of concepts with which he is familiar. Experience should not be
844
followed blindly. The new situations. Should be analysed on the basis of past knowledge. A
successful decision in the past may not prove useful this time also, on times in future.
4. Considered options
Some managers use consideration opinions as a basis of decisions making. Besides, pertinent
statistics, opinion and also given due weightage. Sometimes discussed and considered by more
persons become logical and may form a sound basis for decision making. A marketing manager,
before deciding whether to market a new product or not, will like to see marketing statistics as will as
considered opinions before finally making choice.
5. Operations research
The traditional methods of taking decision on the basis of intuition, experience, etc. are replaced by
systematic techniques based on analysis of data. The operations research is one of the techniques used
by modern management for decision important maters. It helps managers by providing scientific basis
for solving organized problems involving interaction of components of the organization.
6. Linear programming
This technique is used to determine the best use of limited resource for achieving given objectives.
This method is based on the assumption that there exists a linear relationship between variables and
that the limits of variations could be ascertained. Linear programme can be used for solving problems
in areas like production, transportation, warehousing, etc.
7. Values
Being confused and unclear about one‘s values may affect decision-making ability. Overcoming a
lack of self-awareness through values clarification decreases confusion.
People who understand their personal beliefs and feelings will have a conscious awareness of the
values on which their decisions are based. This awareness is an essential component of decision
making and critical thinking.
8. Individual Preference
Overcoming this area of vulnerability, involves self-awareness, honesty and risk taking. The need for
self-awareness was discussed previously but it is not enough top be self-aware, people also must be
honest with themselves about their choices and their preferences for those choices. Additionally, the
successful decision makers must take some risks. Nearly every decision has some element of risk, and
most involve consequences and accountability. Those who are able to do the right but unpopular
thing and who dare to stand alone will emerge as leaders.
QUALITIES OF MANAGER FOR DECISION MAKING AND CRITICAL THINKING
Courage
Courage is of particular importance and involves the willingness to take risks.
Sensitivity
Good decision makers seem to have some sort at antenna that makes them particularly sensitive to
situation and others.
Energy
People must have the energy and desire to make things happen.
Creativity
Successful decision makes tend to be creative thinkings. They develop new ways to solve problems.

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Similarities and differences between the leader and manager
Leader Manager

• May or may not have official appointment
• Have power &authority to enforce decisions as
long as followers are willing to be lead.
• Influence others either formally or informally
• Interested in risk-taking and exploring new
ideas
• Relate to people personally in an empathetic
manner
• Feel rewarded from personal achievements
• May or may not be successful as manager
• Appointed officially to the position
• Have power and authority to enforce decisions
• Carry out predetermined policies , rules and
regulations
• Maintain an orderly ,controlled ,rational
&equitable structure
• Relate to people according to their roles
• Feel rewarded when fulfilling organizational
goals or mission
• They are managers as long as they hold the
appointment

CONCLUSION
Leadership is the art or process of influencing people so that they contribute willing and
enthusiastically toward group goals. Leadership requires followership. There are various approaches
to they study of leadership, ranging from the trait to the contingency approach.
EFFECTIVE LEADER: CHARACTERESTICS AND SKILL
Characteristics of leadership:
a. Influence
b. Involves the leader & his followers (a specific goal, situation, communication, feedback)
c. A reciprocal relationship between the leader & his followers
d. A leader must be acceptable to his followers- employees
e. A leader gains influence through their speech behaviors.

4.4 Leadership skills:

 There is now recognition in both leadership theory and practice of the importance of skills,
how leaders behave and perform effectively.
 Although there are many skills, such as cultural flexibility, communication, HRD,
creativity, and self-management of learning, the more research- based skills identified by
whetten and Cameron seem most valuable.
 Their personal skills model, involving developing self-awareness, managing stress, and
solving problem creativity, and the interpersonal skills model, involving communicating
supportively, gaining power and influence, motivating others, and managing conflict, are
especially comprehensive and useful.
 Finally, the ore widely recognized organizational behaviour techniques such as, training
such as, training; job design and behavioral management can also be effectively used by
leaders.

4.5 Leadership functions:

A leader whether formal or informal, is required to undertake several functions in relation to his
group. David Bowers and Stanley Seashore classify the above functions into four categories for
conceptual purposes:
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 a. Support: Behaviour, which enhances the members’ feelings of personal worth and importance.
b. Emphasis on goals: behaviour, which stimulates enthusiasm for meeting the group goals with
excellence.
c. Facilitation of work: Behaviour, which manifests itself in such activities as planning,
scheduling, coordinating and providing resources, information and other infrastructural
facilities.
d. Facilitation of interaction: Behaviour, which encourages group members to develop members
to develop close and mutually satisfying relationships.
4.6 Causes for failure of leadership
1. Inability to organize
2. Unwillingness to do what they wound ask another to do
3. Expectation of pay for what they know instead of what they do
4. Fear of competition from others
5. Lack of creative thinking
6. The ‘I’ syndrome (ego)
7. Over indulgence – alcohol, abuse, etc
8. Disloyalty
9. Emphasis of the ‘Authority of leadership’ (fear not successful)
10. Emphasis of title
11. Lack of understanding of the destructive effects of a negative environment
12. Lack of common sense.
4.7 Leadership effectiveness:
There are at least three major views on the determinants of leadership effectiveness.
a. One view is that effectiveness is a function of the personal qualities or traits of the individuals
who assume the role of leadership. Although possession of these qualities does not guarantee
effectiveness, all we can say is that they increase the probability of leadership effectiveness.
b. The second view is that leadership effectiveness is not a matter of what leaders are but rather
a matter of what they do and how they behave. This is known as the behavioral approach.
The two most important dimensions of the behaviour of leaders are productivity orientation
and employee satisfaction orientation. Leaders who score very high in both the above
behavioral dimensions are said to be very effective.
c. The third view is that leadership effectiveness is a function of interaction among at least three
variables; the leader, the group of followers and the tasks situations. This is known as the
situational or contingency approach to leadership. Here effectiveness is defined in terms of the
task performance and satisfaction of the group.
4.7.1 Force Determining Effective Leadership:
There are four types of forces which are significant to the leader in shaping his leadership
style:
1. Forces in the leader himself,
2. Forces in his subordinates,
3. Forces in the general situation, and
4. Forces in the organizational system.

1. Forces in the leader himself:

The nature of the leader himself-his attitudes, values, knowledge and skill, experiences and
maturity, emotional flexibility- all which have been developing since birth, influence his feeling,
847
 assumptions, perceptions and behaviour. One important determinant of a leader’s behaviour
towards his followers is the assumptions he makes about man, and particularly how he assumes
man to be motivated.
2. Forces in his subordinates:
The style of leadership is in part determined by the forces within the subordinates. These
include their knowledge and skill, their needs for independence, their acceptance of
management’s objectives, their tolerance for ambiguity and their expectations that they should
share in decision-making.
3. Forces in the general situation:
Important situational forces which have a bearing on leadership style are as follows:
I. Leadership style of the leader’s supervisors:
If the leader’s own boss is a high-task leader, he will expect subordinates to operate in the same
manner. It is as difficult for a leader with a democratic style to work under an authoritarian
superior as it is for one with an authoritarian style to work under a democratic superior.
II. Job demands:
If the job is complex and the followers lack ability, the leader would use a high level of task
behaviour- style I or II. But if the job is simple, style III or IV may be more appropriate.
According to Lawrence, who made a detailed study of six firms in the plastics, food, and
container industries, different functional departments of an organisation need different
leadership style.

III. Pressure of time:

If there is an emergency or crisis or the job has to be rushed through, the leader cannot wait for
the opinions and suggestions of his followers.

4. Forces in the organizational system:

Important among these forces are division of work, organization structure and production
technology.
I. Division of work:
The way in which the work is divided and the activities are organized influences the style of
leadership. Democratic supervision is best carried out in that work group where due to the
physical proximity; people have frequent contact with one another and find it easy to share the
information they need to coordinate their jobs.
II. Organization structure:
Tall organizations frequently lead to high supervisory ratios and therefore tend to encourage
authoritarian supervision. With a relatively small number of subordinate, the supervisor is in a
position to give detailed instructions and to exercise authoritarian control over each one.
III. Production technology:
Production technology, as suggested by Woodward also seems to limit the amount of discretion
which subordinates can be given and the style of supervision used. This led to the classification
of the firms into three groups:
a. Unit or job order
b. Large batch and mass production
c. Long run process production
4.7.2 Condition of Effective Leadership:

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According to McGregor, the subordinate is dependent upon his superior for the satisfaction of
many of his needs. The subordinate depends upon his superior for continuity of employment,
promotion, increased pay, and a variety of social satisfactions. As a consequence of this
dependence, the subordinate has a need for security and a need for independence.
a. Leadership conditions that provide for security:
According to McGregor, there are three conditions that lead to a feeling of security on the part
of the subordinates these are as follows:
I. Atmosphere of approval:
The leader must maintain an atmosphere of approval at work. A good part of the atmosphere
of approval is in the freedom to make a mistake.
II. Knowledge:
Knowledge is another important condition for security because it reduces dependence upon the
unpredictable. There are several different kinds of knowledge that are necessary. First, the
subordinate must know the procedures, rules and regulations that are connected with his job.
Second, he needs to have knowledge of his duties and responsibilities; otherwise he does not
know when to make a decision. Third, the subordinate needs to know something about the
overall policy of the organization. Fourth, the subordinate needs advance knowledge of changes
that affect him or his position.
III. Consistent discipline:
This is the third condition for security. Effective learning requires that the individual knows
when he is performing correctly and when incorrectly. Discipline must involve an invariable
indication of both desirable and undesirable behaviour.

b. Leadership conditions that provide for independence

I. Participation:
Participation is the first condition for independence. When the subordinate has the opportunity
to contribute his suggestion and to express his ideas concerning matters that affect or bear upon
his work, he is asserting himself as an individual and is showing that he is not wholly
dependence upon his superior.
II. Responsibility:
Responsibility is a second condition of independence. When the subordinate are has
responsibility of work, then they try to show the interest on the work and they produce better
outcome in the organization.

4.7.3 Path-Goal Approach to Leadership Effectiveness

The path-goal theory suggests that the main function of the leader is to clarify and set goals with
subordinates, help them find the best path for achieving the goals, and remove obstacles. Proponents
of this approach have studied leadership in a variety of situations. As stated by Robert House, the
theory builds on various motivational and leadership theories of others.
In addition to the expectancy theory variables, other factors contributing to effective leadership
should be considered. These situational factors include
(1) Characteristics of subordinates, such as their needs, self-confidence, and abilities; and
(2) The work environment, including such components as the task, the reward system, and the
relationship with coworkers (see Fig).

Leader behavior is categorized into four groups:

849
1. Supportive leadership behavior gives consideration to the needs of subordinates, shows a concern
for their well-being, and creates a pleasant organizational climate. It has the greatest impact on
subordinates' performance when they are frustrated and dissatisfied.
2. Participative leadership allows subordinates to influence the decisions of their superiors and can
result in increased motivation.
3. Instrumental leadership gives subordinates rather specific guidance and clarifies what is expected
of them; this includes aspects of planning, organizing, coordinating and controlling by the leader.
4. Achievement-oriented leadership involves setting challenging goals, seeking improvement of
performance, and having confidence that subordinates will achieve high goals.
Rather than suggesting that there is one best way to lead, this theory suggests that the appropriate
style depends on the situation. Ambiguous and uncertain situations can be frustrating for

Path-goal Approach to Leadership

Effectiveness
subordinates, and a more task-oriented style may be called for. In other words, when subordinates are
confused, then the leader may tell them what to do and show them a clear path to goals. On the
other hand, for routine tasks, such as those found on the assembly line, additional structure
(usually provided by a task-oriented leader) may be considered redundant; subordinates may
see such efforts as over controlling, which, in turn, may be dissatisfying. To put it differently,
employees want the leader to stay out of their way because the path is already clear enough.

The theory proposes that the behavior of the leader is acceptable and satisfies subordinates to the
extent that they see it as a source for their satisfaction. Another proposition of the theory is that the
behavior of the leader increases the effort of subordinates, that is, it is motivating, insofar as
1) This behavior makes satisfaction of the needs of subordinates dependent on effective
performance and
2) The behavior enhances the subordinates' environment through coaching, directing, supporting,
and rewarding.
The key to the theory is that the leader influences the paths between behavior and goals. The leader
can do this by defining positions and task roles, by removing obstacles to performance, by enlisting
the assistance of group members in settings goals, by promoting group cohesiveness and team effort,

850
by increasing opportunities for personal satisfaction in work performance, by reducing stresses and
external controls, by making expectations clear, and by doing things that meet people's expectations.
The path-goal theory makes a great deal of sense to the practising manager. At the same time, one
must realize that the model needs further testing before the approach can be used as a definite guide
for managerial action.
5.5 Top 10 Characteristics of an Effective Leader
Submitted by Roger Gaelens on July 12, 2010, Revenue Journal is a registered trademark of
Zhivago Management Partners, Inc.
Every business needs an effective leader. And yet, highly effective leadership is rare. Here's a
checklist that comes from helping hundreds of CEOs, entrepreneurs and managers become more
effective leaders.
1) Truly Humble - Leads to Serve
This is first because no one likes to work for a jerk or buy from a jerk. If you are selfish and obsessed
with your own self-image, you will be your own worst enemy. Sure, there are exceptions. But for
every Larry Ellison, there are hundreds, perhaps even thousands, of nice-guy/gal business leaders
whose good character makes people want to associate with them.
I say "truly humble," because we are living in a time where fake humility is an epidemic - and people
are becoming increasingly good at spotting it. And, "leads to serve," because a real leader lives to
help others, using the talents and desires he was born with.
2) Non-Judgmentally Observant
During a working day, the effective leader observes his own behavior and that of others. If you
observe your own behavior non-judgmentally, but with the constant desire to improve, you will get
much farther than if you berate yourself, or excuse or justify your shortcomings. Doing these things
will ensure that your problems remain unsolved. And, if you are asking others to solve their
problems, they must first see you solving your own.
If you take the same "calm observer" approach with others, you will be a dispassionate listener. It will
be more difficult for them to guess what you're thinking, and they will be more likely to tell you
more.
They will still be on their best behavior - after all, the boss is in the room - but they will relax just a
little bit more than they would if you were becoming agitated as you listened to them.

3) Faces and Solves Problems

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Once the good leader has observed and is satisfied that she has uncovered the truth, she then sets out
to solve the problem. She doesn't procrastinate or spend too much time gathering unnecessary
additional data. She gets the right people involved right away, she tells them what she has observed,
tells them what she's decided to do so far, and then works with their help to solve the problem. In the
course of solving that problem, they may uncover others. She takes the same approach with each new
problem.
The leaders who limit their own businesses, on the other hand, will react to a problem in all sorts of
unproductive ways. She may decide that it's personal, and invest her energy in "taking offense." She
may simply refuse to acknowledge there's a problem. Even if she does acknowledge it, she may
decide to ignore it; push it off on to someone else to fix; or blame someone else for causing it, then
fail to do anything about it. If she acknowledges it and starts to do something about it, she may come
up with a solution that doesn't really solve the problem. She may also pretend she is solving the
problem when in fact she is doing nothing.
4) Ruthlessly Improves
The best businesses - the ones that continue to survive, even when massive market shifts affect their
industry - are ruthless about improvement. They are constantly finding new ways to educate their
customers, employees, and partners. They are always looking at their processes, policies, and
systems, and asking themselves: "How could we make this more efficient? What don't we need
anymore? What do we need now?" They don't fall into the "we've always done it this way" trap,
which causes far too many companies to struggle - and fall.

5) Is Fiscally Conservative
Being in the tech business as long as I have, I've seen some spectacular failures. They all had one
thing in common: They overspent. They managed to get some outside funding - either from venture
capital or over-inflated stock prices - and they spent like there was no tomorrow. They were right -
ultimately, for these companies, there was no tomorrow. In our current economic climate, fiscal
conservatism hardly needs mentioning - but it is one of the signs of the effective leader, so it must be
in this list. A good leader will think twice and will keep asking himself, "Do we need this now? Is
there a less-expensive way of doing this?"
6) Invests in the Business
Even in a terrible economy, a good leader will invest in the
business. He will just choose his investments wisely - the goal
is to get the biggest bang for the buck, and to invest where it
will have an immediate positive effect on revenue growth.
For example, I just interviewed a number of salespeople for a
client. The client sells very complex software programs and
services. One of the recommendations I'm making to the client
is to increase education for their salespeople; to make sure that
they are regularly trained by the company's technical folks - and by the company's trainer, who is in
constant contact with customers and their specific concerns/misunderstandings/needs. Salespeople
who can answer customer questions accurately and with confidence always speed up the sales cycle -
and make it more likely that the customer will buy from them.
7) Communicates Consistently, Clearly, Concisely
Tech companies are often run by technical types, or, in times like these, financial types. Both tend to
be poor communicators. But even the CEOs I've worked with in the health, food, and travel
businesses have problems in this area. It's not just a "guy thing," either.
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I'm going to generalize here and say that the guys with communication problems tend to
communicate too infrequently, and in a way that doesn't instill confidence in their troops. The gals
with communication problems may communicate more often, but they tend to go off-subject, to the
point where people leave meetings with too much data and not enough clear direction. Of course
there are exceptions to these general rules - that's the whole point.
The effective leaders communicate regularly, clearly, and concisely. Because they have been humble
and objective enough to get the real story, whatever they say rings true to those hearing it. The
listeners are open to whatever comes next - a solution or a new directive.

8) Gives Clear Direction

The effective leader gives clear directions. He works out how a project should proceed, then presents
the plan in a well-organized, logical fashion that is easy for his customers, employees, or partners to
understand and act upon. He doesn't ramble on, verbally or in emails. He doesn't "think out loud." He
doesn't rant. He doesn't berate anyone (especially in front of others), except in the very rare instance
when it is entirely appropriate and necessary to do so.
I've been in meetings where the CEO allowed himself to ramble, rant, and berate for a half hour
straight. By the time he was done, the employees were more confused than ever, demoralized, and
drained of energy.
9) Is An Aggressive "Evolutionizer"
An "evolutionizer" is a leader who knows that the company's products or services won't be in demand
forever. He doesn't spend any time trying to imagine what the market will need next; that guessing
game is almost always an unprofitable exercise. Instead, he keeps his finger on the pulse of the
customer's world, and the minute the customer feels a need and starts to make a shift, he's all over it.
He learns everything he can about it - from customers. His interviews will either convince him that
it's only a passing fad, or that it's a real trend - and if it's a trend, he starts working immediately to see
how his company can help customers meet their needs in that area. He starts with his current product
offerings. Can they be repositioned? Repackaged? Repriced? Redesigned?
The effective leader becomes a valued and trusted business partner for his customers, opening the
door for him to introduce new products and services to them. They'll be more likely to buy from his
company, because they already trust his company to deliver what they need.
10) Has a Sense of Humor
Running a company is serious business, but if you can't laugh once and a while, you're not going to
be an effective leader. A little wit goes a long way; no one considers a clown a leader. Self-
deprecating humor is best, but that can also be taken too far. A business owner or CEO who
constantly makes fun of himself will erode confidence in his abilities.
It's a balance, as are most things in life. You should know what your strengths and weaknesses are.
You should be able to laugh about them, while constantly working to eliminate those weaknesses.
5.6 Effective Leader skills
1. Passion
An effective leader is a person with a passion for a cause that is larger than they are. Someone with a
dream and a vision that will better society, or at least, some portion of it. I think a very key question
has to be answered: Can someone who is a charismatic leader, but only to do evil or to promote
herself, be a leader -- especially if she has a large following?” I would say no, she is a manipulator.
Also, without passion, a leader will not make the necessary courageous and difficult decisions and
carry them into action. This is not to imply that all decisions are of this nature. But you can be sure,
some of them will be. The leader without a passion for a cause will duck.
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2. Holder of Values
Leadership implies values. A leader must have values that are life-giving to society. It is the only kind
of leadership we need. This then also implies values that are embedded in respect for others. So often
we think of people skills or caring about people as being “warm and fuzzy.” I think a leader can be of
varying ‘warmth and fuzziness,” but a leader has to respect others. You can’t lead without it.
Otherwise we are back to manipulation. Respect means also that one can deal with diversity -- a
critical need for a leader in today’s world -- probably always has been, although diversity may have
been more subtle in the homogenous societies of the past.
3. Vision
This is a bit different than passion, but in other ways it isn’t separable. If one doesn’t care about a
subject, an issue, a system, and then one won’t spend the time thinking about how it could or should
be different. Yet, one could have strong feelings about something and not good ideas, particularly if
she didn’t spend a good deal of time studying the topic. Thus a leader has to have some ideas about
change, about how the future could be different. Vision then is based on two components that leaders
also need: creativity and intellectual drive.
4. Creativity
One has to try to think out of the box to have good visions and to come up with effective strategies
that will help advance the vision. I’d also add here the need for a sense of humor. It’s a creative skill
that is in great need by leaders. We should read the funnies more!
5. Intellectual Drive and Knowledge
I believe a leader has to be a student. In general it is hard for a leader to be around enough other
leaders to pick this up just through discussion, so I think a leader has to be a reader and a learner.
Furthermore, I can’t see someone leading in a field they know nothing about.
6. Confidence and Humility Combined
While one can have a great vision and good ideas for change, and even passion for it, if one isn’t
confident, then action will not occur. Without action, there is no change. Yet, paradoxically, a leader
needs to have humility. No matter how creative and bright one is, often the best ideas and thinking
are going to come from someone else. A leader needs to be able to identify that, have good people
around who have these ideas. This takes humility, or at least lack of egocentricity. The leader is
focused on the ends and doesn’t have to see herself always as the conduit or creator of the strategy to
get to that end.
7. Communicator
None of the above assets will work for a leader if she can’t speak or write in a way to convince others
that they should follow along, join the team, and get on board. All the above gets to the old adage that
a leader knows how to do the right thing and a manager knows how to do things right. But a leader
has to be a manager, too. I don’t think these skills and abilities can be separated out very easily. Both
need to be in the mix.
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Thus a leader has to be some of the following, too:
Planner/Organizer
Someone who can see what needs to be done and help the team plan and organize the getting it done.
Management is getting things done through people. While a writer or other visionary person may be
very influential, even seminal for the cause of change, this is not quite my definition of a leader. A
leader means to me, someone who is taking action, trying to get others to do something they want to
see done.
Interpersonal Skills
Leaders must have the ability to act in an interpersonally competent manner, yet they also need to
learn the techniques of good listening, honest and open communication, delegating, conflict
resolution skills, etc., to actually get work done and keep the whole movement/organization/project
together.
Other Business Skills
While in some arenas you may be able to get by with only some of these skills or none of them (if
you can hire good enough people to do it for you), generally speaking you must have at least some
skills in financial management, human resources, information management, sales, marketing, etc.
CONCLUSION :
Good leaders often switch instinctively between styles, according to the people they lead and the
work that needs to be done. Establish trust – that's key to this process – and remember to balance the
needs of the organization against the needs of your team.
The mantle of leadership does not fall to only a few. Indeed, all nurses must think of themselves as a
leader, act as a leader, and take on the challenges of a leadership role. All leaders are not managers or
organizational office holders; many of them are staff nurses, faculty, and individuals on the “front
lines” of patient care. By the same token, all managers are not leaders. Nurses also need to be
effective followers, knowing who to follow, when to follow, and how to follow. It is only through the
exercise of leadership and effective followership 10 Understanding the Theory of Leading,
Following, and Managing that nurses will be able to influence health care and create a preferred
future for the profession. Those of us who are leaders in the field must guide, support, and encourage
those who aspire to this role. Those who aspire to genuine leadership must learn about this role, take
the risks associated with expressing and moving forward to achieve a vision, and allow passions to
drive actions. The patients, families, and communities we serve deserve nothing less.

Chapter- XI jaqulin mary

GROUP DYNAMICS
INTRODUCTION
“Never doubt that a small group of thoughtful citizens can change the world. Indeed, it is the only
thing that ever has.” Margaret Mead In today‘s explosion of information technology,
communication continues to be a complex process. Group dynamics can be very positive and
helpful where team members support each other and do what is best. It can alternately become
destructive if individuals are allowed to continue with more selfish behaviors such as never
helping someone else, making their personal life and personal problems permeate their work, being
negative about everything that happens or complaining all the time.
The word dynamic means ‗force‘. The term group dynamics refers to the forces operating in
groups. Group dynamic is concerned with the dynamic interaction of individuals in face to face
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relationship. The task goal of the group originating from the basic organization objectives provide
for their continued interaction. As a leader understanding the group dynamics is essential in order
to both compose and guide individuals within a group for the purpose of successfully and
efficiently completing an assignment. Ideally an understanding of group dynamics and effect of the
interplay of personalities and abilities would enable a leader to structure the composition of a
group so as to partner complementary characteristics The nurse manager has an important role in
this situation, because it may be necessary to counsel individuals exhibiting negative behavior to
achieve positive group dynamics.
DEFINITION
GROUP:
 A goal. People join groups to achieve goals that cannot be achieved by them alone.
group may be defined as a number of individuals who join together to achieve
Johnson & Johnson (2006)
 A collection of people who interact with one another, accept rights and obligations
as members and who share a common identity.
 A group is an association of two or more people in an interdependent relationship
with shared purposes.
GROUP DYNAMICS:
 Group dynamics may be defined as the social process by which people interact
face to face in small groups.
 A branch of social psychology which studies problems involving the structure
of a group.
 The interactions that influence the attitudes and behavior of people when they
are grouped with others through either choice or accidental circumstances.
 A field of social psychology concerned with the nature of human groups, their
development, and their interactions with individuals, other groups, and larger
organizations.
OBJECTIVES OF GROUP DYNAMICS
 To identify and analyse the social processes that impact on group development and
performance.
 To acquire the skills necessary to intervene and improve individual and group
performance in an organizational context.
 To build more successful organizations by applying techniques that provides positive
impact on goal achievement.
PRINCIPLES OF GROUP DYNAMICS
♪ The members of the group must have a strong sense of belonging to the group.
♪ Changes in one part of the group may produce stress in other person, which can be reduced only
by eliminating or allowing the change by bringing about readjustment in the related parts
♪ The group arises and functions owing to common motives.
♪ Groups survive by placing the members into functional hierarchy and facilitating the action
towards the goals
♪ The intergroup relations, group organization and member participation is essential for
effectiveness of a group.
♪ Information relating to needs for change, plans for change and consequences of changes must be
shared by members of a group.
TYPE OF GROUPS
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  Formal groups: refers to those which are established under the legal or formal
authority with the view to achieve a particular end results. Eg: trade unions.
 Informal groups:refers to aggregate of personal contact and interaction and
network of relationship among individual. Eg: friendship group.
 Primary groups: are characterized by small size, face to face interaction and
intimacy among members of group. Eg: family, neighbourhood group.
 Secondary groups: characterized by large size, individual identification with the
values and beliefs prevailing in them rather than cultural interaction.
Eg: occupational association and ethnic group.
 Task groups:are composed of people who work together to perform a task but
involve cross-command relationship. Eg: for finding out who was responsible for
causing wrong medication order would require liaison between ward in charge,
senior sister and head nurse.
 Social groups: refers to integrated system of interrelated psychological group
formed to accomplish defined objectives. Eg: political party with its many local
political clubs. Friendship group.
 Reference groups: A reference group is a type of group that people use to evaluate
themselves. According to Cherrington, the main purposes of reference groups are
social validation and social comparison.
 Membership groups: those where the individual actually belongs.
 Command groups: Command groups are specified by the organizational chart and
often consist of a supervisor and the subordinates that report to that supervisor. An
example of a command group is an academic department chairman and the faculty
members in that department.
 Functional groups: the individuals work together daily on similar tasks.
 Problem solving groups:it focuses on specific issues in their areas of
responsibility, develops potential solution and often empowered to take action.

CRITERIA FOR A GROUP

♥ Formal social structure
♥ Face-to-face interaction
♥ 2 or more persons
♥ Common fate
♥ Common goals
♥ Interdependence
♥ Self-definition as group members
♥ Recognition by others

PHASE OF GROUPDEVELOPMENT:
The phase of group development includes
 Dependence
 Independence
 Interdependence
 Termination
Dependence:

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 It refers to a need for support. During the dependent phase members are becoming acquitted with
each other. They also tend to be very ego centered they function alone and for their own benefit
communication is being established but members still thinks of themselves first.
Independence:
During this phase members become concerned with the organization of the groups and roles are
established. If leaders are not present one will usually be appointed.
Interdependence:
It occurs when each member views the goals and purpose of the group as more important than
individual performance.
This phase last long and based on
 Size of the group
 Task to the members
 The environment
 Time allotted
 Previous group experience
Termination:
An effective group is able to dissolve or change itself when its purpose is achieved. Group
members may feel sad, angry, guilty, anxious or glad when the group ends. The leader can
facilitate a positive termination.
REASONS FOR GROUP FORMATION:
The people often join groups since the groups give the members stability and enhance their
achievement capacity.
The main reasons to join a group are:
1.Have a sense of security: The group enables the person to reduce a sense of insecurity and have
stronger feeling with few self-doubts and more resistant to threats when they are a part of the
group.
2. Have a status:The persons in a group can be easily recognized and a status is achieved by them.
3. Develop Self-esteem: The groups can help a person develop a sense of “to – belong”. This
provides with feelings of self- worth and develops confidence in its members.
4. Affiliation:The groups can fulfill social needs. People enjoy the regular interaction that comes
with the group membership.
5. Power:The power is derived on the strength of closeness of the group members with greater
power achieved when in group then if a person is alone or individually.
6. Goal achievement: The goal can be achieved more easily when a group effort is present as
“United we stand, divided we fall”. The pool of talents, knowledge or power of doing things and
management for job – accomplishment is present when individuals act in groups.
STAGES OF GROUP DEVELOPMENT:
According to Tuckman's theory, there are five stages of group development: forming, storming,
norming, performing, and adjourning. During these stages group members must address several
issues and the way in which these issues are resolved determines whether the group will succeed in
accomplishing its tasks.
1. Forming.
This stage is usually characterized by some confusion and uncertainty. The major goals of the
group have not been established. The nature of the task or leadership of the group has not been
determined (Luthans, 2005). Thus, forming is an orientation period when members get to know
one another and share expectations about the group. Members learn the purpose of the group as
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 well as the rules to be followed. The forming stage should not be rushed because trust and
openness must be developed. These feelings strengthen in later stages of development. Individuals
are often confused during this stage because roles are not clear and there may not be a strong
leader.
Individual task: the first individual task, then, is to learn about the group and to find out what will
be expected, that is, what roles and responsibilities they will be fulfilling in this particular group.
Along with this need to become acquainted with the group and its expectations comes the need to
deal with individual feelings about entering a new group. These feelings include uncertainty,
mistrust, and anxiety related to the unknowns of the group.
Group tasks: the group as a whole also has two tasks to accomplish in the forming stage. As was
mentioned earlier, the first task is to establish its identity as a group. This is done in several ways.
One way is by defining who is and who is not a member of the group. Another is to define and to
talk about what members of the group have in common with each other.
The second group task is to provide support for individual members who in this formative stage
are experiencing varying degrees of discomfort.
Leader actions: as the leader of the forming group, you will experience some of the same feelings
of uncertainty and insecurity that the rest of the group does. Recognizing that these feelings are
related to the formation of the group can help you deal with them constructively. One way to do
this is by helping the group accomplishes its developmental tasks and completes this stage
successfully.
2. Storming.
In this stage, the group is likely to see the highest level of disagreement and conflict. Members
often challenge group goals and struggle for power. Individuals often vie for the leadership
position during this stage of development. This can be a positive experience for all groups if
members can achieve cohesiveness through resolution. Members often voice concern and criticism
in this phase. If members are not able to resolve the conflict, then the group will often disband or
continue in existence but will remain ineffective and never advance to the other stages.
Individual task: as the group rearranges and reorganizes itself through this stage, the main task of
the individual member is to find a position in the group, the degree to which one can fulfill group
expectations, and whether or not that individual member will remain a part of the group.
Group tasks: The tasks of the group as a whole in this second stage are to resolve the conflicts
that emerge and to begin reorganizing itself into a more functional whole. These conflicts were
avoided in the first stage but now emerge and demand almost the total energy of the group to
resolve them.
Leader actions: confrontation is the appropriate kind of communication at this stage. There is
much that the leader can do to channel the energies released during this stage into constructive
activity. These actions include the use of confrontation and negotiation, linking, testing for
consensus, encouragement and reinforcement.
3. Norming
This stage is characterized by the recognition of individual differences and shared expectations.
Hopefully, at this stage the group members will begin to develop a feeling of group cohesion and
identity. Cooperative effort should begin to yield results. Responsibilities are divided among
members and the group decides how it will evaluate progress.
Individual task: the main task of the individual group member at this stage is to clarify one’s
position in the group and to develop one’s ability to be a fully functional group member. By this
stage an individual has made a decision to remain a member of the group and has begun the task of
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 defining a position for oneself in the group. In the norming stage, the members have an
opportunity to test and refine their positions and to begin functioning as an integral part of the
group as a whole.
Group task: a major task of the group in this stage is to decide on the specific goals or objectives
that will carry out in the next stage. If the purpose was not clearly defined during the second stage,
it will do it, that is select tasks and assign them to people.
Leader action: as the leader you can help to guide the group through the planning process by
doing such things as keeping the group from getting side tracked, testing the feasibility of
suggestions, encouraging the use of consensus in making decisions. At the same time, it is
important to avoid the temptation to give advice. The group should assume the responsibility of
doing the planning and will, therefore, feel that it owns the final plan and be more committed to it.

4. Performing.
Performing, occurs when the group has matured and attains a feeling of cohesiveness. During this
stage of development, individuals accept one another and conflict is resolved through group
discussion. Members of the group make decisions through a rational process that is focused on
relevant goals rather than emotional issues.
Individual task: during this stage, individual members carry out the roles and responsibilities that
were gradually defined over the course of the last three stages. The two different tasks of the
individual member can be described in terms of those two familiar aspects of leadership styles-
tasks and relationships.
Group tasks: The tasks of the group at this stage are to move toward its goals by engaging in
productive behavior and to maintain relationships within the group and with the environment. As
you can see, these tasks are closely related to those of the individual group member. This happens
because the needs and goals of the group as a whole are much more congruent with those of the
individual members now than they were in early stages.
Mature Immature
Definite boundary Indefinite, shifting boundary
Defined purpose Vague purpose
Common shared goals Conflicting or no goals
Strong identity as a whole Uncertain identity threatened by gain or loss of
members
Relaxed, informal Rigid and formal or chaotic
Open, confronting communications Closed, concealing communications
Accepting Rejecting, indifferent, or hostile
Tolerates differences Suppresses or it is disrupted by differences
Flexible, predictable norms Rigid or inconsistent norms
Cohesiveness Few connections between members
Deals with both tasks and relationships Ignores relationships concerns, focuses on tasks
Recognizes and responds to member’s Often fails to recognize or respond to its members
input and needs
Feedback is constructive Feedback is minimal or destructive or
both

Leader actions: the leader is still a valuable resource for the group. Groups in the performing
stage still need feedback on their progress. In addition, they often need refocusing on objectives
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when they are sidetracked, support when they face a particularly difficult task, and guidance for
such things as how to delegate responsibility, make assignments, and revise their plans when
necessary.
5. Adjourning.
Not all groups experience this stage of development because it is characterized by the disbandment
of the group. Some groups are relatively permanent (Luthans, 2005). Reasons that groups disband
vary, with common reasons being the accomplishment of the task or individuals deciding to go
their own ways. Members of the group often experience feelings of closure and sadness as they
prepare to leave.
Individual tasks: the task of the individual in this stage is to evaluate both the process and the
outcome of the group to complete the group experience. All members both give and receive
feedback on their roles, other member’s roles and on the group as a whole.
Group tasks: two task of the group are to support a thorough evaluation of the group process’s
and outcome to continue to foster an open climate in which the evaluation can take place. Without
this support, individual members will not be able to engage in objective, worthwhile evaluations.

Leader actions: as a member of the group, the leader should expect to both give and receive
feedback. An important function of the leader at this stage is to encourage this sharing of the
feedback. Since many groups are reluctant to do this the leader can initiate the process by asking
the others to evaluate the leader’s role.
CURATIVE FACTORS OF GROUP DYNAMICS:
Yalom (1985) identified 10 curative factors that individuals can achieve through interpersonal
interactions within the group:
1. The instillation of hope:
By observing the progress of others in the group with similar problems, group members garner
hope that their problem can also be resolved.
2. Universality:
Individuals realise that they are not alone in the problems, thoughts and feelings they are
experiencing. Anxiety is relieved by the support and understanding of others in the group who
share similar experiences.
3. The imparting of information:
Knowledge is gained through formal instruction and the sharing of advice and suggestions among
group members.
4. Altruism:
Altruism is assimilated by group members through mutual sharing and concern for each other.
Providing assistance and support to others creates a positive self- image and promotes self-growth.
5. The development of socializing technique:
Through interaction with and feedback from other members in the group, individuals are able to
correct maladaptive social behaviour and learn and develop social skills.
6. Imitative behaviour:
In this setting, one who has mastered a particular psychosocial skill or developmental task can be a
valuable role model for others. Individuals may imitate selected behaviours that they wish to
develop in themselves.
7. Interpersonal learning:
The group offers many and varied opportunities for interacting with other people. Insight is gained
regarding how one perceives and is being perceived by others.
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 8. Group cohesiveness:
Members develop a sense of belonging. Out of this alliance emerges a common feeling that both
individual members and the total group are of value to each other.
9. Catharsis:
Catharsis, or open expression of feelings, is beneficial for the members in the group. In the group,
members, to express both positive and negative feelings.
10. Existential factors:
The group is able to help individual members take directions of their own lives and to accept
responsibility for the existence of their relationship.

STAGES OF GROUP DYNAMICS:

The group dynamics has following stages.
1. Mutual acceptance
2. Communication and decision making
3. Motivation and productivity
4. Control and organization
STAGES
MUTUAL ACCEPTANCE – I
 Making acquaintances
 Sharing Information
 Discussing subjects
 Testing each other
 Being defensive
COMMUNICATION & DECISION MAKING – II
 Expressing attitudes
 Establishing norms
 Establishing goals
 Openly discussing tasks

MOTIVATION & PRODUCTIVITY- III

 Cooperating
 Working actively on tasks
 Being creative
CONTROL & ORGANISATION - IV
 Working independently
 Assigning tools based inability
 Being flexible

THE ROLE OF THE GROUP LEADER

 A person who is not in a position of authority, who is outranked and is new to the organization,
can still be a leader.
 Managing or Leading - refers to a person's ability to successfully lead a group of people.
 Organizations have realized that more leading characteristics are needed to be more
competitive in the work world.
 Success of an organization or the individual person (nurse) can be examined and fostered
through mentoring other nurses in reaching a professional or personal goal (i.e. furthering their
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 education or obtaining certifications in specialized procedures or areas of nursing), in attaining
a leadership role (i.e. charge nurse or supervisor) or being rewarded in performance
(recognition or raises).
 The nurse leader provides an atmosphere that allows open communication among group
members.
 What are the characteristics that may affect attitudes and behavior's of the group members?
o Group size, gender composition, race, ethnicity and age
 Cohesion - refers to the degree of attraction and motivation to stay in the group.
 Commitment - refers to a person's feelings and how they identify and are attached to the group's
goals or activities.

The following are effective technique in group process leadership:

o Use open-ended questions to start discussions.
o Encourage all members to ask questions.
o Respond with a positive comment or summary each time a member makes a
contribution.
o Give your full attention to each person's contribution.
o Refrain from negative comments about member's contributions.
o Don't take sides, instead summarize opinion differences. State that issues can be viewed
from different perspectives.
o Seek equal input from all members.
o ACTIVELY LISTEN to all members.
o Focus discussion on the purpose of the group.
o Check perceptions of the group.
o Convey the meaning of what a team member has said so that all members can
understand.
o Clarify statements. Sort out the confusing and conflicting.
o Restate and summarize major ideas and feelings. Summarize points of opinion
differences among team members.
o Encourage open expression of member's feelings and thoughts.
o Avoid frequent questioning. Too many questions at one time are annoying.
o Confirm members' ideas, emphasize the facts and encourage further discussion.

TECHNIQUES FOR MANAGING GROUP DYNAMICS:

There are several techniques which assist facilitator in managing the agenda and group dynamics.
The facilitator has to use different techniques for different situations. The various techniques used
are:
1. Pacing: pacing means keeping a flow. It is the responsibility of facilitator to choose
such techniques which encourage balance and co-operation.
2. Listing: listing is the way of adding the person’s name in the list of speaker, by silently
signaling the facilitator.
3. Equalizing participation: allowing the participants of the group to speak at a time in
order so as to have fair distribution of attention towards all.
4. Taking a break: it is good to give a five minute break after 20-30 minutes in the group
discussions or debates.

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BENEFITS OF GROUP INTERVENTION:
Benefits for client:
 Able to learn from others experience
 Able to observe others in social interaction; others are role models
 Able to try out new ways of interaction in a supportive environment
 Have a place to belong; a group identity
Benefits for the group leader:
 Able to serve several clients at once; cost and time effective
 Able to provide additional social and supportive interactions to clients
 Can draw on strength and ideas of group to arrive at creative solutions
ROLE OF NURSE MANAGER IN GROUP DYNAMICS:
Knowledge of group dynamics is needed by nurse managers to improve leadership competencies
and facilitates group discussions and communication. Groups are a common feature of a majority
of experiences of all nurses in such roles is outcome management, team co-ordination and teaching
of students, patients and families.
The nurse manager usually has following role in group dynamics:
1. Supervise and manage the overall performance of staff in department.
2. Analyzing, reporting, giving recommendations and developing strategies on how to improve
quality and quantity of nursing care.
3. Achieve business and organization goals, visions and objectives. Involved in employee
selection, career development, succession planning and periodic training.
4. Working out compensations and rewards.
5. Responsible for the growth and increase in the organizations' finances and earnings.
6. Identifying problems, creating choices and providing alternatives courses of actions.
GROUP EVALUATION:
Evaluation may be powerful internal force that affects group productivity. We should recognize
that evaluation is ever present in groups. In some more or less systematic fashion, consciously or
subconsciously, each of us is evaluating our role, status, contribution or feelings towards the
group. We evaluate other group members in same fashion. We evaluate how well our interests or
needs are being met by this group. We evaluate other groups about us. Evaluation is the force that
is always present in a group.
The main point to be made in relation to this force is that systematic, rational evaluation has great
potential in leading group members and the group to greaterproductivity. Members participate the
most in group activities when they understand the goals and objectives of the group and evaluate
the group as making satisfactory progress toward these goals. The more satisfied members are with
the progress of the group toward its goals, the more they participate. Those who evaluate the group
and its progress and are satisfied with that progress, identify better with the group.
Leaders who make greater use of the various procedures for evaluating their work and the work of
the group are more often rated as the most effective. It is even more important in terms of group
productivity and morale to know exactly how well the group or individual is doing even when the
evaluation is not high. It seems more important to know where you are in terms of progress than to
have a hazy idea of where you might be.
Following points should be kept in mind while evaluating groups:
1. Does the group take time to adequately evaluate progress toward action or content goals?
2. Does the group adequately evaluate group process?
3. Are many group members involved in the evaluation process?
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4. Is the group objective about its functioning?
5. Does the group make rational decisions regarding its functioning and does it implement changes
suggested?
6. Does the group evaluate accomplishments as well as disappointments?
7. Is evaluation periodic, or is it continuous?
8. Are the results of evaluation available to all members?
Every group has an actual or a potential dynamic state from which will arise the processes and the
productivity of the group. Many of the forces which go to establish this dynamism do provide a
further step in the development of information which may be applied to all groups - both to
encourage their progress and to further their ends.
CONCLUSION:
Group dynamics refers to the understanding of the behaviour of people in groups, such as task
groups, that are trying to solve a problem or make a decision. Group norms are followed and
collective pressure is exerted to ensure the effectiveness of the group.
POWER AND POLITICS IN NURSING
INTRODUCTION:
Nursing is a fast developing professional field. One of the characteristics of a profession is that
professionals have power over the practice of their discipline which is often referred to as
professional autonomy. In earlier period nurses are unaware of the term “power”. Autonomy
represents one kind of power that nurses need, and has been defined as "the freedom to act on what
one knows". ". Therefore power is a key element of empowerment is nurse‘s control over their
practice.
HISTORY OF POWER IN NURSING:
Power was considered as a taboo in nursing. Any one nurse who excised power was not
appreciated; it was looked upon as inappropriate, and out of nursing profession. Major decisions
about nursing education and practice were taken by persons out of nursing. Slowly and gradually
nurses began to exercise their collective power, as there was a rise of nursing leaders like Lillian
Wald, Isabel Stewart, AuvieGoodrish, Lavinia Dock, M. A Delaide Nutting and Isabel Hamptal
Robb. Also there was development of organizations and associations at national level for nurses.
Over the last century, many social, technological, scientific, and economic trends have shaped
nursing and nurses, and their ability to exercise power towards the development of the profession.
However, even these days we the nurses behave like oppressed group and get involved in intra and
intergroup conflicts and don‘t feel the need to join professional organizations/associations.
DEFINITIONS:
 Power - ability to influence behavior.
 Power can be defined as the capacity to produce or prevent changes. –
 Sullivan and Decker 1997.
 Power is the ―force of energy to accomplish a task, meet a goal, promote changes
or influence others.
 Power is the capacity to control behaviours surrounding life events, the freedom to
make choices and decisions, the capacity to create order and sustain influence.
 Power is a means of protecting ourselves against the cruelty, indifference or
ruthlessness of other people. - Korda 1975
 Henin (1998) state that to process power implies the ability to change the attitude
and behaviors of individual people and groups.

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 
Power can be defined as the capacity to act or the strength and potency to
accomplish something.
CHARACTERISTICS OF POWER:

person answers control other person gives it up.

TYPES OF POWER
In order to acquire power, maintain its, and use it effectively a manager must recognize power
sources and know what types of power are needed to effect change.

According to Etzioni (1961) power is classified into 2 types.

- Position power
- Personal power
1. Position Power: This power is derived from within an organization. A manager who can
influence a group to accomplish a goal because of his position in an organization is said to use
position power. Heresy and Blauchard asserted that position power flows down in an
organization. Superiors delegate authority and responsibility to followers, who repeat the
process again. In a sense one’s position power may be related to the amount of authority and
responsibility that is given to and/or taken from one’s superior. Simply having a position of
management therefore does not always mean that one has position power order to use or
operationalise power. Power can only communicated through behaviors.
According to Hoelzel (1989) significant positional sources of nursing power are
i. Chain of command
ii. Centrality
iii. Specialization and
iv. Formalisation
2. Personal power: Personal power is propositional to the strength of the manager’s self-
concept and self-esteem. Self – trust gives the manager confidence that she or he can
influence others.
According to Etzioni, personal power is derived from followers. If flows upward to a manager and
is the extent to which followers respect and are committed to their leader. Personal power is
informal power and position power is formal power.

Informal power is seen as a day-to-day phenomenon since it can be earned from followers and also
can be taken away. Informal leaders in groups are example of people who have been given or have
taken personal power.

French and Raven (1965) identified the types of power based on source. Power is derived from a
variety of sources. There sources are called power bases.

1. Legitimate power: It is based on manager’s position.Followers believe that the manager

has the right to influence them’ their compliance follows. The higher one’s position is, the
more legitimate power one possesses.

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It is often termed as authority that arises from a organizational structure and policies that place
control in specific positions within that organization. In general whoever holds the position has the
same amount of authority. This authority may include making decisions on behalf of the
organization, acquiring or controlling information, having access to people of higher status or
power, and control of the human and material resources of the organization. The person who holds
legitimate power is usually given a little to indicate the authority that has been delegated. For
example, the head nurse or the unit manager has legitimate power associated with the
responsibility for a patient care unit. The head nurse may develop and control the budget at the unit
level, hire staff and meet regularly with those at the next higher level of organization. As a charge
nurse on the evening shift you would have authority delegated to you by the head nurse, you must
have the authority to make all patient assignments and determine who will float to another unit for
the evening.

2. Referent power: It is based on the manager’s personality trait. It is a part of one’s personal
power. A manager who is admired, liked and identified within can induce compliance
from followers.
It is based on personal characteristics of a powerful person. The term charisma is also been used to
describe referent power. This is the type of power often seen in political figures. In hospital
settings, a very popular and outgoing nurse may influence decisions in ways that do not reflect any
official position in the organization.

Another aspect of referent power is appearing to be a powerful person. Behaviour that says “I am
confident, sure, of myself” tends to encourage others to give power to the individual.

The characteristics of a person with referent power are

i. Remaining calm in crisis.
ii. Controlling emotional responses.
iii. Acting with firm determination.

Manner of dress has also been associated with referent power. Business people speak of “power
dressing” or “power suit”.

Much of this is based on the research of Jhon Molloy who has examined the responses of people to
various forms of dress (Molloy, 1988). His conclusions were that most people associate certain
types of clothing with power.

The majority of powerful people in business environment dresses conservatively and avoid
extreme of fashion. Their clothing is of good quality and always well-cared for. They present
themselves as business-like and avoid a social appearance in the business environment.

3. Reward Power:It is grounded on the belief of followers that the manager can provide
rewards for their compliance, with the manager’s strategies, result in gains such as increased
pay, recognition and so forth.

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It helps people exert control through providing reward on the promise of record to others.
Although the person with legitimate power may control rewards many other people also control
reward in any given environment.

A client controls the rewards associated with positive feedback for the care that you provide, you
control rewards of praise and recognition given to co-workers.

4. Expert power:Competence, knowledge, expertise and skills comprise expert power.

Followers are influenced because their manager is seen as possessing the ability to facilitate
accomplishment of their work assignment.

Experts are able to accomplish their ends because others recognize their knowledge and ability,
and turn to them for guidance. When experts give an opinion it has more weight in any decision
than an opinion given by someone without expert knowledge.

Expert power can be protected by developing a professional structure that controls access to these
skills or knowledge. The claim to a unique body of knowledge makes it impossible for outsiders to
pass judgment on professional performance.

A clinical nursing specialist can have direct authority over the behaviour of individual nurses and
therefore can evaluate or promote these nurses. The clinical nurse specialist is able to alter the
manner in which care is delivered on a nursing unit by providing information and resources and
appropriate changes in case.

5. Coercive power:Coercive power is based on fear. Compliance is induced because failure

to comply will result in punishment or penalties. It allows people to attain control through
fear, threat or coercion. The power of some authoritarian leaders is coercive. They control
through fear of loss of job or of punishment, such as undesirable assignments or shifts. Your
just response may be that coercive power is inherently inappropriate. But some situation may
require coercion. The law exercises coercive power to maintain safety for citizens.

In a hospital setting, coercion is sometime used to solve the problems that involve potential danger
to clients. For example, if a nurse is discovered to be abusing drug, the threat of loss of license, job
and ability to support herself may force her into an approved treatment and monitoring
programme. Although there may be philosophical support for self-direction in obtaining help, the
safety of clients is so important that it must be the first consideration. Therefore, coercion may be
used when other avenues are unsuccessful.

6. Connection power:A manager with connection power has bonds with influential and
important people within or outside an organization. By complying with the manager,
followers believe that favour will be gained with the important people connected with their
leader.

Connection power is very important to masses. Nursing is the single largest healthcare occupation.
The force of all nurses working together could be phenomenal. Even with a patient care unit a

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group of nurses working together towards a single goal will produce results. In a climate in which
there is a shortage of nurses this connectional power of nurses can be very strong.

7. Information power:This is based on possession of or access to information. This can

influence people because of the belief that compliance will result in sharing of information. It
occurs when a person controls information that is needed or could be used by others.
Information that provides power may be knowledge of the institution’s budget or income.

All these sources are related to one another. Coercive power and reward powers are two ends of
the same continuum. A manager can reward those who comply and can punish those who fail.
Such authority may be granted by the nature of a position that is legitimate power. Referent power
and expert power are contained within a person and therefore can be labeled as personal power.
Connection power can be involved position or can refer to those connected to the manager
regardless of the position held. Connection power, therefore, can be both position power and
personal power. Information power also can be both personal and position power because a
manager can have access to information given the nature of one’s position or because of personal
reasons.

RESOURCES FOR DEVELOPING POWER

Various personal and material resources are necessary to develop power effectively. Personal
resources include both physical and psychological ones. You must have energy, without it you are
powerless. Material resources may come from within the organization, but where and how they are
used may vary greatly.
Physical Resources:
Physical resources for power are the strength you bring to each day’s tasks. Health that provides
energy and enthusiasm for activity is the base for the ability to act effectively. Nurses who
recommend healthful living patterns, including diet, exercise, rest and relaxation to client should
incorporate those patterns into their own lives. Although some are successful in spite of lack of
physical health, the better your general health state the easier it will be to become more powerful.
Psychological resources:
The need for psychological resources for power is also important. The ability of the psychological
system, to affect work done over time, may result in either more or less work, than a person is
capable of doing.
To achieve power we must develop a strong self-concept. Without a positive value of ourselves
and abilities other will not come to view you as competent and resourceful. To develop self-esteem
we must have clear awareness of our strengths and limitations. All of us have areas in which we do
better. Limitations may be more constructively viewed as areas in which growth is needed.
Another important point for developing the personal power is maintaining a positive forward
outlook in the current situation. This does not imply that you ignore problems and difficulties, but
that you choose to view them as challenges to be overcome. When mistakes are made, you can
look for situations and directions for growth rather than for someone to blame.
Material resources
It is needed for the exercise of power. It includes money or objects. Without material resources,
some actions just are not possible. Even when resources are available if you do not control their
use then you lack these resources for your own action. Much power in our society drives from the
control of material resources.
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Nurses who control supplies, secretarial services and coping facilities have a potential for power in
an organization. That is not possible for those who do not have their material resources.
An awareness of the need for material resources and where these are controlled is an essential base
for developing power.
POWER IN HEALTHCARE SYSTEM:
If we define power as the capacity of doing or accomplishing something then understanding how
power is distributed and used in the healthcare system will help us to function more effectively.
The power in the health care system is divided as follows:
1. Regulatory Power: The primary regulating agencies in healthcare are government bodies.
These agencies administer licensing laws that govern who is allowed to practice. There are also
agencies that approve or accredit institutions that educate personnel for healthcare and
licensing, or approve these that provide services.
2. Financial Power: It represents the financial interest of a large group of people and control
payment for services, third-party-prayers, and have the power to demand changes in the
healthcare system. They have set increasingly rigid criteria for payment for services. Insurance
companies reduce the choices available to those who carry insurance and subscribes usually
must select from the choices available if they wish to be reimbursed. Third – party payers
therefore exert a more powerful influence over institutions and care provides than do individual
subscribes.
3. Physician Power: Physicians historically have had almost unlimited power within the
healthcare system. They determined who entered the system and when they decided, if and
when other services and personal would be used and they determined when clients would leave
the system. As other agencies and professionals in the healthcare system have obtained some
power and independence the overall power of the physician has diminished. Despite changes,
physicians are still very powerful within healthcare system.
4. Consumer power: Consumers do have rights in the healthcare system. These are stated in
different ways by different ways by different institutions and groups, but all revolve around the
recognition of healthcare consumer as an adult with the ability and right to self-determine.
Consumers are in a particular valuable position in the healthcare system. Because they depend
on those within the system for life itself, they are often reluctant to complain or request
changes for fear of offending those on whom they depend. Consumers are most often effective
in exerting power in the system by working in exerting power in the system by working in
groups, and through established committees and agencies consumers are becoming vocal in
their demands for care they receive to be of benefit.
5. Nurse Power: Nurses historically have had limited power in the healthcare system. As
changes leading to healthcare reform are occurring, nurses sometimes feel that their power is
decreasing. Nursing education programmes try increasingly to educate nurses to act as client
advocates and agents of change. Nursing organizations are working to provide nurses with a
voice at higher decision-making levels in the healthcare. Collective bargaining and shared
governance have provided nurses with mechanisms for demanding recognition of the
importance of their role and for being participants in decision-making process.

STRATEGIES FOR DEVELOPING A POWERFUL IMAGE

As Margaret Thatcher, former prime minister of Great Britain, said, “Being powerful is like being
a lady. If you have to tell people you are, you aren’t”.

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The most basic power strategy is the development of a powerful image. Lady Thatcher’s statement
emphasizes the importance of this powerful image. If nurses think they are powerful others will
view them as powerful; if they view themselves as powerless, so will others. A sense of self-
confidences is a strong foundation in developing one’s “power image”, and it is essential for
successful political efforts in the workplace or within the profession. Such self-confidence is
simply the belief that one has the power to make things happen (Grainger, 1990).
Key factors those contribute to one’s power image are:

i. Self-image: Thinking of one’s self as powerful and effective.

ii. Grooming and dress :Well groomed hair and face, clothing and appearance that are neat,
clean and appropriate to the situations.
iii. Good manners : Treating people with courtesy and respect.
iv. Body language : Good posture, gestures that avoid too much drama, good eye contact,
confident movement.
v. Speech: A firm, confident voice, good grammar and diction, an appropriate vocabulary and
good communication skill.
vi. Career Commitment : Make a commitment to nursing as a career, nursing as a profession.
Profession effects career, not just a series of positions. Having career commitment does not
preclude leaving employment temporarily for family, education of other demands. Having
a career commitment implies that a nurse views himself or herself first and foremost as a
member of the discipline of nursing with an obligation to make a contribution to the
profession.
vii. Continuing professional education: Valuing education is one of the hallmarks of a
profession. The continuing development of one’s professional skills and knowledge is an
empowering experience, preparing the nurses to make decisions with support of an
expanding body of knowledge. Seminars, workshops and conferences offer opportunities
for higher degrees which is also a powerful growth experience and reflects commitment to
the profession of nursing.
viii. Attitudes and beliefs: Attitudes and beliefs are another important aspect of power-making
image. They reflect one’s values. Believing that power is a positive force in nursing is
essential to one’s powerful image. It is also important to believe firmly in nursing values to
society and the certainly of nursing contribution to the healthcare delivery system.

ADDITIONAL PERSONAL POWER STRATEGIES

i. Be honest.
ii. Always be courteous, it makes other people feel good.
iii. Smile whenever appropriate; it puts people at ease.
iv. Accept responsibility for your own mistakes and learn from them.
v. Be a risk-taker.
vi. Win and lose gracefully.
vii. Learn to be comfortable with conflict and ambiguity; they are both normal status of the
human condition.
viii. Give credit to others.
ix. Develop the ability to takes constructive criticism gracefully; learn to let destructive
criticism “roll off your back”.

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x. Use business cards when introducing yourself to new contacts and collect the business
cards of those you meet when networking.

APPLICATION OF POWER IN NURSING:

Although nurses do have the potential for power, display certain facts of power from time to time,
nurses as a group are yet to realize the full power that is in nursing. Nurses have strength and
energy, but action in nursing is less. Nurses need to mobilize that strength and energy into
meaningful action, thereby utilizing their power potential.

To manage patient care successfully and to be more effective, nurses must understand the concept
and importance of power. Then they must be willing to acquire power by developing a power base
that has the potential for maximum influences. The willingness to use the power increases a
nurse’s ability to acquire the resources needed to improve patient care. To acquire power, maintain
it effectively and use it skillfully, nurses must be aware of the sources and types of power that they
will use to influence and transform patient care.

Nurses overuse referent power and under-use expert and reward power. Most of the time nurses
ascribe power over themselves to others. They belittle themselves and diminish their professional
self-esteem and self-respect while enhancing that of others.

Nurse Managers have the responsibility to recognize and develop their own power to coordinate
and uphold the work of staff members. Nurse managers who understand power, its bases and its
responsibilities are in an advantageous position for getting things done through others.

Levinsinger (1977) asserted that there is probably no discipline so deeply involved in power,
politics and territoriality as nursing. Nurse should understand the need for powerful, dynamic
leaders in educational system, service system and policy making groups. There 3 systems are
really subsystems in nursing power structure. There subsystems however move from and to one
another. They are independent of one another; even through they have interdependent function.
Position power increases as one move from the bottom of any sub-group towards the top of the
same sub-group.

POWER IN NURSING:
There are at least three types of power that nurses need to be able to make their optimum
contribution. The various types of power can all be categorized as stemming from nurses' control
in three domains:

The continued lack of control over both the content and context of nursing work suggests that
power remains an elusive attribute for many nurses. Now power will be discussed as it is
manifested by nurses' control over the content, context, and competence of nursing practice.
Power and Nurses Roles
Nurse historically had limited power in the health care system. But nor nursing organization are
working to provide nurses with a voice at higher decision making level in health care
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1. Working together:
By understanding the political realities and the way in which decisions are by working together to
speak with a unified voice, nurses can increase their power in the system
2. Nursing education programs
Increasingly try to educate nurses to out as client advocate and agent of change. The higher
educations like M.Sc (N), M.Phil(N), and Ph.D in nursing and specialized courses will help the
nurses to gain power in health system.
3. Collective bargaining and shared governance
It helps the nurses with mechanism for demanding recognition of the importance of their role for
being participants in decision-making process.
a. Collective bargaining
It is a process that allows employees who are member of the union to participate in management
decisions with regard to terms of employment salaries, benefits, working conditions and similar
issues. Nurses believe that people who choose nursing as a carrier should have the opportunity to
have same voice in patient care assignment length of work day and week benefits any wages etc.
b. Shared governance
It is a professional proactive modern in which the nursing staff and the nursing management are
both involved in decision-making this allows the nursing staff to make major decisions with in the
organization and helps in quality improvement and gaining power
4. Power as a tool for leadership
Power is an increasingly important form of influence of nursing leader. Leaders are found
throughout the organization and have formal and informal leadership responsibility gain from
respect and regard for the knowledge and good judgment of the person
POLITICS
Politics is the science or art. It is the business of conducting the affairs of state or organization,
exploring public policy and implementing laws that affect the lives of public. Nurses are even still
uncomfortable about politics, treating ‗politics‘ as if it is a dirty word.
HISTORY OF POLITICS IN NURSING:
Nurse’sinvolvement in politics is limited. Florence Nightingale used her contacts with powerful
men in the government to obtain supplies and the personnel she needed to care for wounded
soldiers. Hannah Ropes was able to fight incompetence and obtain decent care for wound civil war
soldiers because she understood who the influential people in Washington. Lillian and Margaret
Sangar have influenced decision making in areas such as sanitation, nutrition, and birth control. In
1974, the ANA formed the nurse’s coalition in politics (N-CAP), which was the first political
action committee (PAC) for nurses.
DEFINITION
1.Politics is the art of influencing the allocation of scarce resources.
[ Mason&albott, 1985.]
2. Politics means influencing the allocation of scarce resources –
Talbott and Vance 1981.
2. Politics is a means to an end, a means for influencing events and the decisions of others
[Stevens, 1980]
PURPOSES:-
1. Protection of the interests of the whole group or a particular part of a group against subordinates
groups.
2. The preservation of order in the interest of the group of power or of the whole population.
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3. It is important for Analysis and planning.
IMPORTANT TERMS IN POLICY AND POLITICS:
To understand the relationship between policy, politics and laws, one must first understand the
following terms :
- Policy : It is a settled course of action to be followed by government or institution to obtain a
desired end.
- Health policy : It is a set course of action to obtain a desired health action for an individual,
family, group, community, or society.
- Law : It is a system of privileges and processes by which people solve problems based on a set
of established rules; it is intended to minimize the use of force. Laws govern the relationships
of individuals and organizations to other individuals and organizations to other individuals and
government.
- Regulations: After a law is established, regulations further define the course of action to be
taken by organizations or individuals in reaching an outcome.
- Government: Government is the ultimate authority in society and is designed to enforce the
policy whether it is related to health, education, economics, social welfare or any other societal
issue.

A FRAMEWORK FOR POLITICAL ACTION:-

Although most people associate the word politics with government, it pertains to every aspect of
life that involves competition for allocating scarce resources or influencing decision making. As
such, it is relevant to what Nurse do in their daily practice, whether as a Nurse in a home health
agency, a Nurse practitioner in a clinic, or a Nurse Manager in a hospital.
What nurse do in their everyday practice is influenced by, and in Turn influences. What
governments do, what professional organization do. These are over all political power.
1. Politics in work place
Politics in the work place is often regarded with disdain, as reflected in the Remark, ―She plays
politics‖. This statement is used to imply that the individual got what he or she wanted because of
personal connections rather than on MaritEhrat(1983) pointed out that politics is inherent in heath
care delivery because heath care involves multiple special interest groups all competing for their
piece of a limited pool of resources.
2. Politics in Government
Politics in government can influence who gets what kind of heath care, where, and why. Inspite of
many efforts to limit heath care costs, they continue to rise much faster than inflation in general.
In an attempt to control cost and Medicaid programs are anticipated. Towers in 1995 suggested
Nurse Take Responsibility for educating and communicating with new legislators. Nurses must use
their authoritative voices and political muscle to shift resources to expend community Based
services that promote greater access to and availability of health care.
3. Politics in financing:-
Which individual qualifying to be cared for by a Nurse in an organization is, to a certain extent,
determined by the politics of heath care financing in the United States.
Finance also influences where patients receive their care. In metropolitan Regions, one can find at
least two tiers of heath care. One for the poor (Public Hospital) and one for the middle and upper
classes (Private Institution and Private Physician). Although public heath care institution and
agencies can often provide excellent care, they frequently are underfinanced and have limited
resources (Staff, Equipment, Medication).
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4. Politics in organization:-
Once a patient gets into a hospital bed, the kind and quality of nursing care he or she receives also
can be influenced by politics.
Politics decides policies of government; they also determine the shape and focus of nursing
organizations. These organizations are an important forum for nurses to learn, develop, and apply
their political skills.
5 Politics in the community:-
The workplace, government and organization all interact with the community, whether local,
regional, national or international. One nurse found that her leadership in a community effort to
eliminate improper garbage dumping in her town enabled her to develop important connection to
government officials on both the state and local levels.
Applying power and politics to managing nursing care:-
The delivery of nursing services occurs at many levels in health care organization. The
effectiveness of care depends or linked to the application of power and politics and marketing.
For the staff nurse, the politics of beside care involve influencing the allocation of scarce resources
(e.g.- equipment, supplies, time) for the delivery of nursing care.
To maintain access to the resources needed for patient care. Nurses must connect to the whole
organization and beyond not just their own nursing unit.
Staff nurse can use their power when the limitation Interfere with and place restrictions on patient
care whether the restriction come in the from of limited supply, money or time, nurse can use their
power and the political skills of artful collaboration and networking to obtain the necessary
resources to provide care.
Politics of nursing care calls for an action plan, not just a care plan. It is time to force those who
seek to establish policy without nursing‘s input to listen to what nurse have to say.
POLITICAL ACTION:
Political action means getting involved in the process of changes, such involvement is most
effective when nurses use what Vance(1985) calls the 3 C‘s of political action.

- building and
collaboration.

Nurses can use communication, collectivity and collegiality to take political action. To do so they
must

SKILLS that make up a nurse politician:

bility to analyze an issue / assessment skills

recommendation.

POLITICAL FOCUS:

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 community – nurses can become politically active in the community.eg: school lunch
committee, health facilities and prisons, infant and aged care, highway safety, air quality, self help
groups, food distribution centers.
s – for the advancement of profession, influencing health care,
advisory capacity to governmental agencies, support public and private initiative.

In the workplace – political action at the work place of nurses is limited because of enormous
workload.
How nursing voice can become powerful:-
The first step in improving nursing‘s power is to seek out opportunity for change. When you are
ready to influence policy, start in your own workplace, where individuals and families known and
understand the difference nurses make in the health and healing process.
Identify where decisions are made and asked to be invited (e.g.- Nursing council, policy and
procedure committee). Focus your power on political and policy issues that evolve from personal
and professional value and visions.
The professional organization provides an opportunity for developing political skills that its
member can use both in the association and in other area.
Seeking a leadership position with the committee provides additional influence and visibility. Such
visibility often is needed if you are interested in serving on the major policy making body of the
organization. Such as the board of directors. There is no perfect strategy to using power and
politics to manage nursing care. It requires skill, Tact, and relationship building.

THE IMPACT OF POWER AND POLITICS ON NURSING’S FUTURE:-

Health care is in a state of constant change. Acute care hospitals are downsizing and reorganizing
while, at the same time, community sites to deliver nursing care are expanding.
Nurses know the problems and have many of the solutions. Making a case for nursing input into
health care policy is no longer an option for nurse.
Nurses can have a tremendous impact on health care policy. The best impact is often made with a
bit of luck and timing, but never without knowledge of the whole system. This includes knowledge
of the policy agenda, the policy makers, and the politics that are involved once you gain this
knowledge; you are ready to move forward with a political base to promote Nursing.
To convert your policy ideas into political realties, consider the following power point:
1) Use Persuasion over coercion:-
Persuasion is the ability to share reasons and rational when making a strong care for your position.
2) Use patience over impatience:-
Despite the inconveniences and failing caused by health care restructuring, impatience in the
nursing community can be detrimental. Patience, along with a long term perspective on health care
re-form, is needed.
3) Be open minded rather than closed minded:-
Acquiring accurate information is essential if you want to influence others effectively.
4) Use compassion over confrontation:-
In times of change, error and mistakes are easy to pin point.
5) Use integrity over Dishonesty:-
Honest discourse must be matched with kind thoughts and actions.
To manage nursing care in the future, nurses must come to realize that nursing expertise and
clinical judgment are the best combination to effectively influence nursing practice and policy
876
changes. By applying power and politics to the work place, nurse increase their professional
influence.

POLITICAL ACTION IN NURSING:

The delivery of nursing services occurs at many levels in healthcare organization. The
effectiveness of that care delivery is linked to the application of power, politics and policy making.
For the staff nurse the politics of beside care involves the art of influencing the allocation of scarce
resources, equipment, supplies, time and personnel for the delivery of nursing care. To maintain
access to the resources needed for patient care nurses must connect to the whole
organization, not just their own unit. Nurses need to understand that they belong to a
complex organization that is continually confronted with limited resources and is in
competition for these resources.
The politics and power in the workplace depends upon and is influenced by what is happening in
the large community professional organization and government. The effective nurse manager
understands the connections in this sphere and uses them to the advantage of nursing political and
healthcare organization.
The professional organization provides opportunities for developing political skills, policy making
that can be used both in the association and in the other spheres.
By understanding role of nurses in making use of their power, influence of politics and policy
making, they are able to uplift the profession thereby helping in the professional growth.

SUMMARY:-
So far, we have discussed in this seminar about the introduction of power and politics, Definitions,
Types, sources, use in organization, Power as a tool for leadership, frame work of political action,
Applying power to manage Nursing care, impact of power and politics on nursing future.

LOBBYING
Nurses can take an active role in the legislative and political process to affect change. They may
become involved in influencing one specific piece of legislation or regulation, or they can become
involved more universally and systematically to influence health care legislation on the whole.
DEFINITION-
LOBBYING:

advocacy directed at policymakers on behalf of another person, organization or group.

ng a governing body by
promoting a point of view that is conducive to an individual's or organization's goals.

LOBBYIST:
1) A lobbyist is an individual who attempts to influence legislation on behalf of others, such as
professional organizations or industries.
2) Lobbyists are advocates. That means they represent a particular side of an issue.
3) A person who receives compensation or reimbursement from another person, group, or entity to
lobby.

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TYPES OF LOBBYING:

DIRECT LOBBYING
Is communicating your views to a legislator or a staff member or any other government employee
who may help develop the legislation
To be lobbying, one must communicate a view on a "specific legislative proposal." Even if there is
no bill, one would be engaged in lobbying if one asked a legislator to take an action that would
require legislation, such as funding an agency. Asked one‘s members to lobby for this bill is also
considered as direct lobbying.

GRASSROOTS LOBBYING
Is simply citizen participation in government.
The key to successful grassroots lobbying efforts is assembling people who share common goals
and concerns. Grassroots communications are vital in educating legislators to the concerns of the
voting population in their state. If you do not share your views with your representative, then your
views will not be considered by your state representative when he votes on an issue which affects
you. You can make a difference by simply writing, calling, meeting, or faxing your representative.
TYPES OF LOBBYISTS
The Lobbyists Registration Act identifies three types of lobbyists:
The consultant lobbyist:
The consultant lobbyist is a person who is gainfully employed or not and whose occupation is to
lobby on behalf of a client in exchange for money, benefits or other forms of compensation.
Consultant lobbyists may work for public relations firms or be self-employed. For example, he or
she might be a public relations expert, a lawyer, an engineer, an architect.
The enterprise lobbyist:
This is a person who holds a job or has duties in a profit-making organization, whose duties
include, for a significant part, lobbying on behalf of the firm. The organization lobbyist:
This is a person who holds a job or has duties in a non-profit organization. Like the enterprise
lobbyist, this lobbyist is affected by the Act if a significant part of his or her duties is to lobby on
behalf of this organization.
PREPARING FOR LOBBYING CAMPAIGN:
An effective lobbying initiative takes background work.
1. Develop plan of action. Consider, rework, revamp, and define the plan in advance of the trip to
the legislator‘s office.
2. Be sure one is fully aware of all similar initiatives on the same topic and the position of those
opposing one‘s idea.
3. Check with other nursing organizations to determine their positions and if they have information
to help support one‘s position.
4. Fine-tune one‘s presentation to several key points because time will be limited.
5. Follow up after the meeting with a call or correspondence outlining the points.

PREPARING FOR AN EFFECTIVE LETTER-WRITING CAMPAIGN:

-roots campaign.

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that impact the organization. Use this information to plan educational sessions with the goal of
improving the political sophistication of the group.

directly affect their practice. Clearly state what action the legislative body needs to take to meet the
goal, and include the specific bill number and name.
-mail networks that can contact key members quickly. Often
legislative issues are scheduled and moved up quickly on that schedule, requiring an immediate
change of plan.

sed
and send to the legislators.

begin or just prior to the vote o the floor. Too early is ineffective; too late is wasted effort. You
must follow the progress of your issue closely so as to mobilize your members at the right time.

USEFUL TIPS-
Dos:
a. Do write legibly or type. Handwritten are perfectly acceptable so long as they can be read.
b. Do use persona stationary. Indicate that you are a registered nurse. Sign your full name and
address. If you are writing for an organization, use that organization‘s stationary and include
information about the number of members in the organization, the services you perform, and the
employment setting you are found in.
c. Do state if you are a constituent. If you campaigned for or voted for the official, say so.
d. Do identify the issue by number and name if possible or refer to it by the common name.
e. Do state your position clearly and state what you would like your legislator to do.
f. Do draft the letter in your own words and convey your own thoughts.
g. Do refer to your own experience of how a bill will directly affect you, your family, your
patients, and members of your organization or your profession. Thoughtful, sincere letters on
issues that directly affect the writer receive the most attention and are those that are often quoted in
hearings or debates.
h. Do contact the legislator in time for your legislator to act on an issue. After the vote is too late.
If your representative is a member of the committee that is hearing the issue, contact him/her
before the committee hearings begin. If he/she is not on the committee, write just before the bill is
due to come to the floor for debate and vote.

i. Do write the governor promptly for a state issue, after the bill passes both houses, if you want to
influence his/her decision to sign the bill into law or veto it.
j. Do use e-mails to state your points.
k. Do be appreciative, especially of past favourable votes. Many letters legislators receive
feedback from constituents who are unhappy or displeased about actions taken on an issue. Letters
of thanks are greatly appreciated.
l. Do make your point quickly and discuss only one issue per letter. Most letters should be one
page long.

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m. Do remember that you are the expert in your professional area. Most legislators know little
about the practice of nursing and respect your knowledge. Offer your expertise to your elected
representative as an advisor or resource person to his or her staff when issues arise.
n. Do ask for what you want your legislator to do on an issue. Ask him/her to state his/her position
in the reply to you.
Don’ts:
a. Do not begin a letter with ―as a citizen and a taxpayer.‖ Legislators assume that you are a
citizen, and all of us pay taxes.
b. Do not threaten or use hostility. Most legislators ignore ―hate‖ mail.
c. Do not send carbon copies of your letter to other legislators. Write each legislator individually.
Do not send letters to other legislators from other states-they will refer your letter to your
congressional representative.
d. Do not write House members while a bill is in the Senate and vice versa. A bill may be amended
many times before it gets from one house to the other.
e. Do not write postcards; they are tossed.
f. Do not use form letters. In large numbers these letters get attention only in the form that they are
tallied. These letters tend to elicit a ―form letter response‖ from the legislator.
g. Do not apologize for writing and taking their time. If your letter is short and presents your
opinion on an issue, they are glad to have it.
KEEP ABREAST OF LEGISLATION AND REGULATION:
When issues are important to your professional, contact the legislator and provide the important
facts that support your position and be sure to follow up routinely so your opinions stay fresh in
his/her mind.
Legislation: To keep in contact with the legislature, it is important to identify key committees and
subcommittees in the legislative bodies, and to identify and develop communication with the
members of those committees. Ways to keep abreast of new information include the following:
Volunteer for campaign work and develop contacts with legislators.
Obtain pertinent government documents using online resources.
Get the general telephone number for the state government and the mailing addresses for
correspondence.
Develop liaisons with other health professionals and utilize them as information sources and allies
in lobbying for health care issues.
Register a member of your group as a lobbyist- the fee is generally small.
If possible, hire a lobbyist
Once you have notified your legislator about your interest in a particular issue, the legislator‘s
office may routinely send literature outlining his or her activities throughout the sometimes
arduous process.

Regulation: Because lobbying activities can significantly affect individuals and industry,
regulation is essential to avoid abuse. Lobbyists have created ethics codes, guidelines for
professional conduct and standards. The following will help you keep abreast o the newest
regulations and standards:
Subscribe to the state register (which contains all state regulations under consideration).
Identify and develop contacts with state agencies that exert control on or impact your practice and
ask to be added to their mailing lists. A limited list includes the following:
i. Nurse practice act: rules and regulations
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ii. Medical practice act: rules and regulations
iii. Pharmacy act: rules and regulations
iv. Dental practice act: rules and regulations
v. Hospital licensing act: rules and regulations
vi. Ambulatory surgical center licensing act: rules and regulations
vii. Insurance statute: rules and regulations
viii. Trauma center statute: rules and regulations
ix. Department of Health
xi. Podiatric Act: rules and regulations
CONCLUSION:
Power and politics are often discussed together in the nursing literature. Those in power find it
easy to participate in politics, and those who participate in politics gain power. Both power and
politics serve to achieve goals, and both do so through the ability to use skills to convince others to
serve the power holder‘s purposes. Power and politics are the means to achieve health-care goals
in a compassionate and humane way. Application of power and politics through collaboration,
creativity, and empowerment are effective ways to influence policy.
CRITICAL THINKING AND DECISION MAKING
Introduction:
There is nothing more practical than sound thinking. Critical thinking is essential to safe,
competent, skillful nursing practice. The amount of knowledge that nurses must use and the
continuing rapid growth of this knowledge prevent nurses from being effective practitioners if they
attempt to function with only the information acquired in school or outlined in books. Decisions
that nurses must make about client care and about the distribution of limited resources force them
to think and act in areas where there are neither clear answers nor standard procedures and where
conflicting forces turn decision making into a complex process. Nurses therefore need to embrace
the attitudes that promote critical thinking and master critical- thinking skills in order to process
and evaluate both previously learned and new information.
CRITICAL THINKING
“You assist an evil system most effectively by obeying its orders and decrees. An evil system
never deserves such allegiance. Allegiance to it means partaking of the evil. A good person will
resist an evil system with his or her whole soul. ― ~ Mahatma Gandhi
Meaning: "Critical" as used in the expression "critical thinking" connotes the importance or
centrality of the thinking to an issue, question or problem of concern. "Critical" in this context
does not mean "disapproval" or "negative." There are many positive and useful uses of critical
thinking, for example formulating a workable solution to a complex personal problem, "Critical"
as used in the expression "critical thinking" connotes the importance or centrality of the thinking to
an issue, question or problem of concern. "Critical" in this context does not mean "disapproval" or
"negative." There are many positive and useful uses of critical thinking, for example formulating a
workable solution to a complex personal problem,
Definition: Critical thinking is the intellectually disciplined process of actively and skillfully
conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from,
or generated by, observation, experience, reflection, reasoning, or communication, as a guide to
belief and action.
National Council for Excellence in Critical Thinking,1987

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"Critical thinking in nursing practice is a discipline specific, reflective reasoning process that
guides a nurse in generating, implementing, and evaluating approaches for dealing with client care
and professional concerns. - National League for Nursing (2000)
Critical thinking is the skilful application of a repertoire of validated general techniques for
deciding the level of confidence you should have in a proposition in the light of the available
evidence. - Tim van Gelder
Levels of Critical Thinking According To Bloom
Bloom identified six thinking levels:
1. Knowledge (knowing things)
2. Comprehension (understanding things)
3. Application (being apply to apply knowledge in the real world)
4. Analysis (ability to pull things apart intellectually)
5. Synthesis (ability to see through the clutter to the core issues)
6. Evaluation (the ability to make good judgments)

Levels 4, 5 and 6 are the most important one for mid and higher levels of management.
Stages of Critical Thinking
Stage One: We Begin as Unreflective Thinkers. We all begin as largely unreflective thinkers,
fundamentally unaware of the determining role that thinking is playing in our lives. We don‘t
realize, at this stage, the many ways that problems in thinking are causing problems in our lives.
We unconsciously think of ourselves as the source of truth. We assume our own beliefs to be true.
We unreflectively take in many absurd beliefs merely because they are believed by those around
us. We have no intellectual standards worthy of the name. Wish fulfillment plays a significant role
in what we believe. Whatever we want, we believe we should have
Stage Two:We Reach the Second Stage When We Are Faced with The Challenge Of
Recognizing the Low Level at Which We and Most Humans Function as Thinkers. For example,
we are capable of making false assumptions, using erroneous information, or jumping to
unjustifiable conclusions. This knowledge of our fallibility as thinkers is connected to the
emerging awareness that somehow we must learn to routinely identify, analyze, and assess our
thinking.
Stage Three:We Reach the Third Stage When We Accept the Challenge and Begin to Explicitly
Develop Our Thinking
Having actively decided to take up the challenge to grow and develop as thinkers, we become
"beginning" thinkers, i.e., thinkers beginning to take thinking seriously.
Stage Four:We Reach the Fourth Stage When We Begin to Develop A Systematic Approach to
Improving Our Ability to Think. At this stage, we now know that simply wanting to change is not
enough, nor is episodic and irregular "practice." We recognize now the need for real commitment,
for some regular and consistent way to build improvement of thinking into the fabric of our lives.
Stage Five:We Reach the Fifth Stage When We Have Established Good Habits of Thought
Across the Domains of Our Lives. We know that we are reaching the stage we call the Advanced
Thinker stage when we find that our regimen for rational living is paying off in significant ways.
We are now routinely identifying problems in our thinking, and are working successfully to deal
with those problems rationally. We have successfully identified the significant domains in our
lives in which we need to improve (e.g. professional, parenting, husband, wife, consumer, etc.),
and are making significant progress in all or most of them.

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 Stage Six: We Reach the Sixth Stage When We Intuitively Think Critically at a Habitually High
Level Across all the Significant Domains of Our Lives. The sixth stage of development, the Master
Thinker Stage, is best described in the third person, since it is not clear that any humans living in this
age of irrationality qualify as "master" thinkers. It may be that the degree of deep social conditioning
that all of us experience renders it unlikely that any of us living today are "master" thinkers.
Nevertheless, the concept is a useful one, for it sets out what we are striving for and is, in principle, a
stage that some humans might reach.

Components of the Critical Thinking:

The eight components that have been identified as part of the critical thinking process include:
1. Perception
2. Assumption
3. Emotion
4. Language
5. Argument
6. Fallacy
7. Logic
8. Problem Solving
1. Perception: Perception refers to the way we receive and translate our experiences – how and what
we think about them. For some, plain yogurt is delicious, while for others it is disgusting. For the most
part, perception is a learned process. Eg: In the workplace, one employee will perceive a co-worker to
be a constructive decision-maker, while at the same time, another sees the same employee as an
adversarial roadblocto progress.
2. Assumptions: Trying to identify the assumptions that underlie the ideas, beliefs, values, and actions
that others and we take for granted is central to critical thinking. Assumptions are those taken-for-
granted values, common-sense ideas, and stereotypical notions about human nature and social
organization that underlie our thoughts and actions. Assumptions are not always bad. For example,
when you buy a new car, you assume that it will run without problems for a while. When you go to
sleep at night, you assume that your alarm will wake you up in the morning. Remember, assumptions
depend on the notion that some ideas are so obvious and so taken for granted that they don‘t need to be
explained. Yet, in many cases, insisting on an explanation reveals that we may need more factual
evidence in order to develop well-supported viewpoints and to come to sound decisions. The problem
with assumptions is that they make us feel comfortable without present beliefs and keep us from
thinking about alternatives.
3. Emotion: Emotions/feelings are an important aspect of the human experience. They are a critical
part of what separates humans from machines and the lower animals. They are part of everything we
do and everything we think. Emotions can affect and inspire thought, stated William James, but they
can also destroy it. We all have personal barriers

PROCESS OF CRITICAL THINKING

generally begin their critical thinking at step one and, with practice, progress to step 2 and up the
ladder.
Step 1 Identify the problem, the relevant information, and all uncertainties
about the problem. This includes awareness that there is more than
one correct solution. (low cognitive complexity)
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Step 2: Explore interpretations and connections. This includes recognize
one's own bias, articulating the reasoning associated with alternative
points of view, and organizing information in meaningful ways.
(moderate cognitive complexity)
Step 3: Prioritize alternatives and communicate conclusions. This includes
thorough analysis, developing the guidelines used for prioritizing
factors, and defending the solution option chosen. (high cognitive
complexity)
Step 4: Integrate, monitor, and refine strategies for re-addressing the
problem. This includes acknowledging limitations of chosen
solution and developing an ongoing process for generating and
using new information. (highest cognitive complexity)

SIX COGNITIVE SKILLS USED IN CRITICAL THINKING

Interpretation : Involves clarifying meaning
Analysis : Understanding data
Evaluation : Determining outcome
Inference : Drawing conclusions
Explanation : Justifying actions based on data
Self regulation : Examining ones professional practice

Characteristics of a Critical Thinker

Open to new ideas Flexible Creative
Intuitive Empathic Insightful
Energetic Caring Willing to take action
Analytical Observant Outcome directed
Persistent Risk taker Willing to change
Assertive Resourceful Knowledgeable
Communicator “Out of the Box”
thinker

The Marquis-Huston Critical-Thinking Teaching Model

The desired outcome for teaching and learning decision making and critical thinking in
management is an interaction between learners and others that results in the ability to critically
examine management and leadership issues. This is a learning of appropriate social and
professional behaviors rather than a mere acquisition of knowledge. This type of learning occurs
best in groups; therefore, when teaching management and leadership the group process should be
used in some way.

Additionally, learners retain didactic material more readily when it is personalized or when they
can relate to the material being presented. The use of case studies that learners can identify with
assists in retention of didactic material presented.

884
While formal instruction in critical thinking is important, Clancy (2003) maintains that using a
formal decision-making process is mandatory for successful decision making. So often new leaders
and managers struggle to make quality decisions because their opportunity to practice making
management and leadership decisions is very limited until they are appointed to a management
position. These limitations can be overcome by creating opportunities for vicariously experiencing
the problems that individuals would encounter in the real world of leadership and management.

The Marquis Huston Critical Thinking Teaching Model

The Marquis-Huston Critical-Thinking Teaching Model assists in achieving desired learner

outcomes. Basically, the model depicts four overlapping spheres, each being an essential
component for teaching leadership and management. There needs to be a didactic theory
component, such as the material that is presented in each chapter; secondly, a formalized approach
to problem solving and decision making must be used. Thirdly, there must be some use of the
group process, which can be accomplished by the use of large and small groups and classroom
discussion. Lastly the material must be made real for the learner so that the learning is internalized.
This can be accomplished through writing exercises, personal exploration, values clarification, and
risk-taking that is involved as case studies are examined.

This book was developed with the perspective that experiential learning provides mock
experiences that have tremendous value in applying leadership and management theory.
Throughout this text the authors have included numerous opportunities for readers to experience
the real world of leadership and management. Some of these learning situations, which are called
learning exercises, include case studies, writing exercises, specific management or leadership
problems, staffing and budgeting calculations, group discussion or problem solving, and
assessment of personal attitudes and values. Some exercises include opinions, speculation, and
value judgments. Since almost all the learning exercises require critical thinking, problem solving,
or decision making to some degree, the remainder of this chapter will focus on providing a
theoretical foundation for leadership and management problem solving.
problem solving and critical thinking
Critical thinking requires a format. Problem solving can provide that format. In nursing, problem
solving occurs in the contexts of client care, team leadership, client advocacy and case
management.

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creative problem solving
Creative problem solving involves identifying assumption using multiple techniques to approach
a problem (including visualization, modeling and using metaphors), and asking for criticism and
suggestions (Harris, 2002)
Identifying Assumptions
A frequently overlooked step in problem solving is identifying assumptions that you make. An
unidentified assumption can prevent you from developing a solution. Assumptions may be hidden
or unidentified and still affect the problem solving process. Some areas where assumptions may lie
hidden include:
Time: What assumptions are being made about how long the solution will take?
Money: What assumptions are being made about the availability of money?
Co-operation: What assumptions are being made about who will support the solution?
Energy: What assumptions are being made about the amount of energy necessary to find a
solution? Is it better to expend more energy now than later?
Information: What assumptions are being made about the available information, and has it been
triple - checked for accuracy?
Cultural binds: How are attitudes about the culture interfering with thinking and limiting
solutions? (Hams, 2002)
Techniques for approaching a problem
There are a number of techniques to approaching a problem, including examining the problem
carefully, formulating the problem statement carefully, enhances understanding by converting an
idea into something that stimulates the senses.
Reveal relationships between ideas: Models can have profound effects on perception and
conceptualization. They can help viewers think about the relationships between parts and the
associated possibilities. Multiple models allow viewers to think about the same concept in different
ways without the controlling influences that a single model might present.
Simplify the complex: All models make complex concepts manageable or understandable. When
using models, it is important not to eliminate important aspects of a prime concept.
Several types of models exist. Conceptual models concretize an idea and aid memory.
Structural models concretize physical structures, such as nursing centers or nursing units.
A model is created before all large construction projects. Models can be visual (a door, a machine,
a bathroom); physical (a blueprint for a nursing unit); or mathematical (a decision matrix can help
a nurse leader decide whom among many applicants to hire).
There are many paradigms to use when creating models:
System model: a system model is a collection of interacting elements that work together to
accomplish a specific goal.
Example: Improving relationships on a clinical unit
Input: Words, Actions
Processing: reactions
Output: Mutual support/ dissatisfaction
Feedback: Communication through words and actions
Control: Processing is changed to positive reactions, actions and output
Design model: a design model is used to plan an overall pattern
Construction Model: A Construction model emphases the parts in a sequential manner. It can be
used for a yearend report, for ordering information or for building a clinical unit.

886
Recipe model: The recipe model emphasizes proportions and ingredients. Spice or flavor can be
added to a recipe. Toolkits can be used, along with formulas for success. (Harris, 2002)

DECISION MAKING
DEFINITION
Decision making can also be defined as a behavior exhibited in making a selections and
implementing a course of action from among alternative courses of action for dealing with a
sineation or problem.
 In this problem solving process is initiated as the result of an immediate problem
 Decision making however may occur sometime later.

There are 5 core elements needed to take decision making as follows

1) Identification of problem, issues or situation
2) Establishments of the criteria to be used to evaluate potential solutions
3) Search for alternative solutions or actions
4) Evaluation of the alternatives
5) Selection of a specific alternatives

These elements can be summarized as the 3 phase of deliberation, judgement& choice Nurses
managers are there 3 phases in managing the resources & the environments of acre delivery. The
management of decision making involves an evaluation of the effectives of the outcomes that
result from the decision making process.

Wren (1974) recommended the following 10 steps in decision making

1) Become aware of the solution
2) Investigate the native of the solution
3) Determine the objective of the solution
4) Determine alternative solutions
5) Weight the consequences & reliable efficiency of each alternative solution
6) Evaluate or various alternatives
7) Select the best alternatives solution
8) Implement the decision communicate in & trans there who will carry out the solution
9) Evaluate the solution at intervals to determine if it was the best solution & if it is still solving
the problem
10) Correct change or with draw the solution if evaluation indicates if its is no longer appropriate
organization.

Decision making situation

Personal Clinical Organisation

Decision

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The situation in which decisions are made may be personal clinical or organization.
Personal decision making
- It is a familiar part of everyday life
- Personal decision range from multiple of small daily choices to time management & career or
life choices
Clinical decision making
Clinical decision making in Nursing relates to quality of care & competency issues. Also called
clinical problem solibiy clinical reasoning, clinical judgement or the nursing process it is defined
as the series of decisions made by the nurse in interaction with the client.
In nursing clinical decision making is made difficult
Organizational decision making
Organizational decision making is choosing options directs toward the resolution of organizational
problems & the achievement of organizational goals.
Janis and Mann (1977) described & types of administration decision making strategies
It includes
- Satisfying
- Instrumentalism
- Mixed scanning
- Optimizing
 Satisfying has the goal of selecting a course of action that is “Good enough”.
 Instrumentalism is glow progress toward as optimal course of action
 Mixed scanning combines the straight rationalisms of optimizing with the “Muddling through”
approach of instrumentalism to form sub strategies.
 Optimizing has the goal of selecting the course of action with the higher pay off
 Still the decision maker needs to focus on techniques that will entrance effectiveness in
decision making situations
Decision making styles by (Hersey et al 2001)
 Authoritative or autocratic- The leader makes the decision without seeking assistance.
 Consultative or collective participative- The leader seeks input before making the decision yet
makes the final decision.
 Facilitative The leader and followers work together to reach a shared decision
 Deligative
 Only the group is involved in the decision and the leader gives up contract over the decision.
 The choice of the style is dependent on the situation for effectiveness.
Decision Process
5 steps in the decision to action process
1) Collect information’s
2) Process information into advice
3) Make the choice
4) Authorise the implementations
5) Execute what is to be done

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 Situation
What can be done? 
Advice
What should be done? 
Choice
What is intended to be 
done?
Authorisation
What is authorized to be 
done?
Execution
What is in fact done? 
Action

THE MANAGERIAL DECISION-MAKING PROCESS

The managerial decision-making model, a modified traditional model, eliminates the weakness of
the traditional model by adding a goal-setting step. Harrison (1981) has delineated the following
steps in the managerial decision-making process:
1. Set objectives.
2. Search for alternatives.
3. Evaluate alternatives.
4. Choose.
5. Implement.
6. Follow up and control.
The managerial decision-making process flows in much the same manner as the nursing process. A
comparison of the simplified nursing process and a model of decision-making are shown in below

Comparing the Decision making process with the Nursing Process

Decision Making Process Simplified Nursing Process

Identify the decision Assess

Collect Data

Identify criteria for decision Plan

Identify alternatives

Choose alternatives Implement

Implement alternatives

Evaluate steps in decision Evaluate

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THE NURSING PROCESS
The nursing process provides another theoretical system for solving problems and making
decisions. Educators have identified the nursing process as an effective decision-making model,
although there is current debate about its effectiveness as a clinical reasoning model (Pesut&
Herman, 1998).

Feedback mechanism of the nursing process

As a decision-making model, the nursing process has a strength that the previous two models lack,
namely its feedback mechanism. The arrows in Figure 1.2 show constant input into the process.
When the decision point has been identified, initial decision-making occurs and continues
throughout the process by using a feedback mechanism. Although the process was designed for
nursing practice with regard to patient care and nursing accountability, it can easily be adapted as a
theoretical model for solving leadership and management problems. Table 1.1 shows how closely
the nursing process parallels the decision-making process.

The weakness of the nursing process, like the traditional problem-solving model, is in not
requiring clearly stated objectives. Goals should be clearly stated in the planning phase of the
process, but this step is frequently omitted or obscured.

However, because nurses are familiar with this process and its proven effectiveness, it continues to
be recommended as an adapted theoretical process for leadership and managerial decision making.

Many other excellent problem analysis and decision models exist. The model selected should be
one with which the decision maker is familiar and one appropriate for the problem to be solved.
Using models or processes consistently will increase the likelihood that critical analysis will occur.
By cultivating a scientific approach, the quality of one's management and leadership problem
solving and decision making will improve tremendously.

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INTUITIVE DECISION-MAKING MODEL
According to Hansten and Wahburn (2000), many nursing scientists in the past did not value
intuition in decision making as they felt intuitive reasoning did not align itself well with the status
and power of a true science. Recently, however, there has been a renewed interest in intuitive
thinking and Ignatavicious (2001) identifies it as one of the characteristics of an expert critical
thinker. It must be remembered, however, that intuition can be overpowered by emotions.
Therefore, using an intuitive decision-making model is helpful in order to prevent emotions from
clouding the decision-making process.

Intuitive decision making model (Romiszowski, 1981) Reprinted with permission of Journal
of Nursing Staff Development

Romiszowski (1981) built on die nursing process in creating the intuitive decisionmaking model
shown in Figure 1.3. In this model, the decision maker consciously incorporates recall or
cumulative knowledge that comes from education, both formal and informal, as well as
experience, in planning the decision. Inexperienced or novice decision makers spend more time in
the assessment, recall, and planning phases, whereas experienced decision makers gather
information, recall, and often leap direcdy to implementation, because planning has become
automatic. That novice nurses and experienced nurses process information differendy has been
supported by Benner (1994).

Ironically, this "leap" from information gathering to implementation may be the greatest weakness
of this model. In discussing intuitive decision making, Lamond and Thompson (2000) warn that
since the process is largely invisible, there is litde,.information to evaluate if the outcome of the
decision is less than positive.

QUALITIES OF SUCCESSFUL DECISION MAKERS

Although not all experts agree, Huston (1990) suggests that the following are qualities of
successful decision makers:
 Courage. Courage is of particular importance and involves the willingness to take risks.
 Sensitivity. Good decision makers seem to have some sort of antenna that makes them
particularly sensitive to situations and others.
 Energy. People must have the energy and desire to make things happen.

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 Creativity. Successful decision makers tend to be creative thinkers. They develop new ways to
solve problems.

DECISION MAKING IN ORGANIZATIONS

In the beginning of this chapter the need for managers and leaders to make quality decisions was
emphasized. The effect of the individual's values and preferences on the decision making process
was discussed. But it is important for leaders and managers to also understand how the
organization influences the decision-making process. Since organizations are made up of people
with differing values and preferences, there is often conflict in organizational decision dynamics.

EFFECT OF ORGANIZATIONAL POWER ON DECISION MAKING

Powerful people in organizations are more apt to have decisions made (by themselves or their
subordinates) that are congruent with their own preferences and values. On the other hand, people
wielding little power in organizations must always consider the preference of the powerful when
they make management decisions. Power is frequently part of the decision factor (Good, 2003). In
organizations choice is constructed and constrained by many factors, and therefore choice is not
equally available to all people.

Additionally, not only does the preference of the powerful influence decisions of the less powerful,
but the powerful also are able to inhibit the preferences of the less powerful. This occurs because
individuals who remain and advance in organizations are those who feel and express values and
beliefs congruent with the organization. Therefore, a balance must be found between the
limitations of choice posed by the power structure within the organization and totally independent
decision making that could lead to organizational chaos.

The ability of the powerful to influence individual decision making in an organization often
requires adopting a private personality and an organizational personality. For example, some might
believe they would have made a different decision had they been acting on their own, but they
went along with the organizational decision. This "going along" in itself constitutes a decision;
people choose to accept an organizational decision that differs from their own preferences and
values.

RATIONAL AND ADMINISTRATIVE DECISION MAKING

For many years, it was widely believed that most managerial decisions were based on a careful,
scientific, and objective thought process and managers made decisions in a rational manner. In the
late 1940s, Herbert A. Simon's classic work revealed that most managers made many decisions
that did not fit the objective rationality theory. Simon (1965) delineated two types of management
decision makers: the economic man and the administrative man.

Managers who are successful decision makers attempt to make rational decisions, much like the
economic person described in Table 1.2. Because they realize that restricted knowledge and
limited alternatives directly affect a decision's quality, these managers gather as much information
as possible and generate many alternatives. Simon believed that the economic model was an
unrealistic description of organizational decision making. The complexity of acquiring information
makes it impossible for the human brain to store and retain the amount of information that is
available for each decision. Because of time constraints and the difficulty of assimilating large
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amounts of information, most management decisions are made using the administrative model of
decision making. The administrative person never has complete knowledge and generates fewer
alternatives. Simon argued that the administrative person carries out decisions that are only
"ssatisfying," a term used to describe decisions that may not be ideal but result in solutions that
have adequate outcomes. These managers want decisions to be "good enough" so that they "work,"
but they are less concerned that the alternative selected is the optimal choice. The "best" choice for
many decisions is often found to be too costly in terms of time or resources, so another less costly
but workable solution is found.

STRESS MANAGEMENT
Definitions
Selye (1978) defined stress as the ‘non-specific response of the body to any demand for change’.
Selye later defined stress as ‘the rate of war and tear on the body’, which Rosch (1993) pointed out
is also the definition of aging.
Stress is defined by the Gale Encyclopedia of Medicine as "the body's normal response to
anything that disturbs its natural physical, emotional, or mental balance," and stress reduction
"refers to various strategies that counteract this response and produce a sense of relaxation and
tranquility."
Stress is the emotional and physical response you experience when you perceive an imbalance
between demands placed on you and your resources at a time when coping is important. (Scott
Brunero, 2006)
The Nature of Stress
Because of the difficulty of defining stress, the term has come to mean a subjective phenomenon
that differs for each person. What is distressing for one person can be pleasurable to others. For
example, some nurses may perceive a code as an exhilarating challenge, and others may find it
highly stressful. The code itself is not inherently stressful. It depends on how each individual
perceives the event.
An unpleasant event or threat – such as having to constantly deal with an intimidating boss,
coworker, or client – may be identified as stressful by some people. Others may only be aware of
how they react to such situations, and this can range from anxiety and depression to palpitations,
agita and stomach upset, diarrhea, sweaty palms, and dozens of other emotional and physical
responses (Rosch, 1998). NO matter how stress is identified, it is clear that job stress is on the
upswing (Sauter et al, 1999).
SOURCES OF STRESS:
Personal stressors
 Adjustment to change is stressful. Many events in life produce individual stress reactions.
 The death of a spouse or close family member, divorce, marital separation, marriage or
remarriage and personal injury or illness are highly stressful events.
 A change in health of a family member, pregnancy, gain of a new family member, marital
reconciliation, increased arguing with spouse, sexual difficulties, changes in financial state,
mortages, trouble with in-laws, a son or daughter leaving home and the death of a close friend
are stressful.
 Changes in living condition or personal habits, such as changes in work residence, school,
recreation, church activities, social activities, sleeping habits, and eating habits, cause stress.
 Even personal achievements, vocations and holidays are stressful.
 These personal stressors can affect one’s job performance.
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Stressors at work:
Dismissal and retirement are highly stressful. Business read adjustments such as changing jobs or
responsibilities, changes in working hour or conditions, and problems with the boss are stressful.
Poor physical working conditions, physical danger, work overload, time pressures, responsibility
for people, role ambiguity and conflict, conflicts with superiors, peers and subordinates,
restrictions, little participation in decision making, over promotion or under promotion, lack of job
security are stressors common to jobs.
Nurses face stress with life and death situations, heavy workloads involving physical and mental
strain, knowledge of how to use numerous pieces of equipment and the consequences of equipment
failure, reporting to numerous bosses, communication problems among staff members, physicians,
Families and other departments and awareness of the serious consequences of mistakes. A hospital
is one of the most stressful work environments.
People often needlessly increase their own stress. The difference between the demands people
place on themselves or perceive from others and the resources they perceive as available to meet
the demands is a threat or stress. Individuals are typed by the demands they place on themselves.
Type A people set high standards, are competitive, put themselves under constant time pressure,
and are very demanding of themselves even in leisure and recreational activities. Type B people
are more easygoing, relaxed are less competitive, and are likely to accept situations than fight
them. (Neill, 2005).
SYMPTOMS OF STRESS
Numerous symptoms indicate the stress is becoming distress. These include but are not limited
to those given below;
Physical symptoms
Physical symptoms can be caused by other illnesses, so it is important to have a medical doctor
treat conditions such as ulcers, compressed disks, or other physical disorders. Remember, however,
that the body and mind are not separate entities. The physical problems outlined below may result
from or be exacerbated by stress:
 sleepdisturbances  irregular heartbeat, palpitations
 back, shoulderorneckpain  asthmaorshortness of breath
 tensionormigraineheadaches  chestpain
 upset or acid stomach, cramps,  sweatypalmsorhands
heartburn, gas, irritable bowel  coldhandsorfeet
syndrome, indigestion.  skin problems (hives, eczema,
 constipation, diarrhea psoriasis, tics, itching)
 weight gain or loss, eating  periodontal disease, jawpain
disorders  reproductiveproblems ,menstrual
 hairloss disturbance
 muscletension  immunesystemsuppression: more
 fatigue colds, flu, infections
 highbloodpressure  growthinhibition
Emotionalsymptoms
Like physical signs, emotional symptoms such as anxiety or depression can mask conditions other
than stress. It is important to find out whether they are stress-related or not. In either case, the
following emotional symptoms are uncomfortable and can affect your performance at work or
play, your physical health, or your relationships with others:
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  nervousness, anxiety  troublethinkingclearly
 depression, moodiness  feelingout of control
 “butterflies”  substance abuse
 irritability, frustration  phobias
 memoryproblems  overreactions
 lack of concentration  fatigue
 withdrawal  tearfulness

Relationalsymptoms
The antisocial behavior displayed in stressful situations can cause the rapid deterioration of
relationships with family, friends, co-workers, or even strangers. A personunder stress
maymanifestsignssuch as:
 increasedarguments  roadrage
 isolationfrom social activities  domesticorworkplaceviolence
 conflict with co-workers or  overreactions
employers
 frequentjobchanges

Severe stress reactions that persist for long periods of time and recur without warning after a
traumatic event or even after an intense experience such as an accident, hospitalization, or loss,
may become a post-traumatic stress disorder (PTSD) requiring professional assistance to
overcome.

High stress levels accumulated over several months are likely to result in physical and
-
psychological reactions. The amount of stress necessary before one manifests symptoms varies,
and depends on factors such as heredity, habits, personality, past illness, and previous crises and
coping mechanisms. Well- educated, intelligent, creative people in management are at high risk for
burnout. They may become workaholics but get little accomplished; experience chronic fatigue;
feel they do not want to go to work; take increasing amounts of sick time; become negative; blame
and criticize others; engage in back biting, and talk behind others’ back.
MODELS OF STRESS
1. General Adaptation Syndrome
A diagram of the General Adaptation Syndrome model.
Physiologists define stress as how the body reacts to a stressor, real or imagined, a stimulus that
causes stress. Acute stressors affect an organism in the short term; chronic stressors over the longer
term.
Selye researched the effects of stress.
Alarm is the first stage. When the threat or stressor is identified or realized, the body's stress
response is a state of alarm. During this stage, adrenaline will be produced in order to bring about
the fight-or-flight response. There is also some activation of the HPA axis, producing cortisol.
Resistance is the second stage. If the stressor persists, it becomes necessary to attempt some
means of coping with the stress. Although the body begins to try to adapt to the strains or demands
of the environment, the body cannot keep this up indefinitely, so its resources are gradually
depleted.
Exhaustion is the third and final stage in the GAS model. At this point, all of the body's resources
are eventually depleted and the body is unable to maintain normal function. The initial autonomic
nervous system symptoms may reappear (sweating, raised heart rate, etc.). If stage three is
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extended, long-term damage may result, as the body's immune system becomes exhausted, and
bodily functions become impaired, resulting in decompensation.
The result can manifest itself in obvious illnesses such as ulcers, depression, diabetes, trouble with
the digestive system, or even cardiovascular problems, along with other mental illnesses.
2. Selye: eustress and distress
Selye published in 1975 a model dividing stress into eustress and distress. Where stress enhances
function (physical or mental, such as through strength training or challenging work), it may be
considered eustress. Persistent stress that is not resolved through coping or adaptation, deemed
distress, may lead to anxiety or withdrawal (depression) behavior.
The difference between experiences that result in eustress and those that result in distress is
determined by the disparity between an experience (real or imagined) and personal expectations,
and resources to cope with the stress. Alarming experiences, either real or imagined, can trigger a
stress response.
3. Lazarus: cognitive appraisal model
Lazarus argued that, in order for a psychosocial situation to be stressful, it must be appraised as
such. He argued that cognitive processes of appraisal are central in determining whether a situation
is potentially threatening, constitutes a harm/loss or a challenge, or is benign.
Both personal and environmental factors influence this primary appraisal, which then triggers the
selection of coping processes. Problem-focused coping is directed at managing the problem,
whereas emotion-focused coping processes are directed at managing the negative emotions.
Secondary appraisal refers to the evaluation of the resources available to cope with the problem,
and may alter the primary appraisal.
In other words, primary appraisal includes the perception of how stressful the problem is and the
secondary appraisal of estimating whether one has more than or less than adequate resources to
deal with the problem that affects the overall appraisal of stressfulness. Further, coping is flexible
in that, in general, the individual examines the effectiveness of the coping on the situation; if it is
not having the desired effect, s/he will, in general, try different strategies.
Coping stress based on lazarus model
4. The Stimulus-BasedModel ofStress:
Holmes and Rahes advanced this theory. It proposed that life changes (LIFE EVENTS) or
(STRESSORS), either positive or negative, are stressors that tax the adaptation capacity of an
individual, causing physiological and psychological strains that lead to health problems.
They developed the Social Readjustment Rating Scale (SRRS). They hypothesized that people
with higher scores in the SRRS, -that is major life changes-are more likely to experience
physical or mental illness.
There is some supporting evidence to this, but the correlation is fairly low. Moreover, this
theory was criticized as ignoring the cognitive aspects of the effects of stress. In other words, it
does not account for the individual appraisal of the meaning of various life events.
MEASURING STRESS
Five Quick Ways to Measure Stress
In order to effectively manage stress, you must become aware of the amount and types of stressors
in your everyday life. One way of developing awareness is to assess the frequency and amount of
stress in your daily routine, and then trace the stress to its source (i.e., the stressor). Below is a list
of five quick, easy ways of measuring stress in your daily life. These methods can be easily used
anytime and anywhere.
Check muscle tension by "Scanning"
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When you scan, you are checking different muscles in your body as if you could X-ray each part
and look for tension. Start at the top of your head and work your way down. Check your forehead,
eyes, jaws (are you clenching your teeth?). Then move to your neck and shoulders and check for
tension or pain; Next your arms, chest and stomach. Check your breathing to see if it is rapid and
shallow rather than slow and deep. Scan your upper legs, calves and your feet and toes.
Check hand temperature
Place your hand on the side of your neck just above your collar. If your hand is noticeably cooler
than your neck, your hand temperature indicates that your body is probably stressed.
Check for nervous sweating
Many people perspire when they are tense. This is an involuntary stress response that is caused by
the secretion of certain stress hormones. This is yet another simple indicator that your body is
responding to some stressor.
Check for a rapid pulse rate (> 75 bpm)
At rest, most people will have a pulse rate in the 50s or 60s. However, if your pulse rate is higher
than 75 bpm, it may indicate that your body is responding to a stressor.
Check for rapid, shallow breathing
When people are relaxed, they breathe slowly and deeply with relaxed stomach muscles. When
people are tense, they often tighten their stomach muscles and breathe through their chests. Since
the chest is not as expandable as the stomach, one will exhibit rapid, shallow, chest breathing. One
technique for managing stress is to learn to breathe in a more relaxed fashion. Relax the stomach
and breathe in slowly, filling the stomach first and then the chest. Relax again as you exhale and
repeat.
Note that each of these methods for dealing with body stress utilizes a physical sign or symptom to
assess stress levels. These signs may not always be perceptible however, becoming more aware of
stress symptoms may reinforce healthy attitudes and practices in response to common stressors.
After you have used these methods to uncover the most stressful times and places in your day, then
take some time to analyze these situations to see what seems to be causing the stress. For example,
let's say that you have noticed that the most stressful time for you is at work. What do you think is
causing such a stressful reaction? Perhaps it has to do with your workstation. A computer display
terminal that is set too close to your face so that you experience eye strain, or a chair that is too
high or too low. A keyboard that is too high or too low. Or, perhaps your problem is that you and
your boss constantly disagree, or that he or she is putting extra pressure on you to perform tasks
within unreasonable deadlines.
Once you are able to define your most stressful situations and what causes them, you will then be
able to map out your strategy for managing these stresses.
STRESS AND NURSES
Nurses work in high stress and even dangerous environments. In an online health and safety
survey of 4,826 nurses ( from every age group, experience level, and type of care facilities)
conducted by the American Nurses Association (ANA), over 70% of respondents cited the acute
and chronic effects of stress and overwork as one of their top three health and safety concerns.
Nurses are forced to some type of mandatory or unplanned overtime every month. Studies stated
that stress not only affects the nurses health but also the quality of care to the clients.
Job strain results when the psychological demands of a job exceed the worker’s discretion in
deciding how to do the job. Job strain strongly related to fair or poor physical and mental health
and to lengthy or frequent absences from work for health related reasons. Short staffing of nurses
leads to increased client mortality, nursing dissatisfaction, and nursing burnout.
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STRESS AND THE WORK ENVIRONMENT
While employers believe that stressful working conditions are a necessary evil and that
workers must be pressured to set aside health concerns for health corporations to remain profitable,
research findings challenge those assumptions. Creating a healthy work environment for nursing
practice is crucial to maintaining an adequate nursing workforce. Being a nurse is associated with
multiple and conflicting demands imposed by leaders, managers and medical and administrative
staff. The stressful nature of the profession often leads to burnout, disability, and high absenteeism.
New sources of stress are developing at what seems like supersonic speeds along with changes
in society. The new sources include technostress, restructuring and disconnectedness.

TECHNOSTRESS
In 1984, Craig Brod, a silicon valley psychiatrist, impressed with the steady increase in stress-
related disorders resulting from the activities in this fast-paced and hectic community, coined the
term Technostress. He even wrote a book: Technostress: The Human Cost of the Computer
Revolution. Technostress resulted from difficulties in dealing with computer technologies or from
an unusual attraction to them.
According to Brod, technostress is related to technophobia, or a fear of new and constantly
upgraded computer software and hardware devices as well as the computers themselves.
Technostress can also stem from a preoccupation with computer-related activities and information
overload.
Technology is all around- from computers to cell phones, pagers, ipods, blackberrys, electronic
monitoring devices, video terminals and more- and was supposed to make life less difficult. Rather
than reduce the work week, technology has increased it. Nurses are now tied to the workplace
24/7, on weekends, on holidays, and even on vacations. There is no rest period allowed anymore.
The requirement to be constantly alert can only result in increased stress.
A part of technology enhancement in health care is the movement toward placing individual client
records online. This can lead to additional mental stress for nurses who may be asked to add
another task to their already full day and may be especially stressful for those who are not
computer savvy.
Working with computers can also lead to physical stress. Repetitive stress injuries, such as carpal
tunnel syndrome, are now the most common costly work place injury.

RESTRUCTURING
Companies, including healthcare corporations that have eliminated jobs are more likely to see
increases in disability claims ranging from back pain to gastro intestinal disorders than firms that
haven’t cut jobs. What is being saved in payroll costs through downsizing may be eaten up in
stress related disability costs. Simply removing people without eliminating the work they did could
cost more in the long run. Overworked and overstressed healthcare professionals make mistakes
that can be fatal. For nurse managers, the dilemma is doubly challenging. On the one hand,
employees are experiencing greater stress; on the other hand they have less time to attend stress
management training.

DISCONNECTEDNESS
As nurses become too busy or too tired for healthy relationships, stress increases. Nurses are
working more now and enjoying it less. They may be so overloaded that they cannot maintain
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those close family and friend relationships that are so crucial to reducing stress. In many
households, family members have their own television sets and cell phones, which cuts down on
those social support opportunities that are so important to stress reduction.
Satisfaction in life comes from close relationships, sense of belonging, positive attitudes,
managing expectations, high self-esteem, work goals that are congruent with personal values, and
an active leisure lifestyle. When these elements are not available because of job requirements,
stress overload and burnout can occur.

STRESS RESPONSE
Stress is impossible to avoid. It is nonspecific response of the body to any demand. There are
two types of stress. 1. Eustress, a positive force that adds excitement and challenge to life and
provides a sense of well being, and 2. Distress, a negative force caused by unrelieved tension that
threatens effectiveness. Whether one will experience eustress or distress largely depends on the
person’s perceptions, physical activity or inactivity, mental activity or inactivity, nutrition and
relationships.
A stressor is anything an individual perceives as a threat. Stressors produce a state of stress by
disrupting homeostasis. There are three stages in the stress response. First, the alarm reaction is the
mobilization of resources to confront the threat. Second, in the resistance stage, there is a large
increase in energy consumption. Once the reserve energy has been used, the body needs time to
recover and to replenish the supply. When stress continues for long periods of time, the energy is
used but not replaced, and the third stage, exhaustion, results because our body cannot maintain
homeostasis and long-term resistance to combat prolonged stress.
Consequently, unrelieved stress interferes with one’s physical and mental well being. After the
stress event the body returns to a state of equilibrium. Stable periods for body to restore adaptive
energy allow one to meet new stressful situations.
BURNOUT
Burnout, a term coined by Freudenberger and Richelson (1980), is a debilitating psychological
condition brought about by unrelieved work stress. Signs of burnout include:
- Depleted energy and emotional exhaustion
- Lowered resistance to illness
- Increased depersonalization in interpersonal relationships
- Increased dissatisfaction and pessimism
- Increased absenteeism and work inefficiency
Maslach and Leiter (1997), defined burnout as disconnect between expectations about work versus
the realities of what is actually experienced. Burnout is - a disconnect between what nurses are and
what they have to do. Burned out people can be too depleted to give of themselves in a creative
and cooperative fashion. This can be a real problem for nurses whose role is to provide care.
Burnout represents an erosion in values, dignity, spirit, and will – an erosion of the human
soul. Maslach and Leiter do not fault the worker, but rather the work environment.
Burnout can be considered a crisis of caring. Nurses are caring individuals and tend to work
harder at caring than some other professionals. As they become more successful at caring, they are
apt to be noticed and asked to do even more for the cause. This can put additional demands o their
time and energy.

Burnout is both a physical and an emotional exhaustion during which the professional no
longer has any positive feelings, sympathy, or respect for clients. Overtime, unless nurses take care
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of themselves, they may experience burnout. Nurses are at a greater risk for burnout than people in
other professions. The very fact that nurses are about other people puts them at a greater risk than
if they did not care because strong emotions takes more energy and can be depleting.
According to Maslach and Leiter, the six systemic sources of burnout are
1. Work overload
2. Lack of control
3. Insufficient reward
4. Unfairness
5. Breakdown of a sense of community
6. Value conflict

Some of the negative behavioural effects of burnout include:

- Rudeness
- Sarcasm
- Criticism and insults
- Irrational anger or isolation and introversion
- Eating too much or too little
- Abusing alcohol and drugs
- Suffering physical symptoms, such as hypertension and frequent headaches
- Downhill spiral of relationships with family, friends and colleagues
- Fading dedication and commitment to the organization
Working to exhaustion and not stopping to engage in restorative activities can lead to burnout and
force the body to take its own break. Pain, chronic illness, and other conditions can be messages
from the body to pay attention, stop and restore. Rest and sleep are two ways the body takes a
restorative break. Nurses who stop to sleep and rest can combat stress and burnout. Many nurses
don’t even stop for lunch, let alone for a break.

STAGES OF BURNOUT ( Veninga&Spradley, 1981)

STAGE I: Honeymoon, this stage is marked by high job satisfaction, commitment, energy, and
creativity. If positive and adaptive patterns of coping are developed, it’s possible to remain in the
honeymoon stage indefinitely.
STAGE II : Balancing act, A noticeable increase in job dissatisfaction, work inefficiency,
avoiding making necessary decisions, losing stuff at work, general and deep muscle fatigue, sleep
disturbances ( because of thought about work) and escapist activities (eating, drinking, smoking,
zoning out) is experienced.
STAGE III: Chronic symptoms, The stage 2 symptoms intensify and include chronic exhaustion,
physical illness, anger, and depression.
STAGE IV: Crisis, The symptoms become more critical, and the physical symptoms intensify and
/ or increase in number; this may include obsessing about work frustrations, allowing pessimism
and self-doubt to dominate thinking, and developing an escapist mentally.
STAGE V: Enmeshment, The symptoms of burnout are so embedded in a person’s life that he or
she is more likely to be labeled as having a significant mental or physical illness than burnout.
The above model provides hope that taking action can break the cycle. It is always possible to
strengthen your coping skills and return to an earlier stage. The wise course of action is to involve
you in positive self-care to prevent anything after stage 1 from developing.

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THEORIES RELATED TO STRESS AND ITS MANAGEMENT
1. HARDINESS: A PERSONAL THEORY OF STRESS PROTECTION
2. BANDURA’S THEORY OF SELF EFFICACY

1. HARDINESS: A PERSONAL THEORY OF STRESS PROTECTION

Dr. Suzanne Ouellette Kobasa (1984) researched the ability of humans to survive stress. She found
that psychological hardiness, or the ability to survive stress, is composed of three ingredients:
1. A commitment to self, work, family, and other important values
2. A sense of personal control over one’s life
3. The ability to see change in one’s life as a challenge to master
Kobasa tested executives, lawyers, women in gynecologist offices, supervisors, US army officers,
and college students. Her results were same for each population: biology is not destiny.
A hardy personality is more important than a strong constitution. It is possible to come from a
family with chronic illness and do better under stress if you are hardy than if you had come from a
healthy family and have fewer inner resources.
Exercise is a good antidote to stress but may be short term. Jogging after an argument can help you
that evening, but the next morning, your stress levels may rise if you reencounter the stress-
provoking situation. Hardiness skills may be long term inoculations against stressors. Two studies
even found that hardiness is more powerful than optimism and religiousness in coping with stress.
(Maddi,2006).
Judkins, Massey,and Huff (2006) provided evidence for the importance of hardiness. They
discovered that intense job-related demands affected job performance and increased the use of sick
time. The found that managers with high hardiness skills and low stress used less sick time than
managers with low hardiness skills and high stress.

In another study of hardiness, Judkins, Reid, and Furlow (2006) investigated the development of a
model hardiness training program to reduce stress and increase hardiness among nurse managers.
Thirteen nurse managers at an urban hospital completed pretests for hardiness levels before
undergoing a 2.5 day hardiness training program. Post tests were completed after the initial
training, after each of 6 weekly sessions, and after 6 and 12 months. Findings suggested that the
hardiness program and intermittent follow up increased and sustained hardiness levels in nurse
managers and may have had a positive effect on staff turnover rates.
Three helpful techniques for increasing hardiness are:
1. Focusing on body signals that something is wrong
2. Restructuring stressful situations
3. Compensating through self- improvements

Focusing
Focusing is a technique developed by Eugene Gendlin (1978) that can help you recognize signals
from your body that stress is interfering with comfort. Gendlin found that executives are so used to
pressure in their temples, tightened necks, or stomach knots that they have stopped noticing these
signals that something is wrong.
A beginning focusing question might be “where is tension located in my body?” those who have
learned to tune out body signals can begin with a progressive relaxation tape to help them identify
the location of stress and tension.

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Reconstructing Stressful Situations
The second technique for enhancing hardiness is reconstructing stressful situations. This is
accomplished by thinking about a recent episode of distress and writing about:
- Three ways it could have gone better
- Three ways it could have gone worse
- --this exercise will increase your ability to put the situation in perspective, which is useful for
reducing stress.

Compensating through Self-Improvement

- The third technique Kobasa found useful for enhancing hardiness was compensating through
self-improvement. This approach works most effectively for stressors that cannot be avoided,
such as an illness, an intimidating or unfair boss, or an unexpected change or loss. You can
balance the feeling of lost control that results from such unexpected events by taking on a new
challenge. Learning a new skill or teaching someone else can reassure you that you can still
cope with life adequately.

BANDURA’S THEORY OF SELF-EFFICACY

- Bandura (1977, 1986, 1997, 2001, 2004) developed a social cognitive theory that has been
widely used and accepted. Bandura (1986) wrote that individuals possess self-beliefs that can
enable them to exercise control over their thoughts, feeling and actions
- Self-efficacy, or the belief in one’s ability to perform adequately, has proved to be a more
consistent predictor of behavioural outcomes than others (Bandura,2004). Learners with high
self-efficacy expect more of themselves and put forth the effort to get it. They approach
difficult tasks as challenges rather than as situations to avoid.
- Certain environmental characteristics can cause even highly self- efficacious and well skilled
learners not to behave in concert with their beliefs and abilities if they:
- - lack the incentive
- Lack the the necessary resources
- Perceive social constraints
Bandura (1977) believed that learning would be laborious and hazardous if people had to rely only
on themselves. Luckily, employees have nurse managers to model appropriate behavior for them.
This vicarious learning permits individuals to learn novel behaviours without going through the
arduous task of trial and error learning.
Bandura (1977) emphasized the importance of modeling behaviours, attitudes and emotional
reactions. He believed that it was the human ability to symbolize that allowed learners to:
- Extract meaning from the environment
- Construct guides for action
- Solve problems cognitively
- Support well thought out courses of action
- Gain new knowledge by reflective thought
- Communicate with others at any distance in time and space
- Use self- reflection to make sense of their experiences
- Engage in self evaluation and alter their thinking and behavior accordingly.
A series of principles underlie Bandura’s social cognitive theory:
- The highest level of observational learning is achieved by first organizing and rehearsing the
modeled behavior symbolically and then enacting it overtly.
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- Coding modeled behavior into words, labels, or images results in better retention of
information than does simply observing.
- Individuals are more likely to adopt a modeled behavior if it results in outcomes they value, if
others admire the role model, and if the behavior has functional value.
- Self-efficacy beliefs are paramount; motivation levels, affective states and actions are based
more on what people believe than on what is objectively true (1997).
INDIVIDUALAPPROACHES TO JOB STRESS
Hardiness and Bandura’s theory of self-efficacy can certainly help nurses combat job-related
stress. Other individual approaches to job stress include employee assistance programs and
nutrition.
Employee Assistance Programs
Employee assistance Program (EAP) that provided stress management and support. Stress
management programs teach workers about the nature and sources of stress, the effects of stress on
health, and personal skills to reduce stress, such as relaxation exercises. EAP’s also counsel
employees on their work and personal problems. Stress management training can rapidly reduce
stress symptoms, such as anxiety and sleep disturbances; it is also inexpensive and easy to
implement.
The rationale for the provision of EAP is quite simple: levels of psychological distress among staff
contribute to lower productivity and studies have shown that workplace counselling helps reduce
psychological distress.
Nursing staff can access EAP for any issue that may have an impact on the health and safety of
staff at work, including:
• relationship problems at home or at work;
• mental health issues;
• organisational change;
• substance abuse;
• gambling problems;
• workplace conflict;
• health concerns;
• financial problems.
Stress management programs have 2 drawbacks:
1. The beneficial effects on stress symptoms can be short lived.
2. Focusing on individual stress levels ignores important root causes of stress.
When the stress management program is administered b an EAP, a third drawback may come into
play.
3. A lack of confidentiality about shared personal information can help corporations fight
employee initiated lawsuits. For that reason, referral to off-site programs, nurse-led programs,
or organizational change may be more optimal choices.
Many colleges, universities, adult education centers and distance education providers offer stress
reduction programs. Nurse leaders can develop a list of resources and suggest that staff participate
in them.
Nurse leaders can also develop their own stress reduction programs for staff, ask mental health
clinical nurse specialists to design one, or hand out stress reduction information at staff meetings
or shift reports.
RELAXATION TECHNIQUES

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Relaxation is a skill. With frequent practice you will improve these skills to control your emotions
and improve your physical well being. These techniques can be practiced either day or night to
assist you to relax and feel in control. It is really important to practice regularly.
Slow breathing technique
This is useful if you start to over breath and when you are feeling the first signs of anxiety or
stress. You are required to do the following:
1. STOP what you are doing and sit down.
2. Hold your breath and count to 10.
3. When you count to 10 breathe out and say the word “relax” to yourself in a calm soothing
manner.
4. Breathe in and out through your mouth, focus on your breathing. Breathe in for 3 seconds and
out for 3 seconds. Repeat saying “relax” to yourself every time you breathe out.
5. At the end of each minute hold your breath for 10 seconds and then continue the 6- second
breathing cycle.
6. Continue doing this breathing cycle until all of your symptoms of over breathing are gone and
you feel relaxed and back in control.
Muscle relaxation technique
This technique involves you using your slow breathing technique in conjunction with muscle
relaxation. This can be practiced any time. The more you practice the easier it will be to achieve
total relaxation and also the duration of feeling relaxed and being as stress free will last longer.
1. Sit down in a comfortable chair in a quiet location without disruption or distraction.
2. Make sure your body, feet and arms are supported, feet in front of you, arms by your sides.
3. Focus on the tension in your body or muscles.
4. Breathe in and out slowly and deeply, at your own pace until you settle. If you feel your anxiety
rise start again by holding your breath, focus on your breathing.
5. Breathe in for 3 seconds and out for 3 seconds. In through your nose, out through your mouth
saying “relax” to your self-every time you breath out. As you say the word relax allow the tension
go from your muscles.
6. Close your eyes. Continue breathing in through your nose and out through your mouth saying
“relax” to yourself every time you breath out.
7. Repeat this process until you feel relaxed and practice it a few times a day.

Relaxation and imagery exercise, that nurse leaders can use and teach to supervises.
1. Find a quiet place where you won’t be disturbed
2. Slip off your shoes, loosen tight clothing, and sit or lie down and get comfortable.
3. Close your eyes.
4. Focus on your breathing. Let your breath slowly move toward your center as you inhale and
exhale. Just let it move naturally.
5. Begin to breathe in relaxing and healing energy with each inhale. See that relaxing healing
energy as a color.
6. With each exhale, let go of any old thoughts, feelings, or situations that you don’t need any
more. Perhaps view them as a different color. Just breathe out whatever it’s time to be rid of.
Inhale relaxing energy, and exhale what you are ready to let go of for a while until you feel
relaxed.
7. When you are ready, scan your body, and exhale any remaining tension or ideas you don’t
need any more.
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8. Slowly open your eyes, feeling relaxed and refreshed. Take this relaxed and refreshed feeling
with you throughout the day.
Another stress reduction measure includes using coping thoughts. Much of the internal dialogue
people have with themselves consists of negative words and feelings. Coping thoughts counteract
such negativity and provide a positive supportive voice for nurses to use.

COPING STRATEGIES
“Grant me the courage to change the things I can change, the serenity to accept those that I
cannot change and the wisdom to know the difference”
Reinhold Niebuhr
This famous quote from philosopher Reinhold Niebuhr has been the inspiration for many people
who have successfully managed to turn their lives around by consciously challenging many of
their thoughts and assumptions in order to change the way they think and feel about their
situations. With the level of day-to-day pressure faced by many nurses, it is easy for us to fall into
negative patterns of thinking that have a big impact on how we feel at work and at home. The trick
is to recognize negative thinking patterns and work towards changing them. The nursing literature
suggests that there are a range of interventions to help you reduce stress in nursing.

A recent review suggests that cognitive behavioural interventions and relaxation/meditation

strategies are effective in reducing your personal levels of stress.

Cognitive-behavioural interventions are designed to help people live longer, feel better and avoid
having self-defeating thoughts. They assist people to understand themselves so that they may live a
more fulfilling and happier existence. Developed in the 1950s by Aaron Beck and Albert Ellis,
these interventions are designed to increase your emotional self management, to allow you to
change the things you can change and accept (though not like) those things you cannot change.

This type of intervention targets the individual thoughts as a cognitive (thinking) process. It is
based on the theory that changes in our emotions and behaviours are determined by our thoughts
about events that occur. People are often disturbed by their view or perception of events rather than
the events themselves. By
being able to change the way that you think about things you then are able to change the way that
you also feel about them. By identifying and then modifying those thoughts which produce
negative feelings, you are then able to reach your goals and make changes in the way that you
perceive and feel about life situations. It sounds easy but this takes some practice to change the
way you react to situations. The model is as easy to use as A.B.C.
A = Activating event (what happened) An occurrence, which triggers an emotional consequence.
Eg: My bus is running late, I won’t make it in time for work
B = Belief (what you are thinking, self talk) An evaluation and judgement about the demands on
yourself, demands about others and demands about the world or life conditions. These may be
rational and realistic or irrational.
Eg: People will look down on me for being late. They will think I’m stupid and unreliable
C= Consequence (outcome) an emotional and/or physical consequence linked to a belief.
Eg: Anxiety

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It is easier to work out the Activating event (problem) and Consequences (outcome) first, as the
Beliefs (what you are thinking) are not always so obvious to us. To help us resolve a problematic
situation we can use these steps.
Activating Event (A) Write down a problem which has happened or may happen in the future,
which leads you to perform ineffectively and/or experience a negative emotional reaction.
Consequences (C) Write down your behaviour and your negative emotional stress
reactions/feelings, which regularly occur in the face of the above activating event (A). Beliefs (B)
Write down your beliefs, thoughts, attitudes and self talk about the activating event (A), which are
irrational, not true or useful that lead to yourself defeating behaviour.
Goals: Write down how you would like to behave and feel about the Activating Event (A) the
next time a similar problem occurs.
Examples of negative thoughts and stressful thinking
Our thoughts or types of thinking (B - beliefs) directly affect our feelings. Some of our thoughts
are healthy while some are not beneficial to us. By addressing and changing our thinking we can
then influence and change our emotions and physical wellbeing.
Some examples of errors in thinking are:
1. Black & white thinking:
Sometimes we see things in extremes. No middle ground. Eg: good or bad, success or failure,
perfect verses useless or moral verses immoral. When we do this we forget that things are rarely
one way or the other but usually somewhere in between. Another name for this is “All or nothing
thinking”.
Eg: “If I am not perfect then I am useless.”
2. Filtering:
You tend to see all the things that are wrong, but ignore the positives and take all the positives for
granted.
Eg: “I forgot how to set up for the catheterisation. Then I panicked. I can’t do anything right. I’m a
failure.”
3. Overgeneralising:
When people build up one thing about themselves or their
circumstances and end up thinking that it represents the whole situation or happens all the time or
is part of a never ending pattern.
Eg: “No-one here knows what they are doing.”
4. Mind reading
Where we jump to conclusions without enough evidence or where we make guesses about what
other people are thinking about us.
Eg: “I wasn’t given the shifts I asked for because she doesn’t like me.”
5. Fortune telling
When you predict the future in a totally negative way.
Eg: “It will be another shift I can’t handle.”
6. Personalising
When you jump to a conclusion that something is directly connected to you.
Eg: “Every one knows I’ve been off work because I can’t cope.”

Challenging negative and unhelpful thinking

How do we do this? The first step is to become more aware of your emotional stress reactions and
understand that they are not helpful in you getting what you want and need.
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Try this: On a piece of paper draw two columns. In the first column write down an irrational
belief; one that caused you to become overly upset about a situation, person, or task. In the second
column, write down the more realistic response that would make you feel better about the
situation. The table below includes some common examples.
Coping thoughts:
Directions: Read through the list of positive thoughts that follow. Choose at least two to use to
reduce your stress and enhance your coping ability. Say them often to yourself. Consider writing
them down on index cards and carrying them with you or posting them on your mirror, your
refrigerator, your desk, or your dashboard to remind you to be positive.
Preparatory stage: (use these comments when preparing to enter a stressful situation)
- I can handle this
- There is nothing to worry about
- I am picturing myself succeeding again and again until I believe it.
- I will jump right in and be fine.
- It will be easier once we get started.
- Soon this will be over.
The situation (use these comments in the stressful situation)
- I refuse to let this situation upset me.
- Take a deep breath and relax
- I can take this step-by-step
- I can do this; I am handling it now.
- I can keep my mind on the task at hand.
- It does not matter what others think; I will do this.
- Deep breathing really works.
Reinforcing Success (Use these comments after the stressful situation to enhance self-esteem)
- Situations don’t have to overwhelm me anymore
- I did it!
- I did well.
- I’m going to tell about my success.
- By not thinking about staying calm, I stayed calm.
- By picturing myself being successful, I was successful.

NUTRITION
Stress is not just a mental or psychological issue; it has very real physical effects, including:
- Slowing digestion
- Releasing fats and sugars into the blood stream
- Increasing adrenaline production, which causes the body to set up its metabolism of proteins,
fats, and carbohydrates to produce a quick source of energy.
- Excreting amino acids, potassium, and phosphorus
- Depleting magnesium stored in muscle tissue
- Storing less calcium.
- -the result is the body becomes deficient in many nutrients, and in chronic stress, it is unable to
replace them adequately.
Good nutrition helps to maintain the body for full functioning. Eating a balanced diet, taking
vitamin supplements, and drinking plenty of water are important. In general people need to reduce
fat and cholesterol, sugar, salt, and food additive consumption. They need to increase exercise
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while decreasing the caloric intake, particularly from fats and sugars. At the same time, the
percentage of calories from foods containing fiber, such as fresh fruits, vegetables, and whole
grains, should be increased. Although improving eating habits may not prevent stress, it is one way
to maintain the level of fitness needed to fight stress.
Values clarification
Values clarification is a useful activity. Values should be chosen from alternatives with thoughtful
consideration to the consequences of each alternative. They should be cherished and shared with
others. The value should be integrated into one’s lifestyle, and actions should be consistent with
the values. To help clarify one’s values, one may assign priorities to a list of values such as the
following: Affection, duty, expertise, family, health, independence, leadership, parenthood, power,
pleasure, prestige, security, self-realization, service, spirituality, wealth, honesty, responsibility,
courage etc,.
Goal setting
Goals should be consistent with one’s values, and one should consider goal alternatives. To do
this, one considers why a goal is desired. One may want promotion for recognition or for economic
reasons. If the promotion is not forthcoming, one may receive recognition through community
service. Money might be generated through wise investments or fees for community services. The
achievement of desired outcomes through different approaches increases flexibility and decreases
stress caused by unmet goals.
Stress Avoidance and Regulation
When reappraising situations, one should avoid troublesome transactions. The frequency of stress
inducing situations should be minimized. Every change takes energy. Therefore during periods of
high stress, routines and habits should be maintained as much as possible. One should be cautious
about moving and starting a new job at the same time one is getting a divorce. That also would be
a particularly poor time to try to stop smoking or lose weight. Unnecessary changes should be
prevented during periods of high stress. Deliberately postponing some changes helps one deal with
unavoidable change constructively and reduces the need for multiple adjustments at one time.
However, increasing positive sources of tension that foster growth, such as learning a sport, can
help offset the deleterious effect of negative tension.
Time blocking
Time blocking is the setting aside of specific time for adaptation to a stressor. To reduce the stress
from having been promoted to a management position, one can set aside time for reading about
leadership and management or for observing a leader or manager. This helps ensure that concerns
are addressed and tasks accomplished. It decreases anxiety, time urgency, and feelings of
frustration. Define off-limit times, and set aside time when one will not be interrupted by phone
calls or individuals except for emergencies. Schedule free time and exercise time, and put social
events on the calendar like you would a business appointment.
Time management
Time management helps control stress. Much time can be conserved when one knows one’s value
system and acts consistently with it, sets goals, and plans strategies for accomplishment of those
goals. One can also use organizers such as to-do lists and calendars to plan good use of one’s time.
Assertiveness
When one asserts oneself, one increases self-esteem and reduces anxiety, thus reducing stress. As
with time management, assertiveness involves thinking through goals and acting consistently with
one’s values through the use of effective work habits, and by setting limits on others attempts to
block one’s goals. It involves stating what one wants and how one feels, making requests, taking
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compliments, handling putdowns, and setting limits. An assertive person makes eye contact with
others; stands straight; sits in an open, listening posture; and speaks in a clear voice. Assertive
people choose for themselves and achieve desired goals through self-enhancing behavior that
reduces stress.
Feeling Pauses
Feeling pauses are useful. One should take time to identify a feeling, label it, distinguish between
thinking and feeling, and accept the feeling for what it is rather than talking oneself into what it
should be. One should be aware of both positive and negative feelings and if one is feeling the
following positive feelings:
One should also acknowledge negative feelings, such as the following:
Then one should determine whether the feeling is appropriate for the situation and decide how to
express the feeling in a safe and appropriate way. Feelings can be expressed in “I feel” messages
rather than “you” messages that blame or attack others. Feelings can be talked about with an
uninvolved person. One can fantasize about how one would like to handle the situation better the
next time. Negative feelings may be acted out symbolically by punching a pillow, drawing a
picture, or writing a poem. One may set aside negative feelings by getting involved in something
pleasant, such as exercise, hobbies, music, television, or talking to a friend. Feelings can also be
experienced vicariously by getting involved in another’s experience through reading a book,
watching a movie, or listening to someone. Pausing to consider feelings can help create new
beginnings (Kingsley, 2006).

Inner shouting
Inner shouting is the process of shouting “ I feel…” inside one’s head or out loud privately. When
the person blurts the feeling out spontaneously and publicly rather than saying it quietly inside
one’s head, adversary confrontation can occur. Anger should be viewed as a symptom. Pains
should be focused on helping one take responsibility for feelings of hurt and humiliation; a person
can try to humiliate you, but you do not have to fl humiliated.
Anchoring
Anchors are associated feelings that are initiated either by an event or by the memory of that event.
Anchors may be sounds, sights, smells, tastes, or touches that stimulate positive or negative
feelings. Birds chirping may remind one of happy, lazy mornings with the family. One may recall
an awful accident at the sight of blood. A taste may revive memories of grandma’s home cooking.
Our lives are filled with anchors that cause associations. We can use anchoring in a useful way to
experience desire feelings.
Anchoring is neurolinguistic programming. The anchor is a stimulus that triggers an emotion, and
anchoring can create a new response to that stimulus by programming the subconscious to
associate the desired feeling with specific words and gestures, which would then trigger the desired
feeling. To create an anchor, identify the desired emotional state; think of oneself in that situation
as if it were happening at this moment; feel the state build and then decline; repeat that process, but
at the peak of the feeling make a unique gesture with the fingers of one hand and say a word or
phrase to evoke the feeling before it declines; repeat that gesture and word or phrase at least five
times; and then reinforce the gesture and word or phrase periodically to keep the intensity from
fading over time. (Murphy, 2007).
Sorting
Sorting is choosing the interpretation of an event. One can have an optimistic or pessimistic
interpretation of events. Is the glass half full or half empty? We become what we think and
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therefore can make ourselves happy or miserable. To be happier and more fun loving, one should
focus on the positive aspects of situations.
Thought stopping
Thought stopping helps to get rid of negative thinking. Excessive rehearsals in our minds of
negative past events are unhelpful thoughts that waste time, reduce self-esteem, and encourage
maladaptive behavior patterns. To prepare for thought stopping, one should think of beautiful,
pleasant experiences: a sunrise, a waterfall, a flower, a pet, favorites music etc,. One should also
identify not so helpful thoughts; I’m stupid, I’m fat, nobody likes me. One should identify the
negative thoughts that are more bothersome.
Compartmentalization
Compartmentalization of thought is the deliberate decision to think negative thoughts at specified
times of the day. During the allotted time one thinks about worry, guilt, or jealousy. One de not
allows oneself to think these thoughts at other times of the day.
Environmental changes
Environmental changes can be designed to reduce stress. This may be as extreme as changing jobs
or residence, or as minor as painting a room a favourite color or adding a picture, candle, or basket.
The short time inconvenience of remodeling may be worth the long-term stress reduction.
Temporary changes in jobs can add variety and stimulation.

Humor
Humor related to an attitude toward life is most likely to reduce stress. There is a cluster of
qualities that characterize this frame of mind, including flexibility, spontaneity, unconventionality,
shrewdness, playfulness, humility, and irony. These are qualities that can be developed.
Centering
Centering helps reduce stress by bringing the mind and body back into balance. With left sided
dominance, intuitive, aesthetic, and creative functions are reduced under stress. To center oneself,
one puts one’s tongue on the “centering button”, which is about one quarter of an inch behind the
upper front teeth. This spot apparently stimulates the thymus gland, weakens the effect of stress,
and balances the cerebral hemispheres. Other activities that seem to balance the 2 hemispheres af
the brain include reading a poem in a rhythmic fashion; listening to a person with soothing voice;
listening to classical music; looking at pictures of pleasant landscapes etc,. Good posture and deep
slow breathing are also beneficial.
Exercise
Regular, vigorous exercise can also help one withstand chronic stress. It develops greater
capacities in several areas of function. It increases the strength of the cardiac contractions, the size
of the coronary arteries, the blood supply to the heart, the size of the heart muscle, and the blood
volume per heartbeat. It increases lean muscle mass and functional capacity during exercise. It also
reduces strain nervous tension resulting from psychological stress and reduces the tendency for
depression.
Sleep
Sleep is also important for dealing with stress. Physical (exercise, digestive problems), emotional
(anger, fear, guilt) and nutritional ( alcohol, caffeine consumption) factors affects sleeping
patterns.
Massage
Massage can relieve tension, provide a passive form of exercise, and foster tactile communication.
It stimulates relaxation and flexibility. Self massage can be done from a chair. It can be done as a
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full body massage or to a part of the body that is particularly tense. Massage is done in circular
motions. Full body massage can be done after a warm bath at bedtime to foster sleep.
Progressive Relaxation
Progressive relaxation may also be used to foster sleep. It is the conscious contraction and
relaxation of muscles. By deliberately tensing muscles, one can learn to identify what muscles are
tight and learn to relax them. It can be used before, during or after an anxious situation. If done
routinely once or twice daily, it can help keep one’s anxiety level down.
During progressive relaxation, one tenses specific muscles to a maximal degree and notes how
tight the muscles feel for about 5 seconds. Then the muscle is relaxed, and the pleasant feeling of
relaxation is enjoyed for about 10 seconds. For a head to toe progression, one starts by wrinkling
up the forehead and noting where it feels particularly tense. Then one relaxes that part slowly,
identifies the muscles that are relaxing, notes the difference between tension and relaxation, and
enjoys the relaxed feeling.
Biofeedback
Biofeedback uses mechanical devices to gain self-regulation to control autonomic responses. The
galvanic skin response uses electrodes attached to the fingertips to measure skin resistance, which
is moisture of the skin that indicates nervousness. Arteries contract under stress and dilate with
relaxation. A thermister on the finger detects changes in peripheral skin temperature that are
associated with activity of the smooth muscles in peripheral arteries. This skin temperature is
particularly useful for migraine headache control. Because the instruments convert skin resistance,
skin temperatures, brain waves and muscle tension into readily observable signs, people can tell if
they are controlling their body responses or not. They can also learn to read and interpret body
signals without the use of instruments to modify their autonomic responses.
Autogenic training: Self-hypnosis
Autogenic training produces deep relaxation through self-hypnosis. These regular but brief
sessions of passive concentration on physiologically adapted stimuli reduce other extraneous
stimuli, and they have helped people with asthma, arthritis, constipation, hypertension, migraine,
and sleep disturbances.
Each autogenic training session should last 2-20 minutes, preferably 20 minutes, 2-3 times daily.
There are 6 phrases; the first phrase focuses on heaviness, the second on warmth, the third on
heartbeat, the fourth on breath, the fifth on solar plexus and the sixth on the forehead. When
learning autogenic training; only one phrase should be added at a time, one per week, until all six
are being used each session.
Meditation
Meditation focuses attention on an experience, helps one become aware of one’s response, and
facilitates the integration of the physical, mental emotional and spiritual aspects of one’s life.
There are many methods for meditating. One may focus on an object such as a candle or chant,
listen to music, or meditate on one’s own breath.
Visualization and Mental imagery
Visualization and mental imagery can be used to relax. One starts in a relaxed position and
visualizes pleasant thoughts. One can imagine being in a favourite place such as on a sandy beach,
in the mountains, or in front of a fireplace in a favourite room listening to music. One can
concentrate on the sights, sounds, smells, tastes, colors and feelings of the pleasant thoughts.
Poetry
Poetry reading or writing is useful for reducing tension, particularly if one is depressed and
movement and verbalizing have not worked sufficiently. Poems are chosen for their rhythm, their
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mood, and feelings expressed. Poems can be read in a one-to-one or group meeting. Discussions
about the meaning can help verbalize feelings.
Music
Soft classical music can help release feelings and emotions and bring about relaxation.
Baths
Water is a relaxant. One should fill the bathtub with water that is at body temperature and immerse
oneself up to one’s neck for about 15 minutes. Hot tubs and swimming pools can also be used for
water therapy.
Enhancing Self-Esteem
Positive affirmations can be used to enhance one’s self-esteem. One can become more comfortable
with positive thoughts about oneself and decrease the amount of self devaluation. Several methods
can be used. One might imagine positive scenes and see oneself as one wants to be. One can repeat
positive affirmations such as- I am happy; I am healthy, or I am beautiful. One can also write
positive affirmations on cards, put them in conspicuous places and read them often. People may
take turns making positive comments about each other.
Enhancing Self-Esteem by:
- Positive affirmations
- Positive images
- Positive self-talk
- Positive writing
- Support of others.
- Support groups
- Support systems are synergistic. Some can accomplish more through support groups than by
themselves. Support groups provide a feeling of being accepted, valued, loved and esteemed,
as well as a sense of belonging. In addition to providing emotional support, support systems
help provide a social identity and are a source of information, services and material aid.
- The several types of support systems. Eg: Family, support from friends, colleagues, voluntary
service groups, self-help groups, peers, professional support systems.
Protection from workplace violence
Dysfunctional families, anger, anger about illness and ding, disgruntled workers, and
subsequently workplace violence are too common. People may express their stress through
violence.
Establish a zero-tolerance policy for violent behavior. Identify patients with history of aggressive
or violent behavior, and communicate this behavior to staff while maintain confidentiality.
Transfer violent patients to units with higher staffing ratios or with staffs trained to deal with
violent behavior. Don’t let employees work alone in isolated units or units with walk-in patients.
Don’t allow employees to be alone with patients during intimate physical examinations. Don’t let
employees enter seclusion rooms alone.
OTHER STRESS REDUCTION IDEAS
There are many ways to reduce stress, depending on the situation and the person, including:
 Putting job stress in perspective: jobs are temporary, but friends, families, and health aren’t. If
your employer can’t or won’t change, begin looking for a new job.
 Modifying your work situation: If you like your employer but the job is too stressful, ask about
tailoring your work to your skills or making a lateral transfer.

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 Taking a break: Walk away from a stressful situation that you feel unable to handle at the
moment. Take a walk up a few flights of stairs or out in the sunshine, doing a meditation, have
a cup of tea etc,.
 Organizing your work place: clutter and disorganization can increase a sense of loss of control.
 Keeping track of accomplishments: keep a to-do list, and cross off each item as you complete
it.
 Rewarding yourself for your achievements: Your boss may not notice, but you should. Take
yourself (or a friend) out for a nice dinner or cook at home together, and present yourself with
a certificate of achievement. Don’t forget to hang it on your wall and take pictures to carry
around to remind you of your accomplishment.
 Using your support system: Talk out your frustrations and stress with supportive others. Ask
for suggestions, but carefully weigh putting them into action until you have thought them
through.
 Cultivating allies at work: Make a pact that you will support each other when you encounter
stress.
 Finding humor in the situation: share a joke or a funny story with friends or colleagues.
 Stopping micromanaging: No situation is perfect, and no person is, either. Change your motto
from “Everything must be perfect” to Everyone must perform at the highest level possible
given the situation”.
 Avoiding negative people and situations: Maintain a positive attitude by relaxing, using coping
skills, and making good nutritional decisions. Don’t allow negativism to suck the energy and
motivation out of you.
 Distinguishing between stress you can change and stress you can’t change: Write down
stressors affecting you and separate them into those you can change and those you can’t. focus
on those you can change. Prioritize this list, and go to work.
 Following a healthy lifestyle: Eat healthy foods.
 Finding time to be alone: Turn off cell phones, and other forms of technology. Put a “do not
disturb” sign on your door. Defend your time alone ruthlessly.
 Keeping a stress diary: Note when you feel stressed, and begin to notice patterns so that so that
you can intercept stress and reduce it.
 Cutting back on commitments: talk to your boss and family about making a workable solution
to over scheduling.
 Developing a hobby: Make sure that whatever you choose is low stress and non competitive.
 Spending time outdoors: like engage in gardening. Go for a walk in fresh air.
 Writing in a journal: Keep a journal by your bedside, and write about your best moments that
day.
 Speaking with your nurse manager: talk about an over whelming assignment, and ask for
smaller assignments.
 Speaking to the unit educator: ask for help with prioritizing your workload.
 Saying no selectively: learn to say no appropriately. Take an assertiveness course, if necessary.
 Being empowered by what you do: you are a nurse who helps people, keep that in focus.
ORGANIZATIONAL APPROACHES TO JOB STRESS
Organizations have tried quick fix solutions (higher salaries, housing, benefits and flexible
scheduling) to increase nurse retention. These actions hide the real problem and underlying causes.
An organization must nourish and care for its staff, or it will become sick- and the stuff will
become sick, too.
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Recent studies of so called healthy organizations suggest that policies benefiting worker health
also enhance profits. A healthy organization is defined as one whose workforce has low rates of
illness, injury, and disability and is itself competitive in marketplace. Research from the National
Institute for occupational safety and Health has associated healthy, low stress work and high levels
of productivity with organizations that:
- Recognize employees for performance
- Offer opportunities for career development
- Foster an organizational culture that values the individual worker.
- Make management decisions that are consistent with organizational values.
Judkins, Reid, and Furlow (2006) say that organizations can cultivate hardiness by institutions
policies that promote:
- Collaborative practice
- Self-scheduling
- Shared governance
- Staff education on coping with stress.
The nurse manager should not only teach the staff about stress reduction measures but also should
bring in a consultation to recommend ways to improve working conditions. Such a direct approach
involves identifying stressful aspects of work, including excessive workload and conflicting
expectations, and designing strategies to reduce or eliminate stressors. The advantage of this
approach is that it deals with the roots causes of stress. Several of the nurses who had grown
comfortable with work routines and schedules fought the suggested changes; they eventually left
the unit. Although not everyone reported a large reduction in job stress, most staff did.
A combination of organizational change and stress management can be the most useful approach
for preventing stress at work, especially when the organization is sick. In this case, nurses must
tune in to their own stress and empower themselves with personal stress management procedures,
including assertiveness skills. Empowerment can help nurses be more assertive and raise their
voices regarding the dangers of the practice environment.
Suggestions on changing the organization to reduce job stress
 Ensure the workload is in line with worker capabilities and resources
 Design jobs to provide meaning, stimulation, and opportunities for workers to use their skills.
 Clearly define staff roles and responsibilities.
 Give employees opportunities to participate in decisions and actions that affect their job.
 Improve communications and reduce uncertainty about career development and future
employment prospects.
 Provide opportunities for social interactions among workers.
 Establish work schedules that are compatible with demands and responsibilities outside the job.
Implementing a Stress Prevention Program
At a minimum, preparation for a stress prevention program should include:
- Building general awareness about the causes, costs, and control of job stress.
- Securing top management’s commitment and support for the program
- Incorporating employee input and involvement in all phases of the program
- Establishing the technical capacity to conduct the program, including specialized training for
staff or the use of stress consultants.
It may not always be clear that job stress is high. Sometimes employees are fearful of losing their
jobs and hide the signs of stress a lack of obvious signs is not a good reason to dismiss concerns

914
about job stress. The National Institute for Occupational Safety and Health suggests a problem-
solving approach to prevention.
Step 1: Identify the problem
Ways to identify job stress include:
 Holding group discussions with employees
 Designing and administering an employee survey that measures perceptions of job
conditions, stress, health, and satisfaction.
 Collecting information about absenteeism, illness, and turnover rates or performance
problems to gauge the scope of job stress.
 Analyzing the data to identify problems and stressful job conditions.
Step 2: Design and Implement Interventions
Once information has been collected and analyzed, the stage is set for designing an intervention
strategy. On small units, informal discussions may provide fruitful ideas for prevention. In larger
organizations, a team may be asked to develop recommendations alone or in concert with outside
experts.
Sub steps include:
- Targeting the sources of stress
- Proposing and prioritizing intervention strategies
- Communicating planned interventions to employees
- Implementing interventions.
Step 3: Evaluate the Intervention.
Short and long –term frames for evaluating interventions should be established. Evaluations should
include objective measures, such as absenteeism and healthcare costs, and subjective measures,
such as employee perceptions of job conditions, stress, health and satisfaction.

CHAPTER- XII Jennifer mary

“Ethical committee, Code of Ethics& Professional Conduct”

1.INTRODUCTION:
To the extent that nursing as a profession has altruism motivation, ethics is the foundation for
nursing practice. Altruism means that nurses are motivated to act best interest and welfare of
their clients, in other words, nurses have an ethic of care. Ethics is the system of beliefs about
what is rigor or wrong, good or bad, in human conduct and helps us make decisions about what
constitutes moral conduct and moral judgment. To be ethical is to acts as an independent moral
agent who accepts responsibility for ones actions.

Ethical decision-making is not same as legal decision-making. Nurses have an obligation to

practice within the law as written by the legislature, interpreted by the courts, and written into the
administrative rules of agencies given by the authority under the law. Law is the system of
manmade rules and regulations by which a society is governed and through which people can live
together.

Decision making in nursing practice involves complex interplay of a system of ethics and legal
mandates. Primarily laws at times determine our actions, at time by ethics, and at times by a
combination of the two laws.
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2. TERMINOLOGY

 Accountability: Responsible for ones action expected to explain them

 Assertiveness : Being confident or forceful
 Autonomy : Refers to a person’s right to make individual choices
 Beneficence : It is the promotion of good
 Code :A system of words, figures, or symbols used to represent others, especially for the
purpose of secrecy
 Conduct:The way in which a person behaves
 Ethics :A set of moral behavior
 Justice :It is moral rightness, fairness, or equity
 Law :It is a body of rules of action or conduct prescribed by a controlling authority
 Morals : Are standard of conduct that represents the ideal in the human behavior.

3. DEFINITION
Ethics is systematic enquiry into principles of right or wrong conduct, of virtue and vice, and
of good and evils as they relate to conduct
(or)
It is the branch of philosophy that systematically examines behavior to determines what
constitutes good, bad, right and wrong in human behavior and provide guidance for moral action.

4. ETHICAL THEORIES:
Deontological (from the Greek “deon” or duty) theories:

Deontologicaltheories focus on the intent of the action and are duty and rights based. Emphasis
is on individual rights, duties, and obligations and the dignity of human beings. The intention of
the action rather than the end of the action is considered. The intent is considered moral if it
follows an impartial and objective principle.

Teleological (from the Greek “telos” or end) theories

Teleological theories derive the rules and norms for conduct from utilitarian consequences of
actions. They favor the common good. Right has good consequences, and wrong has bad
consequences. The greatest amount of good and the largest amount of happiness are good.

Principlismtheories

Principlism is a deontological theory that includes ethical principles. The ethical principles
control ethical decision making more than the ethical theories. The principles are moral norms,
including autonomy, beneficence, fidelity, justice, nonmaleficence, paternalism, respect for others,
utility, and veracity. Each principle can be used individually, but they are often used in concert.

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Utilitarianism
Utilitarianizm is a consequentialist theory that considers a good act as one that causes the least
harm and brings the most good to the most people.
Egoism theories
Egoism is based on self-interest and self-centeredness. Decisions are made for personal comfort.
It is based on the principle that the right decision is the one that brings pleasure to the decision
maker.
Relationships theories
Relationships is caring-based theory that emphasizes generosity and promoting common good for
the welfare of the group rather than individual rights.
Obligationismtheories
Obligationism is a theory that tries to balance distributive justice (dividing equally among all
citizens regardless of age, gender, race, religion, or socio-economic status) and beneficence (doing
good and not harm). One should do what is good and prevent harm and evil. It is useful for
determining public policy.
Social contract theory
Social contract theory is based on a concept of original position and considers the least advantaged
persons in society as the norm. the determination of what is right or wrong is from the perspective
of the lease advantaged people, such as children or handicapped people. It is based on distributive
justice and supports giving the most to the least advantaged.
Natural law theories
Natural law is called the virtue of ethics. Actions are considered right when in accord with
human nature. People should do good, avoid evil, and have opportunities to reach their potential.
Happiness occurs when people thing rationally and make conscious choices rather than responding
to instincts).
5. ETHICAL DECISION MAKING MODEL :
Nurses must learn how to make ethical decisions and nurse managers / leaders must direct and
guide nurses in making such decisions. Nurses , in increasing numbers , are being invited to
participate on ethical committee .
(i) “ MORAL “ Model of ethical decision making
M:Massage the dilemma .
 Identify and define the issues in the dilemma.
 Consider the options of all the major players in the dilemma and their value systems.
 This includes patients , family members, nurses, physicians, clergy, and any other
interdisciplinary health care members .
O: Outline the options.
 Including those that are less realistic and conflicting stage is designed only for considering
options and not for making a final decision.
R: Resolve the dilemma.
 Review the issues and options applying basic principles of ethics to each option.
 Decide the best option , based on the views of all those concerned in the dilemma.

A : Act by applying the chosen option.

 This step is usually the most difficult because it requires actual implementation , whereas the
previous steps require only dialogue and discussion.
L : Look back and evaluate the entire process , including the implementation.
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  No process is complete without a through evaluation.
 Ensure that those involved are able to follow through on the final option.
 If not a second decision may be required one and the process must start again at the initial
step

5.2. A BIOETHICAL DECISION MODEL

Review the situation to determine health problems, decision needed,

Step One
ethical components, and key individuals

Step Two Gather additional information to clarify situation

Step Three Identify the ethical issues in the situation

Step Four Define personal and professional moral positions

Step Five Identify moral positions of key individuals involved

Step Six Identify value conflicts, if any

Step Seven Determine who should make the decision

Step Eight Identify range of actions with anticipated outcomes

Step Nine Decide on a course of action and carry it out

Step Ten Evaluate / review results of decision / action

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Bioethics Decision-Making Model

Articulate the dilemma. This may be phrased as a

statement or question, but should summarize the
problem clearly and succinctly. List at least 10
legal, medical, and social facts about the issue.

Identify the who and what will be affected by your

decision. Who has a vested interest in the
outcome? Think of as many stakeholders as
possible including non-human entities like the
environment, and past or future stakeholders who
will be affected.

Identify the values that play a role in the decision.

What values do you have that will affect your
decisions? What about the values of society?
What are the legal implications, if any? Describe
the moral, legal, and social concerns others may
have.

Present possible solutions and describe each one.

Include ALL options even those you don’t agree
with. Rank the possible solutions from best to
worst. Choose the one which seems to make most
sense to you as an individual.

Explain WHY your choiceseems like the best.

Whatpersonal values areinvolved in making
thisdecision? Are you entirelysatisfied with this
choice?Why or why not? Willothers be happy with
yourchoice and why? Referback to the rest of
yoursheet for help in thedecision.

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6. PRINCIPLES OF ETHICS

IMPLICATIONS FOR NURSING

PRINCIPLE MORAL RULE
PRACTICE
Autonomy Respect the rights Provide the information and support patient
(Self- of the patients or and families need to make the decision that is
determination) their surrogates to right for them; at times, this may be mean
make health care collaborating with other members of the
decisions health care team to advocate for the patient
Nonmaleficence Avoiding causing Seek not to inflict harm: seek to prevent harm
harm or risk of harm whenever possible
Beneficence Benefit the Commits yourself to actively promote the
patient, and patient benefit (health and well-being or good
balance benefits dying). Be sensitive to the fact that the
against risks and individuals (patients, family members and
harms care givers) may identify the benefits and
harms differently. A benefit to one may be a
burden to another
Justice Give each his or Always seek to distribute the benefits, risks
her due: act fairly and cost of nursing care justly. This may
involve recognizing subtle instances of bias
and discrimination.
Fidelity Keep promises Be faithful to the promise you made the
public to be competence and to be willing to
use your competence to benefit the patients
entrusted to your care. Never abandon a
patient entrusted to your care without first
providing for the patient’s needs.

7. ETHICAL POSITIONS
An ethical dilemma occurs when there is no correct decision, there is a conflict between two or more
ethical principles, or a decision needs to be made between two equally unsatisfactory choices. There are
several ethical positions that do not solve dilemmas. However, they do provide ways to structure and clarity
them.

Utilitarianism
Utilitarianism is a community-oriented position that focuses on the consequences and prefers the greatest
amount of good and happiness for the most people, or the lease amount of harm.

Egoism
In contrast, egoism seeks solutions that are best for oneself without regard for others. One’s own pleasure is
the concern.
Formalism
Formalism considers the nature of the act and the related principles without thought to personal position or
consequences of the actions: be honest; remember the golden rule.
Rule ethics

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Rule ethics expects obedience to laws, rules, professional codes, and authority.
Fairness
Fairness considers distribution of benefits and liabilities from the viewpoint of the least advantaged
population. Benefit to the least advantaged group is the norm in this type of decision making.

8. ETHICS COMMITTEES
Ethical committee a committee appointed to consider ethical issues.The importance of ethics committees in
nursing homes consists in their ability to balance reasonable treatment and guidance with the respect and
dignity that comes as a right to all residents. The basic approach of ethics committees then is to maintain a
healthy relationship between caregivers (at all levels) and residents so that the former are permitted to do
their job and maintain a reasonable quality of life for all involved while not treating their charges as objects
of a routine.
Members of ethical committee :
The obvious answer is anyone with a deep commitment to medical ethics. It is important not to skew
membership by having several persons from the same discipline. It is also essential to ensure representatives
of:
 administration
 clinicians - medical, surgical, other disciplines
 basic sciences
 social workers
 nurses
 rehabilitation personnel
 priests/philosophers
 lawyers
 statisticians
9. INSTITUTIONAL ETHICAL COMMITTEE :
Specific members of IECs

 Chair should preferably be from outsidethe Institution and not head of the sameInstitution to maintain the
independenceof the Committee.

 Member secretary, from same institutionshould conduct the business of the

Committee
Members of IEC:
Chair

 1-2 basic medical scientists

 1-2 clinicians from various institutes
 One legal expert or retired judge
 One social scientist/representative of NG
 voluntary agency
 One philosopher/ethicist/theologian
 One lay person
 Member Secretary
 If required, subject experts could be invited to offer view

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Functioning of IECs
Described in terms of;
 Review procedures
 Decision making processes
 Documentation requirements
Review Procedures:

 Scientific evaluation should be completed before ethical evaluation

 Evaluate possible risks to the subjects with proper justification
 Expected benefits
 Adequacy of documentation for ensuring privacy, confidentiality and justice issues
 The ethical review should be done through formal meetings and should not resort to decisions through
circulation of proposals
 Decisions are preferably arrived at by consensus
Steps towards the IEC meeting – I
 Prefixed dates for routine IEC meetings.
 Submissions made by researchers inkeeping with the requirements of the IEC’s.
 Finalizing primary and secondary reviewers.
 The proposals circulated to membersgiving sufficient time for review.

Steps towards the IECmeeting – II

 The members undertake the review.
 The meeting of the IEC.
 Discussions at the IEC.
 Decisions made.
 The process and decisions areDocumented.
 These decisions and the reasons are communicated to the researchers.

Decide
Submissions Primary
IEC Send
made by and Review
Date Proposals
Researchers Secondary
fixed
reviewers

Documenting
The IEC The The the
Meeting discussions Decision discussions
and decision

Communicate Revisions /
the decision to Resubmissions /
researchers Cleared
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Preparatory phase: steps 1-4

Step 1. Prefixed dates

 Need to be finalised in advance
 This helps researchers develop, finalise the materials.
 Plan in advance.
Step 2.Submissions to the IEC
 Knowledge of the dates facilitates timely submissions

Step 3. Primary and secondaryreviewers

 The secretariat of the IEC sorts throughthe proposals, allocates primary andsecondary reviewers for the
proposals thatneed full review.

Step 4. Sending of proposals

 Proposals are mailed to all members.
The Review Phase: Steps 5-9

Step 5. The review

 The members review the proposal keepingin mind the subjects (vulnerability, etc),the process(consent,
requirements forprivacy and confidentiality etc), the studyrequirements (risks/benefits etc).
 Seeks and obtains clarifications ifNecessary.
Step 6. The IECmeeting
 Presided over by thechair
 The members have donetheir homework!
 Attend meeting andengage in discussion
 If further clarificationsneeded, ask for the PI tobe present
 Discuss and discuss

Step 7. The discussions

 The various members raise concerns regardingaspects of proposal
 Many of the issues are clarified by within groupdiscussions
 Usually the guidance from the ICMR guidelinesand the various govt. regulations are referred toalready
by specific members when there arecontentious issues
 In case these are not adequate, the membersalso use other guidelines and use scholarlyjournals for
additional support for decisions

Step 8. The decision

 Usually all concerns are adjusted into the decisionby way of recommendations to be taken intoaccount
before giving clearance
 In case the requirements are trivial, the MS isauthorised to obtain clarifications and giveclearance

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 In case additional information is needed or theclarifications need further review, a sub-committeemay be
appointed or resubmission recommended

Step 9. Documenting the decisions

 The member secretary keeps track of thediscussions and decisions
 Compiles the minutes and has them sent toall members present for corrections if any
 Once these are returned, s/he prepares theminutes for approval by Chair.
Step 9. The communication with theresearchers
 The MS communicates these decisions tothe researchers and also advices them onwhat is necessary in
case of anyrecommendations that call for changes
 Decision making process
 If necessary the PI may be invited to present the protocol or offer clarifications.
 Representatives of interest groups can be invited during deliberations to offer their viewpoint
 Subject experts views can be invited, but they should not form a part of the decision making process.
Their opinions must be recorded

The Final Phase:The decision

The decision making
Step10. The decision:
 Out right approval (at most, only very minor changes are suggested. The application contained all
necessary information.)
 Approval with modifications (there is enough information to judge the study, but clarification or changes
are needed)
 Resubmit with more information (there is not enough information to judge the application appropriately
 Outright disapproval (there is no way the
 researcher can ethically do study)

DOCUMENTATION REQUIREMENTS

Record Keeping Requirements

 Meetings must be minute and approved and signed by chair
 Strict confidentiality
 All documentation, including final reports of the study, microfilms, CDs and video recordings need to be
kept safe for about 15 years (currently revised to a minimum
 of 3 years)
Responsibilities of IECMembers
 To provide competent review of all ethical aspects of the project
 Undertake review free from bias and influence
 Provide advice to the researchers on all aspects of welfare and safety of research participants

1. To provide competent review of all ethical aspects of the project

 Undergo appropriate training to enhance competence
 To maintain confidentiality of
documents obtained and discussions during the review process
 To allocate time for reviewing the proposals

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2. Undertake review free frombias and influence
 Need to put on record various interests,financial or otherwise to avoid conflict of interest
 Reflexivity about the nature ofengagement with protocols
 Non-judgmental and unbiased decisionmaking

3. Provide advice to the researchers on all aspects of welfare and safety of research participants
 Need to build capacity of researchers
 Provide ongoing review
 Monitor the taking of consent
 Keep oneself informed of the research process and re-review when ever necessary

10. HOSPITAL ETHICAL COMMITTEE :

Most Indian hospitals have instituted such a committee principally for the purpose of checking whether
proposals submitted for research meet established guidelines. Once this has been established, the researcher
is permitted to proceed with his work and the committee turns to subsequent proposals. This approach make
a very limited usage of the personnel recruited on such a committee. Much more can be done to improve not
only the quality of research undertaken by the institution but also the care of patients in the institution.
The Hospital Ethics Committee (hereafter referred to as “the committee”) will have three functions or roles:

A.Education
In cooperation with the hospital administration, its various departments and divisions, and its
medical/nursing and allied health professional staff, the committee will undertake educational efforts in
clinical ethics. Depending on the availability of resources, the committee will develop or assist others in the
development of lectures, seminars, workshops, courses, rounds, in-service programs and the like in clinical
ethics. The aims of these educational efforts will be to provide participants with access to the language,
concepts, principles and body of knowledge about ethics that they need in order to address the complex
ethical dimensions of contemporary hospital practice.
B. Policy Review and Development
The committee will assist the hospital and its professional staff in the development of policies and
procedures regarding recurrent ethical issues, questions or problems that arise in the care of patients. In this
role the committee may provide analysis of the ethical aspects of existing or proposed policy or assist in the
development of new institutional policy in areas of need.
C. Case Review
An important function of the committee will be its role as a forum for analysis of ethical questions which
arise in the care of individual patients. In most circumstances these questions concern appropriate care of
patients with diminished capacity to participate in decision making regarding their care. In this role the
committee will attempt to provide support and counsel to those responsible for treatment decisions including
health care providers, patients, surrogates and members of the patient’s family.

Case review is particularly recommended in three specific categories of decision making:

1. decisions involving significant ethical ambiguity and perplexity in which case review may provide
insight into complex ethical issues;
2. decisions involving disagreement between care providers or between providers and patients/families
regarding the ethical aspects of a patient’s care; or
3. decisions that involve withholding or withdrawal of life-sustaining treatment which are not
adequately addressed in policies and procedures included in this Handbook.

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In this role the committee will not act as a decision-making body, but will attempt to assist and to provide
support to those who do have this responsibility. Its role in all such cases shall be advisory.
II. Appointment and Membership
The committee membership will be multidisciplinary. A majority of the membership will be non-physicians.
Additional membership will include as available at least the following disciplines: nursing, social work,
pastoral care, clinical ethics, law, respiratory care, and dietetics and nutrition. In view of the unique ethical
problems involved in situations involving pregnant women, one physician member shall be from the
Department of Obstetrics and Gynecology. The Chief Executive Officer of the Hospital (or designee), the
Chief of the Medical Staff (or designee), and an attorney employed by the Medical Center shall be ex-officio,
non-voting members. The committee will also identify and nominate for appointment at least one
community representative who is not an employee of the Medical Center.
Members will be approved Committee and the Chief Operating Officer of the Hospital. The Medical
Director of Hospital Ethics will serve as the Chair. The Vice-Chair of the committee will be chosen by the
membership of the committee. It is recommended that the Vice-Chair be identified from among those who
have served on the committee at least one year.
III. Jurisdiction
In view of the establishment of a Pediatric Ethics Committee as a standing sub-committee (see “Policies and
Procedures of the Pediatric Ethics Committee”), the mandate of the committee will be to engage in its
functions of education, policy development and case review as these relate to the care of patients who are
adults, i.e. 18 years of age or older. The committee’s jurisdiction will also include the unique ethical issues
involved in decision making involving pregnant women when gestation is felt to have progressed to the stage
of fetal viability. Policies and procedures and all non-case review activities of the Pediatric Ethics
Committee are subject to the review and approval of the Hospital Ethics Committee.
IV. Procedures
A. Educational Functions
A primary educational emphasis for the committee is its own education and mechanisms to ensure its
continuing education. The field of clinical ethics is a new, broad and rapidly evolving one. In order to
maintain an appropriate level of expertise, the committee will develop means of providing members
information about clinical ethics and access to the rapidly expanding body of literature in this field. Methods
may include orientation of new members, specific reading assignments, an annual retreat, seminars, mock
case/policy review exercises and the like. In addition, the committee may participate in networking with
other area/regional ethics committees, such as the Greater Kansas City Ethics Committee Consortium of the
Midwest Bioethics Center, and participate in continuing educational programs for ethics committee members
as feasible.
Any educational efforts undertaken by the committee for members of the hospital staff will be coordinated
with existing educational efforts as much as possible. Primary emphasis will be on assisting departments and
divisions to incorporate material about the committee and the field of clinical ethics into their existing
educational programs and activities.
B. Policy Review and Development Functions
At the request of the Chief Operating Officer of the Hospital, the Chief of Medical Staff, or the Executive
Committee of the Medical Staff, the committee will undertake review of any existing policy, protocol or
procedure; provide analysis of the ethical issues involved; and, provide recommendations regarding
appropriate modifications, where needed. With the approval of the Chief Operating Officer of the Hospital,
the committee may also undertake such review at the request of any member of the hospital staff.
In addition, when requested, the committee will assist the hospital and/or its staff in the development of new
policies in areas that involve significant ethical questions or problems. If the committee feels that there is a
926
need for policy development in order to address a significant ethical issue, it will submit a written
recommendation to this effect to the Chief Operating Officer of the Hospital and request permission to
develop a policy statement. Any recommendations for modification of existing policies or development of
new policy must be submitted in writing to the Chief Operating Officer of the Hospital.
C. Case Review
1. Access to Committee. A case review team will be available on-call to respond to requests for case
review at all times. A roster of team leaders and members will be available through the Hospital
Operator. A member of the committee will attempt to have an initial discussion with the person
making the request within twenty-four hours of the request, whenever possible. The Team Leader
will undertake case review only in response to a reasonable and appropriate request for review by
either (1) any of the following persons who is involved in the case: a member of the medical staff,
house staff, hospital staff, or hospital administration, or (2) the patient, patient’s guardian, surrogate
or a member of the patient’s family. Prior to proceeding with the consult, the Team Leader will
notify the patient’s designated attending physician of the request for review, discuss the possible basis
for the review and request his/her support and involvement.
2. Informal and Formal Case Review. Committee members will be available to provide advice
regarding a case in both an informal and formal manner. The remaining portions of this section (C)
relate only to requests for formal case review. In the case of a request for informal case review, no
documentation of the comments of any committee member will be placed in the patient’s medical
record. Informal requests for case review will, however, be reported by the involved committee
member to the full committee at the next regularly scheduled meeting of the committee.

3. Determination of Need for Review by Full Team. Following the receipt of a request for case
review, the Team Leader will determine whether or not there is a need to present the case before the
full team. In most situations, there is likely to be no such need, and the Team Leader can, on his or
her own, proceed to review the case, and provide a recommendation, as is otherwise described in the
remainder of this section. Formal case review by the entire team will most likely be advisable in cases
that involve especially complex ethical issues.

4. Preparation for Review Team Meeting. Following a decision by the Team Leader that it is
appropriate to have review by a team, the team will consist of two to five members of the committee
and will reflect the multi-disciplinary composition of the committee. The team leader will review the
request to determine the nature of the case, the status of the patient, the ethical question(s), concern(s)
or problem(s) prompting the request and any other information needed in order to determine if review
is appropriate.

If in the judgment of the leader of the case review team the request is appropriate, he/she will contact the
patient’s physician to discuss the request, to request his/her participation and to schedule the case review
meeting. In addition, absent special considerations, the patient or the patient’s family or surrogate decision
makers, as the case may be, should also be notified that the case review will be taking place, and invited to
participate. Their decision not to participate, or their objection to the consult, should not prevent a formal
ethics consult from taking place, assuming the consult is otherwise determined to be appropriate by the team
leader. If the patient’s attending physician believes that ethics case review is not appropriate, this conflict
should be referred immediately to the Chief of Medical Staff for resolution. In the event of a persistent
conflict, the Chief of the Medical Staff will assist in the orderly transfer of responsibility to another attending
physician who is willing to permit the case review to go forward.

927
The members of the team may determine that it is appropriate to invite other participants to some or all of the
meetings in which the team discusses the case. Among those persons who might be invited so such meetings
are: members of the professional staff who are directly involved in providing care to the patient; resource
personnel with special expertise; and the patient and/or members of the patient’s family.
If in the judgment of the case review team, the request for ethics case review is inappropriate, the team leader
will so inform the party requesting review and/or the attending physician. This action will also be reported to
and reviewed by the full committee at its next regularly scheduled meeting.
5. Conduct of Case Review Meeting. At the meeting the leader of the team will instruct all non-
members present regarding the advisory role of the committee; the intent of the committee to serve as
a supportive forum for those who have the primary decision-making responsibility; and the need for
strict confidentiality of all material presented and discussed.
If the patient’s attending physician and other health care providers are present, it will likely be appropriate
for them to present information to the review team regarding the history of the patient, the present condition
of the patient, the prognosis and any other material believed to be relevant to the case review. The leader
might then find it useful to ask those involved, including patient/family members if present, to describe what
specific ethical questions, problems or issues prompted the request for case review.
Following appropriate discussion of these and issues identified by members of the team, the team leader
may, if non-members were present during the earlier portions of the meeting, convene a “closed” (members
only) session in order to develop a specific recommendation if appropriate.
Members of the case review team may also decide before or after the case review meeting that formal review
of the case by the entire ethics committee is appropriate. In this case, the leader of the review team will
notify the Chair (or designee) who will convene an emergency meeting of the entire committee as soon as
possible.

6. Recommendations. The results of the case review and any recommendations will be communicated
to the individual who requested case review; to the attending physician; to other members of the staff;
and, to the patient/family as appropriate. Following these discussions, and with the concurrence of
the attending physician, the team leader will record the results of the ethics case review in the
patient’s medical record. These results will also be reported to, and reviewed by, the full committee
at its next meeting.
V. Meetings
The committee shall meet monthly in addition to any meetings called for specific case review. An agenda
will be developed by the Chair and distributed one week prior to the meeting. Meetings which do not
involve discussion of specific case material will be open to any member of the hospital community. Guests
and other interested parties will be allowed to attend at the discretion of the chair. For purposes of
conducting business, seven members shall constitute a quorum. Actions of the committee shall be taken by
the vote of a majority of the members attending the meeting. Each member will be required to attend at least
five of the committee’s regularly scheduled meetings each year. Failure to do so can be considered to
constitute a resignation and the vacancy shall be filled by appointment of a new member.
VI. Record Keeping
The committee will maintain minutes of all of its meetings which will include summaries of all case reviews
and recommendations. Minutes will be submitted by the chair for approval by the committee and forwarded
to the Chief Operating Officer of the Hospital. Records will not include identifying information about
specific patients, family members, individuals requesting case review or professional staff participating in the
case review process. These records will be maintained in accordance with hospital policy and applicable law
governing the confidentiality of records of medical review committees.
VII. Liability
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The Hospital will take whatever steps are necessary in order to provide liability protection for committee
members who do not have such protection by virtue of their status as members of the professional staff.
VIII. Adoption and Approval of Policies and Procedures
Policies and procedures of this committee will be reviewed as deemed appropriate by the membership of the
committee. Proposed modifications of approved policies or procedures will be submitted to the committee in
writing at least four weeks in advance of a regularly scheduled meeting. Following approval by the
committee, they will be forwarded to the Chief Operating Officer of the Hospital for review and approval.

11. THE ICN CODE OF ETHICS FOR NURSES

The ICN Code is remarkable in its brevity. It sets out very simply what the underlying values of nursing
are in detailing the four fundamental responsibilities :
a) to promote health,
b) to prevent illness,
c) to restore health, and
d) to alleviate suffering.

THE INTERNATIONAL COUNCIL OF NURSES CODE OF ETHIFCS FOR NURSES

An international code of ethics was first adopted by the International Council of Nurses (ICN) in 1953.
It has been revised and reaffirmed at various times since; most recently with this review and revision
completed in 2000.
THE CODE
The ICN Code of Ethics for Nurses has four principle elements that outline the standards of ethical
conduct.

1. Nurses and people

 The nurse’s primary professional responsibility is to people requiring nursing care.
 In providing care, the nurse promotes and environment in which the human rights, values,
customs and spiritual beliefs of the individual, family and community are respected.
 The nurse ensures that the individual receives sufficient information on which to base consent for
care and related treatment.
 The nurse holds in confidence personal information and uses judgment in sharing this
information.
 The nurse shares with society the responsibility for initiating and supporting action to meet the
health and social needs of the public, in particular those of vulnerable populations.
 The nurse also shares responsibility to sustain and protect the natural environment from depletion,
pollution, degradation and destruction.

2. Nurses and practice

 The nurses carries personal responsibility and accountability for nursing practice and for
maintaining competence by continual learning.
 The nurse maintains a standard of personal health such that the ability to provide care is not
compromised.
 The nurse uses judgment in relation to individual competence when accepting and delegating
responsibility.

929
  The nurse at all times maintains standards of personal conduct which reflect well on the
profession and enhance public confidence.
 The nurse, in providing care, ensures that the use of technology and scientific advances are
compatible with the safety, dignity and rights of people.

3. Nurses and the profession
 The nurse assumes the major role in determining and implementing acceptable standards of
clinical nursing practice, management, research and education.
 The nurse is active in developing a core of research-based professional knowledge.
 The nurse, acting through the professional organization, participates in creating and maintaining
equitable social and economic working conditions in nursing.

4. Nurses and co-workers

 The nurse sustains a cooperative relationship with co-workers in nursing and other fields.
 The nurse takes appropriate action to safeguard individuals when their care is endangered by a co-
worker or any other person.

ANA Code of Ethics for Nurses:

 The nurse, in all professional relationships, practices with compassion and respect for the inherent
dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic
status, personal attributes, or the nature of health problems.
 The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.
 The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
 The nurse is responsible and accountable for individual nursing practice and determines the appropriate
delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.
 The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and
safety, to maintain competence, and to continue personal professional growth.
 The nurse participates in establishing, maintaining, and improving health care environments and
conditions of employment conducive to the provision of quality health care and consistent with the values
of the profession through individual and collective action.
 The nurse participates in the advancement of the profession through contributions to practice, education,
administration, and knowledge development.
 The nurse collaborates with other health professionals and the public in promoting community, national,
and international efforts to meet health needs.
 The profession of nursing, as represented by associations and their members, is responsible for
articulating nursing values, for maintaining the integrity of the profession and its practice, and for
shaping social policy.
12.ELEMENT OF THE CODE ETHICS :
Element of the Code # 1: NURSES AND PEOPLE
Practitioners and Educators and National Nurses'
Managers Researchers Associations
Provide care that respects In curriculum include Develop position
human rights and is sensi- references to human rights, statements and guidelines
tive to the values, customs equity, justice, solidarity that support human rights
and beliefs of all people. as the basis for access to and ethical standards.

930
 care.

Provide continuing Provide teaching and Lobby for involvement of

education in ethical issues. learning opportunities for nurses in ethics review
ethical issues and decision committees.
making.
Provide sufficient Provide Provide guidelines,
information to permit teaching/learning position statements and
informed consent and the opportunities related to continuing education
right to choose or refuse informed consent. related to informed
treatment. consent.
Use recording and Introduce into curriculum Incorporate issues of
information management concepts of privacy and confidentiality and privacy
systems that ensure confidentiality. into a national code of
confidentiality. ethics for nurses.
Develop and monitor Sensitise students to the Advocate for safe and
environmental safety in the importance of social action healthy environment.
workplace. in current concerns.

Element of the Code # 2: NURSES AND PRACTICE

practitioners and Educators and National Nurses'
Managers Researchers Associations
Establish standards of care Provide Provide access to
and a work setting that teaching/learning continuing education,
promotes safety and opportunities that foster through journals, confer-
quality care. life long learning and ences, distance education,
competence for practice. etc.
Establish systems for Conduct and disseminate Lobby to ensure
professional appraisal, research that shows links continuing education
continuing education and between continual learning opportunities and quality
systematic renewal of and competence to care standards.
licensure to practice. practice.
Monitor and promote the Promote the importance of
Promote healthy lifestyles
personal health of nursing personal health and
for nursing professionals.
staff in relation to their illustrate its relation to
Lobby for healthy work
competence for practice. other values. places and services for
nurses.
Element of the Code # 3: NURSES AND THE PROFESSION
Practitioners and Educators and National Nurses'
Managers Researchers Associations
Set standards for nursing Provide Collaborate with others to
practice, research, teaching/learning set standards for nursing
education and opportunities in setting education, practice,
management. standards for nursing research and management.

931
 practice, research,
education and
management.
Foster workplace support Conduct, disseminate and Develop position
of the conduct, utilise research to advance statements, guidelines and
dissemination and the nursing profession. standards related to
utilisation of research nursing research.
related to nursing and
health.
Promote participation in Sensitise learners to the Lobby for fair social and
national nurses' associa- importance of professional economic working
tions so as to create nursing associations. conditions in nursing.
favourable socio-economic Develop position
conditions for nurses. statements and guidelines
in workplace issues.
Element of the Code #4: NURSES AND CO-WORKERS
Practitioners and Educators and National Nurses'
Managers Researchers Associations
Create awareness of Develop understanding of Stimulate co-operation
specific and overlapping the roles of other workers. with other related
functions and the potential disciplines.
for interdisciplinary
tensions.
Develop workplace Communicate Develop awareness of
systems that support nursing ethics to other ethical issues of other
common professional professions. professions.
ethical values and
behaviour.
Develop mechanisms to Instil in learners the need Provide guidelines,
safeguard the individual, to safeguard the position statements and
family or community when individual, family or discussion fora related to
their care is endangered by community when care is safeguarding people when
health care personnel. endangered by health care their care is endangered by
personnel. health care personnel.
CODE OF ETHICS IN HOSPITAL :
1. Hospital must recognize that the care of the sick is their first responsibility and a sacred trust, striving, at
all times, to provide the best possible care and treatment to all in need of hospitalization.
2. Hospitals, recognizing their unique role in safeguarding the nation's health, should seek through
compassionate and scientific care and health education, to extend life, alleviate suffering, and improve the
general health of the communities they serve.
3. Hospitals should remain and promote harmonious relationships within the organization, to insure the
proper environment for effective, efficient and equitable care and treatment of patients.
4. Hospitals should seek to inspire the confidence of the entire community and should appreciate and respect
the social and religious practices and customs of patients.
5. Hospitals, to the extent possible and within their limitations, should conduct educational projects,
stimulate research, and encourage preventive health practices in the community.

932
6. Hospitals should cooperate with other hospitals, health and welfare agencies, government and non-
government, and other recognized organizations engaged in activities related to the health of the country.
7. Hospitals, in reporting their work to the public, should give a factual and objective interpretation of
accomplishments and objectives without putting down directly or indirectly by implication, the work of other
hospitals or related organizations.
8. Hospital, cognizant of their social responsibilities, should actively support and encourage every effective
means which will ease the financial burdens of illness.
9. Hospital should be fair, honest and impartial in all their business relationships and utilize legal and
legitimate means in promoting their public relations.
10. Hospitals should be progressive in policies, personnel policies, and effort to maintain up-to-date
equipment, methods and standards of performance.
CODE OF ETHICS IN INSTITUTION
This Code of Ethics lays down general principles which can be used to determine action, which will conform
to the high standards and values expected in the public sector.
A. Overview of general values
1. In all College activities it is important to develop and promote a set of core values, relevant to its mission
to provide high quality learning opportunities for students.
2. As an institution within the public sector, the College accepts that those values must be in conformity with
the principles laid down by the Nolan committee for those holding public office, namely:
• selflessness
• integrity
• objectivity
• accountability
• openness
• honesty
• leadership
3. The College recognises its obligations to all those with whom it has dealings - students, employees,
employers, suppliers, other educational institutions and the wider community - and also to the public
generally, and more particularly, the taxpayer.
4. The reputation of the College, including the trust and confidence of those with whom it deals, is one of its
most vital assets, the protection of which is of fundamental importance.
5. The College demands and maintains the highest ethical standards in carrying out its activities.
6. In its dealings with individuals the College will adhere to the principles of natural justice and individuals’
civil and human rights.
7. The College will seek to encourage a culture of openness aimed at ensuring that matters connected with
the operation of the College can be discussed frankly with staff and students. It will adopt and maintain
procedures on whistleblowing which will enable concerns to be raised on a confidential basis, where that is
appropriate, both inside, and if necessary outside, the organisation.
8. The College is committed to securing equality of opportunity for staff and students alike and to
discharging its legal duties under relevant discrimination legislation.
CODE OF ETHICS IN RESEARCH:
Research underpins nursing's effectiveness and standing within the health services. The following statement
on the ethics of nursing research is intended to be read by all nurses who are in any way involved with
research, extending from the initial project approval and funding stages through to the use of research
findings as the basis for practice and education. In short it its relevant to all nurses.
Honesty

933
Strive for honesty in all scientific communications. Honestly report data, results, methods and procedures,
and publication status. Do not fabricate, falsify, or misrepresent data. Do not deceive colleagues, granting
agencies, or the public.
Objectivity
Strive to avoid bias in experimental design, data analysis, data interpretation, peer review, personnel
decisions, grant writing, expert testimony, and other aspects of research where objectivity is expected or
required. Avoid or minimize bias or self-deception. Disclose personal or financial interests that may affect
research.
Integrity
Keep your promises and agreements; act with sincerity; strive for consistency of thought and action.
Carefulness
Avoid careless errors and negligence; carefully and critically examine your own work and the work of your
peers. Keep good records of research activities, such as data collection, research design, and correspondence
with agencies or journals.
Openness
Share data, results, ideas, tools, resources. Be open to criticism and new ideas.
Respect for Intellectual Property
Honor patents, copyrights, and other forms of intellectual property. Do not use unpublished data, methods, or
results without permission. Give credit where credit is due. Give proper acknowledgement or credit for all
contributions to research. Never plagiarize.
Confidentiality
Protect confidential communications, such as papers or grants submitted for publication, personnel records,
trade or military secrets, and patient records.
Responsible Publication
Publish in order to advance research and scholarship, not to advance just your own career. Avoid wasteful
and duplicative publication.
Responsible Mentoring
Help to educate, mentor, and advise students. Promote their welfare and allow them to make their own
decisions.
Respect for colleagues
Respect your colleagues and treat them fairly.
Social Responsibility
Strive to promote social good and prevent or mitigate social harms through research, public education, and
advocacy.
Non-Discrimination
Avoid discrimination against colleagues or students on the basis of sex, race, ethnicity, or other factors that
are not related to their scientific competence and integrity.

Competence
Maintain and improve your own professional competence and expertise through lifelong education and
learning; take steps to promote competence in science as a whole.
Legality
Know and obey relevant laws and institutional and governmental policies.
Animal Care
Show proper respect and care for animals when using them in research. Do not conduct unnecessary or
poorly designed animal experiments.
Human Subjects Protection
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 When conducting research on human subjects, minimize harms and risks and maximize benefits; respect
human dignity, privacy, and autonomy; take special precautions with vulnerable populations; and strive to
distribute the benefits and burdens of research fairly.
14.CODE OF PROFESSIONAL CONDUCT:
The Code of professional conduct was published by the Nursing and MidwiferyCouncil in April 2002 and
came into effect on 1 June 2002. In August 2004 anaddendum was published and the Code of professional
conduct had its namechanged to The NMC code of professional conduct: standards for conduct,performance
and ethics. All references to “nurses, midwives and health visitors”were replaced by “nurses, midwives and
specialist community public healthnurses” and a new section on Indemnity Insurance was included. This
updatedversion of the code was published in November 2004.
1.1. The purpose of The NMC code of professional conduct: standards for
conduct, performance and ethics is to:
 inform the professions of the standard of professional conductrequired of them in the exercise of their
professional accountabilityand practice
 inform the public, other professions and employers of the standardof professional conduct that they can
expect of a registeredpractitioner.
1.2.As a registered nurse, midwife or specialist community public health
nurse, you must:
 protect and support the health of individual patients and clients
 protect and support the health of the wider community
 act in such a way that justifies the trust and confidence the publichave in you
 uphold and enhance the good reputation of the professions.
1.3. You are personally accountable for your practice. This means that you
are answerable for your actions and omissions, regardless of advice or
directions from another professional.
1.4. You have a duty of care to your patients and clients, who are entitled
to receive safe and competent care.
1.5. You must adhere to the laws of the country in which you are
practising.

2. As a registered nurse, midwife or specialist communitypublic health nurse, you must respect the
patient or clientas an individual :

2.1 You must recognise and respect the role of patients and clients aspartners in their care and the
contribution they can make to it. This involves identifying their preferences regarding care and
respectingthese within the limits of professional practice, existing legislation,resources and the goals of the
therapeutic relationship.

2.2 You are personally accountable for ensuring that you promote andprotect the interests and dignity of
patients and clients, irrespective ofgender, age, race, ability, sexuality, economic status, lifestyle, cultureand
religious or political beliefs.

2.3 You must, at all times, maintain appropriate professional boundaries inthe relationships you have with
patients and clients. You must ensurethat all aspects of the relationship focus exclusively upon the needs
ofthe patient or client.

935
2.4 You must promote the interests of patients and clients. This includeshelping individuals and groups gain
access to health and social care, information and support relevant to their needs.

2.5 You must report to a relevant person or authority, at the earliestpossible time, any conscientious objection
that may be relevant to yourprofessional practice. You must continue to provide care to the best ofyour
ability until alternative arrangements are implemented.

3.As a registered nurse, midwife or specialist communitypublic health nurse, you must obtain consent
before yougive any treatment or care:

3.1 All patients and clients have a right to receive information about theircondition. You must be sensitive to
their needs and respect the wishesof those who refuse or are unable to receive information about
theircondition. Information should be accurate, truthful and presented insuch a way as to make it easily
understood. You may need to seek legalor professional advice or guidance from your employer, in relation
tothe giving or withholding of consent.

3.2 You must respect patients’ and clients’ autonomy – their right todecide whether or not to undergo any
health care intervention – evenwhere a refusal may result in harm or death to themselves or a fetus, unless a
court of law orders to the contrary. This right is protected inlaw, although in circumstances where the health
of the fetus would beseverely compromised by any refusal to give consent, it would beappropriate to discuss
this matter fully within the team and with asupervisor of midwives, and possibly to seek external advice and
guidance .

3.3 When obtaining valid consent, you must be sure that it is:
 given by a legally competent person
 given voluntarily
 informed.

3.4 You should presume that every patient and client is legally competentunless otherwise assessed by a
suitably qualified practitioner. A patientor client who is legally competent can understand and retaintreatment
information and can use it to make an informed choice.

3.5 Those who are legally competent may give consent in writing, orallyor by co-operation. They may also
refuse consent. You must ensurethat all your discussions and associated decisions relating to
obtainingconsent are documented in the patient’s or client’s health care records.

3.6 When patients or clients are no longer legally competent and have lostthe capacity to consent to or refuse
treatment and care, you should tryto find out whether they have previously indicated preferences in
anadvance statement. You must respect any refusal of treatment or caregiven when they were legally
competent, provided that the decision isclearly applicable to the present circumstances and that there is
noreason to believe that they have changed their minds. When such astatement is not available, the patients’
or clients’ wishes, if known,should be taken into account. If these wishes are not known, thecriteria for
treatment must be that it is in their best interests.

3.7 The principles of obtaining consent apply equally to those people whohave a mental illness. Whilst you
should be involved in theirassessment, it will also be necessary to involve relevant people close tothem; this

936
may include a psychiatrist. When patients and clients are detained under statutory powers (mental health
acts), you mustensure that you know the circumstances and safeguards needed for
providing treatment and care without consent.

3.8 In emergencies where treatment is necessary to preserve life, you mayprovide care without consent, if a
patient or client is unable to give it,provided you can demonstrate that you are acting in their bestinterests.

3.9 No-one has the right to give consent on behalf of another competentadult. In relation to obtaining consent
for a child, the involvement ofthose with parental responsibility in the consent procedure is usuallynecessary,
but will depend on the age and understanding of the child.If the child is under the age of 16 in England and
Wales,12 in Scotlandand 17 in Northern Ireland, you must be aware of legislation and localprotocols relating
to consent.

3.10 Usually the individual performing a procedure should be the person toobtain the patient’s or client’s
consent. In certain circumstances, youmay seek consent on behalf of colleagues if you have been
speciallytrained for that specific area of practice.

3.11 You must ensure that the use of complementary or alternativetherapies is safe and in the interests of
patients and clients. This mustbe discussed with the team as part of the therapeutic process and thepatient or
client must consent to their use.

4. As a registered nurse, midwife or specialist communitypublic health nurse, you must co-operate
with othersin the team

4.1 The team includes the patient or client, the patient’s or client’s family,informal carers and health and
social care professionals in the NationalHealth Service, independent and voluntary sectors.

4.2 You are expected to work co-operatively within teams and to respectthe skills, expertise and
contributions of your colleagues. You musttreat them fairly and without discrimination 4.3 You must
communicate effectively and share your knowledge, skilland expertise with other members of the team as
required for the
benefit of patients and clients.

4.4 Health care records are a tool of communication within the team. Youmust ensure that the health care
record for the patient or client is anaccurate account of treatment, care planning and delivery. It shouldbe
consecutive, written with the involvement of the patient or clientwherever practicable and completed as soon
as possible after an eventhas occurred. It should provide clear evidence of the care planned, thedecisions
made, the care delivered and the information shared.

4.5 When working as a member of a team, you remain accountable foryour professional conduct, any care
you provide and any omission onyour part.

4.6 You may be expected to delegate care delivery to others who are notregistered nurses or midwives. Such
delegation must not compromiseexisting care but must be directed to meeting the needs and servingthe
interests of patients and clients. You remain accountable for theappropriateness of the delegation, for
ensuring that the person whodoes the work is able to do it and that adequate supervision or
support is provided.
937
4.7 You have a duty to co-operate with internal and externalinvestigations.

5. As a registered nurse, midwife or specialist communitypublic health nurse, you must protect
confidential information

5.1 You must treat information about patients and clients as confidentialand use it only for the purposes for
which it was given. As it isimpractical to obtain consent every time you need to shareinformation with
others, you should ensure that patients and clientsunderstand that some information may be made available to
othermembers of the team involved in the delivery of care. You must guardagainst breaches of
confidentiality by protecting information fromimproper disclosure at all times. 5.2 You should seek patients’
and clients’ wishes regarding the sharing of
information with their family and others. When a patient or client isconsidered incapable of giving
permission, you should consult relevantcolleagues.

5.3 If you are required to disclose information outside the team that willhave personal consequences for
patients or clients, you must obtaintheir consent. If the patient or client withholds consent, or if
consentcannot be obtained for whatever reason, disclosures may be madeonly where:
 They can be justified in the public interest (usually where disclosureis essential to protect the patient or
client or someone else from therisk of significant harm)
 They are required by law or by order of a court.

5.4 Where there is an issue of child protection, you must act at all times inaccordance with national and local
policies.

6. As a registered nurse, midwife or specialist communitypublic health nurse, you must maintain your
professionalknowledge and competence

6.1 You must keep your knowledge and skills up-to-date throughout yourworking life. In particular, you
should take part regularly in learningactivities that develop your competence and performance.

6.2 To practise competently, you must possess the knowledge, skills andabilities required for lawful, safe and
effective practice without directsupervision. You must acknowledge the limits of your
professionalcompetence and only undertake practice and accept responsibilitiesfor those activities in which
you are competent.

6.3 If an aspect of practice is beyond your level of competence or outsideyour area of registration, you must
obtain help and supervision from acompetent practitioner until you and your employer consider that youhave
acquired the requisite knowledge and skill 6.4 You have a duty to facilitate students of nursing, midwifery
andspecialist community public health nursing and others to develop their
competence.

6.5 You have a responsibility to deliver care based on current evidence,best practice and, where applicable,
validated research when it isavailable.
938
7. As a registered nurse, midwife or specialist communitypublic health nurse, you must be
trustworthy

7.1 You must behave in a way that upholds the reputation of theprofessions. Behaviour that compromises
this reputation may call yourregistration into question even if is not directly connected to yourprofessional
practice.

7.2 You must ensure that your registration status is not used in thepromotion of commercial products or
services, declare any financial orother interests in relevant organizations providing such goods orservices and
ensure that your professional judgment is not influencedby any commercial considerations.
7.3 When providing advice regarding any product or service relating toyour professional role or area of
practice, you must be aware of therisk that, on account of your professional title or qualification, youcould be
perceived by the patient or client as endorsing the product.You should fully explain the advantages and
disadvantages ofalternative products so that the patient or client can make an
informed choice. Where you recommend a specific product, you mustensure that your advice is based on
evidence and is not for your owncommercial gain.

7.4 You must refuse any gift, favour or hospitality that might beinterpreted, now or in the future, as an
attempt to obtain preferentialconsideration.

7.5 You must neither ask for nor accept loans from patients, clients ortheir relatives and friends.

8. As a registered nurse, midwife or specialist community publichealth nurse, you must act to identify
and minimise the risk topatients and clients

8.1 You must work with other members of the team to promote healthcare environments that are conducive
to safe, therapeutic and ethicalpractice.

8.2 You must act quickly to protect patients and clients from risk if youhave good reason to believe that you
or a colleague, from your ownor another profession, may not be fit to practice for reasons ofconduct, health
or competence. You should be aware of the terms oflegislation that offer protection for people who raise
concerns abouthealth and safety issues.

8.3 Where you cannot remedy circumstances in the environment of carethat could jeopardize standards of
practice, you must report them to asenior person with sufficient authority to manage them and also, inthe
case of midwifery, to the supervisor of midwives. This must besupported by a written record.

8.4 When working as a manager, you have a duty toward patients andclients, colleagues, the wider
community and the organization inwhich you and your colleagues work. When facing professionaldilemmas,
your first consideration in all activities must be the interestsand safety of patients and clients.

8.5 In an emergency, in or outside the work setting, you have aprofessional duty to provide care. The care
provided would be judgedagainst what could reasonably be expected from someone with yourknowledge,
skills and abilities when placed in those particularcircumstances.

Code of Professional Conduct hospital

939
A. Professional Obligations
1. Respect for Persons
* Maintain the Patient First Ethic.
* Treat patients and staff with the same degree of respect you would wish them to show you.
* Treat patients with kindness, gentleness and dignity.
* Respect the privacy and modesty of patients.
* Do not use offensive language, verbally or in writing, when referring to patients or their illnesses.
* Do not harass others physically, verbally, psychologically or sexually.
* Do not discriminate on the basis of sex, religion, race, disability, age or sexual orientation.
* Refrain from behavior that includes intimidation, foul language, threats of violence or retaliation.
* Refer to patients by their name, not by their diagnosis or location.
* Avoid the use of first names without permission in addressing adult patients.
* Respect with tolerance, the religion, culture and customs of patients, visitors and staff.
* Realize that patients and their visitors are in an environment that can be unfamiliar and frightening.
Communicate frequently in language that a layperson can understand.
2. Respect for Patient Confidentiality
* Do not share medical information with anyone except those health care professionals integral to the
care of the patient or within the context of Hospital operations.
* Do not discuss patients or their illnesses in public places where the conversation may be overheard.
* Do not publicly identify patients, in spoken words or in writing, without adequate justification.
* Do not invite or permit unauthorized persons into patient care areas of the institution.
* Do not share your confidential computer system passwords.
* Do not access confidential patient information without a professional "need to know."
* Do not misuse electronic mail.
* Do not remove confidential patient information from the premises. Staff that must do this in the scope
of their job must assure appropriate safeguards are in place to protect the information.
3. Honesty
* Be truthful in verbal and in written communications.
* Do not cheat, plagiarize, or otherwise act dishonestly.
* Maintain accurate, honest records of patient care and business activities, which include following
procedures to correct and amend records and to make late entries in medical records.
4. Integrity
Integrity means strict adherence to a code or set of values such as this Code of Professional Conduct, the
American Nurse's Association's Code of Ethics for Nurses, or the American Medical Association's Code
of Ethics.

* Acknowledge your errors of omission and commission to colleagues, supervisors and patients.
* Make patient care decisions based on patients' needs and desires not on financial preferences or
compensation.
* Do not knowingly mislead others.
* Do not abuse special privileges, e.g., making unauthorized long-distance telephone calls.
5. Responsibility for Patient Care
* Obtain the patient's informed consent for diagnostic tests or therapies and respect the patient's right to
refuse care or procedures.
* Assume responsibility for the patients under your care until you have handed off (transferred) the care
to another professional and that professional has acknowledged the transfer of care.
* Follow up on ordered laboratory tests and complete patient record documentation promptly and
940
 conscientiously.
* Assure that all patients' tests and treatments are completed and followed up appropriately.
* Coordinate with your team the timing of information sharing with patients and their families to present
a coherent and consistent treatment plan.
* Do not abuse alcohol or drugs that could diminish the quality of patient care or your professional
performance.
* Do not develop romantic or sexual relationships with patients; if such a relationship seems to be
developing, seek guidance and terminate the professional relationship.
* Do not abandon a patient. If you are unable/unwilling to continue care, you have an obligation to assist
in making a referral to another competent practitioner willing to care for the patient.
6. Professional Growth & Awareness of Limitations
* Be aware of your personal limitations and deficiencies in knowledge and abilities and know when and
whom to ask for supervision, assistance or consultation.
* Know when and for whom to provide appropriate supervision.
* Students and other trainees should have all patient workups and orders reviewed and countersigned by
the appropriate supervisor.
* Do not involve patients in personal issues or solicit for personal gain.
* Do not engage in unsupervised involvement in areas or situations where you are not adequately trained.
7. Deportment as a Professional
* Clearly identify yourself and your professional level to patients and staff; wear your name badge at all
times above the waist and in plain view.
* Always maintain the confidentiality of business information and trade secrets.
* Dress in a neat, clean, professionally appropriate manner. Maintain professional composure despite the
stresses of fatigue, professional pressures, or personal problems.
* Do not make offensive or judgmental comments about patients or staff, verbally or in writing.
* Do not criticize the medical decisions of colleagues in the presence of patients or staff or in the medical
record.
* Do not access confidential staff information without a professional need to know.
* Do not abuse alcohol or drugs that could diminish the quality of patient care or professional
performance.
* Do not participate in political campaigns including the wearing of political buttons and discussion of
political issues while on WHHS premises.
8. Avoiding Conflicts of Interest
* Resolve clinical conflicts of interest in favor of the patient.
* While on the premises do not accept gifts of value from drug companies or vendors or suppliers.
* Do not participate in vendor incentive programs without disclosure.
* Do not refer patients to laboratories or other healthcare facilities in which you have a direct financial
stake without disclosure.
* Do not accept a "kickback" (any payment intended to influence decisions) for any patient referral.
* For staff in decision-making positions, disclose any outside financial interests or commercial activities,
including those of immediate family members, domestic partners or others with a significant personal
relationship, that may represent a conflict of interest and affect professional performance.
9. Responsibility for Peer Behavior
* Take the initiative to identify and help impaired staff with the assistance of the Employee Assistance
Program, Employee Health Services, Physicians' Well-Being Committee or other appropriate referrals.
(Impairment includes, but is not limited to, alcohol and/or drug abuse, depression, other physical or
mental illness).
941
 * Report serious breaches of the Code of Professional Conduct to the appropriate person, if unsure,
discuss the situation with your supervisor or department chair. You may report directly to the
Compliance Officer.
* Indicate disapproval or seek appropriate intervention if you observe less serious breaches.
* No action of retaliation or reprisal shall be taken against anyone who reports suspected fraud or
improper conduct.
* Anyone who attempts to or encourages others to retaliate against an individual who has reported a
violation will be subject to disciplinary action.
10. Respect for Personal Ethics
* You are not required to perform procedures (e.g., elective abortions, termination of medical treatment)
that you, personally, believe are unethical, illegal, or may be detrimental to patients.
* Should a patient request a treatment contrary to your personal values but consistent with current
standards of care, you have a duty to refer the patient to another practitioner or facility for such treatment.
11. Respect for Property and Laws
* Adhere to the regulations and policies of WHHS, e.g., policies governing fire safety, hazardous waste
disposal and universal precautions.
* Adhere to local, state and federal laws and regulatory standards.
* Do not misappropriate, destroy, damage, or misuse property of WHHS.
12. Integrity in Research
* Report research results honestly in scientific and scholarly presentations and publications.
* When publishing and presenting reports, give proper credit and responsibility to colleagues and others
who participated in the research.
* Report research findings to the public and press honestly and without exaggeration.
* Avoid potential conflicts of interest in research; disclose funding sources, company ownership and
other potential conflicts of interest in written and spoken research presentations.
* Adhere to WHHS policies and procedures that govern research using human subjects.
13. Use of WHHS' Computer Systems
* Obtain proper authorization before using WHHS computing resources.
* Do not use WHHS computing resources for purposes beyond those for which you are authorized.
* Do not share access privileges (account numbers and/or passwords).
* Do not electronically transmit or distribute material that would be in violation of existing WHHS
policies or guidelines.
* Respect the privacy of other users. More specifically, do not read, delete, copy, or modify another
user's data, information, files, e-mail or programs (collectively, "electronic files") without the other user's
expressed permission.
* Do not intentionally introduce any program or data intended to disrupt normal operations (e.g., a
computer "virus" or "worm") into WHHS computer systems.
* Do not perform forgery or attempt forgery of e-mail messages.
* Do not circumvent or attempt to circumvent normal resources limits, log-on procedures, or security
regulations.
* Do not use WHHS information technology resources for any private activity. Do not export WHHS
systems for personal use.
* Endeavor to use WHHS information computing resources in an efficient and productive manner. Avoid
game playing, use of streaming video or audio, printing excessive copies of documents, files, data, or
programs; or attempting to crash or tie-up computer resources.
14. Respect for Business Ethics
* Charge patients for all and only clinical services provided at the appropriate level as defined by WHHS
942
 policy.
* Ensure that payment requests from vendors, employees and other payees are processed promptly,
accurately and with the appropriate level of documentation.
* Do not promise payments to vendors or other payees or sign contracts that are beyond the scope of your
authority.
* Report all and only hours worked on employee timecards.
* Submit authorized employee timecards that follow the rules and regulations of the bargaining unit,
WHHS, the State of California and the Federal government.
* Do not take or borrow property or cash from patients, visitors or WHHS.
* Do not use WHHS supplies for personal use.
* Record all financial transactions accurately and promptly.
* Provide reports and other information that is accurate, complete, relevant, timely and understandable.
* Do not offer patients discounts or write/offs without proper approval.
* Maintain the confidentiality of employee information.
* Maintain the confidentiality of WHHS' financial information.
* Code medical records accurately, consistent with industry guidelines. Do not upcode to improve
reimbursement.

B. Professional Ideals
1. Clinical Virtues
* Cultivate and practice clinical virtues, such as caring, empathy and compassion.
2. Conscientiousness
* Fulfill your professional responsibilities conscientiously.
* Notify the responsible supervisor if something interferes with your ability to perform tasks effectively.
* Learn from experience and grow from the knowledge gained from errors to avoid repeating them.
* Dedicate yourself to lifelong learning and self-improvement by implementing a personal program of
continuing learning and continuous quality improvement.
* Complete all tasks accurately, thoroughly, legibly and in a timely manner, this may include attending
and participating in meetings and conferences.
* Follow through on whatever you have agreed to do.
* Avoid patient involvement when you are ill, distraught or overcome with personal problems.
3. Collegiality/Cooperation
* Cooperate with all other members of the Health Care System.
* Teach others.
* Be generous with your time when answering questions from staff, patients and visitors.
* Shoulder your fair share of the institutional burden by adopting a spirit of volunteerism and altruism.
* Use communal resources (equipment, supplies and funds) responsibly and equitably.
4. Objectivity
* Avoid providing professional care to members of your family or to persons with whom you have a
close, personal relationship.
5. Responsibility to Community
* Avoid unnecessary patient or societal health care monetary expenditures.
* Provide appropriate emergency services to all patients regardless of their ability to pay.
* Avoid behaviors that impair the community's confidence in the Healthcare System.
* Demonstrate behavior that ensures the future viability of the Healthcare System for the residents of the
District.

943
Additional guidelines regarding Professional Conduct exist in some departments and affiliated organizations
of WHHS including, but not limited to, the Medical Staff, Volunteers Services and Information Services.
CODE OF PROFESSIONAL CONDUCT institution :
Introduction
. Under the Institution's By-Laws:

" Every member of the Institution shall so order his/her conduct as to uphold the dignity and reputation of
the Institution and shall observe the provisions of the Charter and the By-Laws."

2. The Institution demands of its Corporate Members additional obligations:

"Every Corporate Member shall at all times so order his/her conduct as to uphold the dignity and reputation
of his/her profession: and to safeguard the public interest in matters of safety and health and otherwise".

"He/she shall exercise his/her professional skill and judgement to the best of his/her ability and discharge
his/her professional responsibility with integrity."

3. The Council considers it to be the professional and moral duty of every member to understand and accept
these obligations and the specific interpretation of them as defined in the Code of Professional Conduct. A
member should apply the Code diligently and not enter into any contract or arrangement of any nature
whatsoever with any other person, the performance of which will or may involve a breach of this Code.
Safety and Health.
4. Every member shall, at all times and in all respects, take all reasonable care to prevent danger of death,
injury or ill-health to any person or of damage to property, whilst carrying out his/her work or as a
consequence of it.
Protection of the Environment.
5. Every member shall, at all times and in all respects, take all reasonable care to prevent adverse impact on
the working environment of himself/herself and others, and on the wider environment as a consequence of
his/her work.
Competence to Practise.
6. Every member shall take all reasonable steps to maintain and develop his/her professional competence in
relation to new developments relevant to his/her field of professional activity. To this end, every member
should be familiar with relevant codes of practice and guidelines which may be issued or endorsed by the
Institution, especially those concerned with safety and health and protection of the environment. Every
member should also seek to participate in the activities of the Institution appropriately to his/her
circumstances.
7. Every member should maintain a record of his/her Continuing Professional Development activities and
keep it available for inspection by the Institution on request.
8. Every member shall only undertake work which he/she has sufficient competence, time and authority to
perform.
9. A member aware of relevant limitations in, or in any respect unsure of, his/her competence to undertake
professional work shall disclose that fact to the customer of the work. The member should only proceed
when the customer confirms his/her agreement to proceeding on that basis and when the member is then
satisfied as in para 8.
Supervisory Responsibilities
10. Every member shall exercise proper supervision of all work done under his/her authority and accept
professional responsibility for it.
944
11. Every member shall treat those under his/her supervision and all other people with respect, fairness,
honesty and courtesy.
12. Every member shall help and encourage those under his/her supervision to maintain and develop their
professional competence through appropriate education, training and experience and participation in
appropriate learned society activities.
Conflicts of Interest
13. Every member shall take all reasonable care when accepting and undertaking a professional assignment
to avoid any real, or likely to be perceived, conflict of interest between the member or his/her associates and
the customer.

14. Should a member become aware of a possible conflict of interest, he/she shall immediately disclose the
issue to the customer in writing (or other recordable form) and only continue working when the customer so
requests.
Confidentiality
15. A member shall not disclose information concerning the business of his/her employer, a past employer or
a customer which is not already in the public domain, unless clearly authorised to do so or it is clearly in the
public interest under para 25 having exhausted all other reasonable avenues.
16. A member shall not improperly use confidential information either for his/her own benefit or for the
benefit of a third party.
Honesty and Integrity
17. Every member shall at all times conduct himself/herself with honesty, impartiality and integrity.
18. A member shall not offer, give or receive any inducement (financial or otherwise) made to improperly
influence the award or performance of a professional assignment.
19. A member shall not receive remuneration from a second source for work already undertaken for his/her
employer or another unless this is agreed by the parties concerned.
20. In referring in advertisements or papers to his/her own work or competence, a member shall be factual
and avoid misleading statements.
21. A member shall not maliciously or recklessly injure another's professional reputation, prospects or
business.
22. A member who is convicted of any criminal offence related to their professional activities shall
immediately notify the Institution.
Risk Assessment
23. In the course of his/her professional work, every member shall carefully assess possible hazards, their
mitigation and counter-measures in order to minimise risk, particularly to the public and the environment.
24. Every member undertaking a professional assignment should assess his/her potential liability for the
accuracy and consequences of the work and, where appropriate, hold professional indemnity insurance.
Upholding the Code of Professional Conduct
25. Should a member's professional advice be rejected by his/her employer or customer, the member should
take all reasonable steps to ensure that the person who overrules or disregards such advice is made fully
aware of the possible consequences. Where the advice concerns the safety or health of people or of the
environment, the member should make his/her concerns clear in writing and request written
acknowledgement. He/she should also consider taking further action, for example through his/her employer,
relevant national regulators or by seeking the advice of the Institution, in accordance with the spirit of paras 4
and 5.
26. A member who becomes aware of any significant violation of this Code of Professional Conduct by
another member shall immediately inform that member. If a satisfactory response is not obtained, he/she
should notify the Institution with a copy to the member concerned.
945
TYPES OF LAW, TORT LAW AND LIABILITIES
I. INTRODUCTION:
A Knowledge of legal system in nursing is absolutely essential for all nurse to safe guard self and clients
from legal complications. Consumers are becoming in caressingly aware of their legal rights in the health
care. It is essential there for a nurse should know her legal and professional boundaries and their
consequences.
Legislation can be primary or secondary. primary legislation consist of Acts of parliament, known as
statutes, which come into force at a date set in the initial Act of parliament or subsequently fixed by order of
a minister. The date of enforcement is often later than the date the Act is passed by the two houses of
parliament and signed by the Crown.
The statute sometimes gives power to a minister to enact more detailed laws, and this is known as
secondary legislation. Regulations have to be laid before the houses of parliament and in certain
circumstances have to recei.ve express approval. Statutory instruments which are quoted in the text are an
example of this resultant legislation.
Section 60 of the act 1999 gives power to her majesty to make by order in council provisions for the
regulation of various health professions. The order relating to the establishment of the nursing and midwifery
council in turn gives power to the NMC to make rules regulating the practices if midwifery Article 40[1].
Under Article 45, the approval of the Privy Council shall be required for any exercise by the council of a
power to make rules under this order.
Law is dynamic. As conflicts and disputes arise and are brought before the courts, the judges have to decide
in the light of existing statutes and decided cases which are binding upon them, the principles which apply.

II. TERMINOLOGIES:

 Accountability: Being responsible for one’s actions: a sense of duty in performing nursing tasks and
activities.
 Advance directives: Written or verbal instructions created by the patient describing specific wished
about medical care in the event he or she becomes incapacitated to incompetent. Examples include
living wills and durable powers of attorney.
 Adverse event: An injury caused by medical management rather than the patient’s underlying condition.
An adverse event attribute to error is a preventable adverse event.
 Case law: Body of written opinions created by judges in federal and state appellate cases: also known as
judge- made law and common law.
 Civil law: A category of law (tort law) that deals with conduct considered unacceptable. It is based on
societal expectations regarding interpersonal conduct. Common causes of civil litigation include
professional malpractice, negligence, and assault and battery.
 Common law: Law that is created through the decision of judges as opposed to laws enacted by
legislative bodies (i.e., Congress)
 Criminal Negligence: Negligence that in Criminal Negligence: Negligence that indicates “reckless and
wanton” disregard for the safety, well being, or life of an individual; behavior that demonstrates a
complete disregard for another, such that death is likely.
 Defendant: The individual who is named in a person’s (Plaintiff’s complaint as responsible for an injury;
the person who the plaintiff claims committed a negligent act or malpractice.
 Liability: Being legally responsible for harm caused to another person or property as a result of one’s
action; compensation for harm normally is paid in monetary damages.

946
 Licensing laws: Laws that establish the qualifications for obtaining and maintaining a license to perform
particular services.
 Plaintiff: The complaining person in a lawsuit; the person who claims he or she was injured by the acts
of another.
 Tort: Civil Wrong or injury committed by one person against another person or a property.
III. DEFINITION :
LAW:
Law is the sum total of rules and regulations by which a society is governed.
LEGAL SYSTEM:
Legal system is Judges Action rather than intention.
IV. FUNCTIONS OF LAW IN NURSING:
The law serves a number of functions in Nursing.

1) It provides a frame work for establishing nursing actions in the care of clients in legal.
2) If differentiates the nurse’s responsibility from those of other health professionals
3) Helps establish boundaries of independent nursing action.
4) Assists in maintaining standard of nursing practice by making nurses accountable under the law.
V. SOURCES OF LAW:
Along with ethics, professional nursing conduct also is regulated by a variety of laws. There are two
major sources of law.
Statutory Law
Common Law
The standards for professional nursing practice are in great part derived from both statutory and common
law.
Statutory Law:
Laws that are written by legislative bodies, such as Congress or State Legislatures are enacted as Statutes.
Common Law:
Also known as decisional or judge- made law. It is the law that is created through the decision of judges
as opposed to laws enacted by legislative bodies

VI. TYPES OF LAW:

947
Criminal Law and Nursing:

Because a violation of any law governing the practice of any licensed profession may be a crime, you
must be aware of the extent of the Nurse practice Act of the State in which you are practicing. Where the
nurse practice act may be prosecuted as a crime even if no harm occurred to the patient. Act requires that
actions (such as administering drugs) be performed only under the direction of a physician that explicit
authorization must exist. A violation of a professional practice act may be prosecuted as a crime even if no
harm occurred to the patient.

It is costly to the state to undertake criminal prosecution; therefore even when they are discovered, some
violations of criminal law are not prosecuted in court. Knowing this, some nurses make the error of believing
that “minor” violations are acceptable. Even when not prosecuted in court, criminal action could result in the
loss of a job and in the loss of a license to proactive nursing.

For Example:

The Nurse Practice Act does not give the nurse the authority to diagnose disease and prescribe
medication, regardless of the situation. The medical practice Act and the Nurse practice Act on Advanced
Nursing Practice contain this authorization. To give a medication without an order is a violation of the law
and is a crime, even though the client may not be harmed. Violations of laws related to the care and
distribution of controlled substances is also a crime. Altering or changing narcotic records is a crime even if
no diversion of drugs occurred. While finding where the error in a narcotic record occurred may be a tedious
and time-consuming process, as a nurse, you need to look beyond temporary convenience to the potential
consequences of your action

Law is divided into civil and criminal components. Both statutory law and common law may be subdivided
in this way.
• A crime is an offense against the state committed or omitted in violation of a public law.
• Criminal law involves crimes against the state. When a state or federal criminal law is violated, the
government brings criminal charges against the offender.
948
• State criminal laws prohibit such crimes as murder, arson, rape, and burglary.
Felony

A felony is a crime punishable by death or by imprisonment in a state or federal prison for more than one
year.
Some examples of a felony include abuse (child, elder, or domestic violence), manslaughter attempted
murder, and practicing medicine without a license.

Felony – it represents a more serious violation of the law, and carries heavier fines and longer periods of
imprisonment, perhaps even death.

MISDEMEANORS
Misdemeanors are less serious crimes
punishable by fines or by imprisonment in facility other than a prison for one year or less.
petty theft

CIVIL LAW AND NURSING:

Civil law relates to legal disputes between private parties. Malpractice actions '" brought in health care
situations involve civil law.
TORTS:
Torts are civil wrong committed by one person against another person or a person's property. The wrong may
be physical harm, psychological harm, harm to livelihood, or some other less tangible value, such as harm to
reputation. The action that causes a civil wrong may be either intentional or unintentional.

Intentional Tort: It is one in which the outcome was planned, although the person involved may not have
believed that the intended outcome would be harmful to the other person.

949
For Example: Preventing a patient form leaving against medical advice may be based on concern for the
patient, but it is illegal and to do so is intentional tort.

a. INTENTIONAL TORTS
Assault and Battery:
Assault if the threat of touching another person without his or her consent. Battery is the actual harm or
offensive touching of a person.
For example:
A hospital was sued for battery after a coronary care nurse resuscitated a client who had expressed wishes
not to be resuscitated.
A client in radiology sued for battery when the nurse intentionally gave a sedative that the client had
specifically refused, and the client experienced a severe allergic reaction. The nurse who proceeds with an
injection despite a client's objection could be guilty of battery.
Defamation of character:
Defamation of character includes false communication that results in injury to a Person’s reputation by
means of print (libel) or spoken word (slander). The nurse is permitted to make statements about clients only
as part of his or her nursing practice and only within the limits provided by law.
For example:
Disclosure of a false AIDS diagnosis may constitute defamation of character.
A nurse who makes false statements about a client or co-worker in the client's record or the local newspaper
could be guilty of libel.
Telling a client that another nurse is incompetent is slander.
Fraud:
Fraud is the willful, purposeful misrepresentation of self or an act that may cause harm to a person or
property. A nurse who misrepresents his or her qualifications or bills for care not given may be committing a
fraud.
Invasion of Privacy:
The nurse is bound to limit discussion about a client to appropriate parties.
Disclosing confidential information to an inappropriate third party subjects the nurse to liability for invasion
of privacy, even if the information is true. The nurse should discuss the client with others only when the
discussion is necessary for treatment and care or when the client consents to disclosure

Example:
A nurse who discloses that a client has HIV may be liable for invasion of privacy.
False Imprisonment:

Prevention of movement or unjustified retention of a person without consent may be false imprisonment.
Nurses must use restraints only in accordance with agency policies and usually with a physician's order.
Example:
Use of restraints in managing clients
Civil laws protect the rights of individual persons within our society and encourage fair and equitable
treatment among people.
Generally ,violations of civil laws cause harm to individual or property
NEGLIGENCE:

Negligence is a general term that refers to conduct that does not show due cares. If harm is caused by
negligence, it is termed as unintentional tort and damages may be recovered.
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 All negligence has the following 4 essential characteristics:

1. Harm must have occurred to an individual.

2. The negligent person must been in a situation where he or she had a duty toward the person harmed.
3. The person must be found to have failed to fulfill his or her duty. This is called “Breach of duty” This
might include either dong what should not have been done (Commission of an inappropriate action). This
is also referred to as failing to act as a reasonably prudent person. A reasonably prudent person means
someone who demonstrates careful and thoughtful action. Some authorities emphasize that this includes
the responsibility to foresee possible results of a situation and act appropriately.
4. The harm must be shown to have been caused by the breach of duty.

Example:

 Carelessly failing to lock the brakes on a wheelchair before transferring a client

 Leaving an infant on an examinations table without taking steps to prevent falling
 Failing to take the temperature of a client who complains of feeling warm and lethargic

Professional negligence:

Historically, physicians were the healthcare provider most likely to be held liable for nursing care. As
nurses have gained authority and autonomy, they have assumed responsibility, accountability, and liability
for their own practice. As roles have expanded, nurses have begun performing duties traditionally reserved
for medical practice. As a result of an increases scope of practice, many nurses now carry individual
malpractice insurance. This is a double-edged sword. Nurses need malpractice insurance because of their
expanded roles, but they also incur a greater likelihood of being sued if they have malpractice insurance,
since injured parties will always seek damages from as many individuals with financial resources as possible.

Because of the enhanced role of nurses and the increases number of insured nurses, liability suits seeking
damages from nurses as individuals have increases tremendously over the past few decades. From 1998 to
2001, for instance, the National Practitioner Data Bank reveals that the number of malpractice payments
made by nurses increased from 253 to 413 and the trend shows no sign of stopping.

In all liability suits, there is a plaintiff and a defendant. In malpractice cases, the plaintiff is the injured
party and the defendant is the professional who is alleged to have caused the injury. Negligence has been
defined as the omission to do something that a reasonable person, guided by the considerations that
ordinarily regulate human affairs, would do or as doing something that a reasonable and prudent person
would not do. Reasonable and prudent generally means the average judgement, foresight, intelligence, and
skill that would be expected of a person with similar training and experience. Malpractice-the failure of a
person with professional training to act in a reasonable and prudent manner- also is called professional
negligence. Five elements must be present for a professional to be held liable for malpractice.

First, a standard of care must have been established that outlines the level or degree of quality
considered adequate by a given profession. Standards of care outline the duties a defendant has to plaintiff, or
a nurse to patient. These standards represent the skills and learning commonly possessed by members of the
profession and generally are the minimal requirements that define an acceptable level of care. Standards of

951
care, which guarantee patients safe nursing care, include organizational policy and procedure statements, job
descriptions, and student guidelines. Guidelines for standards of care are shown

Second, after the standard of care has been established, it must be shown that the standard was
violated- there must have been a breach of duty. This breach is shown by calling other nurses who practice in
the same specialty area as the defendant to testify as expert witnesses.

Third, the nurse must have had the knowledge or availability of information that not meeting the
standard of care could result in harm. This is called foresee ability of harm. If the average , reasonable person
in the defendants position could have anticipated the plaintiffs injury as a result of his or her actions, then the
plaintiffs injury was foresee able. Being ignorant is not a justifiable excuse, but by conducting investigations
and hearings to ensure the laws enforcement. Administrative laws are valid only to the extent that they are
within the scope of the authority granted to them by legislative body.

The fourth source of law is court decisions. Judicial laws are made by
The courts to interpret legal issues that are in dispute. Depending on the type of court involved, judicial or
decisional law may be made by a single justice, with or without a jury, or by a panel of justices. Generally,
initial trial courts have a single judge or magistrate, intermediary appeal courts have three justices, and the
highest appeal courts have nine justices.

Components of professional negligence

Example: Giving
Elements of liability Explanation
Medications
1.Duty to use due The care that should be A nurse should give
care(defined by the given under the medications accurately,
standard of care) circumstances(what the completely, and on time
reasonably prudent nurse
would have done
2.Failure to meet standard Not giving the care that A nurse fails to give
of care(breach of duty) should be given under medications accurately,
circumstances completely, or on time.
3.Forseeability of harm The nurse must have The drug handbook
reasonable access to specifies that the wrong
information about whether dosage or route may cause
the possibility of harm injury.
exists
4.A direct relationship Patient is harmed because Wrong dosage causes
between failure to meet the proper care is not given patient to have a
standard of convulsion.
care(breach)and injury can
be proved

5.Injury Convulsion or other

serious complication
occurs.
Actual harm results to
patient
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CRIMINAL NEGLIGENCE:
These are the situations in which the actions of the professional fall outside the bounds of simple error
and reflect a serious lack of concern or attention to the safety of the patient. Errors resulting in the serious
injury or death of death of a patient are investigated and may be prosecuted and tried by the criminal courts.
A license to practice nursing may be temporarily withdrawn while such changes are investigated and
tried. If the individual is found innocent, the license then may be restored. If the individual is convicted of
the crime, the nursing license may be revoked, in addition to sentencing and other penalties.
For Example:
In the state of Colorado, Criminal Charges were brought against three nurses for negligent actions that
resulted in the death of an infant. Through a series of actions by the nurses, the infant was given a 10- fold
overdose of (IV) Intravenous penicillin. This case clearly shows that the state has the power to prosecute as a
crime professional conduct that results in serious harm or death.
Nurses who commit felonies such as theft, abuse, or deliberate harm to a patient are always charged under
both criminal laws and the laws regulating nursing practice. Nurses who commit felonies outside of the care
setting can be prosecuted under criminal law and under the law regulating nursing practice if the felony
reflects on their fitness to practice norm.

IV. MALPRACTICE:
• Failure to meet the standards of acceptable care which results in harm to another person.
• Doing or Saying Nothing When Action Is Required
• Injuring a Patient With Equipment
• Improper Administration of Medication
Malpractice is a term used for a specific type of negligence. It refers to the negligence of a specially trained
or educated person in the performance of his her job. Therefore, malpractice is the term used to describe
negligence by nurses in the performance of their duties.

Malpractice is professional negligence liability resulting from improper practice based on standard of care
required by the profession. The professional person must have had a professional duty toward the person
receiving the care. For example, the nurse was performing the professional the professional activities of a
nurse for the person needing the care (in either a paid or volunteer capacity). Additionally, the harm that
occurred to this person dance with professional standards in the situation. This is a higher standard than is
required of the general public: it demands appropriate professional judgment and action.
ESSENTIAL ELEMENTS OF MALPRACTICE:
 Harm to an individual.
 Duty of a professional toward an individual.
 Breach of duty by the professional.
 Breach of duty by the cause of harm.
FACTORS THAT CONTRIBUTE TO MALPRACTICE CLAIMS:
A suit usually does not always follow the poor results or harm that may on occasion occur in the course
of nursing practice. An understanding of the factors that enter into whether a suit is instituted may be helpful
to you.
 SOCIAL FACTORS:
Health care is big business, and patients complain increasing of not being accepted and respected as
individuals. Patients are more willing to bring suit against someone who is part of a large, impersonal
system.

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 Health costs are high and some people think hospitals and physicians have the ability to pay large
settlements, whether directly or through insurance. If a patient’s own income is lessened or disrupted by an
illness, he or she might bring suit as a solution to economic difficulties. Increased public awareness of the
size of monetary judgments that have been awarded may also be an economic incentive to initiating a suit.

 SUIT- PRONE PATIENTS:

Some people are more likely to bring suit, for real or imagined errors. If these people are recognized as being
suit- prone patients, it is possible for you to protect yourself through increased vigilance regarding care and
thorough record- keeping. Although we would warn you to guard against stereotyping, the following general
descriptions may help to avoid problems. Suit- Prone patients usually are identified by over behavior in
which they are persistent fault-finders and critics of personnel and of all aspects of care. They may be
uncooperative in following a plan of care and sensitive to any perceived slight.

Persons who exhibit hostile attitudes may extend their hostile feelings to the nurses and other health care
persons with whom they have contact. The nurse who becomes defensive when faced with hostility only
widens the breach in the nurse-patient relationship. It is necessary to pay careful attention to those principles
of care learned in psychological nursing that deal with how to help the hostile patient. Assisting patients in
solving their own problems and offering support are the best forms of protection for the nurse.

Another type of patient who appears more suit-prone is the very dependent person who uses projection to
deal with anxiety and fear. These individuals tend to ascribe fault or blame for all events to others and are
unable to accept personal responsibility for their own welfare. Again, meeting these patients’ needs with a
carefully considered plan of care is the answer.

A common error is to withdraw and become defensive when confronting a suit-prone patient; this reaction
occurs party because and become a situation is unpleasant and partly because a staff member feels personally
threatened by the patient’s behavior. This reaction increases the likelihood of a suit if a poor result occurs.

Another incorrect nursing response to the suit-prone patient is to become more directive and authoritarian.
This tends to increase the patient’s feeling of separation and distance from the staff and again increases the
likelihood of a suit.

When the staff is helped to view the pertinent as a troubled person who manifests his or her problems in this
manner, sometimes they find it easier to be objective. The patient is in need of all the skill that the thoughtful
nurse can bring to the emotional problems. The entire health team needs to develop a careful and consistent
approach, which provides security and stability to the patient and family. The suit-prone patient does not
always and up suing; much depends on the response of health care personnel.

 SUIT-PRONE NURSES:

Nurses may also be suit-prone. Nurses who are insensitive to the a patient’s complaints, who do not identify
and meet the patient’s emotional needs, or who fail to recognize and accept the limits of their own practice
may contribute to suite instituted not only against the nurse but also against the employer and the physician.
The nurse’s self-awareness is critical in preventing suits.

954
Staff members may contribute to a patient’s distrust of care through complaining about working conditions,
telling patients about problems occurring on the unit, and disparaging other health care providers. There is a
distinction between informing a patient that you meet someone else’s needs and therefore will not return for
a specified period of time, and giving the patient the impression that you do not have time to attend to his or
her needs.

CATEGORIES OF NEGLIGENCE THAT RESULT IN MALPRACTICE:

1. Failure to follow standards of care, including failure to

 Perform a complete admission assessment or design a plan of care.
 Adhere to standardized protocols or institutional policies and procedures.
[Eg: Using an improper injection site].
 Follow a physician's verbal or written order.

2. Failure to use equipment in a responsible manner, including failure to

 Follow the manufacturer's recommendations for operating the equipment.
 Check equipment for safety prior to use.
 Place equipment properly during treatment.
 Learn how equipment functions.

3. Failure to communicate, including failure to

 Notifying a physician in a timely manner when conditions warrant it.
 Listen to clients complaints and act on them.
 Communicate effectively with client.
[Eg: Inadequate or ineffective communication of discharge instructions]
 Seek higher medical authorization for a treatment.

4. Failure to document, including failure to note in points medical record

 A client's progress and response to treatment.
 A client's injuries.
 Pertinent nursing assessment information
[Eg: Drug Allergies].
 A physician's medical orders.
 Inform on telephone conversations and physicians, including time, content of communication between
nurses and physician, and actions taken.
5. Failure to assess and monitor, including failure to
 Complete a shift assessment.
 Implement a plan of care.
 Observe client’s ongoing progress.
 Interpret a client's signs and symptoms.
6. Failure to act as a point advocate, including failure to
 Question discharge orders when a client's condition warrants it.
 Question incomplete or illegible medical orders.
 Provide a safe environment.

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V. PREVENTING MALPRACTICE CLAIMS:

The most significant thing you can do to prevent malpractice claims is to maintain a high standard of care.
To do this, you may work at improving your own nursing practice and also the general climate for nursing
practice where you work. You can do this in many ways.

A) SELF -AWARENESS:

 Identify your own strengths and weaknesses in practice.

 Be ready to acknowledge your limitations to supervisors
 Do not accept responsibilities for which you are not prepared.
Example: the nurse who has not worked in pediatrics for 10 years and accepts an assignment to a pediatric
unit without orientation and education is setting the stage for an error to occur. The standard of care does not
change for an inexperienced nurse.

B) ADAPTING PROPOSED ASSIGNMENTS:

Nurses may find themselves assigned to units where they have little or no experience with the types of
patient problems they will encounter. It is reasonable to be assigned to assist an overworked nurse in a
special area if you can assume duties that are within your own competence, and allow the specialized nurse
to assume the specialized duties. It is not reasonable or safe for you to be expected to assume the specialized
duties. Thus if you were not prepared for coronary care, you might of to that unit, monitor the IV lines, take
vital signs, and make observations to report to the experienced coronary care nurse; the experienced nurse
they would be able to check the monitors, administer the specialized medications, and make decisions. Note
that this does fragment the patient's care, and would not be appropriate as a permanent solution, but could
alleviate a temporary problem in a safe manner.
C) FOLLOWING POLICIES AND PROCEDURES:

It is your responsibility to be aware of the policies and procedures of the institution that employs you. If they
are sound, they can be an adequate defense against a claim, providing they were carefully followed.

For example, the medication procedure may involve checking all medications against a central medication
Kardex. If you do this and there is an error in the Kardex, you might not be liable for the resulting medication
error because you followed all appropriate procedures and acted responsibility. The liability would rest with
the person who made the error in transcribing the medication from the physician's orders to the Kardex. If,
however, you had not followed procedure in checking, you might also be liable because you did not do your
part in preventing error. As discussed previously, policies are often designed to provide legal direction.

D) CHANGING POLICIES AND PROCEDURES:

As Nursing evolves, changes are needed in policies, procedures, and protocols. Part of our responsibility as a
professional is to work toward keeping these up to date. Often facilities that are reluctant to make changes
based on the suggestions of individual nurses are much more receptive to new ideas when the legal
implications of outmoded practice are noted. References such as the guidelines produced by the Agency for
Health

956
Care Policy and Research (AHCPR) and articles with research results may provide strong support for needed
changes in practice.

E) DOCUMENTATION:

Nurses' records are unique in the health care setting. They cover the entire period of hospitalization,
24hours a day in a sequential pattern. The record can be the crucial factor avoiding litigation.

Documentation is the record of observations made, decisions reached, actions taken, and jute evaluation of
the patient's response are considered much more solid evidence than verbal, testimony, which depends on
one's memory.

 Clear documentation of a relevant data is important.

 For legal purposes, observations and actions that are not recorded may be assumed not to have occurred.
 It needs to be factual, legible and clearly understandable. Only approved abbreviations should be used.
 Narrative should have clear statements, and errors should be corrected according to the policy of the
facility.
 Liquid erasing fluid, erasures and heavy crossing out may be interpreted as attempted fraud in record
keeping.
 Avoid any statement that implies negligence on the part of any health care provider.
 Aware that their notes protect not only themselves but often other members of the health care team and
the facility.
 Records might include a complete log of telephone calls to a physician and consultation with any relevant
supervisor.
VII. LIABILITY:

A liability is an obligation or debt that can be enforced by law. In the case of malpractice, a person found
guilty of any tort (whether intentional or unintentional) is considered; legally liable, or legally responsible,
for the outcome. The person legally liable usually is required to pay for damages to the other person. These
may include actual costs of care, legal services. Loss of earnings (present and future), and compensation for
emotional and physical stress suffered.

Although liability is legally determined by a court, an individual who believes that he or she would be held
legally liable if a court were consulted, may agree to pay damages (or that! individual's insurance company
may agree to pay) without actually going to court. This may be done even when the person denies true
negligence or malpractice, but chooses, to settle the issue because a court case would be more costly than the
damages to be paid.'
1. Personal Liability.

2. Employer Liability.

3. Supervisory Liability
VIII. AREAS OF POTENTIAL LIABILITY FOR NURSES:

AREA EXAMPLES
Failure to monitor and  Failure to recognize significant changes in a client’s
asses condition
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Failure to ensure safety
Medication errors
Improper
implementation of skills
or procedures
Documentation errors
 Failure to report significant changes in a client’s condition
 Failure to obtain a complete database
 Failure to monitor a client as indicated by the client’s
condition
 Inadequate monitoring of a client
 Improper use of restrictive services
 Failure to identify a client’s risk for injury
 Inappropriate use of equipment
 Failure to question medication orders that are unclear
 Failure to adhere to established procedures in medication
administration
 Failure to recognize adverse drug reactions
 Lack of familiarity with communication
 Lack of communication in verbal or written medication
orders
 Failure to maintain currency in clinical skills
 Failure to follow agency policy
 Performance of unfamiliar skills
 Failure to initiate appropriate actions based on assessment
 Failure to document nursing actions
 Failure to document information relevant to a client’s
condition
 Failure to document in accordance with agency policies

IX. LEGAL REGULATION OF NURSING PRACTICE:

Nurse Practice Acts:
Among them ,powers granted to states is the ability to regulate the practice of health care
providers, including RNs. Regulation of the health care professions protects the public by r' excluding
uneducated or unlicensed persons from practicing in a health care profession and by defining the nature and
scope of professional practice.
The nursing profession and others had to carefully construct practice acts that excluded responsibilities
addressed in the previously adopted, well accepted definition of medical practice. The historic dominance of
medicine in defining the health care professions continues .to challenge the nursing profession as nurse's
move into more advanced practice roles such as nurse anesthetist, nurse midwife and nurse practitioner.
Common Features of Nurse Practice Acts:
A nurse practice act is the most important law affecting your nursing practice. Each state has its own, and the
definitions and descriptions of nursing sometimes differ from state to state. This has created problems for the
nursing profession, particularly with regard to reimbursement for services.
 A Nurse Practice Act defines the practice of nursing; both registered professional nursing and licensed
practical nursing.
 The services may include assessing health-related topics, and providing supportive care.
 It also delineates the rules and regulations that govern nursing practice for the licensed practical Morse,
the nurse practitioner, the nurse anesthetist, and the nurse midwife.
 The relationship of the professional nurse to other health care providers is outlined in a nurse practice act.

958
 The care nurses provide to clients independent of a physician's order must be consistent with the
treatments ordered by the physician.
 A nurse practice act establishes the requirements for obtaining a license to practice nursing. Another,
common feature of a nurse practice act is the creation of a state board if nursing. The state board is
created to assist in matters related to profession licensing and conduct.
 Finally, a nurse practice act defines professional misconduct.
Professional Misconduct:
Professional Misconduct is a violation of the act that can result in disciplinary action against a nurse.
Examples of Professional Misconduct:
 Exercising undue influence on the client
 Moral unfitness
 Revealing personal information without the client's prior consent
 Practicing beyond the scope permitted is law.
 Delegating professional responsibilities to a person not qualified perform them
 Abandoning or neglecting a client
 Harassing, abusing, or intimidating a client physically or verbally
 Failing to maintain a record reflecting evaluation and treatment of a client
 Failing to exercise appropriate supervision over persons who can practice only under supervision of a
licensed professional.
 Guaranteeing satisfaction or cure from the performance of professiona1 services
 Failing to wear an identification badge
 Failing to use scientifically accepted infection control techniques

Disciplinary Actions:
Disciplinary actions for professional misconduct are part of administrative procedure. A specific state
agency, such as the Board of Nursing, the Office of Professional Discipline, or the Office of Regulation of
the Professions is designated to review all manage allegations of professional misconduct. The state agency
investigations the allegation, prosecutes or settles a disciplinary proceeding, and enforces the penalty
imposed.
The disciplinary proceeding may involve a hearing before an administrative officer if a settlement cannot be
reached.
Penalties that a state agency can impose range from relatively mild to quite severe, and they may be
temporary or permanent.
An administrative warning may be issued to resolve a violation involving a minor or technical matter.
 The most serious penalty is revocation of the nursing license.
 Other possible penalties include censure and reprimand, a fine (not to exceed a specified dollar amount),
a requirement to perform community service, a requirement to complete a specified course of education
or training, and an annulment of registration or license.
 Suspension of license is another penalty that can be imposed.
 A total suspension may be given for a specified period of time' or until a course of therapy or treatment is
completed.
 A partial suspension, which allows you to work is nursing but not in the area or task (e.g., giving
medications) to which the suspension applies, is also possible.

 The suspension could last until successful completion of a course of retraining.

CONTROL OF THE PROFESSION OF NURSING:

959
Credentialing refers to the methods by which the nursing profession attempts to ensure and maintain the
competency of its practitioners. The nursing profession uses several methods of credentialing, including.

 Accreditation
 Licensure
 Certification
These efforts are designed to assure the public that only those persons who have met specified requirements
provide nursing card.

X. HOSPITAL RELATED LAWS

1. Central births and deaths Registration Act 1969.

2. Medical Termination of Pregnancy Act 1971
3. The Infant Mille Substitutes, Feeding bottles and Infant Food ( Regulation of production
supply and Distribution) Act – 1992
4. Transplantation of Human organs Act 1994.
5. Prenatal Diagnostic Techniques (Regulation and prevention of Misuse) Act 1994
6. Drugs and cosmetics (Amendment) Act of 1986
7. Narcotics Drugs psychotropic substance Act 1985.
8. Industrial employment (Standing orders Act 1946)
9. Employee state Insurance Act 1948
10. Payment of wages Act 1972
11. Consumer protection Act 1986

LAWS AFFECTING NURSING PRACTICE:

Several laws not directly focused on the practice of nursing have a significant impact on the way
you must practice nursing. These laws include

 Occupational Safety and Health Act:

Occupational Safety and Health Act of 1970 known as OSHA, established legal standards that define safe
and healthful working conditions. It is periodically updated and expanded, and it affects you as a nurse in
two ways.

1. It sets standards of your working conditions. Example: OSHA directs the manner in which potentially
toxic or flammable chemicals are handled. The use and care of electrical equipment is another area
OSHA regulates.
2. Some of the requirements of the law dictate how you manage clients.
Example: It provides standards for the management of contaminated equipment and supplies and the types
of isolation techniques used for infectious clients. Promoting health and safety is your professional,
obligation and your legal mandate.
 Controlled Substance Acts:
Several laws have been enacted that address standards for drug development and marketing. This law affects
the process by which new drugs become available to clients. Most significant is Comprehensive Drug Abuse
Prevention and Control Act of 1970. This law was enacted to regulate the distribution and use of drugs with
the potential for abuse. The nursing obligations under this law include proper storage and documentation of
controlled substances. Failure to meet the requirements of this law is grounds for charges of professional
misconduct and potential criminal action against nurses.
960
 Health Care Quality Improvement Act (1986)

One of the difficult issues in attempting to protect the public from unsafe and incompetent health care
providers has been the racking information related to adverse licensure actions, malpractice payments, and
adverse professional actions.
The law which does apply to nurses has limited the ability to health care practitioners who had adverse action
taken against them in one state from moving to another state without disclosing their previous performance.
XI. PATIENT'S BILLS OF RIGHTS
The American Hospital Association (AHA) replaced its Patient's bill of Rights recently with a
straightforward brochure informing clients about what they should expect during their hospital stay with
regard to their rights and responsibilities.
The brochure covers six areas described as the basics that clients and their families can expect in their
treatment during their hospital stay.

What to expect during your Hospital stay?

1. High-quality hospital care.
2. A clean and safe environment.
3. Involvement in your care.
o Discussing your medical condition and information about medically appropriate treatment
choices.
o Discussing your treatment plan.
o Getting information from you
o Understanding your health care goals and values.
o Understanding who should make decisions when you cannot.
4. Protection of your privacy.
5. Preparing you and your family for when you leave the hospital.
6. Help with your bill and filing insurance claims.
A Patient's Bill Of Rights:
1. The patient has the right to considerate and respectful care.
2. The patient has the right to obtain from his physician complete current information concerning his
diagnosis, treatment and prognosis in terms the patient can be reasonably expected to understand. When it
is not medically advisable to give such information to the patient, the information should be made
available to an appropriate person on his behalf. He has the right to know, by name, the physician
responsible for coordinating his care.
3. The patient has the right to receive from his physician information necessary to give informed consent
prior to the start of any procedure/ or treatment. The patient also has the right to know the name, the
physician responsible for coordinating his care.
4. The patient has the right to refuse treatment to the extent permitted by law and to be informed of the
medical consequences or-his action.
5. The patient has the right to every consideration of his privacy concerning his own medical care program.
Case discussion, consultation, examination, and treatment are confidential and should be conducted
discreetly.
6. The patient has the right to expect that all communication and records pertaining to his care should be
treated ad confidential.
7. The patient has the right to expect that within its capacity a hospital must have make responsible response
to the request of a patient for services. The hospital must provide evaluation, service and/ or referral as
961
 indicated by the urgency of the case. When medically permissible, a patient may be transferred to another
facility only after he has received complete information and explanation concerning the needs for and
alternative to such a transfer.

8. The patient has the right to obtain information as to any relationship of his hospital to other health care
and educational institutions in so far as his care is concerned. The patient has the right to obtain
information as to the existence of any professional relationships among individuals, be name, which is
treating him.
9. The patient has the right to be advised if the hospital proposes to engage in or perform human
experimentation affecting his care or treatment. The patient has the right to refuse to participate in such
research projects.
10. The patient has the right to know in advance what appointment times and physicians are available and
where. The patient has the right to expect that the hospital will provide a mechanism whereby he is
informed by his physician or a delegate of the physician of the patient's continuing health care
requirements following discharge.
11. The patient has the right to examine and receive an explanation of his bill regardless of source of payment.
12. The patient has the right to know what hospital rules and regulations apply to his conduct as a patient.

XII. BILLS OF RIGHTS FOR REGISTERED NURSES:

The Bill of Rights for Registered Nurses is a tangible tool, which aids in improving workplaces and ensuring
nurses' ability to provide safe, quality patient care. The Bills of Rights is intended to empower nurses by
making it clear what is absolutely none negotiating in the workplace.

The seven basic tenets of the Bills of Rights for Registered Nurses are:

1. Nurses have the right to practice in a manner that fulfills their obligations to society and to choose who
receive nursing care.

2. Nurses have the right to practice in environments that allow them to act in accordance with professional
standards and legally authorized scopes of practice.

3. Nurses have the right to a work environment that supports and facilitates ethical practice, in accordance
with the Code of Ethics for nurses and its interpretive statements.

4. Nurses have the right to freely and openly advocate for themselves and their patients without fear of
retribution.

5. Nurses have the right to fair compensation for their work, consistent with their knowledge, experience,
and professional responsibilities
6. Nurses have the right to a work environment that is safe for themselves and their patients.

7. Nurses have the right to negotiate the conditions of their employment, either as individuals or
collectively, in all practice settings.

XIII. ROLE OF REGULATORY BOARDS TO ENSURE SAFE PRACTICE:

962
Role of the Board of Nursing:

The Board of Nursing (or its equivalent) is legally empowered to carry out the provisions of the law. The
membership of the board, the procedures for appointment and removal, and the qualifications of board
members are determined by the Nurse Practice act. The board has the power to write the rules and
regulations used in daily operations.

The Governor of the state usually appoints the members of the State Board of Nursing. The law specifies the
occupational background of the candidates; nominates may be made by nurse's organizations and other
interested parties. North Carolina is the only state in which the RN members of the state board are elected by
the RNs in the state. Boards of nursing range in size from 7 to 17 members.

The responsibilities of these centralized agencies may range from administrative matters (such as collecting
fees, managing routine license renewals, and providing secretarial services) to decision making, relegating
individual boards like the Board of Nursing, to an advisory status. They also cooperate with the ANA and the
National League for Nursing (NLN) in some matters, but maintain the separation that is required of a
governmental body.

The Board of nursing typically must perform the following functions:

1. Establish standards for licensure.

2. Examine and license applicants.

3. Provide for interstate endorsement.

4. Renew licenses, grant temporary licenses, and provide for inactive status for those already licensed who
request it.

5. Enforce disciplinary codes.

6. Provide rules for revocation of license.

7. Regulate specialty practice.

8. Establish standards and curricula for nursing programs.

Approve nursing education programs

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XIV. LEGAL ROLE OF NURSES
conclusion
Legal responsibility in nursing to practice nursing within the guide lines laid legal guidelines for nursing
practice while
caring for
parents since
negligence
may cause a
great distress
to nurse
parent and
others as well
as to
reputation of
the down by
the law of
centre/state,
statutory
bodies and
institutional
Policies.
Every
Nurse should
act as per the
legal
guidelines for
nursing
practice while
instilled.

CHAPTER-
XII
Karol anbu
jayarani.D.

“PATIENT
CARE
ISSUES,
MANAGEM
ENT ISSUES, EMPLOYMENT ISSUES, MEDICO LEGAL ISSUES”
INTRODUCTION:
The role of nurses and professional nursing has expanded rapidly within the past ten years to
include expertise specialization, autonomy and accountability, both from a legal and ethnical perspective.
This expansion has forced new concern among nurses and a heightened awareness of the interaction of legal
and ethnical principles. Areas of concerns include professional nursing practice, legal issues, ethnical
principles, labor management and employment.
TERMINOLOGIES:
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Ethics:
Ethics is the study of good conduct, character and motives.
Ethics are the rules or principles that govern right conduct. They deal with what is good and bad, and with
moral duty and obligation.
Nursing Ethics:
Nursing Ethics is a system of principles concerning the actions of the in his or her relationships with
patents, patients' family' members, other health care providers, Policy makers and society as a whole. A
Profession is characterized by its relationship to society
Tort:
Civil wrong or injury committed by one person against another person or a property.
Negligence:
Negligence is a general term that refers to conduct that does not show due cares. If harm is caused by
negligence, it is termed as unintentional tort and damages may be recovered.
Liability:
Being legally responsible for harm caused to another person or property as a result of one’s action;
compensation for harm normally is paid in monetary damages.
Accountability:
Being responsible for one’s actions; a sense of duty in performing nursing tasks and activities.
Malpractice:
Malpractice is a term used for a specific type of negligence. It refers to the negligence of a specially
trained or educated person in the performance of his her job.
Law:
The Law constitutes body of principles recognized or enforced by public and regular tribunal has the
administration of justice. —Pound.
3. REVIEW OF IMPORTANT LEGISLATIONS:
(a) Consumer Protection Act – 1986.
In view of the Supreme Court affixing its seal of approval on the applicability of the Consumer
Protection Act (COPRA/ CPA) to the services provided by the medical profession, it has become imperative
for medical professionals to exercise a greater degree of caution while undertaking diagnosis and treatment
of patients. A good doctor – patient relationship, open channels of communication, patient education and
transparency can minimize litigations.
(b) Bio-medical Waste (Management and Handling) Rules 1998 (as amended in 2003).
It shall be the duty of every occupier of an institution generating bio-medical waste which
includes a hospital, nursing home, clinic, 40 dispensary, veterinary institution, animal house, pathological
laboratory, blood bank by whatever name called to take all steps to ensure that such waste is handled without
any adverse effect to human health and the environment.
These rules apply to all persons who generate, collect, receive, store, transport, treat, dispose or handle bio-
medical waste in any form. Bio-medical waste shall be treated and disposed of in accordance with Schedule
I, and in compliance with the standards prescribed in Schedule V.
(c) Transplantation of Human Organs Act 1994 (as amended in 2003).
Under this Act, registration of hospitals is must for the removal, storage and transplantation of
human organs. No such activity is permitted unless registered under the Act. Application on prescribed form
with fees is required. Certificate is given for specific period and the same has to be renewed when due.
Further, Registration can be cancelled after giving notice to hospital. Appeal against cancellation of
registration is to be made within 30 days of receipt of notice. Criminal action can be initiated with or without
notice.
(d) The Drugs & Cosmetics Act, 1940 with the Drugs, Cosmetics
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(Amendment) Act 1995 and the Drugs & Cosmetics Rules, 1945 (as amended in 2006).
An Act to regulate the import, manufacture, distribution and sale of drugs and cosmetics.
Amendment 2006 is related to importing of drugs, (to be tested in India before release for sale in India). Few
salient features of the above mentioned Act:
(i) Provision to empower the Drug Inspector to stop and search any vehicle, vessel or other conveyance
when he has reason to believe that those are being used for carrying any drug or cosmetic in respect of which
an offence under the Act is being committed.
(ii) Enhancement of the quantum of punishment for offences relating to the manufacture or sale of
adulterated, spurious drugs.
(iii) The main objective of the Act is to prevent sub-standards in drugs, presumably for maintaining high
standards of medical treatment.
(iv) Substances governed by the Act can nevertheless be applicable to narcotic or intoxicating liquor
which are subject to Excise by State under Entry 51, List II of the Constitution.
(v) Blood banks are required to regulate their services in accordance with the provisions of Ministry of
Health and Family Welfare, Dept of Health, notification dated April 1999 and need license to operate.
However, blood transfusion services of Field Medical Units are exempted from this provision.
(e) The Pre-natal Diagnostic Techniques (Regulation and prevention of misuse) Act 1994 and amended
Preconception and Prenatal Diagnostic Techniques (PNDT) Act, 2003.
The Act covers pre-conceptual techniques and all prenatal diagnostic techniques. All diagnostic
centers must be registered with the Appropriate Authority. They are required to maintain detailed records of
all pregnant women undergoing test there. These records must include the referring doctor, medical and other
details of the woman, reason for doing the test, and signatures of the doctors. These records must be
submitted to the authorities periodically. Doctors will be reported to the state medical council which can take
the necessary action including suspension. In the AFMSF, the powers have been delegated to DGAFMS,
who has nominated appropriate authority for each state for all AFMS units located there.
(f) MTP Act 1971 and MTP (Amendment) Act 2002. Medical
Termination of Pregnancy Act, 1971 provides for the termination of certain pregnancies by
registered medical practitioners and for matters connected therewith or incidental thereto. It extends to the
whole of India except the State of Jammu and Kashmir. In accordance with this Act, a MTP may be carried
out either in a hospital established or maintained by Government, or at a place for the time being approved
for the purpose of this Act by Government. Consent of the patient / legal guardian in case of minors or
mentally handicapped persons must be obtained before performing MTP. A pregnancy may be terminated by
a registered medical practitioner in the following conditions: -
(i) Where the length of the pregnancy does not exceed twelve weeks if such medical practitioner is, or
(ii) Where the length of the pregnancy exceeds twelve weeks but does not exceed twenty weeks, if not
less than two registered medical practitioner are, of opinion, formed in good faith, that the continuance of the
pregnancy would involve a risk to the life of the pregnant woman or of grave injury to her physical or mental
health

abnormalities to be seriously handicapped.

(g) Right to Information Act 2005.
An Act to provide for setting out the practical regime of right to Information for citizens to secure
access to information under the control of public authorities, in order to promote transparency and
accountability in the working of every public authority, the constitution of a Central Information
Commission and State Information
Commissions and for matters connected therewith or incidental thereto. The AFMS is not kept out of the
purview of the said Act. All members of AFMS are required to know the details of the content of the letter
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 No. 17732 / 6 / Info Act / AG / DV-1(C), dated 18 Nov 2005 issued from Human Rights Cell, Addl Dte Gen,
Discipline and Vigilance, AG’s Br, Army HQ, New Delhi and Office of DGAFMS letter No 43244/ RTI/
DGAFMS/ DG – 1C dated 16 Dec 2005.
(h) Medical examinations of apprehended persons.
During Counter Insurgency Operations, MOs may be called upon to medically examine and
render a fitness certificate before / after interrogation or handing over of an apprehended person to civil
police / release. MOs must exercise great caution and minutely note down all findings and maintain a record
of the same. While courts may not rely upon the report rendered by service MOs, terming them as
Departmental reports, any major discrepancy in findings of the service MO and that of a civil MO may invite
adverse comments by the Court.
. LEGAL SAFEGUARDS IN NURSING PRACTICE:
Nursing Legal Issues: How to Protect Yourself
With any professional license comes ethical and legal responsibility. Doctors take the Hippocratic
Oath pledging to do no harm to patients; lawyers are held responsible for their clients in court; and architects
are responsible for the safety of the structures they build. Nurses are no different. Whether it's administering
a medication incorrectly or failing to obtain an informed consent from a pre-op patient, nurses may be held
legally responsible if they fail to meet certain standards.
All nurses should be familiar with nursing law and ethics and understand how nursing legal issues can
affect them. Know your basic nursing laws and avoid lawsuits and liability:
4.1. Signatures Are Golden
When a physician or other health care provider orders a procedure be done to a patient, it is the nurse's
responsibility to obtain an informed consent signature. This means that the patient:
 Understands the procedure and the alternative options
 Has had a chance to ask the provider any questions about the procedure
 Understands the risks and benefits of the procedure
 Chooses to sign or not sign to have the procedure performed.
If the nurse does not obtain signatures, both the nurse and the operating provider can be held liable for
damages incurred.
4.2. Document, Document, Document
It is the nurse's responsibility to make sure everything that is done in regards to a patient's care
(vital signs, specimen collections, noting what the patient is seen doing in the room, medication
administration, etc.), is documented in the chart. If it is not documented with the proper time and what was
done, the nurse can be held liable for negative outcomes. A note of caution: if there was an error made on the
chart, cross it out with one line (so it is still legible) and note the correction and the cause of the error.
4.3. Report It or Tort It
Allegations of abuse are serious matters. It is the duty of the nurse to report to the proper authority
when any allegations are made in regards to abuse (emotional, sexual, physical, and mental) towards a
vulnerable population (children, elderly, or domestic). If no report is made, the nurse is liable for negligence
or wrongdoing towards the victimized patient.
4.4. Rights to Privacy
The nurse is responsible for keeping all patient records and personal information private and only
accessible to the immediate care providers, according to the Health Insurance Portability and Accountability
Act of 1996 (HIPAA). If records get out or a patient's privacy is breached, the liability usually lies on the
nurse because the nurse has immediate access to the chart.
4.5. You're Dosing WHAT?!
Medication errors account for 7,000 deaths and 770,000 patients injured each year in the US. It is
the nurse's responsibility to follow the five "rights" of medication administration: right dose, right drug, right
967
 route, right time, and right patient. If a nurse pays attention to those details, the likelihood of a medication
error is greatly reduced, thereby saving the nurse and health care institution from liability for damages.
4.6. Licensure:
All nurses who are in nursing practice have to possess a valid licensure, issued by the respective State
Nursing Council/Indian Nursing Council. He/she is being in possession of license to practice which is her/his
sole authority. Their practice is confined to that for which they have been prepared by a controlled
educational programme.

Hence, the purpose of the professional licensure on the one hand is, to secure society the benefits which
come from the services of a highly skilled group.
4.7. Good samaritan laws:
In response to health professionals, fear of malpractice claims, most states enacted 'Good samariton laws' that
exempt doctors and nurses from liability when they render first aid during emergency. A nurse who renders
assistance at an accident scene is held to same preparation.
4.8. Good rapport:
Developing good rapport with the client is very important to prevent malpractice. A lawsuit is ofen
circumvented when the nursing staff treats the client with warrants and caring. So nurses must never
underestimate rapport' with the client in malpractice prevention. The ability to develop good rapport with
clients is dependent on the Nurse having good interpersonal communication skills, e.g. listening.
4.9. Standards of care:
All professional practicing in the medical field are held to certain standards when administering care.
Standards of care come from several sources including laws, organizational standards, and institutional
policies and procedures. It is always better to follow standards of care to avoid malpractice and do not
attempt anything beyond the level of competence.
4.10. Standing orders:
Although a nurse may not legally diagnose illness or prescribe treatment, she or he may after assessing
patients' condition, apply 'standing orders' or treatment guideline that have been established by the
physician/doctor as appropriate for certain problems and conditions. Each nurse supervisor is responsible for
persuading the Doctor in charge of the unit to periodically review, sign and date any standing orders that
nurses are to implement in her or his absence. When a nurse has reason to question a medication order, she or
he is expected to promptly notify the patient's physician of the previewed problem, so that physicians can
clarify or modify the order. Nurses do not take chance, if there is any doubt rise in their mind, and seek
advice from the service or supervisors or any one who authorised to do so. And it is always better to follow
written orders instead oral orders.
4.11. contracts:
A contract is a written or oral agreement between two people in which goods or services are v exchanged.
Section 13 to the Indian Contract Act defines the word, saying that two or more persons are said to consent
which they agree upon the same thing in the same sense. Treating a patient without obtaining proper consent
can lead to a charge of assault and/or battery. As stated earlier, assault is the threat of an unauthorised
touching, battery is unauthorised touching of a patient.
4.12. The misuse of drugs act:
The Act aims at checking the unlawful use of the drugs liable to produce dependence or cause harm if
misused. Drugs affected by this act are referred to as controlled drugs and are divided into 4 schedules. The
common drugs controlled under the Dangerous Drug Act include.
Cocaine, Dinmorphine (heroin), Levorphanol, Methadone, Morphine, Opium, Pethidine and others.
Medical practitioners and registered dentists may prescribe preparations containing these poisons. A
prescription must bear:
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 1. Patient's name and address
2. Date
3. Signature of prescriber
4. Total quantity to be supplied, in words or figures.
Every general practitioner is required to keep a record of all purchases of these drugs, and of the amount
issued to individual patients.
In hospitals the use of these drugs is under strict control, although minor variations in details may occur in
individual institutions.
 A special cupboard is used for storing such drugs, and this should be marked 'CD'.
 The cupboard is kept locked, and the key carried on the person of the state registered nurse in charge.
 Renewal of supplied can only be obtained by an order signed by a Medical officer; and the drugs can only be
given under the written instructions of such.
 Each dose of these drugs administered must be entered into a special register provided for the purpose, with
the date, patient's name and time of giving. The persons giving and checking the drug must sign this entry.
While administering drug, it is always remember that five R's, i.e. Right patient, Right drug, Right dosage,
Right time and Right route.

In most hospitals it is a rule that each dose given must be checked by two persons, one of whom should by a
state registered nurse. This person should see the bottle from which the drug is taken, and check the dose
with the written prescription.
All bottles containing controlled drugs should be marked conspicuously
with a special label.
4.13. consent for operations and other procedures:
A patient coming into hospital still retains his rights as a citizen and his entry only denotes his willingness to
undergo an investigation or a course of treatment. Any investigation or treatment of a serious nature, or an
operation in which an anaesthetic is used, requires the written consent of the patient. A patient may give his
own consent if he is of full age, i.e. has attained the age of 18 years or is a minor who has attained the age of
16 years.
For patients less than 16 years of age, consent of the parent or guardian Is normally obtained. In the event of
any difficulty the ward sister should inform the surgeon and the senior administrative officer. This also
applies in those cases where the patient is unfit to give consent and no relative is available.
4.14. Self discharge of patient:
When the patient demands to discharge himself, the nurse on duty should try to dissuade him and should
inform the medical officer concerned with his care. If the patient is adamant, each hospital will follow its
own procedures. It is probable that a senior administrative officer will see the patient and ask him to sign a
written statement to the effect that he is discharging himself against medical service. If he refuses to sign, a
note to this effect will have to be made and signed by two witnesses one of whom is usually the
administrative officer concerned and the other is the nurse in charge at the time. The patient must be allowed
to leave.
4.15. Documentation:
Documentation is by far the best once a lawsuit filed. The medical record is a legal document and admissible
in court as evidence. It enjoys a privileged status in that it is presumed to be an accurate account of what
transpired. This is because it was written at the time of occurrence, by someone with knowledge of events
and before litigation was initiated. From litigation stand point, the jury often assumes that if something has
not charted, it was not done. Nurses should give themselves credit for care they provided thoroughly
documenting it in the medical record.
4.16. Reporting:
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 In some situations, nurses have obligation or are required to report certain communicable disease or criminal
activities such as abuse, gunshot wounds, attempted suicide or rape to the appropriate authority.
 Some 'Don'ts and 'Dont's for the Nurses are as guidelines for their safe practice.
 Do document all unusual incidences.
 Do report all unusual incidents
 Do follow policies and procedures as established by your employing agency.
 Do keep current year license to practice.
 Do perform procedures that you have been taught and that are within the standard scope of your practice.
 Do protect patients from injuring themselves.
 Do not remove side rails on patient’s bed, unless there is an order or hospital policy to do so.
 Do not allow patients to leave the hospital or nursing home unless there is an order or signed release.
 Do not accept money or gifts from patients
 Do not give advice that is contrary to doctor’s orders or the nursing care plan.
 Do not give medical advice to friends and neighbors,
 Do not witnesses patients will.
 Do not take medications that belong to patients.
Do not work as a nurse, in a state in which you are not licensed
5. PATIENT CARE ISSUES:
5.1. Nurse Practice Act
Each state has what is called a Nurse Practice Act. The guidelines and laws outlined in the act
pertain to all nurses who are licensed in that particular state. Nurse limitation is one of those laws. Each nurse
has a limitation on what he is allowed and trained to do. He must follow the chain of command, especially
with the care of a patient. If he does not have the authority or knowledge to give a prescription, analyze a lab
report, or advise the patient on treatment, he may not legally do so. Any wrong information or practice he
commits is punishable by the law and the patient or family may file a suit against him and the health agency
or hospital he works for.
5.2. Patient's Advocate
A nurse has a legal obligation to act as the patient's advocate in case of emergency. The nurse is
to act as the liaison between the patient and the health care provider, such as a physician. The nurse will
monitor the patient, ensuring that if any complications or abnormalities arise, a physician notified
immediately. The nurse is legally obligated to keep the personal data and information of the patient private;
not doing so is a violation of the code of ethics for nurses.
5.3. Administering Medication
Nurses are responsible for administering the correct doses and medications to patients. If the
nurse gives a fatal dosage amount, she may face legal malpractice suits. It is also the responsibility to
research the patient's records, or ask the patient and family members if there are any allergies or
complications that may pose a risk if a certain medication is administered.
5.4. Informed Consent
When a nurse is administering treatment, she must explain what the effects and outcomes could
be, and any other important information. It is the responsibility of the nurse to confirm that the patient or
family member who will sign the informed consent form is coherent, and understands all the negatives and
aspects of the treatment. The nurse, patient, or patient family member will sign the informed consent form in
front of a witness, a physician or another nurse. Not having this legal document signed and in front of a
witness could be a legal issue for the nurse if complications arise during treatment
5.5. HIV screening
Pregnant women are ethically obligated to seek reasonable care during pregnancy and avoid causing
harm to the fetus Maternity nurses should be advocates for the fetus, but not at the expenses.
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 Mandatory HW screening involves ethical issues related to privacy invasion discrimination, social stigma
and reproductive asks to the pregnant women, incidence of prenatal transmission from and HIV positive
mother to her fetus ranges from 25% & 35% Methods of preventing maternal fetal transmission and fetal
Treatment are not available at present. Until there is a change in technology that alters the diagnosis or
treatment of the fetus testing of the pregnant woman should be voluntary. Make sure that pregnant woman is
well informed about HIV symptoms testing.
5.6. Living wills
One Possibility of ensuring that our wishes are respected is to have an advance directive (living
will). Bright Dimond (2001d) writes that, in 1999, the Government decided that it would not legislate about
advance statements, considering that all adults have the right to consent to or refuse medical treatment.
Where the patient’s refusal to give his consent has been expressed at an earlier date, before he became
unconscious or otherwise incapable of communicating it; though in such circumstances special care may be
necessary to ensure that the prior refusal of consent is still properly to be regarded as applicable in the
circumstances which have subsequently occurred (Diamond 2001)
5.7. Fetal abnormalities and diseases
The statistics given above about the number of abortions carried out each year make no
distinction between abortions for unwanted pregnancies and those carried out for therapeutic reasons.
Research in embryology has made significant advances and genetic abnormalities in a fetus can be diagnosed
early. When parents are informed of such a possibility they are given the choice of an abortion. Hereditary
diseases transmitted through, or affecting, one sex only can be detected at a very early stage of in-vitro
fertilization and it is therefore possible to transfer only the non-affected pre-embryos to the mother for
gestation.
Similarly, Ann-Marie Begley (2000) describes a couple who had undergone fertility treatment, with the
woman finally having a positive pregnancy test. The first scan showed that she was in fact carrying seven
live fetuses. The couples were recommended to undergo multifocal pregnancy reduction. Faced with such a
dilemma, the woman was determined that she could not live with the possibility of killing four fetuses to give
three others a chance to develop. Her husband was strongly in favor of the reduction.
Both examples show how couples are often thrown into confusion by unexpectedly having to face
decisions that will affect their whole lives, yet they are given little or no help in reaching such decisions.
5.8. Abortion
The Abortion Act, 1967, originally allowed termination of pregnancy up to the 28th week of
gestation, but this was reduced in 1990 to 24 weeks. The ethos of the Act is to save life and prevent
suffering.
Anti-abortion groups base their arguments on the unquestioned principle of the sanctity of life. This
makes it difficult to reason for the saving of the mother’s life, or to consider the kind of life that either
mother or baby will have.
Nurses rightly feel that abortion is an issue of ethical debate for them. They are concerned with
preserving and enhancing human life, not destroying it. The conscience clause (sub clause 2.5) in the Nursing
and Midwifery Council Code (2002) means that nurses can opt out of taking part in an actual abortion, but
those working in a gynecological ward are still duty-bound to care for a woman before and after the
operation
5.9. Resuscitation of extremely premature infants:
There are different opinions about resuscitation of extremely preterm infants weighing between
500 gram to 750 gram ethical issues related to this issues for nurses.
 Whether or not to resuscitate?
 Who should decide
 Is the cost of resuscitate justified.
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Do the benefits of technology outweigh the burdens relation to quality of life.
5.10. Fetal sex
Raises the number of elective abortion for selection of sex. This rationale for elective abortion
raises serious ethical questions for health care provider faced with these situations.
The reports of recovery of female fetuses from wells drains, garbage dumps, and public lavatories in
Punjab visibly challenged the implementation of the PC & PNDT Act. The boards displayed in nursing
homes saying sex determination test are not conducted here were just a ploy to hood wink the authority.
5.11. Assisted suicide
The term ‘assisted suicide’ is generally used when a doctor supplies a patient with the necessary
medication to end life as and when desired. The patient has the choice whether to use the medication or not.
The doctor does not actually give the medication. Nicholas Dixon (1998) believes that there is no moral
difference between euthanasia and physician - assisted suicide. He states that the only reason for preferring
one to the other [physicians-assisted suicide to active euthanasia] is the purely pragmatic consideration that
the willingness to commit suicide gives compelling evidence of the patient’s desire to die’. He argues that, if
Killing is absolutely wrong, then so is helping to kill someone. He compares this with a situation when
someone is shot and killed because of a mugging. All the muggers are charged with killing, not only the one
who pulled the trigger.
5.12. Right to die:
The concepts surrounding death and dying have become more intricate and diverse. It is therefore
necessary to address several issues that overlap.
A right to die has become a more frequent demand. It applies in particular to terminally ill people who do
not want further treatment. Alongside a right to die has also emerged a duty to die. This refers to terminally
ill people who feel that they have no choice but to refuse treatment because of social factors, such as being a
burden on their family or a financial cost to society.
Eg the case of Diane Pretty was in the news because of her request that her husband should not
prosecuted if he helped here to die. She was a 42-year-old woman with advanced motor neuron disease. This
right was refused in the English courts and she took her case to the European Court of Human Rights,
claiming several articles under the Human Rights Act, 1998. However, the European Court of Human rights
also refused her claim. Emma Wray (2001) had argued that there were strong indications for and against
giving Ms Pretty her right.
5.13. Forced cesarean birth
Refusal of a cesarean birth for fetal reasons by a woman is often described as a maternal-fetal
conflict. Health care providers are ethically obliged to protect the well being of both mother and the fetus it is
difficult to make a decision for one without affecting the other. If a woman refuses a cesareans that is needed,
health care providers need to make every effort to find out why she is refusing and provide information to
persuader her to change her mind. If the woman continues to refuse surgery, then health care providers must
decide if it is ethically right to force her to make the decision and to try and get a court order for the surgery.
Every effort should be made to avoid this legal step.
5.14. Fetal tissue transplantation:
Another technology with ethical implications is the use of fetal tissue transplantation (Erlen, 1990, Gero,
Giordano, 1990). Current research suggests that fetal neurologic, liver and pancreatic tissues transplanted
into adults with parkinson’s disease. Metabolic disorders or head and spinal cord injury hold promise of
recovery of those adults. The importance ethical issue is to reduce any pressure for fetal tissues on a mother
who is contemplating an elective abortion. Elective abortion continues to be a controversial issue with many
issues gets to be resolved.
5.15. Euthanasia:

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 In the past, several terms were used for different aspects of euthanasia. While the word itself
means a ‘good death’, the way we use it means the intentional killing of someone. Thus, generally speaking,
only the terms ‘voluntary’ and ‘involuntary’ euthanasia are now used. Indeed, in the Netherlands, the word
euthanasia is used only for deliberate acts of liking; voluntary euthanasia is referred to as ‘termination of life
on request’. The Royal Colleges of Physicians and General Practitioners’ working Group on Euthanasia have
defined euthanasia as ‘the active, intentional, ending of the life of a competent patient, by a doctor, at that
patient’s request’
The Dutch Bill to decriminalize voluntary euthanasia and doctor-assisted suicide became law in April
2001. The criteria for voluntary euthanasia and doctor-assisted suicide are as follows:
The doctor must be convinced that the patient:
A has made a voluntary and well-considered request to die
B is facing interminable and unendurable suffering.
Criteria A and B imply a long standing doctor-patient relationship, which, in effect, restricts voluntary
euthanasia or doctor-assisted suicide to residents of the Netherlands.
The doctor must also:
 Inform the patient about his or her situation and prospects
 Together with the patient be convinced that there is no other reasonable solution.
 Consult at least one other independent doctor
 Give a written assessment of the due care requirements covered by criteria A-D
 Helps the patient to die with due medical care
 Report to the relevant regional committee (made up of at least three members, including a legal expert, a
doctor and an expert in ethics or philosophy).
 As before, all cases must still be reported and must still go to a review committee, but the significant
difference now is that if the review committee is satisfied, that is the end of the matter (Sanders 2001,)
5.16. Organ donation:
Anatomical gift is the legal term for organ donations (Kidneys, hearts, liver, lungs, Pancreases) and
tissues including corneas, eyes, bones, bone marrow, skin, and heart valves. Bone marrow and kidneys can
be donated while the donor is still alive. If the person did not indicate whether organs were to be donated, the
family makes the decision after the patient dies.
5.17. With holding and with drawing treatment:
Patients in persistent vegetative state (PVS) and the associated burden on their families raise disturbing
questions for doctors and nurses on what would really be best for them, considering the usually poor
prognosis.
In its guidance for decision making, the British Medical Association (1999) states that few issues in medicine
are more complex and difficult than those addressed by patients, their relative and their doctors concerning
the decision to withhold or withdraw life-prolonging treatment.
In similar circumstance, doctors should be able to consult with colleagues and senior clinicians outside the
treatment team in difficult situations, rather than having to seek court approval before withdrawing artificial
nutrition. Although it is easier to withhold treatment in the first instance, the British Medical Association
believes that there are no morally relevant differences between withholding and withdrawing treatment.
6. MANAGEMENT ISSUES:
Emerging issues in the Indian context:
6.1. Recruitment:
Even when attempts to recruit more people into nursing have been successful most schools and
universities find themselves unable to expand nursing programs to accept the qualified applicants because
they are faced with a serious shortage of nursing faculty
2. Aging work force and retention:
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 Strategies must be developed to retain the older expert professional nurse with the nursing work
force statistics detail the nursing work force statistics detail 2004 the national average age of professional
nurse was 46-8 years.
RN under 30 years of age represented only *% of the total nurse population. More than the age of 40 now
represent nearly 60% of the work force & 25% more than 54 years old.
The shortage will worsen by 2010 when many of these RNs reach their retirement years.
3. Policy development:
Special relationship between the nursing profession and society. Nurses have a legal obligation to
provide at the minimum “Safe” standard of care to the persons they serve. Allowing use of non-RNs to
circulate in even selected operative cases could jeopardize nurses’ commitment and obligation to safe guard
patients.
Connection between standards of practices and standards of education. RN circulations possess advanced
skills, knowledge and judgment that surpass the to clinical skill of non RNs (1992)
Lack of health insurance is the greater barrier to accessing health care and has a tremendous impact on an
individual health studies have consistently of and that the uninsured review less than adequate health care
California.
4. Decision making:
The nurse must meet the minimal requirement for the position desired one year of experience
might be required for a nurse to work a weekender program (or) in a critical area operating room (or)
experience may be required for (or) nursing position M.Sc. (or) Bsc (N) needed for Nursing superintendent
The nurses’ suitability for contributing to the mission of the health care delivery system.
6.5. Bud get / Finance:
A unique challenge of APNS is reimbursement for nursing services as advanced practice
continues to expand nurses have move from secondary to in depend dent billing for services. Federal
regulations all direct reimbursement for some nursing services yet state and local practices vary.
6.6. Staffing:
Floating and mandatory ever time. An emerging shortage of professional nurses began to further
complicate staffing levels.
1. Professional nurses being required to float to the patient care units for which they had little (or) no
orientation experience (or) support.
2. Implementation of mandatory over time (or) mandatory on call requirement.
6.7. Delegation and supervision:
A patient with cardiac problems sued after suffering catastrophic physical and mental disabilities when a
graduate nurse, not yet licensed administered five times the ordered close of dioxin. The shift change nurse
assigned another nurse with only 7 month experience to act as the graduate nurse preceptor. The preceptor
did not supersize the new graduate when she administered the drug. The court criticized the shift change
nurse for assigning a novice nurse as a preceptor.

6.8. Supervisory liability:

In the role of charge nurse, head nurse, supervisor, or any other role that involves delegation, supervision, or
direction of other people, the nurse is potentially liable for the actions of others. The supervisory nurse is
responsible for exercising good judgment in a supervisory role, including making appropriate decisions about
assignments and delegation of tasks. If an error occurs and the supervising nurse is shown to have exercised
sound judgment in all decisions made in that capacity, the supervising nurse may not be held table for the
error of a subordinate. If poor judgment was used in assigning an inadequately prepared person to an
important task or oversight was inadequate, the supervisory nurse might be liable for resulting harm. The

974
extent of the subordinate's responsibility would depend on his or her level of education and training. People
with limited
Education or training might not be liable for some errors; the more education subordinates have, the more
likely they will be liable also. Example for supervisory responsibility for an educated staff member:
Two sudden admissions to the coronary care unit create a situation in which additional help is needed to
care for the patients in the unit. A "float" nurse is sent to the cru to assist. The charge nurse does not ask the
temporary float nurse volunteers this information. The temporary float nurse, however, has no background or
experience in coronary care.
He temporary nurse is assigned by the charge nurse to the complete care of two patients. Because of the
float nurse's inability to accurately interpret the monitors, a potentially life-threatening problem is not
identified until the patient "arrests". Resuscitation efforts are successful, but the patient suffers some brain
damage.
Both the change nurse, who assigned the inadequately prepared nurse to total care, and the temporary nurse
could be found liable; the charge nurse for incorrectly assigning the nurse, and the temporary nurse for not
recognizing her own limitations.
Example for supervisory responsibility for staff member with limited education:
The RN is working on a unit that assigns a nursing assistant to work with each RN. One evening, the regular
nursing assistant is absent due to illness. A new nursing assistant is assigned to work with the RN. During the
evening, the RN asks the nursing assistant to monitor the new postoperative patient. The RN lists

For the nursing assistant the items that is to be checked: vital signs, hourly Time output, pain and condition
of the dressing. Each hour, the RN stops the Nursing assistant asks if the patient is doing okay, and receives
affirmative reply. When the RN stops to chart, he reviews the last 4 hours of flow sheet information listed by
the nursing assistant. He sees that the urine output has been only 15ml/hr for the last 4 hours. When he
questions that, he learns that the assistant had no idea what information needed to be reported immediately.
The RN completes and assessment and calls the physician. The patient is found to have developed renal
failure.
The RN might be found negligent in this case for assigning the nursing assistant Monitor a critical
postoperative patient without proper direction or supervision. The Sing assistant might not be found
negligent because she had no basis for recognizing
The seriousness of the situation or for recognizing her own lack of ability to meet the Responsibilities
involved in this assessment.
The health insurance company that makes payments for health care insurance coverage (or) third party
payment adds to the confusion of health care markets.
6.9. Senior Management
All nurses have a managerial role, from the way they organize their care of even a small number of
patents or staff to being in charge of teams and departments. In considering here some issues of senior
management, only some aspects are highlighted.

When working as a manager, you have a duty towards patients and clients colleagues, the wider
community, and the organization in which you and your colleagues work.. your first consideration in all
activities must be the interests and safety of patients and clients.
 Can managers challenge the situations they are presented with but over which they have no control?
 Can managers expect that their staff are willing to work with new ideas and practices when they have
become cynical, having seen it all before?
There are not usually monetary incentives, so managers have few other means of enthusing their staff to
make changes again.
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6.10. Complaints
Managers will probably spend much of their time and energy dealing with complaints, large and small.
The buck stops there or at least long enough to be considered. Depending on the role of a manager,
complaints may be about staff or work, the running of the institution itself, or the customers of the institution.
In the NHS a comprehensive complaints procedure is in place for patients. This was introduced after
publication of the Wilson report, being heard (Department of Health 1994). The report recommended that the
following principles should be incorporated into any NHS complaints procedure.
 Responsiveness
 Quality enhancement
 Cost effectiveness
 Accessibility
 Impartiality
 Simplicity
 Speed
 Confidentiality
 Accountability
These principles are also ethical aspects of resolving any conflict and they should be applied if dealing
with patient or staff complaints.

 People who have been wronged or hurt often want or need redress. When this is not forthcoming., they
may pursue compensation. A more ethical way may be for parties to be brought together, ensuring that
people on each side are heard of personal effort, but it may also be cost-effective in terms of
compensation saved. More is gained and learned by being hman with each other (because a relationship
is formed) than by money changing hands.
6.11. Leadership
Managers are leaders, and leaders are also managers. They may not always be in both roles at once. Leaders
are not necessarily born; with good training they can also be ‘made’ Styles of leadership vary depending on
the psychological make-up of the person. Some people lead from the front, others from behind.
Leaders have to have a good knowledge of psychology a know how they can best lead others, and what
makes some people leaders and others willing or needing to be led. Alison Binnie (1998) commented that, as
a ward sister, she appointed many nurses who0 had had a thoroughly modern education and were able to talk
intelligently about the nurse-patient relationship and the impact of individualized care. However, it was not
until they actually experienced patient-centered nursing that they began to ‘know’ what these concepts mean
in proactive. External and internal knowing may not happe4n at the same time. It is the leader job to enable
the two to come together.
If we are to be creative in caring, it also means expressing this in relationships by being receptive,
relating and responsive.
 How much can leaders use and express their own values in which they work?
 Do they need first of all to express the values of the organization they work in?
 This may lead to conflict between personal and organizational values, which set of values has
precedence?
 Can managers encourage their staff to develop in the best interests of the person concerned, or do they
need staff that follow rules and cause no problems in the organization?
 Is it enough for leaders to have commitment, courage and resilience? From where do they receive their
support?

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  Most ethical problems are caused by values of one kind being in conflict with different values. First
asking, what is happening? Will provide a starting point. Then asking, ‘what would happen if…?’
enables the creative and whacky ideas to develop and the possible outcomes to be envisaged in terms of
ethics. Next, ‘What is the fitting answer?’ may present itself, and the outcomes may be seen before too
long.
7. EMPLOYMENT ISSUES:
7.1. Nurses Work Place Advocacy to Work Force Advocacy
7.1.1. Promoting a Professional Practice Environment:
Professional nurses are seeing the drawn of an era of involvement and control in the work environment that
was unheard of a decade ago. Important research is validating the contribution and value of RNs in the
following areas:
 Improved patient outcomes.
 Prevention of premature mortality.
 Increased hospital profitability.
Nurse’s strong concern and commitment to patient care and their role as patient advocates often places
them in direct conflict with those who have more control, such as physicians and health care administrators.
How the nurse reacts to such conflicts within the workplace and continues to advocate improving patient care
is a new focus for the profession as we enter the twenty-first century a focus called "workforce advocacy".
Nurses working on the medical unit are concerned because there is a limited amount of safe patient handling
equipment available on their unit. The patients on the medical unit often have mobility issues, and the nurses
are worried about suffering musculoskeletal injuries when transferring and repositioning patients. Where will
they find information about ergonomic safety and other workplace safety issues?
7.1.2. Examples of Workforce Advocacy
 Promoting and protecting the occupational safety and health of nurses.
 Using nurse practice acts and other legislative and regulatory protections.
 Using the political process to influence legislative and regulatory agencies for the protection of nurses
and patients.
 Providing education regarding employment rights and responsibilities
 Developing skills related to public relations, media presentations, and conflict resolution.
 Building coalitions and support groups to enable nurses to speak and advocate for their professional
practices.
 Participating in committee structures of the health care organization to ensure a nursing voice in safety
and workplace issues.
A process in which nurses are supported with a program of services and tools designated to help them
self-advocate in the workplace and in their professional and personal development. This organizing
framework is based on having the individual nurse, rather than the nurse's workplace, as the focus. This
subtle but fundamental shift embraces a model that addresses the various elements of the nursing workforce:
workforce staffing, work-flow design, personal and social factors, physical environment, and organizational
factors.
7.1.3. Workforce Advocacy Ecosystem Model
Staffing: Refers to job assignments including: the volume of work assigned to individuals, the professional
skills required for particular job assignments, the duration of experience in a particular job category, and
work schedules.
Workflow design: Pertains to on-the-job activities of health care workers, including interactions among
workers and the nature and scope of the work.

977
 Personal and social factors: Refer to individual and group factors, such as stress, job satisfaction, and
professionalism, in addition to skills that may be underdeveloped in the nursing population, such as financial
literacy.
Physical environment: Includes aspects of the workplace, such as light, aesthetics, and sound. These
elements will be crucial as the Center explores the needs of a maturing workforce and offers solutions to
health care employers
Organizational factors: Structural and process aspects of the organization as a whole, such as the use of
teams, divisions of labor, shared beliefs, and an increasing leadership capacity among nurses.
7.1.4. Five Opportunities and Challenges for Workforce Advocacy
1. Identify mechanisms within health care systems that provide
opportunities for RNs to affect institutional policies.
a. Shared governance
b. Participatory management models
c. Magnet hospital identification
d. Statewide staffing regulations
2. Develop conflict resolution models for use within organizations that
address RNs' concerns about patient care and delivery issues.
a. Identification of the reporting loop
b. Appointment of a final arbiter in disputes
3. Seek legislative solutions for workplace problems by reviewing
issues of concern to nurses in employment settings and introducing appropriate legislation, such as:
a. Whistle-blower protection
b. "Safe harbor" peer review
c. Support for rules outlining strong nursing practice standards
4. Develop legal centers for nurses,-which could provide legal support
and decision-making advice as a last recourse to resolve
workplace issues.
a. Provide fast and efficient legal assistance to nurses.
b. Earmark precedent setting cases that could impact case law and health care policy.
5. Provide RNs with self advocacy and patient advocacy information,
such as:
a. Laws and regulations governing practice
b. Use of applicable nursing practice standards
c. Conflict resolution and negotiation techniques
d. Identify state and national reporting mechanisms that allow RNs to report concerns about health care
organizations and/or professionals.
7.2. Responsible use of supplies:
 If you find yourself in an emergency situation that is going to cause you to be
delayed, it is important that you notify your suspension that you are going to be
delayed
 It is also expected that you will not abuse breaks or sick leave
 If you are working in an area where you have affair amount of privacy, it is
important to remember that you should not conduct personal business during your
work shift
 When you decide to terminate your employment, it is expected that you will give
appropriate notice
7.3. Protection of the employee:
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  Pilfering includes stealing in small amounts or stealing objects of little value
 Employers often take home adhesive bandage strips, pens and other such objects, so routinely that
they do not even consider whether this is right or wrong.
 As a leader in care setting, RN is often in a position to communicate clearly all employers, that
pilfering is unacceptable.
 You can help reduce costs by being judicious in your use of resources.
Example
 Using extra linen (bath towels) to clean up spills adds to costs
 Determining that clean glove is acceptable rather than reaching sterile gloves reduces cost.
7.4. Responsible work ethic:
The government has recognized the need to protect staff from being victimized if they bring attention to the
hazards at work. Following a consultation exercise on the Secretary of State’s guidance on relations with the
public and media, the NHS Management Executive issued guidance EL(93)51, published 8 June 1993. This
guidance made it clear that:
Under no circumstances are employees who express their views about health service issues in accordance
with guidance to be penalized in any way for doing so. Many trusts now incorporate within their contracts of
employment terms that registered practitioners should follow the professional guidance of their registration
bodies as part of the contract o employment. Such terms should prevent a conflict between the duties
required of a practitioner by their employer and by their professional registration body. This was
recommendation of the Report of the Inquiry into Bristol Royal Infirmary children’s hear surgery, but was
rejected by the Department of Health in respect of the contracts of medical practitioners.
Code of ethics defines a profession’s ethical standards and expectations, codes of ethics are not stagnant.
Codes of ethics should be modified and revised as the profession is faced with new situations. The Florence
Nightgale pledge which was written by Lystra Gretter in 1893 is believed to be the original nursing code of
ethics.
8. MEDICO - LEGAL ISSUES:
Most particularly medical malpractice, and informed consent, the right to refuse treatment, confidentiality,
end-of-life issues, and inappropriate relational concerns.
8.1. Medical negligence:
Our guidelines give a list of what is usually considered to be negligence:
1. Fails to give prompt attention to a patient.
2. Manifests incompetence in clinical assessment of patient.
3. Wrong diagnosis in the presence of obvious clinical presentation.
4. Fails to advise a patient on the risks attendant on a particular course of management or operation.
5. Makes glaring mistakes.
6. By action or omission causes other members of the health team under his supervision to act to the
detriment of the patient.
There are four areas in the area of medical negligence which needed addressing.
• Vicarious liability.
• The Duty of care.
• Resource Limitation in health delivery.
• Standard of care.
Baledrokadroka also looked at the issues related to Patient Autonomy as a human rights issue. He
referenced the World Health Organization Document on the Promotion of Rights of Patients in Europe,
which has unifying themes even for the people of the South Pacific.
8.1.1. Vicarious liability.

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 There are no specific legislated laws in the South Pacific covering vicarious liability. We have
common law and precedent case laws within the region to fall back on. The constitutions of the region also
deal in minimal words matters relating to health by way of regulations and some human rights issues of
recent. All the same, issues of vicarious liability appear to be rather clear to the legal profession and the
judiciary in the region, with the health departments and Attorney Generals liable on behalf of the State.
Although without judicial authority, the operation of the hospital system revealed a shockingly low standard
of care and supervision at the hospital.
8.1.2. Duty of care.
Patients are vulnerable humans, with basic human rights. Modern medical law has begun to take
on the language of rights. Consequently I learnt of the language of “Duties” whilst studying medico-legal
issues. The duty of care is incumbent on the medical practitioner as a matter of negligence, contract and
public law. The vast majority of duty of care cases in medicine is medical negligence actions.
In general terms where there is an allegation of negligence against a doctor, the patient has to show, on the
balance of probabilities, that the particular defendant owed the patient a duty of care, has breached that duty,
by acting below the standard prescribed by law and that this breach has caused legally recognized damage.
There are also significant difficulties for the patient plaintiff. The difficulties lie in the particular rigors of
negligence actions as a whole, but more significantly for the patient, by the historical dominance of the
medical profession in the doctor-judge as well as the doctor-patient relationship.
In 1995 the World Health Organization (WHO) published a document entitled Promotion of the Rights of
Patients in Europe:
Proceedings of a WHO Consultation.
This is a significant modern piece of work for the study of human rights and medical law. It
indicates that there are certain international unifying rights themes for medical law. The principles of
patient’s rights, which emerged, focused more than ever before on a beneficial doctor patient relationship,
which encouraged the participation of and respect for the patient and protected the patient’s dignity and
integrity.
Further it would allow patients to obtain the fullest possible benefit from the health care system and
would encourage a wider dialogue between societal pressure groups, doctors and patients.
The document makes a number of important points, which are considered to be general guiding
principles for the fullest expression of human rights in health care. All health care providers must respect the
patient as an individual.
Patient autonomy supersedes sanctity of life if these two principles are in conflict.
The medical profession must inculcate the following issues in their patient management scheme.i.e.
• Self determination respected
• Respect for their moral, cultural, philosophical and religious convictions
• Need to have their health status protected.
The jurisdictions of the South Pacific region do not have any health policy or legislation that outlines the
rights of patients. These rights however, may be implied from the Fundamental Rights sections of the
respective Constitutions.
8.1.3. Resource Limitation in Health Delivery.
Increasing demands and limited resources in the South Pacific region, places a heavy burden on
health delivery by the State. The question remains whether the State can sustain defense on this basis. Are
limited health care delivery resources, including human ones a defense in a court setting?
There has been a great deal of debate about the extent of these duties in the region where there are
finite resources available to fund medical care. One should be aware that the primary duty of the hospital is
to provide for arrangements, in areas of limited funding, to be in place in a particular hospital. This issue has
been and is increasingly being questioned in the courts. The focus of this legal debate has been delay or
980
absence of a particular form of treatment alleged to create an unsafe operational system in a hospital.
However the reply of the hospital authorities in turn has been that the level of service is the best that the
available money can buy.
Despite resource limitations the medical system must endeavor to safe guard the existence and
scope of the direct duty of care of the hospital and those it employs. In that, the employed are suitably
qualified for the desired task and are competent to perform the task, in the hospital. Allied to this there is a
duty for the hospital to make arrangements to see that the staffs are effectively supervised in what they do.
These senior employees should also instruct in relevant areas. There is a primary duty on the hospital to
provide a system of operation that is safe in terms of its employees and the patients who enter it. Finally, the
hospital has a duty to provide proper facilities and equipment in the hospital. There have been a number of
cases and reports from the region, which highlight the failure of hospitals to provide a system of operation
that is safe in terms of its employees and the patients who use the system. A 1997 report of the Vanuatu
Ombudsman into the system of operation at Villa Central Hospital is of some personal interest to me. The
report and investigation revealed a “shockingly low standard of care and supervision at the hospital”.
The conditions, which emerged, involve the entire operation of hospital services in Port Villa, and
one of the main findings was that there has not been gynecologist/obstetrician since 1993 despite the offer
from the British for no cost to Vanuatu, which was repeatedly ignored by the Director of Health. The report
states that “Appointments to senior positions had been made for personal reasons, instead of medical
competence and inexperienced persons have been placed in positions of responsibility which are entirely
beyond their competence.”
8.1.4. Standard of care.
The Bolam principle has been used in the regional courts determining the standard of care
provided. However, court adjudication has also been applied additionally, in some cases. Justice Shameem in
a recent judgment ruled that the court had looked at the limitations and found that the gross negligence
resulted in the death of the patient. She included vicarious liability by the State in that case.
Court adjudication will in future play a major role in the rulings of the courts for medical negligence. Areas
of misdiagnosis and wrongful treatment will be addressed using the Bolam principle but issues in non-
disclosure of foreseeable events will fall into the ambit of the courts adjudication.
8.2. Issues of Consent.
Our consent forms in the public hospitals are encompassing and will never stand a chance in the
courts. There is nothing specific about a procedure Beware; you may end up with a circumcision when you
enter the premises for an elective tonsillectomy. The consent form allows for that
The consent is seldom information based, especially with the shortage of doctors and your request may
threaten the young practitioner that you are being difficult and you may find yourself at the tail-end of the list
ready to be jettisoned if the earlier cases take their fair share of time.
This issue of raising our age of consent to 21 is outrageous in the medical arena. Chronological age, in
this day and age is superseded by intelligence, maturity and being streetwise. If a 16 year old can consent to a
dental extraction and can purchase the bootlegger’s ware and see movies rated PG and pick up condoms in
the pharmacy and get prescribed the oral contraceptive pill, then we need to re-address consent of minors.

8.3. Records and Confidentiality.

Records and confidentiality issues are poorly addressed in the health care system. Manual records
get soiled and destroyed much earlier then the mandated 8 years. Maternity records, supposed to be held for
13 years are in the same category. Very short and incomplete reports are submitted to patients, lawyers and
courts. More often, this is as a result of fear of being caught in the legal crossfire. On the other hand it may
reflect the rapid changes in positions as staff are reshuffled and others migrate. A lot of times major portions
of records cannot be located and the least said, the better it is.
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 The issue of public interest and that of public health interest in competition to confidentiality are
issues we need to streamline within the medical sphere. This issue is readily highlighted by the lack of clear
guidelines on the management of HIV patients. With the gazetting of HIV as a notifiable disease [January
2006] the Ministry of Health is still thinking of setting up the mechanics towards reporting. Wilful
transmission of HIV will be a criminal offence under the penal code but the mechanics of such are still not
clear to the medical profession as debate, if any, is elsewhere. Release of results to third parties does occur
and the system is liable.
8.4. Palliative Care.
Refusal to medical treatment will in the not to distant future need to be addressed.
Similar to the 2002 ruling in UK, R B (adult):
Refusal for medical treatment will test the system soon enough. Sanctity of live and patient autonomy may
raise a few issues when in conflict for the medical profession and your legal letter to the law will be
appreciated.
8. 5. Euthanasia
The global debate on this issue has not stirred anything of note. Still a very topical issue and with
longevity comes much distressing malignancies. Where will the two professions stand on this issue in the
future?
Active euthanasia will result in a charge of criminal negligence, as in the case of Dr the debate continues
whilst the medical profession falls back on the sanctity of life principle and the dying patient continues to
suffer, without an advanced health directive.
Unless Law Reform considers this an issue and parliament considers legislation, the predicament
continues. The patient pays the price for our procrastination.
8. 6. Organ and tissue donation
We have no laws governing Organ and tissue donation. This increasing demand for organs could generate the
need for illicit competition by way of human trafficking and smuggling. The vulner able in the community
could suffer due to their financial crisis and the middleman may stand to benefit.
8. 7. Surrogacy
This is another medico-legal immerging issue. With fewer children for adoption individuals will
enter into surrogacy arrangements.
When biological mothers opt out of an agreement, the courts will be tested. When the agreements become
commercial the legality of the actions will be questioned.
Medicolegal Issues in Clinical Practice in effect covers the waterfront of legal matters for the clinician. It
addresses all the major legal issues, some in more depth than others, which we all need to; understand in the
current medical care environment. The book should be considered required reading for practicing physicians,
residents in training, and other professionals who treat patients.
8.8. Right and Responsibilities
· Only a registered practitioner may practice.
· Other members of the health team must perform under the permission and supervision of a doctor or
dentist.
When an MDCN- registered practitioner is not available, others perform according to standing
orders prepared by the supervising doctor or dentist of the institution. If they per- form outside the
framework of the standing orders, then they become liable for the error.
8.9. Professional Misconduct (Infamous Conduct)
This is a general term describing a clinician’s avoidable act of omission or commission against
the principles of good practice, with consequences detrimental to the patient. The act may be deliberate, with
some ulterior motive, or more commonly, due to negligence or carelessness. The term more or less covers all
offences for which clinicians may be charged before their professional disciplinary tribunal.
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8.10. Malpractice:
A definition can be composed from information the MDCN pamphlet on “Rules of Professional
Conduct”
Thus: Malpractice is failure, in the practice of medicine or dentistry, to exercise the skill, decorum and
standards adjudged appropriate and acceptable to the generality of the registered members of the profession
and recognized by the MDCN.
Medical Negligence (Malpractice)
(a) Medical negligence or malpractice is defined as “lack of reasonable care and skill or willful
negligence on the part of a doctor in the treatment of a patient whereby the health or life of a patient is
endangered”. The term “damage” means mental or functional injury to the patient, while “damages” are
assessed in terms of money by the court on the basis of loss of concurrent and future earnings, treatment
costs and reduction in qualities of life.
(b) In order to establish charges for negligence, the following points are required to be established
to the satisfaction of the court, by the consumer, that:
(i) The doctor (defendant) owed him a duty to conform to a particular standard of professional conduct.
(ii) The doctor breached that duty
(iii) The patient suffered actual damage
(iv) The doctor’s conduct was the direct or proximate cause of the damage.
(c) The burden of establishing all above elements is upon the patient / consumer. Failure to provide
substantial evidence on any one element may result in “No compensation”.
(d) In an emergency situation the medical officer has to attend the patient at the place where the patient
is, if the medical condition so warrants. Inability to do so without a valid reason will constitute medical
negligence.
(e) Criminal Negligence. Here the negligence is so great as to go beyond a matter of mere compensation;
not only the doctor has made the wrong diagnosis and treatment, but he has shown gross ignorance, gross
carelessness or gross neglect for life and safety of the patient. For this, the doctor may be prosecuted in a
criminal court for having caused injury or death of the patient by a rash and negligent act amounting to
culpable homicide under Sec 304-A of Cr. P.C., under following conditions:
(i) Injecting anesthetic in fatal dosage or in wrong tissues
(ii) Amputation of wrong finger, operation on wrong limb, removal of wrong organ etc.
(iii) Operation on wrong patient
(iv) Leaving instruments or sponges inside the part of body operated upon
(v) Leaving tourniquet too long resulting in gangrene
(vi) Transfusing wrong blood
(vii) Applying too tight plaster or splints, which may cause gangrene or paralysis
(viii) Performing a criminal abortion
The skills and correct method of practice in medicine and dentistry are learned by apprenticeship
over 5 to 10 years after graduation. This is why the residency programme exists. Graduation from a medical
or dental college is only an indication that the new graduate has attained sufficient theoretical knowledge to
start training to be a clinician.
Only consultants are fully trained. All other professionals are not supposed to work on their own. One of
the most dangerous aspects of clinical training is to be a self-taught practitioner. Unfortunately, our system
promotes being self-taught, for it is the new graduates that are sent to work in remote rural areas where they
have no senior colleagues or even a library to consult. In order to solve unfamiliar problems, they often
invent methods that are not in accordance with the safer established standard practice in the profession. We
should remember that scientific medicine is built on knowledge and skills acquired and improved over the
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centuries, and passed from one generation to another. Many of these skills and attitudes cannot be found in
textbooks.
The greatest weapon against malpractice is to be thorough and pay attention to detail. Take a complete
history, do a complete examination and base your provisional diagnosis on the evidence before you. Avoid
diagnosis by guesswork and inspiration.
The MDCN has now insisted that every doctor must own personal basic diagnostic equipment,
which they should always use during clerking.
A concerned practitioner, who devotes one hundred percent attention to his or her clinical
responsibilities, would hardly get involved in malpractice.
The temptation to quickly get away or tally in order to meet other engagements elsewhere may
cause an otherwise skilled practitioner to take regrettable decisions. Needless to say, the temptation to make
more money by choosing the more expensive or invasive procedure is malpractice.
8.11. Self-Advertisement
Direct and indirect self-advertisement aimed at attracting patients is forbidden, whether done by
the doctor or through an agent. Other forbidden actions are:
( i.) Press announcement of dramatic breakthroughs in treatment.
( ii.) Professional touting.
(iii.) Sign boards that are advertorial rather than informative in nature.
8.12. Consent
(a) This is an important responsibility of the doctor. Consent is defined as
“Two or more persons are said to consent when they agree upon the same thing in the same sense” (Sec 13,
The Indian Contract Act). For the purpose of clinical examination, diagnosis and treatment, any person who
is conscious, mentally sound and is above 18 years of age can give consent.
(b) Consent is not legally valid when given under fear, fraud or misrepresentation of facts or is given by a
person who is under 12 years.
(c) Types of consent
(i) Implied consent
(ii) Express consent, which may be verbal consent or written consent
(iii) Informed consent
Implied consent.
This is most common type of consent in both general practice and hospital practice. The fact that
a patient comes to a doctor for an ailment implies that he is agreeable to medical examination in general
sense. In clinical practice, implied consent can be used for general examination and systemic examination
including inspection, palpation, percussion and auscultation.
Expressed consent.
In expressed consent, a patient specifically grants permission to a physician to undertake
diagnosis and treatment of a specific problem. Expressed consent may be given either verbally or in writing.
Expressed consent must conform to the doctrine of informed consent to be legally acceptable. Once a patient
has forbidden any action, the question of implied consent does not arise. Expressed written consent should be
obtained for the following:
(i) All invasive and major diagnostic procedures
(ii) General anesthesia
(iii) Surgical operations
(iv) Medicolegal examinations for determining age, potency, virginity etc, where the person being examined
is not in police custody.
(f) Doctrine of Informed consent:

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 The doctrine of informed consent aims at giving sufficient information to a patient to enable him
to make a knowledgeable and informed decision about the use of a drug, device or procedure in the course of
treatment. The duty to warn a patient of any likely harm in the course of treatment has also been included in
the doctrine.
(g) In order to conform to the doctrine of informed consent, the following conditions should be
fulfilled:
(i) Disclosure of information
(ii) Free and voluntary decision-making by the patient
(iii) Patient is legally competent to decide
(h) The treating physician must ensure that the patient is explained the following in a language he / she
understands:
(i) Provisional Diagnosis
(ii) Nature of procedure / treatment
(iii) Risks involved
(iv) Prospect of success
(v) Likely outcome in case the procedure is not performed
(vi) Alternative methods of treatment.
(j) Situations where consent is not required. Consent is not required to be obtained in the following
situations:
(i) Medical emergencies: consent to emergency treatment is implied.
(ii) Treatment of notifiable diseases: in the interest of public health.
(iii) Medical examination under Sec 53, Cr PC.
(iv) Psychiatric examination / treatment by court order.
(k) Under Section 53 (1) of Cr P.C., a person can be examined at request of the police by use of force.
Section 53 (2) lays down that whenever a female is to be examined, it shall be done only by or under the
supervision of a female doctor.
(l) As far as possible, consent must be obtained from the patient, when he
/ She is competent to give it.
(m) Consent to treatment or a procedure or an operation is limited to the parameters that were expressed
before the commencement of medical intervention. However in certain circumstances, extension of the scope
of consent would be legally permissible. This principle of extension applies in cases of consent to treat an
emergency.
(n) Consent should be obtained when procedure has finally been decided and planned and not while the
investigation is still contemplated.
(o) Consent should be obtained in the presence of a witness before the pre-operative medication is
administered and the same documented in writing.
(p) Only in situations where the patient is minor, unconscious or mentally unsound, consent should come
from legal guardian/ NOK, who are present.
(q) In case of an unconscious patient, consent to emergency treatment is implied.
(r) Legally it is essential to take consent for the following reasons:
(i) It provides a practitioner legal protection in case of an action for negligence. The practitioner can cite
proof of consent as evidence of disclosure, thereby protecting him from an action based on failure to disclose
material facts.
(ii) Secondly, protection has been provided to practitioners who have obtained informed consent in
accordance with the provisions of Sec 88, I.P.C.
(iii) Thirdly, it may be pertinent to note that exercise of reasonable skill and care is not sustainable in law as a
defence against assault and battery.
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8.13. Legal responsibility:
Legal responsibility in nursing practice means the way in which nurses are obligated to obey - the law in
professional activities. The law is the final authority for regulating activities of all citizens including
professional practitioner. Disobedience of the law results in punishment.
It is always better that all nurses should understand the legal responsibility. When assuming a position to take
care of a client, as a professional nurse needs to update with the fast changing and advancing professional
knowledge to provide safe nursing to their consumer on the basis of their needs. And nursing professionals
should be aware of their limitations and shall be familiar with the law of nursing practice in their own
country. So, the nurses should not give any room for any tort, i.e. negligence or malpractice in their practice.

Tort is a civil wrong committed against a person or property. Torts may be subtle. They may be classified as
intentional or unintentional.
1. Unintentional torts include negligence for example, malpractice.
2. Intentional torts are wilful acts that violate another's right. For example assault, battering,
defamation, invasion of privacy, false imprisonment and fraud.
8.14. Nurse-client relationship:
The brief ideas of those issues are as follows:
1. Assault is any wilful attempt or threat to harm another, coupled with the ability to actually harm the person.
The victim believes that harm caused as a result of the threat. Assault may be subtle. For example
involvement of nurse in handling an unco-operative client in the casualty room.
2. Battery is intentional touching of another's body or anything the person is touching or holding without
consent. Injury is not a requirement. Informed consent is necessary in such cases. It has been allowed in
mental health institutions.
3. Invasion of Privacy Clients have claims for 'invasion of privacy', e.g. their private affairs, with which the
public has no concern, have been publicised. 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.
4. Defamation of character is the act of holding up of a person to ridicule, scorn or contempt within the
community. There are two types of defamations; slander and libel.
a. Slander defamation is in the form of spoken words for, e.g. if a nurse tells a client that his doctor is
incompetent, for which
nurse could be held liable for slander.
b. Libel defamation is in the form of written words, e.g. the nurse who writes such a comment could be
shed for libel.
5. Informed consent is the authorisation by the patient or the patient's
legal representative to do something to the patient and is based upon legal capacity, voluntary action, and
comprehension. It is a person's agreement to allow something to happen based on a full disclosure of facts
needed to make an intelligent decision. On who performs a procedure on client without informed consent
may be found civilly liable for committing battery. A patient's consent must be obtained before any
medical, surgical or Nursing treatment is administered The patient's consent is his or her authorisation for
another to touch him or her for the purpose of care or treatment. Deliberate touching of another without
authorisation, constitute a tort called battery. Knowingly threatening another with likelihood of immediate
harmful or offensive body contact is a 'tort' called assault.
9. LEGAL ISSUES IN NURSING SPECIALTIES:
Within every specialty of nursing they are legal issues that affect nursing practice. Some of the more
common legal follow.
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.1. Community health nursing:
 In community settings are occupational or institutional work sites where nurses provide
preventive and ongoing primary care to workers.
 Nurses also work in public or community health, where preventive services such as
immunizations and well-child care are provided in schools, homes and clinics.
 Professional nurses who are accountable for the autonomous judgments they make while working
in a community.
 The community health nurse must work collaboratively with other health care team members to
verify that the care provided and information shared is timely and accurate.
 State legislatures enact statutes under the health code, which described the reporting laws,
intended to promote health and reduce health risks in communities.
 The purposes of public health laws are protection of the public’s health, advocating for the rights
of people, regulating health care and health care financing, and ensuring professional
accountability for the care provided.
.2. Emergency department:
 Congress enacted the Emergency Medical Treatment and Active Labor act (1986).
 This act provides that when a client comes to the emergency department or the hospital, an
appropriate medical screening must be done within the hospital’s capacity.
 If an emergency condition exists, the client may not be discharged or transferred until the
condition is stabilized.
 The client can be discharged or transferred before he is stable, however, if the client requests in
writing to be transferred or discharged after being informed of the benefits and risks, or if a
physician certifies that the benefits of transfer outweighs the risks.
 The transfer must always be appropriate, which means
 That the receiving facilities agree to the transfer, has space for the client, and has
qualified personnel to receive the client.
 The Client must be transported by Qualified personnel and transportation equipment.
.3. Nursing care of children:
 Every state with child abuse legislation requires that suspected child abuse or neglect must be
reported.
 Health care professionals such as nurses are mandated to report suspected cases.
 Health care professionals who do not report suspected child abuse or neglect may be held liable
for civil or criminal legal action.
 The nurse is responsible for preventing a child in his or her care from accidentally substances and
sharp objects should be kept out of the reach of small children.
 When possible, small children should be kept out of the reach of small children.
 When possible, small children should be kept under constant watch to minimize opportunities for
accidental harm.
As in all areas of nursing practice, negligence involving paediatric clients is possible. Paediatric nurses are
responsible for preventing children, in their care from accidentally harming themselves. Cribs which
sometimes have a restraining device over the top, are designed to keep infants and toddlers from climbing
out of bed and injuring themselves. All poisonous substances and sharp objects should be kept out of the
reach of children. Children should be kept under constant surveillance to minimise opportunities for
accidental harm.

987
 It is advisable that the health care professional including nurses should report to the concerned authority if
they come across the suspected cases of child abuse or neglect. Those who do not report such cases may be
liable for civil or criminal legal action.
.4. Medical-surgical nursing and geriatrics:
 Adults, who are disoriented or confused, however may require some form of restraining device to
prevent accidental self-injury.
 Standards of Care, laws and regulations concerning the use of restraints and supervision requited
apply to nursing practice with medical-surgical and other clients
 The FDA has set guidelines for the use of restraints.
 The nurse must know when and how to use restraints correctly.
 Orders for a restraint are limited to 24 hours.
 After a client is restrained, the nurse is required to make frequent client assessments and to
periodically release restraints.
 A client who falls out of bed and becomes injured or who suffers injury from improper restraint
application may bring a lawsuit against the nurses and the institution.
Common acts of negligence in medical-surgical nursing are:
1. Overlooked sponges, instruments needles: In the operation theatre, it is a responsibility of the
nurse to count the sponges, instruments, needles before the closure of the abdomen or any cavity.
The nurse may be liable if she makes an error in their count.
2. Burns: The professional nurse is required to know the cause and effect of any heat application so as
to avoid burns. Some of the common heat applications are applications, of hot water bags, heating
pads, double sitzbath etc.
3. Falls: The Nurse could be held liable if a patient falls from the bed or due to improper securing of
patient on examination table or improper application of restraint or provision of a proper bed for an
unconscious patient or a child.
4. Injury: Injury due to the use of defective apparatus or supplies, e.g. defective bed pans infect
patients. The nurse could be held liable if she uses equipment or supplies them which she/he knows
to be faulty, e.g, the use of unsterilised gauze of surgical dressings.
5. Injury: Injury due to administration of wrong medicine, wrong dosage and wrong concentration.
Administration of medicine without prescription by the concerned authority, mixing up of poisonous
and non-poisonous drug in cupboards leading to errors, and failing to identify right medication for
right patient, in right dosage, at right time, considered as negligent act can be liable to be used.
6. Loss or damage: The nurse is held liable if a patient's property is lost when it has been entrusted to
her/his care.
7. Assault and battery: Failure to take the informed consent of the patient prior to any procedure,
treatment, investigation or operation, the nurse be held liable.
8. Failure to report accidents: The nurse has a moral and legal responsibility to report to the
concerned authority any accidents, losses or unusual occurrences. Failure to do this is an act of
negligence.
9. Maintenance of records and reports: Failure to maintain accurate record and reports or removing a
position of record may also make the nurse liable.
9.5. Psychiatric nursing:
 A Client can be admitted to a psychiatric unit involuntarily or on a voluntary basis
 A petition for involuntary detection must be filed with the court within 96 hours of the client’s
initial detention
 A hearing must be conducted within 2 day of the filing of the involuntary petition.
988
  If the judge determines that the client is a danger to self or others, the judge will grant the
involuntary detection, and the client can be detained for 21 more days for psychiatric treatment.
 If the client’s history and medical records indicate suicidal tendencies, the client must be kept
under supervision.
 Lawsuits result from client’s attempts at suicide within the hospital
 Documentation of precautions against suicide is essential.
The practice of psychiatric nursing is influenced by the law, particularly in concern for the bright of patients
and the quality of care they are receiving. In the past 20 years, civil, criminal and consumers rights have been
established and expanded through judicial decision. Previously powerless and neglected groups such as the
mentally ill are now using the legal system as both, a forum for the expression of legitimate grievances and
as a vehicle for social change.
A psychiatric nurse should be sufficiently acquainted with the legal aspects of psychiatry so that she/he can
be aware of the patient's rights and can avoid giving poor advice or innocently involving herself/himself in a
legal entanglement.
In psychiatric setting, the process of hospitalisation can be traumatic or supportive for the individual
depending on the institution, attitude of the family and friends, response of the staff and type of admission.
At present three major types of admission are being used, i.e. informal, voluntary and voluntary.

Informal admission: This type of admission to the psychiatric hospital occurs in the same way as, a'person
is admitted to a general medical hospital, i.e. without formal or written application. The individual is then
free to leave at any time, as he would be in a general medical hospital. The patient is often requested to sign
on an agreement of medical advice, but he is not compelled to do so.
Voluntary admission: Under this procedure any citizen of lawful age may apply In writing (usually by use
of a standard admission form) for admission to a public or private psychiatric hospital. He agrees to receive
treatment and abide by the hospital rules. His reason for seeking help may be his own personal decision or
may be based on the advice of family or a health professional. If a person is too ill to complete the admission
process but voluntarily seeks help, a parent or legal guardian may request admission for him.
Involuntary admission (commitments): Involuntary commitments are continuously recognised by the court
on the basis of two theories; first, under its 'police power1, the state has the authority to protect the
community from the dangerous acts of the mentally ill; second, under its 'Parens Patriae' powers, the state
has an interest in providing care for citizens who cannot care for themselves, such as some mentally ill
persons.
Involuntary commitments do not always imply compulsion. It means that the request for hospitalisation did
not originate with the patient and may signify that either it was actively opposed by him or he was indecisive
and did not resist. The criteria for commitment vary among states and reflects the confusion present in the
medical, social and legal arenas of society.
9.6. Maternal nursing:
 Midwives respect a woman’s informed right of choice and promote the woman’s acceptance of
responsibility for the outcomes of her choices.
 Midwives hold in confidence client information in order to protect the right to privacy, and use judgment
in sharing this information.
 The person should be given as much information s and reasonable person could be expected to
understand.
 Informed consent means full information before treatment.
 A real dilemma for maternity service staff is that of consent for caesarean sections
 Pregnant women cannot legally be forced to have a caesarean section for competent and the fetus has no
rights in law until it is born.
989
  In trying to save the life of a fetus, therefore health professionals are constrained by the law that protects
its mother.
 Risk management and clinical governance are high on most health service agendas.
 It may be seen that in being supported by the law you may also be constrained by it.
9.7. Forensic nursing
Nursing focuses on forensic is specific applications of nursing process by forensic nurses for formal
assessment, diagnosis, planning, evaluation and interventions aimed at the resolution of human responses to
violence. Essential skill sets for forensic nurses include advanced physical and psychological assessment of
violence, trauma and abuse such as recognition and identification of injury pattern, assessment for risk of
violence or self-injurious behaviour, differentiation of factitious disorders and manipulation and delineations
of boundaries. Handling, processing and documentation assessments and interventions as evidence is clearly
a distinguishing feature of forensic nursing.
Crime and violence bring together the two most powerful systems that affect the lives of people throughout
the world—health care and justice. The need for policies to address critical issues related to violence and its
associated trauma is a multidisciplinary issue concerning physicians, nurses, attorneys, judges, sociologists,
psychologists, social workers, forensic and political scientists, advocates and activists, and criminal justice
practitioners. Effective management of forensic cases is an area previously lacking in sufficient policy and
legislation to ensure protection of the patient's legal, civil, and human rights.
As an emerging discipline, forensic nursing assumes a mutual responsibility with the forensic medical
sciences and the criminal justice system in concern for the loss of life and function caused by human violence
and liability-related issues. The concept of a nurse investigator represents one member of an alliance of
health care providers, law enforcement officials, and forensic scientists in a holistic approach to the study and
treatment, of victims and perpetrators of physical, psychological, and sexual violence. Forensic nurses do not
compete with, replace, or supplant other practitioners; rather, they fill voids by accomplishing selected
forensic services concurrently with other health and justice professionals. This role provides a uniquely
qualified clinician, blending biomedical knowledge with the basic principles of law and human behavior. The
forensic nurse examiner provides the traditional nursing associate that has been historically absent in forensic
medicine.
Problem faced by the Forensic Nurses
 Lack of clear understanding of the law in the nurse-patient relationship
and concerning the police.
 Fear of incriminating the patient.
 Fear of self-incrimination.
 Fear of intimidation during cross-examination in court.
 Lack of confidence in medico-legal documentation.
 Concern for staff involvement in potential legal issues.
 Lack of confidence where nurses must seek physician approval.
 Perception by the patient of participating in perceived police abuses.
 Lack of understanding the rules of reasonable search and seizure.
 Fear of disciplinary actions for involving the hospital in legal issues.

10. ROLE OF THE ADMINISTRATOR IN ETHICAL ISSUES:

The leadership roles and management functions of an administrator in ethics as follows:
1. He or she is self aware regarding own values and basic beliefs about the rights, duties and goals of human
beings.
2. Accepts that some ambiguity and uncertainty must be a part of all ethical decision making.

990
3. Accepts that negative outcomes occur in ethical decision-making despite high quality Problem-solving
and decision-making.
4. Demonstrates risk taking in ethical decision-making.
5. Role models ethical decision making, which are congruent with the code of ethics and inter respective
statements
6. Actively advocates for clients, Subordinates and the profession.
7. Clearly communicates expected ethical standards of behavior.
8. Uses a systematic approach to problem-solving or decision-making when faced with management
problems with ethical ramifications.
9. Identify outcomes in ethical decision-making that should always be sought or avoided
10. Uses established of ethical frameworks to clarify values and beliefs.
11. Applies principles of ethical reasoning to define what beliefs or values form the basis of decision-
making.
12. Is aware of legal precedents that guide ethical-making and is accountable for possible liabilities should
they go against the legal precedent.
13. Continuously re-evaluate quality of own ethical decision-making based on the process of decision-
making problem-solving used.
14. Recognizes and rewards ethical conduct of subordinates takes appropriate action when subordinates use
unethical conduct.
15. Serves as a role model by providing nursing care that meets or exceeds accepted standards of care.
16. Is current in the field and seeks professional certification to increase expertise in a specific field.
17. Reports substandard nursing care to appropriate authorities.
18. Fosters nurse/patient relationships that are respectful, paring and honest, thus reducing the possibility of
future lawsuits.
19. Joins and actively supports professional organisations to strengthen the lobbying efforts of nurses in
health care legislation.
20. Practices nursing within the area of individual competence.
21. Prioritizes patient's rights and welfare first in decision-making.
22. Demonstrates vision, risk taking, and energy in determining appropriate legal boundaries for nursing
practices, thus defining what nursing is and should be in the future.
23. Is knowledgeable responding sources of law and legal doctrines that affect nursing practice.
24. Delegates to subordinates wisely, looking at the managers scope of practice and that of those they
supervise.
25. Understands and adheres to institutional policies and procedures.
26. Practices nursing within the scope of the state nurse practice act.
27. Monitors subordinates to ensure that they have a valid, current and appropriate license t© practice
nursing.
28. Uses foreseeability of harm in delegation and staffing decisions.
29. Increases staff awareness of intentional torts and assists them in developing strategies to reduce their
liability in these areas.
30. Provides educational and training opportunities for staff on legal issues affecting nursing practice.

NURSING REGULATORY MECHANISMS AND CONSUMER ACT INTRODUCTION

The standard of nursing care delivery is set by certain regulations of nursing practice called
―nurse practice acts‘. Nurse practice acts are legally defined and describe regulations of nursing actions by
an administrative board such as a state board of nurse examiners. These boards generally have the authority
to regulate nursing practice and education within the states.
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NURSING REGULATORY MECHANISMS
The main functions of these regulations include

nursing practice

The regulatory bodies that define the laws and regulations in nursing practice are the nursing councils at the
international national and state levels. Such as

ACCREDITATION
The concept of accreditation of educational programs in nursing is very important. Accrediting is
the process whereby an organization or agency recognizes a college or university or a program of study as
having met certain predetermined qualifications and standard Accreditation refers to a voluntary review
process of educational programs by a professional organization. The organization is called an accrediting
agency is invited to compare the educational quality of the program with established standard and criteria.
Accreditations has four major purposes which include the following

Accreditation is vital to the welfare of institution of higher education. Accrediting organizations in

higher education are generally classed into three types
i. National accrediting agency
ii. National professional accrediting agency
iii. State accrediting bodies
National agencies
National accrediting agencies are concerned with appraising the total activities of the institutions of
higher learning, and with safe guarding the quality of liberal education, the foundation of professional
programs in colleges and universities. Each agency establishes criteria for the evaluation of institutions in its
region it reviews those institutions periodically, and it publishes from time to time a list of those agencies
which it has accredited. India has following all India Educational Councils:

National Professional Accrediting Agency

These professional groups aim to foster research, to improve service to the public and the number of
individuals admitted to the profession. Controlling admissions is vital to a professional group particularly in
the early stages when the professional is struggling for status. In India, particularly in the field of health,
national professional accrediting agencies have existed.

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Indian nursing council, (INC) is the official accrediting agency for all programs of nursing, which include
Diploma (GNM), Bsc Nursing (both basic and post basic), NM/Msc N /M.phil (Masters) and PhD (Doctoral
programs in Nursing)
NURSING LICENSURE
The registry of nurses initiated by Nightingale provided institutions and clients with the means to
ascertain the skills and knowledge of graduates. However, this was not enough. As nursing programs
proliferated, variations developed among the programs. Educational programs were structured to meet the
needs of the host hospital. Another method was needed to distinguish those trained in providing nursing care.
This method led to nurses developing criteria for licensure. The primary purpose of licensure was, and still
is, the protection of the public.
Current licensure activities
Efforts to provide common definitions of nursing practice, standards of education, and testing for
entry into practice across state boundaries have been successful, although nurses are still required to apply
for licensure in each state in which they practice. With the mobility of nurses, the movement toward
telecommunications, and care of clients across wide distances, state boards of nursing recognized the need to
provide practicing nurses with more than procedures of endorsement of their initial license. This need has led
to further changes in nursing licensure. In 1997, the Delegate Assembly of the National council of state
Boards of Nursing moved to a new level of nursing regulation. The assembly approved a resolution
endorsing a mutual recognition model of nursing regulation. Through this model individual state boards will
develop an interstate compact allowing nurses licensed in one state to practice in all other states and
territories. Nurses will be responsible for following the laws and regulations of those states, although they
will not be required to apply for individual state licensure.
COMPONENTS OF NURSING PRACTICE ACTS
All nursing practice acts include two essential components. First each includes statements that refer
to protecting the health and safety of the public. The second is protection of the title of RN. This protection is
ensured by describing those individuals covered by the regulations and those excluded from the act. The
legal title, registered nurse, is reserved for those meeting the requirements to practice nursing in the state. A
section of each nursing practice act describes the requirements for licensure. An initial requirement is
graduation from high school and an accredited nursing program.
ENTRY INTO PRACTICE
Each nursing practice act includes the requirements and procedures necessary for initial entry into
nursing practice. There are several steps necessary in obtaining a license to practice nursing. Candidates for
licensure must submit evidence of graduation as defined by each state. Frequently a transcript of course
work, a diploma or letter from the dean of the program attesting to the graduation of the applicant is
necessary. A temporary permit may be available for nurses moving from one state to another. The process of
obtaining a license in another state is to apply for licensure by endorsement. Nurses licensed in one
jurisdiction apply for licensure in a second jurisdiction by submitting a letter to the second state board of
nursing. Typically evidence for the new license is similar to that for initial licensure. In addition, proof of the
nurse‘s current license to practice will be required.
RENEWAL OF LICENSURE
In addition to outlining requirements for initial licensure, each nursing practice act includes
information on renewal of licensure requirements. These regulations define the period; a license is valid and
any additional requirements for renewal of licensure. All nurses are expected to remain competent to practice
through various means of continuing education.
PATIENT RIGHTS
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PATIENT RIGHTS AND RESPONSIBILITIES
As a patient, patient have certain rights and responsibilities. These rights and responsibilities have been
framed to ensure that to receive medical care of the highest standards and to make the stay with us as
comfortable as possible.
Patient Rights
As a patient you have the following rights:
 You deserve to be treated with respect.
 You have the right to request for any information about your condition and be provided with that
information.
 You are entitled to ask for, and obtain copies of the records pertaining to your medical care in the hospital
by paying a copying fee. You can do this without hesitation. All medical records, whether prepared in our
hospital or elsewhere, will remain the property of the hospital, once you have started your treatment here.
These records will remain confidential.
 You have the right to receive medical care that is of accepted standards, as per the standards set within
the country, and even as per some of the standards that have been set in the West.
 You are entitled to the same level of medical care, irrespective of the ward you are admitted to.
 You have the right to ask for and consult with any doctor or doctors in our panel of doctors, without
prejudice and interference. You can do this at any point of time during the course of your medical care.
 You have the right to patient confidentiality and privacy.
 You have the right to a second opinion.
 You have the right to refuse treatment. However, this decision will have to be taken by you at your own
risk. We cannot be held responsible for any consequence(s), medical or otherwise, arising due to your
refusal to be treated against the advice of (a) medical professional(s).
 You have the right to receive medical treatment and hospital services for which you have paid for,
irrespective of your religion, caste, creed, race or any other such discriminatory factor(s).
Patient Responsibilities:
 Please bring with you all your medical records, lab reports, x-rays, scans, etc., that provide a record of
your medical history at the time of admission.
 Please keep up all your appointments and follow-up appointments. If unable to do so, please call and
inform us at the earliest that you are not able to keep your appointment.
 Please provide the medical insurance card during admission if you will be paying through insurance
 Please strictly follow the treatment plan that has been prescribed for your condition. Please take the
medicines prescribed on time as per the doctor's advice.
 Please ensure that you retain all your medical records in the correct order. Please bring them along with
you every time you visit the doctor(s).
 Please ensure that you do not take up the time of the medical professionals through delays.
 Please ensure that you contact the doctors outside hospital hours only in the case of an emergency.
 Please ensure that you immediately bring to the notice of the management, any shortcoming(s) in your
care at the hospital.
 Please do not withhold any information about your condition from the doctor(s) treating you or from the
hospital staff.
 Please abide by the hospital's rules and regulations
 Please pay your medical bills promptly on time.
 Please treat the hospital staff and your fellow patients with respect.
Patient rights according to American medical association

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 A patient's rights occur at many different levels, and in all specialties. The American Medical Association
(AMA) outlines fundamental elements of the doctor-patient relationship in their Code of Medical Ethics.
 These rights include the following:
o The right to receive information from physicians and to discuss the benefits, risks, and costs of
appropriate treatment alternatives
o The right to make decisions regarding the health care that is recommended by the physician
o The right to courtesy, respect, dignity, responsiveness, and timely attention to health needs
o The right to confidentiality
o The right to continuity of health care
o The basic right to have adequate health care
 Patients often have certain responsibilities for ensuring their rights., physicians should also serve as
advocates for patients and promote these basic rights. Every time a patient visits a doctor, both parties are
seeking answers to these questions:
o Diagnosis: What is wrong with the patient?
o Prognosis: What does the diagnosis mean for the patient?
o Caring and management component: What can be done for the patient?
o Research dimension: What can the doctor learn from this patient?
o Public health dimension: How can others benefit from the treatment process of this patient?
o Educational opportunities: What can the patient and the professionals learn from this experience
and teach others?
The Universal Declaration of Human Rights
The Universal Declaration of Human Rights has been instrumental in enshrining the notion of human
dignity in international law, providing a legal and moral grounding for improved standards of care on the
basis of our basic responsibilities towards each other as members of the “human family”, and giving
important guidance on critical social, legal and ethical issues. But there remains a great deal of work to be
done to clarify the relationship between human rights and right to health, including patient rights.
Recognizing this challenge, the United Nations Commission on Human Rights (UNHCR) has designated a
Special Rapporteur to provide it with a report that examines and clarifies the broader relationship between
human rights and the right to health. This report has great importance for the World Health Organization,
whose mission is to ensure “health for all”. Grounding this mission in a fundamental human right to health
would be an important milestone, and a great step forward realizing this goal.
PATIENTS RIGHTS AND RESPONSIBILITY
Health is a subject closer to everybody’s heart. Improvement of one’s health and health of one’s
family is a universal aspiration. However health has been always given a low priority status in the nation’s
political and social agenda. With the increasing privatization of the health care services in the country, the
state is slowly abdicating its responsibility to provide health care to the people. Medical profession
contributes to the healthcare to the extent of only 25-30%. Approximately 70% input in the health care is by
various sectors like the pharmaceutical industry, hospitals, blood banks etc. This 70% inputs are mostly
managed on a commercial basis and therefore patient as a consumer must have certain rights. These rights of
a patient as a consumer are more important than the rights of a general consumer because patient usually has
very little choice in the treatment.
PRECAUTIONARY MEASURES TO PROTECT THEIR RIGHTS
In India there is very little perception about the rights of the patients even amongst the educated persons.
Therefore blatant violation of patient’s rights is a routine occurrence. However the situation can be changed
if every citizen takes certain precautions while undergoing treatment or while taking drugs/vaccines etc.
1) In case of surgical treatment or invasive investigations and procedures, please make sure that you have
understood the nature of the operation. You have the right to know the details of the surgery as well as the
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details like the expected time of post-operative recovery, expenses likely to be incurred for the surgery, the
risks involved, whether there is any non-surgical treatment for your ailment etc.
2) Please make sure the details are understood by you before you sign the consent form. The consent form
should be in your mother tongue or the language known to you.
3) At the time of discharge, please make sure that you have been given copies of all the relevant records.
As per the decision of the Bombay High Court (Raghunath Raheja v/s Maharashtra Medical Council), every
patient or his legal heirs have the right to get the copies of all the case papers on payment of relevant charges.
4) At the time of discharge from the hospital, please make sure that you have received the bills for all the
payments made by you. You have the right to get details of the bill like details of drugs administered to you,
the details of investigations etc.
5) In case of any treatment, you have the right to ask for a second opinion. However, the second opinion
should be taken ONLY with the consent of your physician.
6) If you have any doubts about the treatment you should request the doctor to clarify them. Doctor-Patient
communication is of vital importance for the success of any treatment.
7) Please make sure that the doctor has given you all the instructions for the medicines prescribed. You
have the right to get all the relevant information about the drugs prescribed to you.
8) In case of invasive/costly investigations, you have the right to know of the alternatives as well as the
necessity of the investigations.
9) As a patient, you have the right to take second opinion and/or change the doctor. However, this right
should be exercised very judiciously and cautiously. ‘Doctor Shopping is not in the interest of consumers
and can cause serious harm due to irregular treatment.
10) Please always preserve all the bills of the purchase of medicines.
11) If you have any complaints about the treatment/investigations/drugs etc., first approach the concerned
doctor/hospital. Many times the complaints are due to misunderstanding and failure in communication.
These can be resolved at the local level.
12) If you find that your complaint remains unresolved, then please write down
Your grievance giving all the relevant details in a sequential format and take the advice of a Consumer
Organisation in your area before taking any legal action. Please remember that most of the times the
complaints can be resolved at the hospital level.
13) In case of substandard drugs, preserve the drug packages with labels/cartons/boxes etc. The complaints
about the drugs have to be lodged with the local Food and Drugs Administration.
14) If you are participating in any trial for drugs/therapeutic devise/treatment protocol, you have the right to
refuse to participate in the trial. Please make sure that you have understood all the details like duration, risks
involved, the expected complications etc. Also make sure that the doctor/hospital conducting the trial has
agreed to treat completely any complication arising out of the trial, free of cost. Please make sure that the
consent form includes all the details.
15) As a patient you have to expect the medical record pertaining to your illness be treated as confidential. If
the details are to be used in a medical conference, please make sure that your consent has been obtained by
the doctor/hospital.
16) In case of HIV positive patients, the details can only be disclosed with the patient’s permission. You
have to be vigilant to see the HIV reports are not disclosed to the employers/friends/other unauthorized
persons.
RIGHTS OF THE PATIENT
 Right to considerate and respectful care.
 Right to information on diagnosis, treatment and medicines
 Right to obtain all the relevant information about the professionals involved in the patient care.

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  Right to expect that all the communications and records pertaining to his/her case be treated as
confidential
 Right to obtain all the relevant information about the professionals involved in the patient care.
 Right to expect that all the communications and records pertaining to his/her case be treated as
confidential
 Right to every consideration of his/her privacy concerning his/her medical care programme.
 Right to expect prompt treatment in an emergency
 Right to refuse to participate in human experimentation, research, project affecting his/her care or
treatment.
 Right to get copies of medical records
 Right to know what hospital rules and regulations apply to him/her as a patient and the facilities
obtainable to the patient.
 Right to get details of the bill.
 Right to seek second opinion about his/her disease, treatment, etc.
RESPONSIBILITIES OF PATIENTS:
 To faithfully undergo the agreed therapy.
 To follow the doctors instructions diligently.
 To take necessary preventive measures in case of infectious diseases as per the doctors instructions.
 To be aware that doctors and nurses are also human beings and are amenable to mistakes and lapses.
 To make the payment for the treatment, wherever applicable, to the doctors/hospital promptly.
 To respect the autonomy of the doctors and nurses.
 To treat doctors and nurses with respect.
 To be punctual to attend the clinics/hospital/dispensary for the treatment at the given time.
 To preserve all the records of one’s illness.
 To keep the doctor informed if the patient wants to change the hospital/doctor.

Patient's bill of rights

The legislative controls of nursing practice primarily protect the rights of the patients. Until the 196o’s
patients had few rights, in fact patients often were denied basic human rights during a time when they were
most vulnerable. In 1973, however the American hospital association published its 1st bill of rights, which
was revised in 1992. Many health care organizations and states have passed abill of rights for patients since
that time .
1. A patient has the right to considerate and respectful care.
2. The patient has the right to obtain from his physician complete current information concerning his diagnosis,
treatment, and prognosis in terms the patient can be reasonably expected to understand. When it is not medically
advisable to give such information to the patient, the information should be made available to an appropriate
person in his behalf. He has the right to know, by name, the physician responsible for coordinating his care.
3. The patient has the right to receive from the physician information necessary to give informed consent prior
to the start of any procedure and/or treatment. Except in emergencies, such information for informed consent
should include, but not necessarily be limited to, the specific procedure and/or treatment, the medically
significant risks involved, and the probable duration of incapacitation.
Where medically significant alternatives for care and treatment exist, or when the patient requests
information concerning medical alternatives, the patient has the right to such information. The patient has
also the right to know the name of the person responsible for the procedures or treatment.
4. The patient has the right to refuse treatment to the extent permitted by law and to be informed of the medical
consequences of his action.

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5. The patient has the right to every consideration of his privacy concerning his own medical care programme.
Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly.
Those not directly involved in his care must have the permission of the patient to be present.
6. The patient has the right to expect that all communications and records pertaining to his case should be
treated as confidential.
7. The patient has the right to expect that within its capacity a hospital must make reasonable response to the
request of the patient for services. The hospital must provide evaluation, service, and/or referral as indicated by
the urgency of the case.
When medically permissible, a patient may be transferred to another facility only after he has received
complete information and explanation concerning the need for and the alternatives to such a transfer. The
institution to which the patient is to be transferred must first have accepted the patient for transfer.
8. The patient has the right to obtain information as to any relationship of his hospital to other health care and
educational institutions in so far as his care is concerned. The patient has the right to obtain information as to the
existence of any professional relationships among individuals, by name, who are treating him.
9. The patient has the right to be advised if the hospital proposes to engage in or perform human
experimentation affecting his care or treatment. The patient has the right to refuse to participate in such research
or projects.
10. The patient has the right to expect reasonable continuity of care. He has the right to know in advance what
appointment times and physicians are available and where. The patient has the right to expect that the hospital
will provide a mechanism whereby he is informed by his physician or a delegate of the physician of the patient's
continuing health care requirements following discharge.
11. The patient has the right to examine and receive an explanation of his bill regardless of the source of
payment.
12. The patient has the right to know what hospital rules and regulations apply to his conduct as a patient.
No catalogue of rights can guarantee for the patient the kind of treatment he has the right to expect. A
hospital has many functions to perform, including the prevention and treatment of diseases, the education of
both health professional and patients, and the conduct of clinical research.
All these activities must be conducted with an overriding concern for the patient, and above all, the
recognition of his/her dignity as a human being. Success in achieving this recognition assures success in the
defence of the rights of the patient.

THE CONSUMER PROTECTION ACT, 1986

INTRODUCTION
The industrial revolution and the development in the international trade and commerce has led to the vast
expansion of business and trade, as a result of which a variety of consumer goods have appeared in the
market to cater to the needs of the consumers and a host of services have been made available to the
consumers like insurance, transport, electricity, housing, entertainment, finance and banking. A well
organised sector of manufacturers and traders with better knowledge of markets has come into existence,
thereby affecting the relationship between the traders and the consumers making the principle of consumer
sovereignty almost inapplicable.
The advertisements of goods and services in television, newspapers and magazines influence the
demand for the same by the consumers though there may be manufacturing defects or imperfections or short
comings in the quality, quantity and the purity of the goods or there may be deficiency in the services
rendered.
In addition, the production of the same item by many firms has led the consumers, who have little
time to make a selection, to think before they can purchase the best. For the welfare of the public, the glut of
adulterated and sub-standard articles in the market have to be checked. Inspite of various provisions
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providing protection to the consumer and providing for stringent action against adulterated and sub-standard
articles in the different enactments like Code of Civil Procedure, 1908, the Indian Contract Act, 1872, the
Sale of Goods Act, 1930, the Indian Penal Code, 1860, the Standards of Weights and Measures Act, 1976
and the Motor Vehicles Act, 1988, very little could be achieved in the field of Consumer Protection. Though
the Monopolies and Restrictive Trade Practices Act, 1969 arid the Prevention of Food Adulteration Act,
1954 have provided relief to the consumers yet it became necessary to protect the consumers from the
exploitation and to save them from adulterated and sub-standard goods and services and to safe guard the
interests of the consumers. In order to provide for better protection of the interests of the consumer the
Consumer Protection Bill, .1986 was introduced in the Lok Sabha on 5th December, 1986.
CONSUMER PROTECTION ACT
Consumer rights have become an important issue. For the 1st time in India , the consumer protection act
1986 provided consumers a forum for speedly redresssal of their grievances against medical services. In the
entire health care delivery system the most vital sectors is the medical profession. The active participant and
dedication of doctors is very important for its survival . over the centuries the medical profession has been
accorded respect by the society, since last decade or so, increasing commercialization of the profession has
eroded this faith.
As far as the professional services are concerned, the evolution of law has followed a set course. Under the
general law, a member of a profession is required to show a standard of care which a person of that
profession is expected to posses.
If a patient or the relations of a patient feel that the suffering or death of patient is because of either
negligence by the concerned doctor or the health facility, they can complain to the medical council of India,
which is a statutory body created to monitor the medical profession has only ethical jurisdiction . the council
can only cancel the registration of the concerned doctor or give a compensation.
 Rights of the patient
 Right to information of health care, services available to them, diagnosis and treatment .
 Right to have information about professionals involved in the patient care.
 Right to safety from errors and malpractice.
 Right to confidentiality and privacy.
 Right to have prompt treatment in the emergency
 Right to get copies of medical records.
 Right to informed consent
 Right to refuse to participate in humans experimentation and research
 Right to be informed about the rule and regulations of the hospital that apply to the patient and the
facilities obtainable to the patient
 Right to choose and to seek second opinion about the disease treatment etc.
 Right to complain and have compensation within reasonably short time.
STATEMENT OF OBJECTIVES AND REASONS
1.The Consumer Protection Bill, 1986 seeks to provide for better protection of the interests of consumers and
for the purpose, to make provision for the establishment of Consumer councils and other authorities for the
settlement of consumer disputes and for matter connected therewith.
2. It seeks, inter alia, to promote and protect the rights of consumers such as-
(a) the right to be protected against marketing of goods which are hazardous to life and property;
(b) the right to be informed about the quality, quantity, potency, purity, standard and price of goods to protect
the consumer against unfair trade practices;
(c) the right to be assured, wherever possible, access to an authority of goods at competitive prices;

999
 (d) the right to be heard and to be assured that consumers interests will receive due consideration at
appropriate forums;
(e) the right to seek redressal against unfair trade practices or unscrupulous exploitation of consumers; and
(f) right to consumer education.
3. These objects are sought to be promoted and protected by the Consumer Protection Council to be
established at the Central and State level.
4. To provide speedy and simple redressal to consumer disputes, a quasi-judicial machinery is sought to be
setup at the district, State and Central levels. These quasi-judicial bodies will observe the principles of
natural justice and have been empowered to give relief of a specific nature and to award, wherever
appropriate, compensation to consumers. Penalties for noncompliance of the orders given by the quasi-
judicial bodies have also been provided.
5. The Bill seeks to achieve the above objects.
ACT 68 OF 1986
The Consumer Protection Bill, 1986 was passed by both the Houses of Parliament and it received the assent
of the President on 24th December, 1986. It came on the Statutes Book as the Consumer Protection Act,
1986 (68 of 1986).
LIST OF AMENDING ACTS
1. The Consumer Protection (Amendment) Act, 1991 (34 of 1991).
2. The Consumer Protection (Amendment) Act, 1993 (50 of 1993).
3. The Consumer Protection (Amendment) Act, 2002 (62 of 2002
An Act to provide for better protection of the interests of consumers and for that purpose to make provision
for the establishment of consumer councils and other authorities for the settlement of consumers' disputes
and for matters connected therewith.

CONSUMER PROTECTION COUNCILS

The Central Consumer Protection Council. –
(l) The Central Government shall, by notification, establish with effect from such date as it may specify in
such notification, a Council to be known as the Central Consumer Protection Council .
(2) The Central Council shall consist of the following members, namely:
(a) the Minister in charge of the 1[consumer affairs] in the Central Government, who shall be its Chairman,
and
(b) such number of other official or non-official members representing such interests as may be prescribed.

NANDAKUMAR

Introduction

A Patient's Rights is a statement of the rights to which patients are entitled as recipients of medical care.
Typically, a statement articulates the positive rights which doctors and hospitals ought to provide patients,
thereby providing information, offering fair treatment, and granting them autonomy over medical decisions.

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1)RIGHTS OF HIV PATIENTS

1.1) Legal and Human Rights Issues In Context To Aids Affected Inflect Individuals

Due to stigma and AIDS related discrimination, the rights of people living with AIDS and their families are
frequently violated simply because they are known or presumed to have AIDS. This violation of rights hinders
the response and increase the negative impact of epidemic.

Health in relation to such disability includes freedom from discrimination in the matter of access to prevention,
treatment, care and support.

 Access to HIV/AIDS related treatment is fundamental to the realization of the right to health.
Prevention, treatment, care and support are a continuum.
 Access to medication is one element of comprehensive treatment, care and support.
 International co-operation is vital in realizing equitable access to care.
 Treatment & Support to all in need.

1.2) Constitutional Provisions

Art 21 of the Constitution f India is the Heart of the Human Rights in the sense that this Article alone is
comprehensive enough to encompass all Human rights.

Art 21 reads: "Protection of life and Personal Liberty. No person shall be deprived of his life or personal
liberty expect according to the procedure established by law". This article is closely related to Article 3 of
Universal Declaration of Human Rights (UDHR).

1.3) Legislative Efforts

Having an eye to the scope and effect of Art 21 in the light of provision contented in the part IV of the
constitution, the Supreme Court of India in number of decisions has pronounced the concept of "Right to life"
guaranteed under Art 21 includes:

1. Right to live with dignity.

2. The Right to livelihood
3. The Right to education
4. The Right to health.
5. The Right to protection of Health and so many other correlated rights.

There is, however, no direct law on AIDS. There are however few cases decided by the Courts. A person
cannot be regarded as medically unfit and denied employment merely on the ground that he is found to be HIV
positive (Bombay High Court). In Paschim Bengal Khet Mazadoor Society case the Supreme Court held that
the timely medical treatment in Govt Hospital is a fundamental right

1001
Supreme Court held that AIDS patient is entitled to get medical treatment without any discrimination. It is
possible for him to secure damages if he is denied medical treatment as a result of any injury suffered.

1.4) Violation Of Human Rights

By the end of the decade, the call for human right and for compassion and solidarity with people living with such
disease had been explicitly included in the first WHO global response to AIDS. No doubt this approach was
motivated by moral outrage but on realization that protection of human right was a necessary element of a
worldwide public health response to the emerging epidemic.

There are three fold obligations on the State in the case of victims of AIDS viz.

1) They must respect the rights.

2) They must protect the rights
3) They must fulfill the rights.

The right to education is violated if children are barred from attending school on basis of their HIV status. The
state has to take all appropriate measures towards fulfilling its obligation in providing essential AIDS education
to everyone and failure to do so could be regarded violation of the right to education.

2)RIGHTS OF CHILDREN

Consider the following rights of children highlighted in the International Declaration of Children's Rights of 1989
and the Vienna Convention of 1993.

 Right to life
 Right to preserve the identity
 Right to citizenship and nationality
 Right not to be separated from parents
 Right to freedom of expression
 Right to know
 Right to privacy, honour and fame
 Right for protection against sexual abuse
 Right to protection of health
 Right to protection against drugs and other harmful things
 Right to get the adaptation rules protected
 Rights of the refugee child
 Rights of the parentless children

2.1) The Constitution Of India And The Rights Of children

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 Let us examine the protection of the rights of children given by the constitution of India

 Article 15 says that there can be special provisions for children.

 Article 24 prohibits child labour.
 Artie le 21 (A) states that all children between the age of 6 and 14 should be given compulsory education that
the government decides as per the rules.

2.2) Violation Of The Rights Of Children

 Right to protection of health

 Right to education
 Right to live

2.3) Un Declaration Of The Rights Of The Child

 Non-discrimination.

 Special protection, opportunities and facilities to develop physically, mentally,- morally,

spiritually and socially in a healthy and normal manner and in conditions of freedom and dignity.

 The right to a name and nationality.

 The right to social security, adequate nutrition, housing, recreation and medical services.

 The differently-abled child to be given special treatment, education and care.

 The need for love and understanding so that the child grows in the care and responsibility of
his/her parents, and in an atmosphere of affection and moral and material security.

 Entitlement to education,: which should be free and compulsory, at least in the elementary stages.

 The child should be among the first to receive protection relief in alt circumstances.
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  Protection against all forms neglect, cruelty and exploitation| including that associated with
employment.

 Protection from practices that may foster racial, religious and other forms of discrimination.

3)RIGHTS OF WOMEN

3.1)Women Rights

The Independent India witnessed many forces of social change particularly towards women. Realizing the sufferings and
hardships of women, the Government of India passed many legislations to remove the injustice done to women. These
legislation paved the way for the upliftment and progress of women. Constitution of India guaranteed the equality of sex
and special favor to women (Article of 14,15,16, of our Constitution). Besides the constitutional guarantee, the
Government also passed many social legislations for the welfare of women.

3.2)Convention For The Elimination Of Discrimination Against Women

This covenant adopted by the U N in December 1979 stipulates certain programmes of action

 Equality among men and women in the social- economic - educational areas
 Up liftment of rural women and their participation in the developmental process
 Equality of civil and political rights

Provision similar to international understanding about the rights of rural women can be seen in the
constitution of India and in the legislation made from time to time by the state and central legislatures. What are they?

 State shall not deny to any citizen equality before law or equal protection of law.
 There shall be no discrimination on the basis of caste, religion, race, or place of birth.
 Equal pay for equal work for both men and women.
 Prevention of Depiction of Immorality Act 1986.
 Immoral Representation of Women (prevention) Act 1986.
 Prenatal Sex Determination (prevention) Act 1994.

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There are some laws formed to prevent discrimination against women. Examine how far these laws have been
effective in protecting the rights of women.

Kerala State Women's Commission is an independent agency that works with the objective of protecting the
rights of women. Collect data on the working of this and prepare a report.

Assess newspaper reports on the violation of women's rights. Does not the violation of women's rights continue
inspire of the protection of several laws? How do these violations of rights occur.

 Opposition for dowry

 Harassment at workplaces
 Discrimination in wages

3.3)Social legislations for Women:

(1) The Hindu Marriage Act of 195 5 stipulate the marriageable age as 18,but now amended to 21 for women.
(2) The Hindu Succession Act of 1956 ensures the right to inherit their parental property.
(3) The Dowry Prohibition Act of 1961 (amendedin 1984)gives severe punishment with imprisonment for the dowry
seekers..
(4) The Hindu Widow Remarriage Act of 1956 legalised the widow remarriage.
(5) The Hindu Marriage Act (Tamilnadu Governement Amendement Act of 1967 gave legal sanction to the self
respect marriages..
(6) The Hindu Succession Act of 1989 (Tamilnadu Amendment Act) provides right to have equal share in the
inheritance property.
(7) The Indecent Representation Act (Tamilnadu Government) of 1999 prohibits the indecent representation of
women in magazines, newspapers, posters, handbills etc.

3.4)Labour legislations for Women

The Government of India has also enacted a number of women labour laws for the protection of working women.
The Factory Act of 1948, Mines Act of 1952, Plantation Labour Act of 1951 were passed to protect and regulate the
wages to women without any discrimination. The Maternity Benefit Act of 1961 assures maternity leave to the pregnant women
with regular pay and wages.

All the above legislations, no doubt enhanced the status of women. But the legislations can only ensure legal equality, to
make it reality there is a need for high movement to raise the social consciousness.

4)THE RIGHTS OF DISABLED PERSONS

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The term "disabled person" means any person unable to ensure by himself or herself, wholly or partly, the
necessities of a normal individual and/or social life, as a result of deficiency, either congenital or not, in his or
her physical or mental capabilities.

 Disabled persons shall enjoy all the rights set forth in this Declaration. These rights shall be granted to
all disabled persons without any exception whatsoever and without distinction or discrimination on the
basis of race, colour, sex, language, religion, political or other opinions, national or social origin, state
of wealth, birth or any other situation applying either to the disabled person himself or herself or to his
or her family.

 Disabled persons have the inherent right to respect for their human dignity. Disabled persons, whatever
the origin, nature and seriousness of their handicaps and disabilities, have the same fundamental rights
as their fellow-citizens of the same age, which implies first and foremost the right to enjoy a decent life,
as normal and full as possible.

 Disabled persons have the same civil and political rights as other human beings; paragraph 7 of the
Declaration on the Rights of Mentally Retarded Persons applies to any possible limitation or suppression
of those rights for mentally disabled persons.

 Disabled persons are entitled to the measures designed to enable them to become as self-reliant as
possible.

 Disabled persons have the right to medical, psychological and functional treatment, including prosthetic
and orthetic appliances, to medical and social rehabilitation, education, vocational training and
rehabilitation, aid, counselling, placement services and other services which will enable them to develop
their capabilities and skills to the maximum and will hasten the processes of their social integration or
reintegration.

 Disabled persons have the right to economic and social security and to a decent level of living. They have
the right, according to their capabilities, to secure and retain employment or to engage in a useful,
productive and remunerative occupation and to join trade unions.

 Disabled persons are entitled to have their special needs taken into consideration at all stages of
economic and social planning.

 Disabled persons have the right to live with their families or with foster parents and to participate in all
social, creative or recreational activities. No disabled person shall be subjected, as far as his or her
residence is concerned, to differential treatment other than that required by his or her condition or by the
improvement which he or she may derive therefrom. If the stay of a disabled person in a specialized
establishment is indispensable, the environment and living conditions therein shall be as close as
possible to those of the normal life of a person of his or her age.

 Disabled persons shall be protected against all exploitation, all regulations and all treatment of a
discriminatory, abusive or degrading nature.

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  Disabled persons shall be able to avail themselves of qualified legal aid when such aid proves
indispensable for the protection of their persons and property. If judicial proceedings are instituted
against them, the legal procedure applied shall take their physical and mental condition fully into
account.

 Organizations of disabled persons may be usefully consulted in all matters regarding the rights of
disabled persons.

 Disabled persons, their families and communities shall be fully informed, by all appropriate means, of
the rights contained in this Declaration.

5)BIBLIOGRAPHY

.
1) Ann Manner Tomery guide to nursing management and leadership eight Edition Mosby.
2) Corwen Moorhead, "Current Issues in Nursing", 7th edition, Mosby Publication 2006, Page No:371-390
3) S.L. Goel, "Management of Hospitals", Deep Publications 2002
4) Joseph.T, ''Nursing Now", 4th edition, Jaypee Publication 2007, Pago No:247-290
5) Linda. A, "Leadership", Mosby Publications, 3rd edition, 1999, Page No; 33-43
6) Laura Douglass, "Nursing Management & Leadership in Action", Mosby Publications, 4th edition 1983,
Page No:200-217
7) Francis and Mario. C. de Souzar, "Hospital Administration", Jaypee Brothers, New Delhi, 3 rd edition,
2000, Page No:150-167
8) Barbara Cherry, "Contemporary Nursing Issues Trends & Management", Mosby Publication,
Philadelphia, 2nd edition. Page No: 100-120
9) Ganong & Ganong, "Nursing Management", Aspin Publication, 2nd edition, Page No;135-140
10) Sakharkar.BM, "Principles of hospital administration & planning",
st
Jaypee brothers, Calcutta, 1998, 1 edition, Page No;82-91
11) Syed Amin Tabish, "Hospitals & Health Service Administration",
nd
Oxford Publications, New Delhi, 2 edition, 2005, Page No: 142-148

Net References

1) www.wikipeida.CvMn
2) www. google.com
3) www.currentnursing.com

6)PROFESSIONAL ACCOUNTABILITY AND RESPONSIBILITY

6.1) Introduction

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 Accountability means being held responsible for having done something. In the early writings about the
nursing profession, the term responsibility meant duty. Florence Nightingale's Notes on nursing frequently
emphasizes the responsibilities of professional nurses. She delineates the nurse's responsibility for the state of the
sick room, the need for careful observation on the part of the nurse to avoid patient accidents, and mentions the
fact that "I have often seen really good nurses distressed, because they could not impress the doctor with the real
danger of their patients".

6.2) Professional Accountability

American Nurses Association (ANA) Code for Nurses states, accountability refers "to being answerable
to someone for something one has done. It means providing. An explanation to self, to the client, to the
employing agency; and the nursing profession.

Accountability is defined as the process in with individuals is answerable for their actions and has an
obligation (or duty) to act.

6.3) Elements of professional accounting:

 Important to first understand social context of nursing.

 Public holds nursing. Accountable for safe nursing care and proper judgment in provision of nursing
services.

 The profession is held accountable by public to ensure that only qualified individuals are granted the
right to practice and that those who fail to uphold the professional standards are denied the future right
to practice.

 Professional accounting with in nursing is fostered through mechanisms by with nurses obtain right to
practice.

 These mechanisms include rights and responsibilities, organizational accountability, Legislative

regulations, individual accountability, and student accountability.

1008
6.4) Who has accountability?

a)Delegator:

 Own Acts
 Acts of delegation
 Acts of supervision
 Assessment of Situation
 Follow up
 Intervention
 Corrective Active.

b)Delegatee:

 Own acts
 Accepting the delegation
 Appropriate notification and reporting
 Accomplishing the task.

5) Types of accountability:

a)Organizational

b)Legislative

c)Individual

d)Student.

a)ORGANIZATIONAL ACCOUNTABILITY:

 Accreditation
 Certification
 Standards of Nursing Practice

b)LEGISLATIVE ACCOUNTABILITY:

 Licensure

1009
 c) INDIVIDUAL ACCOUNTABILITY:

Professional Nurses must understand the method by which board of nursing adopts rules and regulations
in their state of licensure. So that they can be active participants in the development of such regulations.

TWO METHODS TO DEMONSTRATE INDIVIDUAL ACCOUNTABILITY:

1. Continued Competency.
2. Professional development.

1. CONTINUED COMPETENCY:
 Registered Nurse has professional responsibilities to attain, and maintain competency.
 Once licensed, it is responsibility of Registered Nurse to maintain a current active license to practice in
accordance with state registrations.
 Registered Nurses must renew their licenses on an annual or biannual cycle before expiration date and
meet other requirements for license renewal as required by individual state board of nursing.
 Nursing profession has traditionally used three methods of ensuring accountability to public:
1. Licensure examination.
2. Continuing education.
3. Certifications.
 Development of professional portfolio is one avenue for demonstrating continued competence.

2. PROFESSIONAL DEVELOPMENT:

 Active involvement helps to develop critical professional skills and participate in events that may have
an impact on their careers.
 Professional organization and professional association organized around especially practice areas.
 Involve with district and state nurses association is also encouraged.
 Nursing students can participate in these groups through continuing education, legislative activity or
political action.
 Students have opportunities of making contacts with Registered Nurse with in this association who will
eventually be their colleagues.
 It helps in seeking guidance in employment opportunities and can develop into valuable mentoring
relationships.

d) STUDENTS ACCOUNTABILITY:

 Directly related to their legal authority to practice.

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  Accountability for nursing care is shared by the student, faculty, education institution in which student
is practicing and clinical agency.
 For nursing students, accountability for competency begins the first clinical day and continues
throughout their careers.
 Students have responsibility to:
1. Be prepared for clinical practice.
2. Engage only in those skills for which they have gained competence.
3. Seek instructions as necessary.

6)PROFESSIONAL ACCOUNTABILITY

 As nursing evolves to fit all criteria for professional status, increased interest in and concern with
accountability has arisen. Accountability has always been acknowledged as one of the hallmarks of a
profession.
 Flexner (1915) supported this view when outlining characteristics of a profession. In that work, Flexner
indicated that a profession is likely to be more responsive to public interest than are unorganized and
isolated individuals.

 Nurses have another document to guide them for practice accountability—the Code for Nurses, which
also was developed by the ANA. The code for nursing outlines terms for ethical accountability for
professional nurses. Nurses as client advocates base professional decisions on what is best for clients.
More in the nature of an ethical code, the " ANA Code for Nurses provides a clear framework within
which the nurse can seek to uphold the standards of care and protect the clients they serve. Should there
be any doubt about accountability of the nursing profession, the Code lays this to rest by directly con-
fronting the issue. As stated in item 4 of the code. "The nurse assumes responsibility and accountability
for individual nursing judgments and actions".
 The nurse's accountability to self was tested dramatically in the late 1980s and 1990s with the advent of
the human immunodeficiency virus (HIV) epidemic. Some nurses expressed great fear, and some even
refused to provide care for persons with HIV. To protect health care workers, health care agencies and
the Center for Disease Control, established universal precaution guidelines.

a)Accountability to the Public and Client

 A profession exists to provide service to the public. Although it may be intellectually stimulating,
gratifying, and exciting to a professional to perform a role, ultimately the reason for that role lies in its
service relationship with the public. Thus, almost by definition, a profession must be accountable to the
public. The consumer has the right to receive the best possible quality of care-care grounded in a firm
knowledge base and performed by those who can make use of that knowledge base through the
application of sound judgment while using a clear and appropriate value system.
 As consumers become more knowledgeable through formal education and access to information from
many media formats, they know more about what the professions are supposed to be doing. The
increased knowledge empowers consumers to demand more and to make those demands openly. Instead
1011
 of assuming authority positions, nurses work collaboratively with clients to determine and attain health-
related goals.

 Nurses must be aware of increased consumer knowledge and sophistication and be prepared to respond to
it in an equally knowledgeable-and sophisticated manner. Nurses must demonstrate clearly the principles
and concepts on which practice is based. They also need to access current information, use problem
solving to effectively evaluate outcomes of care, and revise care strategies if desired outcomes are not
achieved.

 Society holds nurses legally accountable for professional practice. Each state has a Board of Nursing that
monitors practice according the Nursing Practice Act (NPA). Tire NPA defines professional nursing
practice, specifies the scope of practice, and distinguishes professional nursing from other health
professions. Nurses must practice within these guidelines when working in a state.
 Documentation of care delivered serves as legal evidence when legal action is taken against nurses.
Nurses must know the importance of documenting all work and the processes used when providing
nursing care. Meticulous documentation of events enables the nurse to present a highly professional
image and serves as one of the best defense resources during legal actions.
 As knowledgeable professionals, nurses share accountability for the nation's health care delivery system
with other health team members (Lane, 1985). When nurses blame others, such as physicians,
administrators, or politicians, for the state of the health care delivery system or constantly look to others
to improve the system, nurses weaken their position and power base.

b)Accountability to the Profession

 The profession of nursing exercises its accountability toward itself in the performance of its duty to
formulate its own policy and control its activities.
 Professional nurses determine standards for nursing licensure (National Council of the State Boards of
Nursing and individual State Boards of Nursing) and those that exist for entry into a variety of
professional groups and associations (such as the Association of Operating Room Nursing & the
American Association of Critical Care Nurses). In addition, membership on the National Council of State
Boards of Nursing and individual State Boards of Nursing consist primarily of nurses who set nursing
standards for nursing practice, professional conduct, and discipline.

c) Accountability to the interdisciplinary Health Care Team

 As a professional in the interdisciplinary health care team, nurses have accountability for the unique
contributions they make to client care. The nurse often spends more time with the client than any other
health team member. Nurses who engage in holistic nursing care consider more than just client
physiologic needs; they also identify psychological, sociocultural, and spiritual needs. Many times nurses
identify obstacles for client self-care by spending time assessing, teaching, and evaluating client and
family responses to what they need to know before discharge.

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  For example, when working on a rehabilitation unit, one nurse was caring for an elderly woman who was
going to perform glucose self-monitoring at home. The diabetes nurse educator who provided the basic
instructions on the procedure documented that the woman could effectively perform required tasks.
However, % days before the client was to be discharged, the nurse observed that the woman failed tohave
the manual dexterity to manipulate the glucose monitoring equipment, the vision to read the results. and
the fine hand control to record the results. The nurse inquired about the woman's discharge living
arrangements and discovered she would be living alone and no family members would be available to
assist with glucose monitoring. When noting the problem, the professional nurSe had an obligation to
document this information and share it with the woman's case manager, who then arranged home health
care.

 This example shows how professional nurses are accountable for sharing client information with other
health team members and how in doing so, they fulfill obligations to the client system. In addition, the
proactive steps taken by the nurse in this situation may have prevented poor blood glucose control for the
client or an admission to an acute care hospital, thereby reducing health care costs for the consumer,
third-party payer, or government.

d) Accountability to Self

 Although professional people perhaps display more commitment to their careers, they sometimes can be
exploited by systems in which they work. In the early days of the profession, hospitals and clients
expected nurses to live on the premises in which they work. Unlike the days of old, agencies no longer
assume ownership of nurses and do not expect there to work long hours without breaks. Employers and
clients see nurses as free and independent persons with multiple facets to life other than their professional
role.
 The job situation may cause nurses and others to overlook these basic facts. Staff shortages may keep
nurses from fulfilling their basic needs for nutrition and elimination. In addition, nurses' other life roles
may often affect professional performance. Therefore, nurses must be accountable to themselves for their
actions both on and off the job because of the potential effects of their actions on themselves and others.
 Accountability to self also involves acknowledging one's own limitations and knowing when additional
education or assistance from other is needed for effective client care. Decisions by others must not guide
a nurse's action. Questioning physician orders may sometimes require courage, but it protects both client
and nurse. Deciding when to assume a new nursing position (such as promotion to a nurse manager)
should be based on each nurse's appraisal of personal qualifications for the job rather than the opinion of
other persons. Completing an academic degree (such as a bachelor's degree in nursing) does not
automatically prepare all nurses to assume a managerial role. Other factors such as personality, job
description, and career goals also-play a role before an administrative position is assumed.

1013
e)Accountability to the Employing Agency

 Yet another domain of the nurse's accountability is the agency in which that nurse is employed.
Employees, even those with professional status, have responsibilities and must answer for actions taken
on the job. Although not unimportant, accountability to the agency rightfully takes a back seat to the
client, public, profession, and nurses themselves.
 A health care agency is accountable to the public for the care provided under its auspices. Agency
administration must verify that they have competent persons providing health care to consumers. Thus,
the agency has the right to expect the nurse to be accountable to that agency. The following section
discusses how the nurse is accountable to the employing agency.

1) Quality of Work

The agency holds nurses accountable for the quality of work (nursing care). This includes their
preparation for the job and their fitness each time they report for work. The agency has contracted with nurses
for a specific job to be done at a specific time and place for a specific wage. Nurses must uphold their end of the
bargain in all of these areas. They also have accountability for the nature of the performance of their peers. In
addition, professional nurses are accountable for those whom they supervise in the work setting and must be
aware of what they are doing and how they are doing it, to exercise that accountability.

2)Unsafe Practice Situations

Recent legislation has resulted in legal protection for nurses who report unsafe practice situations.
Sometimes the agency may refuse to correct what the nurses perceive as an unsafe practice situation. Nurses
must refuse to work in areas and situations that they consider unsafe. This further fulfills accountability to the
agency (as well as self) because such nurses are saying, in effect, "I will not put the agency in the position of
giving unsafe care." However, sometimes refusal to provide client care as designated by terms of employment
may result in dismissal from the agency.

3)Attitude Conveyed About Agency

An additional aspect of the nurse's accountability to the agency involves the attitude toward that agency
that the nurse projects to clients. The attitude should be one of objectivity and honesty. Nurses who find joy in
working for a particular agency may appropriately and honestly promote the agency's strengths. However, if
confronted with an agency shortcoming, nurses must be honest in their"responses. Sometimes, in the heat of the
moment, when particularly taxed or following a disagreement, a nurse may denigrate an agency. In this case, the
nurse has not acted maturely and has no awareness of the impact of such statements on the~client, visitors, or
the agency.

4) Use of Outside Agency Personnel

1014
 Concerns- have arisen recently regarding accountability to the employer because of a large and growing
number of nurses employed by nursing agencies and then essentially "rented" to hospitals on a per-diem basis.
In most cases, agency nurses possess high levels of clinical competence. However, they may be unfamiliar with
an employing institution's policies and procedures. Some agency nurses rely on nurses who are employed by the
institution to help them access information and guide them through institutionally set care standards. Agency
nurses may have more accountability to the nursing agency, thus diminishing some of the support they might be
offering the hospital, or they feel primarily accountable to the hospital and wish to provide effective client care.

Nurses have, for too long, maintained their accountability to their employing agency above their
accountability to all others. This has detracted from a desirable image of nurses as working primarily in the
public- interest and instead has fostered the impression of the nurse as being subservient to and totally raider the
control of the employing institution. Now is the time to fully recognize and implement "nursing's accountability
toward its primary foci (the client and public, the profession, and the self) without losing sight of the nurse's
accountability toward the employing agency.

6.7)NURSING ACCOUNTABILITY

 Nurses are accountable for designing effective care plans, implementing appropriate nursing actins and
judging effectiveness of their nursing interventions.
 Nurses are accountable, for their judge’s, decisions, and action to:

1. Clients, families and significant others.

2. Colleagues.
3. Employers.
4. The general public (society)
5. The Nursing Profession.
6. Themselves.

 Nurses demonstrate their commitments to accountability in a variety of ways, including:

1. Maintaining expertise in skills.

2. Participating in continuing education programs.

3. Achieving and maintaining certification.

1015
 4. Participating in peer evaluation.

 The profession is accountable in several domains.

1. Professional.
2. Legal.
3. Ethical.

8) Professional Responsibility

Ethically, to be designated a ‘responsible person’ implies a number of things, namely that one is, or can
be presumed to be, a self-conscious rational being who:

 is capable of acting as an independent moral agent

 is competent to perform the task in hand
 is capable of making a response to other people
 acknowledges a legal or moral obligation of some kind
 has proved that they are reliable and trustworthy
 can give an account of what they have done and why.

In the last-mentioned sense, responsibility is inclusive of accountability, the ability to give an account of
one’s actions, in particular to give a coherent, rational and ethical justification for what one has done. The main
difference between responsibility and accountability is perhaps that the former is self-reflexive, namely relating
to oneself as a moral agent, whereas accountability relates to one’s relationship to other moral agents, in
particular to those who have authority over us, although it may also include reference to oneself.

It may be useful in this connection to distinguish between two different kinds of responsibility to, and
two kinds of responsibility for, and to give their more technical names.

Accountability
Responsibility for one’s own (personal responsibility)
actions
Responsibility for the care of (fiduciary responsibility)
someone

1016
 Responsibility to higher authority (professional accountability)
Responsibility to wider society (public accountability / civic
duty)

9)Types of Professional Responsibility

a)Personal Responsibility

Ordinarily one is held responsible for one’s own actions and omissions, and praised or blamed for them,
provided the following conditions are satisfied:

 That one knows what one is doing

 one has acted freely and voluntarily
 one is capable of performing or avoiding the action
 one can distinguish between right and wrong

b) Fiduciary responsibility

When someone is entrusted into your care (e.g. a child, or an unconscious or mentally disturbed patient),
or when a patient voluntarily entrusts themselves into your hands, whether as a nurse or in the context of lay
care, you acquire ‘fiduciary responsibility’ (from Latin fiducia = trust). Accepting responsibility for the care and
treatment of patients, or for decisions about their individual and collective well-being, is a matter of fiduciary
responsibility, and the moral authority or power of nurses to do these things derives from the trust which patients
and society place in them.

CODE OF PROFESSIONAL CONDUCT FOR NURSES IN INDIA

Professional Responsibility and Accountability

 Appreciates scene of self-worth and nurtures it.

 Maintains standards of personal conduct reflecting credit upon the profession
 Carries out responsibilities within the framework of the professional boundaries
 Is accountable for maintaining Practice Standards set by Indian Nursing Council
 Is accountable for own decisions and actions
 Is compassionate
 Is responsible for continuous improvement of current practices
 Provides adequate information to individuals that allows them informed choices
 Practices healthful behavior

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 INTERNATIONAL COUNCIL OF NURSES CODE OF ETHICS:

(Adopted in 1953 and revised in 1965, 1973 and 2000)

 The fundamental responsibility of the nurses is fourfold; to promote health, to prevent illness, to restore
health, and to alleviate suffering.
 The need for nursing is universal. Inherent in nursing is respect for life, dignity, and rights of humans.
It is unrestricted by considerations of nationality, race, creed, color, age, sex, politics, or social status.
 Nurses render health services to the individual, the family, and the community and coordinate their
services with those of related groups.

Nurses and People:

 The nurse's primary responsibility is to those people who require nursing care.
 The nurse, in providing care, promotes and environment in which the values, customs, and spiritual
beliefs of the patient are respected.
 The nurses hold in confidence personal information and uses judgment in sharing this information.

Nurses and Practice:

 The nurse carries personal responsibility for nursing practice and for maintaining competence by
continual learning. The nurse maintains the highest maintains the highest standards, of nursing care
possible within the reality of specific situation.
 The nurse uses judgment in relation to individual competence when accepting and delegating
responsibilities.
 The nurse, when acting in a professional capacity, should at all times maintain standards of personal
conduct that reflect credit on the profession.

Nurses and Society:

 The nurses share with other citizens the responsibility for initiating and supporting action to meet the
health and social needs of the public.

Nurses and the Co-workers:

 The nurse sustains a cooperative relationship with co-workers in nursing and other fields.
 The nurse takes appropriate action to safeguard the patient when his or her care is endangered by a co-worker
or any other person.

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Nurses and the Profession:

 The nurse plays a major role in determining and implementing desirable standards of nursing practice and
nursing education.
 The nurse is active in developing a core of professional knowledge. The nurse, acting through the
professional organization, participates in establishing and maintaining equitable social and economic
working conditions in nursing.

7)STANDARD SAFETY MEASURE

7.1)INTRODUCTION

The word safety in its purest sense means freedom from injury, risk or harm. The management of any
hospital has a twofold responsibility regarding safety: (a) to make the work place and environment safe by
creating safe conditions and (b) establish, communicate and enforce the safety rules. Safety is everybody's
business and no safety programme can succeed without the cooperation of the people. Everyone has to work as a
team and share the responsibility of safeguarding patients, visitors and the hospital personnel.

1) PATIENT CARE ENVIRONMENT SAFETY MEASURES

Wrist or Ankle Restraint Vest Restraint

1. Identify patients at risk for injury. Those at special risk include:

o Elderly or confused patients.
o Patients with impaired vision or hearing.
o Patients with impaired mobility (wheelchairs, walkers, and partial paralysis).
o Patients with a history of falls.
o Patients with a history of substance abuse.
o Patients receiving medication that interferes with reasoning or motor functions.
2. Protect the patients at risk for injury.
3. To prevent falls:
o Place the bed in the low position.
o Keep the side rails up when the patient is not receiving bedside care.
1019
 o Advise the patient to wear low-heeled shoes that fit well when walking.
o Ensure that nonskid strips or mats are affixed to the bottom of bathtubs and shower floors.
o Ensure that bathtubs have sturdy handrails and shower stools are in place when needed.
o Warn patients and visitors when floors are wet and slippery. Also see that signs are posted.
4. Protective restraints
o Use restraints when careful assessment indicates that these are needed. (Some facilities require a
doctor's order for restraints).
o Movement is essential to the patient's well being. Use the least restrictive type of restraint, which
will protect the patient.
o Apply the restraint for the shortest amount of time necessary. The vest restraint may only be
necessary while a patient is sitting in a wheelchair.
o Provide for as much movement as possible. The waist restraint protects the patient from falling
out of bed but still allows the patient to change position independently.
o Restrain the fewest limbs or body parts possible. However, if leg restraints are necessary, use
wrist restraints also. If this is not done, the patient may remove the leg restraints or he may
accidentally hang by his heels in the restraints.

Waist restraint.

1020
 Half Bow Know
o Tie the restraint with a knot that is not likely to come loose, yet can be released easily by the
nurse in an emergency. A half-bow knot meets these criteria.
o Explain to the patient the reason for the restraint. Position him comfortably and change his
position every 2 hours. Feed the patient who must remain restrained during meals. Help him use
the toilet, bedpan, or urinal at regular intervals.

5. Prevent scalds and burns.

o Place coffee, tea, and other hot liquids where the patient can reach them easily and safely.
o Assist the patient if there is any doubt about whether he can safely regulate the temperature of
water in tubs or showers.
o Carefully follow policy when using hot-water bags or heating pads. Because of the danger of
burning patients, many health care facilities do not allow their use.
6. Prevent the spread of infection. A health care facility may adopt its own infection control policies and
practices. However, the procedures generally follow the recommendations from the Centers for Disease
Control (CDC). This is a federal agency that studies pathogens, outbreaks of contagious diseases, and
methods used to control these outbreaks.
o Preventing disease, including infections, is a high priority in health care. Nurses should use
techniques that prevent microorganisms from living, growing, and spreading.
o Two methods are used to reduce or eliminate the presence of microorganisms and thus prevent
infections. These two methods are called surgical asepsis and medical asepsis.
 Surgical asepsis refers to the practice that eliminates the presence of all microorganisms
(bacteria, viruses, fungi, yeasts, molds, rickettsia, and protozoa). This practice is sterilization.
 Medical asepsis refers to practices that help reduce the number and inhibit the growth of
microorganisms, especially pathogens (those that cause infections or contagious diseases).
Medical asepsis, also called clean technique includes use of antimicrobial agents, hand
washing, cleaning supplies and equipment, and disinfection.
o Infections and infectious diseases begin in a reservoir and move full circle to a susceptible host

1021
 The Infectious Process Cycle

 Reservoir. This is the place on which or in which organisms grow and reproduce. Examples
include man and animals.
 Exit from reservoir. Escape routes for organisms include the nose, throat, mouth, ear, eye,
intestinal tract, urinary tract, and wounds.
 Vehicle of transmission. The means by which organisms are carried about include hands,
equipment, instruments, china and silverware, linens, and droplets.
 Portal of entry. The part of the body where organisms enter include any break in skin or
mucous membrane, the mouth, nose, and genitourinary tract.
 Susceptible host. A person who cannot fight off the organism once it enters his body and
therefore, he becomes ill.

 It is important that the nurse teach patients facts and practices about surgical and medical asepsis. When
teaching a patient you should:
o Observe the patient to identify areas where instruction would be helpful in controlling the spread
of infection.
o Act as a model by using sound practices of asepsis when giving care.
o Provide guidance to the patient who must give himself care at home in the proper way to handle
sterile equipment and supplies and in how to sterilize reusable items.

Report infections. Health care workers must report any infection that occurs. The Infection Control
Committee will investigate any case of infection to determine the cause. If a break in nursing technique is
identified, the committee will propose different procedures to eliminate the problem.

7.2)STANDARD PRECAUTIONS FOR PATIENTS

Standard Precautions represents a system of barrier precautions to be used by all personnel for contact with
blood, all body fluids, secretions, excretions, non intact skin, and mucous membranes of ALL patients,
regardless of the patient's diagnosis. These precautions are the "standard of care." This system embodies the
concepts of "Universal Precautions" and "Body Substance Isolation".

7.3)PURPOSE OF STANDARD PRECAUTIONS

E. The purpose is to reduce transmission of infectious agents between patients, caregivers, and others in the
medical center environment, and to reduce the incidence of nosocomial infections among patients.

1022
F. Hospital departments and clinics will incorporate Standard Precautions into departmental policies and
procedures to be reviewed at least every two years by that department and the Infection Control Committee.

G. Ongoing education concerning Standard Precautions principles will be given to newly hired employees
involved directly or indirectly in patient care. Review classes will be provided as needed for dissemination of
new information or for reinforcement upon request of the department manager. Documentation of training
will be maintained by the individual departments.

H. Standard Precautions will be followed by all personnel and will be based on the degree of anticipated
exposure to body substances. It is the responsibility of the individual to comply with all isolation precautions.
Standard Precautions focuses on reducing the risk of transmission of microorganisms. The use of barriers is
determined by the care provider's "interaction" with the patient and the level of potential contact with body
substances.

7.4)HAND HYGIENE

Nosocomial infections are most frequently spread by contact and the most common form of contact is
hand contact, hand washing is the most important and most effective means of preventing nosocomial
transmission of organisms.

Employees have a responsibility for maintaining hand hygiene by adhering to specific infection control
practices. manicured and should not extend past the fingertips.. This includes, but is not limited to artificial nails,
tips, wraps, appliqués, acrylics, gels, and any additional items applied to the nail surface.

A. Indications for Handwashing and Hand Antisepsis include:

8) Before having direct contact with patients.

9) Before donning gloves and performing an invasive procedure.
10) After removing gloves or other personal protective equipment.
11) After contact with body substances or articles/surfaces contaminated with body substances.
12) After contact with patient's intact skin (e.g. taking a pulse, blood pressure or lifting a patient).
13) Before preparing or eating food (do not use alcohol gel).
14) After personal contact that may contaminate hands (e.g. covering sneeze, blowing nose, using bathroom -
do not use alcohol gel)

C. Hand Hygiene Products

5) In patient care areas, alcohol gel, liquid or foam soap will be used for hand hygiene.
6) Alcohol gel hand rub is recommended as the primary hand hygiene product if hands are not visibly dirty,
soiled with proteinaceous material or visibly soiled with blood or body fluids.
7) Antimicrobial agents, including alcohol gel or soap, are recommended for use prior to invasive
procedures, in critical care units, and for patients on special organism precautions.
8) Staff with skin sensitivities should consult with Employee Health regarding the use of alternative hand
hygiene products (preferably in dispenser form).

1023
D. Handwashing Procedure with Liquid or Foam Soap

8) Wet hands first with water.

9) Apply an amount sufficient for lather to cover all surfaces of hands and wrists.
10) Rub hands together will covering all surfaces of the hands and fingers with special attention to areas around
nails and between fingers for a minimum of 15 seconds
11) Rinse well with running water.
12) Dry thoroughly with paper towel.
13) Use paper towel to turn off faucet.
14) Avoid using hot water as repeated exposure to hot water may increase risk of dermatits.

E. Hand Antisepsis Procedure Utilizing Alcohol Gel

3) Apply to dry hands that are not visibly soiled.

4) Rub hands vigorously to apply gel to all surfaces of hands, fingers and fingernails, until hands are dry. If
hands feel dry after rubbing hands together for 10 - 15 seconds, insufficient volume of product was
applied.

F. Skin Care

Healthcare workers should use hospital approved hand lotion to minimize the occurrence of irritant contact
dermatitis associated with hand antisepsis or handwashing.

3.3) PERSONAL PROTECTIVE EQUIPMENT (PPE)

A. Gloves

Disposable (single use) gloves shall be readily available in patient careand specimen handling areas.

2. Gloves must be worn for:

e) Anticipated contact with moist body substances, mucous membranes, tissue, and non-intact skin of all
patients;
f) Contact with surfaces and articles visibly soiled/contaminated by body substances;
g) Performing venipuncture or other vascular access procedures (iv starts, phlebotomy, in-line blood draws);
h) Handling specimens when contamination of hands is anticipated.
8. Don gloves at bedside, immediately prior to task.
9. Replace torn, punctured or otherwise damaged gloves as soon as patient safety permits.
10. Remove and discard gloves after each individual task involving body substance contact, before leaving the
bedside.

Gloves should not be worn:

Away from the bedside or lab bench at the nursing station to handle charts, clean linen, clean equipment or
patient care supplies in hallways or elevators.

1024
11. Perform handwashing or hand antisepsis (per aboveindications) as soon as possible after glove removal, or
removalof other protective equipment. Gloves are not to be washed or decontaminated for reuse (exception:
utility gloves)
12. Caution: Gloves do not provide protection from needlesticks or other puncture wounds caused bysharp
objects. Use extreme caution when handling needles, scalpels, etc.

B. Masks, Eye Protection and Face Shields

Wear masks in combination with eye protection devices (goggles or glasses with side shields) or chin-
length face shields during procedures that are likely to generate droplets, spray, or splash of body substances to
prevent exposure to mucous membranes of the mouth, nose and eyes. Masks are also worn to protect personnel
from the transmission of infectious droplets during close contact with the symptomatic patient.

Situations which may increase risk of splash/splatter include the following:

h. Trauma care
i. Surgery or delivery of newborn
j. Intubation/suctioning/extubation (including code situations)
k. Bronchoscopy/endoscopy
l. Emptying bedpans/suction canisters into hopper/toilet
m. Code blue
n. Patient care of coughing patient with suspected infectious etiology

C. Aprons, Gowns, and Other Protective Body Clothing

The appropriate type of garment shall be based on the task and the degree of exposure anticipated. Gowns are
worn to prevent contamination of clothing and protect the skin of personnel from blood/body fluid exposure.

5) Wear plastic aprons or gowns during patient care procedures that are likely to soil clothing with body
substances.
6) Wear lab coats in laboratory settings.
7) Remove protective body clothing before leaving the immediate work area.
8) In surgical or autopsy areas, additional protective attire may include surgical caps or hoods and shoe covers
or boots

3.4) PATIENT PLACEMENT

A. Private rooms are required for Infection Control reasons for the following groups of patients:

1) Those who soil the environment with body substances. For example, children or adults with altered mental
status.
2) Those requiring precautions for airborne diseases.
3) Those who are considered to be severely immunosuppressed.
4) Patients with the same infectious disease/organism may be cohorted (housed in the same room) after
consultation with Infection Control.

1025
B. Patients who are currently on isolation precautions for any infection may not be admitted to the Comfort Care
Suites. Any questions regarding this policy may be addressed to the Department of Epidemiology and Infection
Control.

7.5) ENVIRONMENT

A. Waste Disposal:

B. Spill management/Housekeeping

4) Spills of body substances should be cleaned up promptly. Workers should wear gloves and use other
protective equipment if there is risk of splash. Encapsulator products may be used to solidify liquid waste
or pickup. Area should then be disinfected with hospital grade disinfectant/detergent.
5) Broken glass will be handled safe
6) Areas not routinely cleaned by Environmental Services personnel shall be cleaned by department
personnel.
c) Work surfaces shall be cleaned and decontaminated after contact with blood or other potentially
infectious materials.
d) Contaminated surfaces shall be cleaned and decontaminated with an appropriate disinfectant after the
completion of procedures; whenever feasible if the surface work area becomes overtly contaminated; or
at the end of the workshift. A tuberculocidal disinfectant is required to clean spills of blood or other
potentially infectious materials.
e) Additional cleaning is required for certain precautions (Special Organism Precautions).

C. Soiled Linen Handling

5) Wear gloves to handle moist or visibly soiled linen.

6) Place soiled linen in plastic laundry bags.
7) Securely close laundry bag when bag is three-fourths full and place in storage area.
8) Laundry workers must always wear gloves.

D. Food Service

No special trays are needed. After patient use, food trays are sent directly for cleaning and disinfection.

3.6) Standard Precautions: Key Components

Handwashing (or using an antiseptic handrub)

 After touching blood, body fluids, secretions, excretions and contaminated items
 Immediately after removing gloves
 Between patient contact

Gloves

 For contact with blood, body fluids, secretions and contaminated items

1026
  For contact with mucous membranes and non intact skin

Masks, goggles, face masks

 Protect mucous membranes of eyes, nose and mouth when contact with blood and body fluids is likely

Gowns

 Protect skin from blood or body fluid contact.

 Prevent soiling of clothing during procedures that may involve contact with blood or body fluids.

Linen

 Handle soiled linen to prevent touching skin or mucous membranes

 Do not pre-rinse soiled linens in patient care areas

Patient care equipment

 Handle soiled equipment in a manner to prevent contact with skin or mucous membranes and to prevent
contamination of clothing or the environment
 Clean reusable equipment prior to reuse

Environmental cleaning

 Routinely care, clean and disinfect equipment and furnishings in patient care areas

Sharps

 Avoid recapping used needles

 Avoid removing used needles from disposable syringes
 Avoid bending, breaking or manipulating used needles by hand
 Place used sharps in puncture-resistant containers

Patient resuscitation

 Use mouthpieces, resuscitation bags or other ventilation devices to avoid mouth-to-mouth resuscitatio

Patient placement

 Place patients who contaminate the environment or cannot maintain appropriate hygiene in private rooms

4) SAFETY MEASURES FOR PROFESSIONALS

A) WORK PRACTICES

 Eating, drinking, smoking, applying cosmetics and lip balm and handling contact lenses in any work
areas where there is a reasonable likelihood of occupational exposure is prohibited, e.g. specimens are, at
1027
 times, temporarily left at a nurse's station. Prior to the consumption of food or drink, after handling
potentially infectious materials, employees will remove potentially contaminated PPE, wash hands, and
exit the work area.
 Food and drink will not be kept in freezers, refrigerators, counter tops, shelves, and cabinets where blood
or other potentially infectious materials are stored or handled.
 Procedures which could potentially generate aerosols or other inhalation hazards shall be performed in a
manner that will minimize pathogen transmission.
 Emergency ventilation devices, such as Ambu bags, will be readily available in patient care areas.

B) HANDLING AND DISPOSAL OF SHARPS

 Sharps disposal is the responsibility of the user of the sharp. Sharps disposal may be delegated only to a
person currently present in the room (i.e., never left for another person to dispose of later). The only
exception to the delegation policy would be in the surgical suite.
 Puncture-resistant sharps containers shall be readily available in areas where sharps waste (needle, all
syringes, scalpels, glass slides or pipettes, etc.) may be generated.
3) DO NOT place sharps in the regular trash.
4) Dispose of sharps as close as possible to the point of use.
 Contaminated needles shall not be recapped or removed from syringes UNLESS the employee can
demonstrate that no alternative is feasible or patient safety is threatened.
1. If recapping is required, then it shall be performed by mechanical means or by a one-handed
technique.
2. If needle removal is required, use needle removal device on sharps container or an instrument such as
a plastic clamp to distance the hand from the needle. Disposable clamps are available on supply carts.
3. When not piercing the skin of the patient, use needleless systems (for example, when accessing an IV
line).
 Needle clippers and other devices which shear, bend, or break contaminated needles are prohibited from
use.
C) DO NOT OVERFILL sharps containers.
3) Look closely at the sharps container before placing a used sharp inside to assure that nothing is
protruding from the container or that the container is not overfilled.
4) When sharps container is 2/3 full (to "full" line), close securely remove and discard as biohazardous
waste, and replace with empty sharps container.
 DO NOT place needles, introducers, or other sharps on food trays or patient bed. DO NOT stick needles
into the mattress after use or while performing a procedure.
 Surgical instruments with sharp edges (e.g. scalpel) should not be passed hand-to-hand but should be
placed on a neutral surface (e.g. tray or basin).

D) Reusable Sharps:
5) Reusable sharps will be placed in puncture-resistant containers for transport.
6) Reusable sharps that are contaminated with blood or other potentially infectious materials will not be
stored or processed in a manner that requires an employee to reach by hand into the container where
these sharps have been placed.
7) Containers for reusable sharps will be decontaminated before reuse.
8) Each department that handles reusable sharps will have written procedures for appropriate use. Each
department that decontaminates containers will have written procedures in compliance with the
policies and procedures of Section 6.
1028
E) Sharps Container Safety
4) All sharps containers are marked with the BIOHAZARD SYMBOL.
5) Whenever possible, have sharps container at point of use i.e., patient area, treatment room. Avoid
walking to container with a used sharp.
6) An open, in-use sharps container should never be on the floor, located under a sink or any other
poorly visible area.
F) Sharps Container Placement
4) Mount and/or secure box whenever possible. Use wire racks, counter holders and other mountings to
prevent a loose container from falling over.
5) Mounting of box with holder should be at a level such that the user can easily see into the opening
where sharps are to be placed.
6) Sharps containers should be kept out of public areas when at all possible. Public area placement
should be limited to only those required for personnel safety and mounted/placed with public safety
consideration. Children, must be supervised by the adult accompanying them to prevent an accident.
4) Broken glassware which may be contaminated will not be directly handled with a gloved or bare hand. It
will be handled by mechanical means (tongs, dust pan and broom). Contaminated broken glass will be
placed in a puncture-resistant container and disposed of as biohazardous waste.
5) Teeth or bone fragments extracted during surgery that are to be disposed of will be considered as sharps
and handled as such. Disposal of such teeth or bone fragments will be into a sharps container. Larger
bone pieces will be handled in a manner to minimize accidental cutting and will be placed in a biohazard
box lined with a red bag.

G) SPECIMEN HANDLING and TRANSPORT

A. Standard Precautions will be used to obtain, transport, and handle ALL specimens. It is not necessary to label
specimens as biohazardous. Packaging of specimens to be transported outside of the Medical Center will be
handled as described in "D" below.
B. Specimens of blood or other potentially infectious materials will be placed in a well sealed primary container
and a secondary plastic bag (ziplock) to prevent leakage during handling, processing, storage, transport or
shipping. During transport, gloves are not required because the specimen is already in a secondary plastic
bag.
Exception: Within each building, blood specimens in vacationer tubes may be transported in the
phlebotomist's tray without a secondary container, provided that the exterior of the tube is not visibly
contaminated with blood. If the exterior is visibly soiled, then it will be wiped clean.
C. Specimens in syringes should be capped off (needle removed) before transporting to the laboratory. The
exception to this is a fine-needle aspirate.
D. Specimen containers for transport or shipping outside of the immediate Medical Center will be labeled with
the universal biohazard symbol or color-coded prior to transport.

H) EQUIPMENT CLEANING, TRANSPORTING AND SERVICING

D. Used equipment will be enclosed in containers or bags to prevent in advertent exposure to patients or
personnel.
E. Equipment which is contaminated with body substances will be cleaned/decontaminated if possible prior
to transport. If this is not possible, place equipment in containers or bags and label.

1029
 F. If equipment cannot be cleaned/decontaminated, the receiving department or individual will be notified
of that contamination so that adequate precautions can be taken.

5) PROCEDURE FOR DEVELOPING A SAFE SYSTEM FOR PROFESSIONALS

1 Identify hazards from:

•Energy

- Electricity
- Steam or high pressure hot water
- Hydraulic systems
- Compressed springs (in cylinders, robots, etc.)

•Materials

- Corrosives
- Asphyxiant gases
- Flammables and explosives
- Toxic substances

• Plant

- Machinery
- Cranes and lifting equipment
- Internal transport

• Dangerous places

- Working at heights in confined spaces strange environment

2 Remove danger

- change process and/or materials.

3 Provide protection

- guardS
- personal protective equipment.

4 Develop sale system of work in writing

- use:
- locking off
- permit-to-work.
5 Provide suitable training.
6 Provide special equipment
- harnesses
- breathing apparatus/masks
1030
 - ear muffs/plugs
- safe working platforms.

7 Monitor that the system is being followed.

A useful mnemonic device is 'IRPSTEM':

I - Identify hazards

R - Remove dangers

P - Provide protection

S - Safe system of work

T - Training

E - Equipment

M - Monitor.

6) SAFETY IN HOSPITALS

Safety awareness is of paramount importance for the success of the hospital's safety programme Every
task that we perform, whether at the work place or home, entails some risk of personal in Our ability to work
safely is directly related to our knowledge of the hazards associated with Work. Therefore, a sufficient
knowledge of the work-related risks is essential.

Some departments of the hospital are more risk-prone and hazardous than others, laboratories, nursing
floors, laundry and kitchen are areas which call for special instructions elaborate safety rules. Ignorance about
the risks associated with the work place and negligence may endanger the lives of employees and turn them into
a liability for the hospital and i families.

It is rightly said that a feeling of safety is, like happiness, a state of mind. It is necessary for the
employees to incorporate this feeling into their work and lifestyle. For this they should develop a 'safe' attitude
and a 'safe' behaviour.

A) GENERAL SAFETY RULES IN HOSPITAL

The following are some of the basic safety rules and principles which everyone should bear in mind and
observe.

 The only correct way to do a job in the hospital is the safe way. Urgency is a poor excuse or neglecting
safety.
 Know your job thoroughly. Do not indulge in any guess. It there is any doubt, ask the supervisor.
 Do not handle or operate machinery, tools and equipment without authorization.
1031
 Be alert and observe keenly. Report immediately any faulty equipment, unsafe conditions or acts, and
defective or broken equipment. Do not try amateur repairs.
 Stay physically and emotionally fit for your work by maintaining good health and a proper diet. Abstain from
alcoholic drinks. Take sufficient rest and practise cleanliness.
 Personal hygiene is important. Wash your hands often. In many areas of the hospital, this is absolutely
necessary.
 Prevent the spread of infection and contagious diseases. Cooperate with the hospital infection control
committee by observing the established procedures. When you are ill with an infectious disease, report to the
doctor immediately and stay at home.
 Wear proper uniform or clothing for your job: neither too tight nor too loose. Tight clothing does not permit
freedom of movement, while loose one runs the risk of getting entangled. Jewellery and high heel footwear
may be hazardous.
 Walk, not run, particularly when you are carrying delicate, breakable articles or instruments. Be extra
cautious at the corridor intersections, in front of swinging doors (particularly when they do not have view
panels), at blind corners and in congested areas.
 If you see some foreign material, loose wire, oil spill, etc. on the floor which may cause an accident, make
sure it is removed at once.
 Never indulge in horseplay or practical jokes involving fire, acid, water, compressed air and other potentially
dangerous things.
 Pay attention to all warning boards. These signs caution you about dangers and hazards that may cause injury
or harm. For example, smoking in an area where oxygen cylinders are stored.
 Be familiar with your work procedure. All departments have written work procedures which include safety
practices at work and for handling equipment.
 Always remember to use handrails on stairways or ramps. They are there to ensure your safety and are meant
to be used by all, not just the sick and the old.

When you want to reach overhead objects, always use a good ladder. Do not climb on chairs or boxes.
Apart from these general safety rules, there are other rules relating to particular areas like fire

B) TECHNIQUES OF HAZARD IDENTIFICATION IN HOSPITAL

The identification of hazards before they cause an accident is central to all accident prevention activities.
However, hazard identification is not an exact science but a subjective activity where the measure of the hazard
identified will vary from person to person depending on their experiences, attitude to risks, familiarity with the
process, etc. By repeating, or employing a range of, identification techniques the number of residual hazards will
be reduced. It is doubtful if they will all ever be totally eliminated.

The findings of each inspection should be recorded so they can be referred to when deciding remedial
action needed and for comparison with previous inspections.

1032
 There are a number of identification techniques from which to select the one that is likely to be most
effective in a particular organization or which will provide the information required in respect of a particular
process. They include:

1) Safety surveys
• Sometimes called safety inspections.
• Entail a general inspection of the whole work area.
• Tend to be less detailed than other techniques.
• Do give an overall picture oi the state of accident prevention across the
particular work area.
2) Safety tours
• Inspection is restricted to a predetermined route.
• Need to plan subsequent routes to ensure complete coverage of work
area.
• Reduces the time taken by each inspection.
3) Safety sampling
• Looks at only one aspect of health or safety.
• Concentrates the mind and identifies more detail.

Need to plan a series of samplings to cover all aspect of health and safety.

4) Environmental checks
• Based on measurements of concentrations of chemicals in the atmosphere.
• Can identify possible health hazards faced in workplace.
• Recording of sequential readings can show improvements or otherwise.
• Checks by grab sampling' are not very accurate and can be expensive.
• Electronic instruments expensive to buy but give instantaneous
accurate reading.
• Electronic instruments can be used continuously over a long period.
5) Accident reports
• Post accident recording.
• Need to include minor as well as lost time injuries.
• Information obtained from accident report.
• Report should give indication of preventative action needed.
6) Near-miss reports
• Reports of incidents that in slightly different circumstances could have
caused an accident.
• Needs the right safety culture to be effective.
7) Feedback from employees
• Can be formally through a safety committee or informally to supervisor.
• Needs a no-blame culture to encourage employees to report matters.
• Employees often know and say what needs to be done.
• Needs feedback on action taken to retain management credibility.

7) SAFETY INSPECTIONS FOR HOSPITAL AND EDUCATIONAL INSTITUTION

a) Welfare facilities:

1033
  Canteen
 Toilets
 First aid
 Smoking arrangements.
b) Fire precautions
 Extinguishers
 Escape routes
 Alarms and fire drills
 Non-smoking areas
c) Machinery
 Guarding
 Following agreed system of work
 State of machinery
 Reports of statutory examinations
 Compliance with legislative requirements
d) Working conditions:
 Temperature
 Lighting
 Cleanliness and housekeeping
 Fumes and dusts
 General decoration
e) Access and gangways:
 Well marked
 Not encroached on
 Surface condition
 Adequately lit.

8) SAFETY ASSESSMENT FOR PUBLIC

 Identify hazards and remove them or take appropriate precautions.
 Monitoring safety standards
 Safety inspections and surveys that are general in nature and cover
whole workplace
 Safety tours that follow a predetermined route and note safety items
 Safety audits comprising detailed examination and quantification of safety items
 Safety sampling that looks only at one specific aspect of health or safety.
 Communicating the safety message by:
 News sheet
 Tool box talks
 Personal example.
 Using safer processes or materials.
 Including health and safety as inherent part of skill training.
 Keeping all plant well maintained
 Planned maintenance.
 Developing and using safe systems of work.
 Ensuring supervisors are trained and competent in health and safety matters.
1034
  Practice of emergency drills and procedures.
 Providing good working conditions and environment.

9) ALARM SYSTEM IN HOSPITALS

A hospital, more than any other institution, is exposed to emergencies and life threatening situation from
medical emergencies like cardiac arrest, accidents, casualties and disasters to dangers arising from fire and bomb
threat. It has to be all the more alert to these situations because nowhere e are such a large number of helpless
people concentrated in one place and are so utterly depends on other people for their safety and health.

Built-in safeguards and preparedness are the essence of all safety programmes. The alarm system is one
such programme. We discuss here some of the alarms that hospitals should have.

a) Fire Alarm

Every hospital must have a fire alarm system which should be a part of the hospital's electrical system.
Wherever possible, it should be designed to transmit an alarm signal directly to the telephone operator so that she
can contact the fire department and notify the hospital person without any loss of time. The fire alarm system can
be automatic or it can be operated manually

Smoke and fire detection devices are installed in the patient rooms and other high risk areas the heating and
ventilating ducts between the floors. These actuate the fire alarm system. on activation, the system sounds
audible alarms throughout the premises or zones, including distinct visual and audible alarm signals at the
respective nurses' station. To indicate the location of fire there is an indicator light outside every patient room.
This is activated when there is a fire in the room.

In the automatic system, smoke detectors not only actuate the fire alarm signals, but also close smoke doors
and simultaneously shut off fans in the central air handling system. If the fire ala system is not automatic, then
anyone noticing or hearing the fire signal should immediately info the telephone operator who, in turn, will call
the fire department and notify the hospital personnel

b) Medical Gas Alarm

In the centralized medical gas system, oxygen and nitrous oxide which are stored in bulk in manifold
room are distributed to other areas of the hospital such as the operating rooms, ICUs s patient rooms through
pipelines. Compressed air and vacuum (suction) are also supplied through pipes to certain areas.

Two kinds of alarm are incorporated into the medical gas system. One monitors the pressure of various
gases at different areas of the distribution system. If abnormal pressure is sensed, the system sets of an alarm-the
normal green signal goes off and the red warning signal glows with audible alarm until the line pressure returns
to normal. The second alarm is called the remote signal lamp which is generally only visible. The lamp lights up
when either of the banks of cylinders becomes empty.

1035
 The remote signal lamp is only a warning signal. No immediate action is necessary because when one
bank is empty, the other takes over and supplies the gas without interruption.

The alarm should be located in the medical gas user areas such as the operating rooms and patient floors
as well as the main working area where medical gas system is maintained. However, these areas, especially the
maintenance area, may not be manned all the time. Secondary signals should therefore be installed in places like
the telephone operators' room, security office and the like where a 24-hour attendance is assured.

C) Blood Bank Alarm

Most hospitals use specially crafted refrigerators-a cold room or walk-in cooler is ideal - to store whole
blood in the blood bank. These refrigerators are set to a particular temperature to maintain blood in good
condition and are provided with an alarm. The alarm which is both audible and visual goes off whenever it
senses high temperature or a drop in voltage. If the blood bank or the laboratory of which it is a part is not
manned round the clock, the alarm signals should be located both in the blood bank and in a place having 24-
hour attendance like the telephone operators' room or the security office

D) Narcotics Alarm

Narcotics are stored in locked cabinets in the nurses' stations as well as the pharmacy. These are
restricted drugs which are constantly stolen by persons addicted to them. Some hospitals install a signal system
that illuminates a light bulb which is visible from the nurses' station and the corridors whenever the narcotics
cabinet door is opened.

E) Cold Room and Walk-in Cooler Alarm

Many hospitals have walk-in cold rooms or coolers in their food service department and laboratory.
There have been instances of the staff of the food service department getting accidentally (or even deliberately)
locked up overnight inside the walk-in coolers. There should be an alarm button that can be used in such an
emergency with a distinguishable audible and visual alarm indicator in a prominent area where there is a 24-
hour personnel coverage.

F) Voltage Fluctuation Alarm

In any hospital where crores of rupees worth of sensitive and expensive equipment is used, stabilize
voltage is essential. Motors are usually designed to withstand only a 10 per cent fluctuation in voltage supply.
Beyond this limit, the motor will get damaged unless it is disconnected.

Low voltage poses the biggest threat to electrical system and equipment. Diagnostic equipment often
gives erroneous readings in low voltage conditions. There are certain areas and sensitive equipment that do not
tolerate excessive low or high voltage. Such areas or equipment may be fitted with a simple voltage-sensitive
alarm along with a voltmeter. The alarm can be set at any desired point.

G) Elevator Alarm

1036
 Many hospitals have more than one passenger and bed-cum-passenger elevators which are i: continuous
operation. Whenever there is an electric power failure, elevators with their passenger get stranded, often in
between the floors. In order to rescue the stranded passengers, a panic o emergency push button is provided in
each elevator. When it is pressed, a battery operated alarm installed in the electric room or the security room
which is manned round the clock is actuated to alert people about the rescue operation. Elevator operators or
maintenance crew then manually wind down the elevator car from the machine room to the next lower floor to
rescue the stranded passengers.

Modern elevators have an optional levelling feature which automatically takes the elevator ca to the next
floor level in case of power failure.

H) Security Alarm

Certain sensitive areas of the hospital like the cashier's office, the psychiatric ward, bank extension
counter and pharmacy which are prone to theft and burglary or where patients suddenly become violent need to
summon immediate help from the security personnel. Some hospitals provide alarm systems in these areas. The
alarm may be of two kinds. One is an automatic alarm like the one used in strong rooms of banks or jewellery
shops, which goes off when someone tries to break in. The other is similar to the one used by bank tellers. The
device is activated by the employee to summon security or police help.

I) Patient Emergency Alarm

Various new features are now available that can be incorporated into the conventional nurse cal system to
meet emergency situations in the patient rooms. If the nurse does not respond to the patient's call immediately,
the system makes the light outside the patient's room and on the nurse call panel in the nurses' station go
blinking. If there is still no response, the blinking of lights and the bleeping signals from the beeper \on the panel
gradually keep on increasing in frequency.

An additional feature that can also be fitted into the nurse call system is the panic button in the patient
toilet which the patient can activate by a pull cord in case of an emergency.

J) Code Blue Alarm

Code blue is a term used in hospitals to announce or signal an emergency of a serious nature such as a
cardiac arrest. In some hospitals, in all patient rooms and other strategic locations, there are independent
buttons — not a part of the nurse call system — named Code Blue which when activated emit distinguishable
emergency alarm signals both at the nurses' station and at the telephone operator's room. While the nurse
attends to the patient instantly, the telephone operator goes on the public address system announcing code blue
three times giving the location of the emergency. In such hospitals there is a written procedure to deal with such
situations and a pre-appointed code blue team which responds to the call instantly. The members of the team
are trained to deal with medical emergencies including cardiac arrest.

To avoid panic among patients and visitors, emergencies in hospitals are announced using codes: code
blue for cardiac arrest, code (doctor) red for fire, code black for bomb threat, code white for security emergency,
doctor major for disaster and code green for all clear

1037
10) NURSE MANAGER ROLES IN THE SAFETY MEASURES

Within an organization the health and safety role played varies according to the person's position within
the hierarchical structure. Thus:

• Managing director

- sets the tone for the organization by his attitude, commitment and involvement
- controls resources and ensures that facilities are available for achieving the safety policy aims
- makes resources available for health and safety matters and ensures they are used effectively

• Production manager

- responsible for organizing the work and ensuring it is carried out

safelyconsults with the employees on health and safety matters
- agrees safety rules and practices
- ensures those safety rules are followed
- provides the means (labour, materials and finance) to achieve and
maintain a safe workplace
- chairs the safety committee

• Safety adviser

- advises managers on all matters of health and safety

- organizes safety committee meetings but does not take the minutes
- acts as contact with outside safety organizations such as HSE, RoSPA,
BSC, local safety groups

• Foreman/chargeman

- front-line manager
- checks that safety rules are being followed
- ensures machinery and equipment are safe to use
- initiates discipline for breaches of safety rules
- initiates requests for safety work

• Safety representative

- represents employees on safety matters

- carries out inspections and investigations with the agreement of the
manager
- ensures employees follow the safety rules

Safety committee

- considers reports from the manager and safety adviser on safety comments on safety
standards and- practices and makes recommendations for improvements
- keeps employees informed oil safety matters

1038
The company safety organization and performance should reflect the. organization and performance elsewhere in
the company, especially where BS EN ISO 9001 registration exists.

Safety organizations

The Institution of Occupational Safety and Health (IOSH)

- the recognized professional body

- sets professional standards for practising safety advisers
- represents the interests of the safety practitioner

• The National Examination Board in Occupational Safety and Health (NEBOSH)

- the recognized examining body for occupational health and safety subjects
- independent and self-financing

• The Royal Society for the Prevention of Accidents (RoSPA)

- largest UK safety organization

- covers safety in all work and leisure activities
- provides training and- safety advice
- organizes major safety exhibitions

• British Safety Council (BSC)

- independent safety organization

- provides training and safety advice
- has strong safety lobby

• British Standards Institution

- not strictly a safety organization but many of its standards contain

safety requirements

• Industry safety bodies

- organized within and by particular industries

- often in co-operation with the HSE through Industry Advisory
Committees
- Set standards particular to their industries
- Voluntary and rely on employers to implement the standards.

Promoting health and safety in the workplace

There are a number of techniques that can be employed to improve and promote effective levels of health
and safety in the workplace that complement legislative requirements and are good industrial and commercial
practice. They aim to increase awareness of the need for high standards of health and safety at work.

Typical techniques include:

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• Evaluation of safety knowledge

- Complete Health and Safety Evaluation (CHASE)

International Safety Rating System (ISRS).

11) HAZARDS IN NURSING PROFESSION

Accident hazards

 Slips, trips, and falls on wet floors, especially during emergency situations.
 Stabs and cuts from sharp objects, especially needle-sticks and cuts by blades.
 Burns and scalds from contact with hot sterilizing equipment or hot water and steam pipes.
 Electrical shock from faulty or improperly grounded equipment, or equipment with faulty insulation.
 Injuries to legs and toes caused by falling objects, e.g., medical instruments.
 Acute back pain resulting from awkward body position or overexertion when handling heavy patients.
 Acute poisoning due to accidental release of a chemical agent.

Physical hazards

 Exposure to radiation from x-ray and radioisotope sources.

 Exposure to laser radiation.

Chemical hazards

 Exposure to chemicals during an accident (contact with scattered or spilled chemicals, leaking agents,
and unidentified chemicals).
 Danger of poisoning due to exposure to vapors or gases released during mixing of unidentified
substances (e.g., strong acids or oxidizers with organic compounds).
 Danger of exposure to anesthetic gases (ethyl bromide, ethyl chloride, ethyl ether, halothane, nitrous
oxide, etc.).
 Skin defatting, irritation, and dermatoses because of frequent use of soaps, detergents, disinfectants, etc.
 Irritation of the eyes, nose, and throat because of exposure to airborne aerosols or contact with droplets of
washing or cleaning liquids.
 Chronic poisoning because of long-term exposure to medications, sterilizing fluids (e.g.,glutaraldehyde),
anesthetic gases, etc.
 Latex allergy caused by exposure to natural latex gloves and other latex-containing medical devices.

Biological hazards

 Risk of contracting a communicable disease from the patients.

 Infections due to the exposure to blood, body fluids or tissue specimens possibly leading to blood-borne
diseases such as HIV, Hepatitis B and Hepatitis C.

Ergonomic, psychosocial and organizational factors

 Fatigue and lower back pain due to the handling of heavy patients and to long periods of work in a
standing posture.

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  Stress, strained family relations, and burnout due to shift and night work, overtime work, and contact
with sick patients, especially accident victims and their relatives.
 Because a general nurse is called to handle problems that can't be solved by other ward workers, the
stress caused by work in emergency situations may be enhanced by frequent exposure.
 Exposure to severely traumatized patients, multiple victims of a disaster or catastrophic event or severely
violent patients may lead to post-traumatic stress syndrome.

12) PREVENTIVE MEASURES

 Wear shoes designed for nurses, with non-slip soles.
 Handle sharp objects with extreme care; use special safety receptacles to store used hypodermic needles
until disposal.
 Use safety needles, if available.
 Install ground fault circuit interrupters; call a qualified electrician to test and repair faulty or suspect
equipment.
 Comply with all safety instructions on the installation and periodic inspection of electrical medical
equipment.
 Keep all passages clearly visible and uncluttered.
 Wear a radiation dosimeter (badge or other) when exposed to radiation; comply with all safety
instructions to reduce exposure to a minimum.
 Install air conditioning with effective general ventilation in the ward rooms to reduce heat stress and
remove odors, gases, and vapors.
 Provide eye wash bottles or fountains.
 Nurses sensitive to natural rubber latex must use powder-free latex or non-latex gloves and avoid contact
with other latex products.
 Follow established appropriate infection control precautions assuming blood, body fluids and tissue are
infectious
 Routinely use barriers (such as gloves, eye protection (goggles or face shields) and gowns)
 Wash hands and other exposed skin surfaces after coming into contact with blood or body fluids
 Follow appropriate procedures in handling and disposing of sharp instruments or needles
 Provide lifting aids for the lifting and transport of heavy patients; consult an occupational safety
specialist on the safe handling of heavy patients.
 Procedures and counselling services should be available to workers exposed to post-traumatic stress
syndrome

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