A_Text_book_on_Nursing_Management_Accord.pdf

PADMASHREE INSTITUTE OF NURSING. M.Sc. Nursing II years (2009-2011 batch)
PREPARED BY: ANOOP, CHETAN, DEEPAK, LINGARAJ, SARATH CHANDRAN, MITHUN
A Text book on
Nursing
Management
(According to Indian Nursing Council Syllabus)
AUTHORS :
Mr. Anoop.N
Mr. Chetan Kumar.M.R
Mr. Deepak.K
Mr. Lingaraju.C.M
Mr. Mithun Kumar.B.P
Mr. Sarath Chandran.C

Dedicated to all
M.Sc. Nursing
students
From:
M.Sc. (Nursing) II year
Batch: 2009-2011
PADMASHREE INSTITUTE
OF NURSING

Forward
It gives me an immense happiness to forward this Text Book of Nursing Management
written by budding authors Mr.Annop, Mr. Chetan.M.R, Mr. Deepak.K, Mr. Sarath
Chandran, Mr.Mithun Kumar, Mr.Lingaraj.C.M, studying in Padmashree Institute of
Nursing, Bangalore, Karnataka.
This book is designed according to INC syllabus of M.Sc. Nursing. Each unit is described in
detailed according to the updated with recent and advanced information on nursing
management and administration. All the authors struggled a lot tirelessly round the clock
for the birth of this successful text book.
It is not an easy task to deliver such excellent knowledge information on nursing
management topics. It is the effort, dedication and commitment of Mr.Deepak.K who was
the backbone, pillars and implanted the seed to initiate, organized arrange systematically
the flow contents of Mr.Anoop, Mr. Chetan Kumar. C.M, Mr.Sarath Chandran,
Mr.Mithun Kumar, Mr.Lingaraj.C.M has joined their efforts with Mr.Deepak.K in
delievering the sweet essence on the units they selected and written in simple language.
I hope this book will be benefitted to Postgraduate nursing students to develop
understanding and apply the nursing management services in clinical setting and
educational institution too.
I am sure that this book will be widely used and will make a worthy contribution to the
nursing profession. I wish all the best for the authors for such a contribution in the field of
nursing management.
Mr. Ellakuvana Bhaskara Raj.D
Associate Professor
HOD of Psychiatric Nursing Department
Padmashree Institute of Nursing
Kommagatta village, Bangalore-60

Acknowledgement
Service to mankind is service to GOD. We believe in invisible power which guided us
throughout our success.
Thandhe, Tayee, Guru, Devaru. We are very much indebted to our lovable parents for
their continuous guidance, support and encouragement for accomplishment of our dream,
the release of this text book.
Guide us when we are in need, we extremely thankful to Asso. Prof. Ellakuvana Bhaskara
Raj.D, for his encouragement, timely guidance, constant advice and support for successful
completion of this book.
We also thank all PG faculties of Padmashree Institute of Nursing who guided, supported
in all our endeavors.
An evergreen unforgettable memory is friendship. We express our deep sense of gratitude
and heartfelt thanks to all my classmates who are the main inspiration behind this book.

UNIT I:
Introduction
 Philosophy, purpose, elements, principles and scope of
Administration
 Indian Constitution, Indian Administrative system vis a
vis health care delivery system: National, State and Local
 Organization and functions of nursing services and
education at National, State , District and institutions:
Hospital and Community
 Planning process: Five year plans, Various Committee
Reports on health, State and National Health policies,
national population policy, national policy on AYUSH and
plans,

UNIT I: INTRODUCTION:
―Administer‖ derived from the Latin word ―ad + ministraire‖, - to care for or to look after
people to manage affairs. Administration is the activities of groups co-operating to accomplish
common goals. -Herbert A Simon
Administration may be defined as the management of affairs with the use of well thought out
principles and practices and rationalized techniques to achieve certain objectives. - Goel
DEFINITION:
ADMINISTRATION:
―Administration is the organization and direction of human and material resources to achieve
desired ends‖ - Pfiffner and presthus
Administration has to do with getting things done; with the accomplishment of defined
objectives. - Luther Gullick
MANAGEMENT:
• Management may be defined as the art of securing maximum results with a minimum of
effort so as to secure maximum prosperity and happiness for both employer and
employee and give the public the best possible service. - John Mee
• Management is distinct process consisting of planning, organising, actuating, activating
and controlling, performed to determine and accomplish the objectives by the use of
people and resources. - George
Management and Administration:
These two words are slightly similar and can employ interchangeable.
 Management‘ refers to private sector. Whereas administration refers to public sector‖.
 Management or Administration is the process for exceeding the goal expected."
- Derek French and Heather Saward.

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

Managerial levels
Who are Managers?
Someone who coordinates and overseas the work of other people so that organizational goals are
accomplished.
First-line Managers
Individuals who manage the work of non-managerial employees.
Middle Managers
Individuals who manage the work of first-line managers.
Top Managers
Individuals who are responsible for making organization-wide decisions and establishing plans
and goals that affect the entire organization.
Functions:
• Planning - Defining goals, establishing strategies to achieve goals, developing plans to
integrate and coordinate activities.
• Organizing - Arranging and structuring work to accomplish organizational goals.
• Leading - Working with and through people to accomplish goals.
• Controlling - Monitoring, comparing, and correcting work.

Role:
• Interpersonal roles - Figurehead, leader, liaison
• Informational roles - Monitor, disseminator, Spokesperson
• Decisional roles - Entrepreneur, Disturbance handler, resource allocator, negotiator
Skills:
• Technical skills - Knowledge and proficiency in a specific field
• Human skills - The ability to work well with other people
• Conceptual skills - The ability to think and conceptualize about abstract and complex
situations concerning the organization
Skills Needed at Different Management Levels
Importance of management:
The Value of Studying Management:
 The universality of management
 Good management is needed in all organizations.
 The reality of work
 Employees either manage or are managed.
 Rewards and challenges of being a manager
 Management offers challenging, exciting and creative opportunities for meaningful and
fulfilling work.
 Successful managers receive significant monetary rewards for their efforts.

Universal Need for Management

PHILOSOPHIES OF ADMINISTRATION
Philosophy is based on the following key points: Administration believes in:
• Cost effectiveness
• Execution and control of work plans
• Delegation of responsibility
• Human relations and good morale
• Effective communication
• Flexibility in certain situation
PRINCIPLES OF ADMINISTRATION
Meaning of management principles: Management principles are statements of fundamental truth
which act as guidelines for taking managerial action.
Management principles are derived and developed in the following two steps.
(a) Deep Observations
(b) Repeated experiments
Henri Fayol (1841 - 1925): Graduated from the National School of Mines in Saint Etrenne in
1860
Fayol‟s 14 principles of management
1. Division of Work. Specialization allows the individual to build up experience, and to
continuously improve his skills. Thereby he can be more productive. Small task, Competent,
Specialization, Efficiency, Effectiveness
2. Principle of Authority and Responsibility Authority means power to take decisions.
Responsibility means obligation to complete the job assigned
3. Principle of discipline: General rules and regulations for systematic working in an
organization.
4. Principle of unity of command: Employee should receive orders from one boss only.

5. Unity of direction: All the efforts of the members and employees of the organization must be
directed to one direction that is the achievement of common goal.
6. Subordination of individual interest to general interest: Subordination of individual
interest to general interest the interest of the organization must supersede the interest of the
individuals.
7. Principle of remuneration of persons: Employees must be paid fairly or adequately to give
them maximum satisfaction
8. Principle of centralization and decentralization: Centralization refers to concentration of
power in few hands. Decentralization means evenly distribution of power at every level.
9. Principle of scalar chain: Means line of authority or chain of superiors from highest to
lowest rank
10. Principle of Order: Principle of Order It refers to orderly arrangement of men and material
a fixed place for everything and everyone in the organization
11. Principle of Equity: Principle of Equity Fair and just treatment to employees.
12. Stability of tenure of personnel: Stability of tenure of personnel No frequent termination or
transfer.
13. Principle of Initiative: Principle of Initiative Employees must be given opportunity to take
some initiative in making and executing a plan
14. Principle of Esprit De Corps: Principle of Esprit De Corps Means union is strength.
PRINCIPLES OF ADMINISTRATION

Fayol's definition of management roles and actions distinguishes between Five Elements:
Five Elements: management roles and actions
• Prevoyance. (Forecast & Plan)- Examining the future and drawing up a plan of action.
The elements of strategy.
• To organize - Build up the structure, both material and human, of the undertaking.
• To command - Maintain the activity among the personnel.
• To coordinate - Binding together, unifying and harmonizing all activity and effort.
• To control -Seeing that everything occurs in conformity with established rule and
expressed command.
ELEMENTS OF ADMINISTRATION:
POSDCORB”
• Planning
• Organizing
• Staffing
• Directing
• Co-ordinating
• Reporting
• Budgeting
SCOPE OF ADMINISTRATION
 Political: Functions of the administration includes the executive –legislative relationship.
 Defensive: It covers the hospital protective functions.

 Economic: Concerns with the vast area of the health care activities.
 Educational: Its involves educational administration in its broadest senses.
 Legislative: It includes most not mealy delegated legislation, but the preparatory work
done by the administrative officials.
 Financial: It includes the whole of financial, budget, inventory control managements.
 Social: It includes the activities of the department s concerned with food, social factors.
 Local: It concerned with the activities of the local bodies.
INDIAN CONSTITUTION
Introduction
The majority of the Indian subcontinent was under British colonial rule from 1858 to
1947. This period saw the gradual rise of the Indian nationalist movement to gain independence
from the foreign rule. The movement culminated in the formation of the on 15 August 1947,
along with the Dominion of Pakistan. The constitution of India was adopted on 26 January 1950,
which proclaimed India to be a sovereign democratic republic.
Evolution of the Constitution
Acts of British Parliament before 1935
After the Indian Rebellion of 1857, the British Parliament took over the reign of India
from the British East India Company, and British India came under the direct rule of the Crown.
The British Parliament passed the Government of India Act of 1858 to this effect, which set up
the structure of British government in India.
Government of India Act 1935
The provisions of the Government of India Act of 1935, though never implemented fully,
had a great impact on the constitution of India. The federal structure of government, provincial
autonomy, bicameral legislature consisting of a federal assembly and a Council of States,
separation of legislative powers between center and provinces are some of the provisions of the
Act which are present in the Indian constitution.
The Cabinet Mission Plan
In 1946, at the initiative of British Prime Minister Clement Attlee, a cabinet mission to
India was formulated to discuss and finalize plans for the transfer of power from the British Raj
to Indian leadership and providing India with independence under Dominion status in the
Commonwealth of Nations. The Mission discussed the framework of the constitution and laid

down in some detail the procedure to be followed by the constitution drafting body. Elections for
the 296 seats assigned to the British Indian provinces were completed by August 1946. The
Constituent Assembly first met and began work on 9 December 1946.
Indian Independence Act 1947
The Indian Independence Act, which came into force on 18 July 1947, divided the British
Indian territory into two new states of India and Pakistan, which were to be dominions under the
Commonwealth of Nations until their constitutions were in effect.
Constituent Assembly
The Constitution was drafted by the Constituent Assembly, which was elected by the
elected members of the provincial assemblies. Jawaharlal Nehru, C. Rajagopalachari, Rajendra
Prasad, SardarVallabhbhai Patel, MaulanaAbulKalam Azad, Shyama Prasad Mukherjee and
NaliniRanjanGhosh were some important figures in the Assembly.
In the 14 August 1947 meeting of the Assembly, a proposal for forming various
committees was presented. Such committees included a Committee on Fundamental Rights, the
Union Powers Committee and Union Constitution Committee. On 29 August 1947, the Drafting
Committee was appointed, with DrAmbedkar as the Chairman along with six other members. A
Draft Constitution was prepared by the committee and submitted to the Assembly on 4
November 1947.
Parts
Parts are the individual chapters in the Constitution, focused in single broad field of laws,
containing articles that address the issues in question.
Preamble
 Part I - Union and its Territory
 Part II - Citizenship.
 Part III- Fundamental Rights
 Part IV - Directive Principles and
Fundamental Duties.
 Part V- The Union.
 Part VI- The States.
 Part XII - Finance, Property, Contracts and
Suits
 Part XIII - Trade and Commerce within the
territory of India
 Part XIV - Services Under the Union, the
States and Tribunals
 Part XV - Elections
 Part XVI - Special Provisions Relating to
certain Classes.

 Part VII - States in the B part of
the First schedule (Repealed).
 Part VIII - The Union Territories
 Part IX - Panchayat system and
Municipalities.
 Part X - The scheduled and Tribal
Areas
 Part XI - Relations between the
Union and the States.
 Part XVII - Languages
 Part XVIII - Emergency Provisions
 Part XIX - Miscellaneous
 Part XX - Amendment of the Constitution
 Part XXI - Temporary, Transitional and
Special Provisions
 Part XXII - Short title, date of
commencement, Authoritative text in Hindi
and Repeals
Federal Structure
The constitution provides for distribution of powers between the Union and the States.
It enumerates the powers of the Parliament and State Legislatures in three lists, namely Union
list, State list and Concurrent list. Subjects like national defense, foreign policy, issuance of
currency are reserved to the Union list. Public order, local governments, certain taxes are
examples of subjects of the State List, on which the Parliament has no power to enact laws in
those regards, barring exceptional conditions. Education, transportation, criminal laws are a few
subjects of the Concurrent list, where both the State Legislature as well as the Parliament has
powers to enact laws.
Changing the constitution
In 2000 the National Commission to Review the Working of the Constitution (NCRWC) was
setup to look into updating the constitution of India.
Judicial review of laws
This section requires expansion.
Judicial review is actually adopted in the Indian constitution from the constitution of the United
States of America. In the Indian constitution, Judicial Review is dealt under Article 13. Judicial
Review actually refers that the Constitution is the supreme power of the nation and all laws are
under its supremacy. Article 13 deals that
1. All pre-constitutional laws, after the coming into force of constitution, if in conflict with it in
all or some of its provisions then the provisions of constitution will prevail. If it is compatible
with the constitution as amended. This is called the Theory of Eclipse.

2. In a similar manner, laws made after adoption of the Constitution by the Constituent Assembly
must be compatible with the constitution, otherwise the laws and amendments will be deemed to
be void-ab-initio.
In such situations, the Supreme Court or High Court interprets the laws as if they are in
conformity with the constitution.
HEALTH CARE DELIVERY SYSTEM IN INDIA
Introduction
Health is the birth right of every individual. Today health is considered more than a basic
human right; it has become a matter of public concern, national priority and political action. Our
health system has traditionally been a disease-oriented system but the current trend is to
emphasize health and its promotion.
Selected health care definitions:
 Health: According to WHO, health is defined as ―a dynamic state of complete physical,
mental and social well-being not merely an absence of disease or infirmity.‖
 Health care services: It is defined as ―multitude of services rendered to individuals,
families or communities by the agents of the health services or professions for the
purpose of promoting, maintaining, monitoring or restoring health.‖
Definitions of health care delivery:
1. Health care delivery system refers to the totality of resources that a population or
society distributes in the organization and delivery of health population services. It
also includes all personal and public services performed by individuals or institutions
for the purpose of maintaining or restoring health. -Stanhope(2001)
2. It implies the organization, delivery staffing regulation and quality control.
J.C.Pak(2001)
Philosophy of Health Care Delivery System:
 Everyone from birth to death is part of the market potential for health care services.
 The consumer of health care services is a client and not customer.
 Consumers are less informed about health services than anything else they purchase.
 Health care system is unique because it is not a competitive market.

 Restricted entry in to the health care system.
Goals/Objectives of Health Care Delivery System:
1) To improve the health status of population and the clinical outcomes of care.
2) To improve the experience of care of patients families and communities.
3) To reduce the total economic burden of care and illness.
4) To improve social justice equity in the health status of the population.
Principles of Health Care Delivery System:
1. Supports a coordinated, cohesive health-care delivery system.
2. Opposes the concept that fee-for-practice.
3. Supports the concept of prepaid group practice.
4. Supports the establishment of community based, community controlled health-care
system.
5. Urges an emphasis be placed on development of primary care
6. Emphasizes on quality assurance of the care
7. Supports health care as basic human right for all people.
8. Opposes the accrual of profits by health-care-related industries.
Functions of Health Care Delivery System:
1) To provide health services.
2) To raise and pool the resources accessible to pay for health care.
3) To generate human and physical sources that makes the delivery service possible.
4) To set and enforce rules of the game and provide strategic direction for all the different
players involved.
Characters of Health Care Delivery System:
1) Orientation toward health.
2) Population perspective.
3) Intensive use of information.
4) Focus on consumer.
5) Knowledge of treatment outcome.
6) Constrained resources.

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

ORGANIZATION AND ADMINISTRATION OF HEALTH SERVICES IN INDIA AT
DIFFERENT LEVELS.
India is a union of 28 states and 7 Union territories. Under the constitution states are
largely independent in matters relating to the delivery of health care to the people. Each State,
therefore, as developed its own system of health care delivery, independent of the Central
Government.
Health system in India has 3 links
1. Central level. 2. State level 3. District level
Synoptic view of the health system in India
1/80,000 – 1,20,000
1/30,000
1/3,000 – 5,000
1/1,000
Community Health
Centres
Sub-district/Taluka
hospital
PHC
Sub-centres
Health worker (M & F)
Village health
guide, trained dai
District health organisation and basic
specialities hospital/districts
States (28) an Union Territories (7)
Ministry of Health and Directorate of Health
National Level
Ministry of Health and Family Welfare
People in the
population

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

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

Ministry of Health and Family Welfare
3. The department of Indian system of medicine and homeopathy
It was established in March 1995 and had continued to make steady progress. Emphasis
was on implementation of the various schemes introduced such as education, standardization of
drugs, enhancement of availability of raw materials, research and development, information,
education and communication and involvement of ISM and Homeopathy in national health care.
Most of the functions of this ministry are implemented through an autonomous
organization called DGHS.
Minister of State
Deputy Ministers
Dept. of Family Welfare
Dept. of Health Dept. of Indian
System of Medicine
and Homoeopathy
Secretary
JS
(ISM)
Director
Ayurveda & Sidha
Secretary
Secretary health
Additional Secretary
Joint Secretaries (9)
Director General of
Health Services
Addl. Director Generals (4)
Chief Director
(1)
Cabinet Minister
Joint Secretary
(3)

II. Directorate General of Health Services
Organisation
The DGHS is the principal adviser to the Union Government in both medical and public
health matters. He is assisted by a team of deputies and a large administrative staff. The
Directorate comprises of three main units:
i. Medical care and hospitals
ii. Public health
iii. General administration
Functions
1. General functions: The general functions are surveys, planning, coordination,
programming and appraisal of all health matters in the country.
2. Specific functions
a. International health relations and quarantine:
b. Control of drug standards
c. Medical store depots
d. Postgraduate training
e. Medical education
f. Medical research
g. Central Government Health Scheme.
Family welfare services
h. National Health Programmes.
i. Central Health Education Bureau
j. Health intelligence.
k. National Medical Library
III. Central Council of Health
The Central Council of Health was set up by a Presidential Order on August 9, 1952,
under Article 263 of the Constitution of India for promoting coordinated and concerted action
between the centre and the states in the implementation of all the programmes and measures
pertaining to the health of the nation. The Union Health Minister is the chairman and the state
health ministers are the members.

Functions
1. To consider and recommend broad outlines of policy in regard to matters concerning
health in all its aspects such as the provision of remedial and preventive care,
environmental hygiene, nutrition, health education and the promotion of facilities for
training and research.
2. To make proposals for legislation in fields of activity related to medical and public health
matters and to lay down the pattern of development for the country as a whole.
3. To make recommendations to the Central Government regarding distribution of available
grants-in-aid for health purposes to the states and to review periodically the work
accomplished in different areas through the utilisation of these grants-in-aid.
4. To establish any organisation or organisations invested with appropriate functions for
promoting and maintaining cooperation between the Central and State Health
administrations.
AT THE STATE LEVEL
Historically, the first milestone in the state health administration was the year 1919,
when the states (provinces) obtained autonomy, under the Montague-Chelmsford reforms, from
the central Government in matters of public health. By 1921-22, all the states had created some
form of public health organisation. The Government of India Act, 1935 gave further autonomy to
the states. The state is the ultimate authority responsible for health services operating within its
jurisdiction.
State health administration
At present there are 31 states in India, with each state having its own health
administration. In all the states, the management sector comprises the state ministry of Health
and a Directorate of Health.
1. State Ministry of Health
The State Ministry of Health is headed by a Minister of Health and FW and a Deputy
Minister of Health and FW. In some states, the Health Minister is also in charge of other
portfolios. The Health secretariat is the official organ of the State Ministry of Health and is
headed by a Secretary who is assisted by Deputy Secretaries, and a large administrative staff.

Organisational structure of the health and family welfare services at state level
Functions: Health services provided at the state level
 Rural health services through minimum needs programme
 Medical development programme
 M.C.H., family welfare & immunization programme
 NMIP (malaria) & NFCP(filarial)
 NLEP, NTCP, NPCB, prevention and control of communicable diseases like
diarrheal disease, KFD, JE,
 School health programme, nutrition programme, and national goitre control
programme
 Laboratory services and vaccine production units
Minister in charge of health and family welfare portfolio in the state
Secretary or commissioner, Department of Health and Family Welfare
Director
Health Services
Director
FW Services
Director
Medical education
& research
Director
ISM and
Homoeopathy
Additional/deputy
joint directors of
health services
dealing with one or
more programmes
Assistant Directors
health services
dealing with one or
more programmes
Principal/Deans of
medical colleges
Divisional set up in
some states
District health
organisation
Taluk Health
organisation
Block level health
organisation

 Health education and training programme, curative services, national Aids control
programme
2. State Health Directorate
The Director of Health Services is the chief technical adviser to the state Government on
all matters relating to medicine and public health. He is also responsible for the organization and
direction of all health activities. The Director of Health and Family Welfare is assisted by a
suitable number of deputies and assistants. The Deputy and Assistant Directors of Health may be
of two types –
Regional
Functional.
The regional directors inspect all the branches of public health within their jurisdiction,
irrespective of their specialty. The functional directors are usually specialists in a particular
branch of public health such as mother and child health, family planning, nutrition, tuberculosis,
leprosy, health education, etc.
AT THE DISTRICT LEVEL
The district is the most crucial level in the administration and implementation of medical /health
services. At the district level there is a district medical and health officer or CMO who is overall
Subdivisions
i. Tehsils (talukas)
ii. Community development blocks
iii. Municipalities and corporations
iv. Villages
v. Panchayaths
Most of the districts in India are divided into two or more subdivisions, each in charge of
an assistant collector or sub-collector. Each division is again divided into tehsils in charge of a
Tehsildar. A tehsil usually comprises between 200 and 600 villages.
Finally, there are the village panchayaths, which are institutions of rural local self-
government.
The urban areas of the district are organised into the following local self-government:
 Town area committee – 5,000 – 10,000
 Municipal boards – 10,000 – 2,00,000
 Corporations – population above 2,00,000.
The towns‟ area committees are like panchayaths. They provide sanitary services.

The municipal boards are headed by a chairman/president, elected usually by the
members.
Corporations are headed by mayors. The councilors are elected from different wards of
the city. The executive agency includes the commissioner, the secretary, the engineer, and the
health officer. The activities are similar to those of the municipalities but on a much wider scale.
Primary Healthcare Infrastructure of District Level
Sub-
Centre
T.B.A.
VHG
T.B.A.
VHG
T.B.A.
VHG
T.B.A.
VHG
T.B.A.
VHG
Primary
Health
Centre
Sub-
Centre
Sub-
Centre
Sub-
Centre
Sub-
Centre
Sub-
Centre
PHC
PHC
District Health and
Family Welfare
PHC
CEO
Zilla
parishad
Community
Health Centre
Covers 1,00,000 population
Covers
30,000
population
Covers
5,000
population
Covers
1,000
population

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

Healthcare systems
The healthcare system is intended to deliver the healthcare services. It constitutes the
management sector and involves the organisational matters. It operates in the context of the
socioeconomic and political framework of the country. In India, it is represented by five major
sectors and agencies which differ from each other by the health technology applied and by the
source of funds for the operation.
i. Public health sector
ii. Private sectors
District
Level
Zilla Panchayat
(ZP)
Taluka
Level
Taluka Panchayat
(TP)
Village
Level
Gram Panchayat
(GP)
Gram
Sabha
Direct election @ 1:40,000
(except Uttara Kannada, Coorg
and Chickmagalore where it is
1:30,000). 20 months‘ term for
Adhyakshas and Upadhyakshas
and 5 standing committees.
Direct election @ 1:10,000.
Voting rights to MPs, MLAs,
MLCs. One year membership to
1/5 of Gram Panchayat
Adhyakshas and 5 standing
committees.
Direct election @ 1:4,000. Ban on
political parties. 5 years term.3
standing committees.
Minimum of two meetings per
annum, under the chairmanship of
GP Adhyaksha, for approval of
Budget/accounts, review of
development programme

iii. Indigenous system of medicine
iv. Voluntary health agencies
v. National health programmes
Primary healthcare in India
It is a three-tier system of healthcare delivery in rural areas based on the
recommendations of the Shrivastav Committee in 1975.
1. Village level: The following schemes are operational at the village level:
a. Village health guides scheme
b. Training of local dais
c. ICDS scheme
2. Sub-centre level: This is the peripheral outpost of the existing health delivery system in
rural areas. They are being established on the basis of one sub-centre for every 5000
population in general and one for every 3000 population in hilly tribal and backward
areas. Each sub-centre is manned by one male and one female multipurpose health
worker.
Functions
a. Mother and child healthcare
b. Family planning
c. Immunization
d. IUD insertion
e. Simple laboratory investigations
3. Primary health centre level: The Bhore committee in 1946 gave the concept of a
primary health centre as a basic health unit to provide as close to the people as possible.
The Bhore committee aimed at having a health centre to serve a population of 10,000 to
20,000. The national health plan, 1983 proposed reorganization of primary health centres
on the basis of one PHC for every 30,000 rural population in the plains, and one PHC for
every 20,000 population in hilly, tribal and backward areas for more effective coverage.
Functions of the PHC
a. Medical care.
b. MCH including family planning.
c. Safe water supply and basic sanitation.
d. Prevention and control of locally endemic diseases.

e. Collection and reporting of vital statistics.
f. Education about health.
g. National health programmes as relevant.
h. Referral services.
i. Training of health guides, health workers, local dais, and health assistants.
j. Basic laboratory services.
Community health centres
As on 31st
March 2003, 3076 community health centres were established by upgrading
the primary health centres, each CHC covering a population of 80,000 to 1.20 lakh with 30 beds
and specialist in surgery, medicine, obstetrics and gynecology, and pediatrics‘ with x-ray and
laboratory facilities.
Functions
1. Care of routine and emergency cases in surgery.
2. Care of routine and emergency cases in medicine.
3. 24-hour delivery services including normal and assisted deliveries.
4. Essential and emergency obstetric cases including surgical interventions.
5. Full range of family planning services including laparoscopic services.
6. Safe abortion services.
7. Newborn care.
8. Routine and emergency care of sick children.
9. Other management including nasal packing, tracheostomy, foreign body removal, etc.
10. All national health programmes should be delivered.
11. Blood shortage facility.
12. Essential laboratory services.
13. Referral services.

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

Organisational structure of health department at district level
DISTRICT HEALTH AND FAMILY WELFARE OFFICER
Dy. CMO/
Medical
Officer (FW
& MCH)
Asst. District
Health &
Family
Welfare
Officer (HQ)
Asst. District
Health and
Family
Welfare
Officer (Sub-
division
level/Dy.
CMOs)
District
Malaria
Officer
Senior
Malaria
Officer
Senior
Medical
Superin
tendent
Medical officers of
Dt. General
Hospital and other
Govt. Hospitals
District
Leprosy
Officer
District
Health
Education
Officer/
Dmeio
Medical
Officer
(District
Lab.)
District
Tubercul
osis
Officer
(TB
Centre)
Gazetted
Assistant
District
Nursing
Supervisor
Medical Officers
of Primary
Health centres
(Coordinators at
PHC level)
Assistant
Statistical
Officer
Lady
Medical
Officers/
11 MO of
Primary
Health
Centres
Service
Engineer
(Mobile
Workshop)

Planning and organizing nursing service at various levels – local, regional, national, and
international
Placement of nurses in the healthcare organization
A high power committee on nursing and nursing profession was set up by the
Government of India in July 1987 under the chairmanship of Smt. Sarojini Vasadapan, an
eminent social worker and former chairperson of Central Social Welfare Board with Smt.
Rajkumari Sood, Nursing Advisor to Government of India, as the member secretary. The terms
of reference of the committee were as follows:
a. Looking into the existing working conditions of nurses with particular reference to the
status of the nursing care services both in rural and urban areas.
b. To study and recommend the staffing norms necessary for providing adequate nursing
personnel to give the best possible care, both in the hospitals and community.
c. To look into the training of all categories and levels of nursing, midwifery personnel to
meet the nursing manpower needs at all levels of health service and education.
d. To study and clarify the role of nursing personnel in the healthcare delivery system
including their interaction with other members of the health team at every level of health
services management.
e. To examine the need for organisation of the nursing services at the national, state,
district, and lower levels with particular reference to the need for planning and
implementing the comprehensive nursing care services with the overall healthcare system
of the country at their respective levels.
f. To look into all other aspects which the committee may consider relevant with reference
to their terms of reference.
g. While considering the various issues under the above norms of reference, the committee
will hold consultations with the state governments.
The findings of this committee give a grim picture of the existing working condition of
nurses, staffing norms for providing adequate nursing personnel, education of nursing personnel
to meet the nursing manpower needs at all levels and the role of nursing personnel in the
healthcare delivery system.
Their recommendations on the organisation of nursing services at central, state and
district levels, and the norms of nursing service and education are given below.
Placement of nurses at the central level
At the central level there is a post of nursing advisor in the medical division of
Directorate General of Health Services. The nursing advisor is directly responsible to the Deputy
Director General (Medical). The nursing advisor is assisted by nursing officer and support staff
for all his/her work. She/he advises the DGHS, Ministry of Health and Family Welfare as well as

other ministries and departments, for example, railways, labour, Delhi Administration, etc. on all
matters of nursing services, nursing education, and research. The nursing advisor also takes care
of administration aspects of Raj Kumari Amrit Kaur College of Nursing and Lady Hardinge
Health School, Delhi.
There is a post of deputy nursing advisor at the rank of Assistant Director General (ADG-
Nsg) in the training division of Department of F. W. Presently the deputy nursing advisor deals
with training of ANMs, dais, health supervisor, etc. There is no direct linkage between the
nursing advisor and deputy nursing advisor as there are independent posts.
Nursing organisational set up at the central level
DGHS
Additional DG (N) Additional DG (M)
Additional DG (PH)
DDG (N)
ADG (Nursing education
& research)
ADG (Hospital nursing
service)
ADG (Community
nursing service)
DADG DADG
DADG
Community &
nursing officer
PHN Supervisor
PHN
LHV
ANM
Principal tutor SON
Senior tutor
Tutor
Clinical instructors
Nursing superintendent
Deputy Nursing
superintendent
Assistant Nursing
superintendent
Ward sister
Staff nurse

Placement of nurses at state level
There is no proper and definite pattern of nursing structure in the state directorates except
the state of West Bengal. Usually one or two nurses are posted with varying designations, e.g., in
Tamilnadu there is one assistant director nursing who is responsible to Director, Medical
Services, and Director, Medical Education.
In Maharashtra, two nurses work, one each in the office of the Director, Medical
Education, and Director, Health Services.
Recommended organization at state level (union territory level)
Secretary (Health)
ADNS (Nursing
education & research)
ADNS (Hospital/
nursing service)
ADNS (Community
nursing)
DADNS Nursing Superintendent
District Nursing
Officer
Public health
nursing officer
PHN at PHC
LHV (HSV)
LHV
ANM
Principal SON
Senior tutor
Tutor
Clinical instructors
Deputy Nursing
superintendent
Assistant nursing
superintendent
Ward sister
Staff nurse
Director, Nursing Services
Joint/Deputy Director, Nursing Services
DADNS (Nursing
education & research)
DADNS (Nursing
service)
DADNS (Community
health nursing)

Note
The Principal, College of Nursing will be equal to the rank of ADNS and will be eligible
for promotion to the post of DDNS/DNS. The salary scales and structure of the staff of colleges
of nursing will be as per norms of the Indian Nursing Council and the UGC.
Placement of nurses at district level
Nurses, public health nurses, lady health visitors, auxiliary nurse midwives, etc. have
played vital role in providing healthcare services at various levels in both urban and rural areas
of the district. They have been the mainstream in providing primary healthcare services in the
rural and urban areas from the very beginning.
Director nursing
officer
DHO
DMO
Dist. P. N. O.
Nsg. Superintendent/Dy.
Nsg. Suptd.
Asst. Nsg. Suptd.
Ward sister
Staff nurse
P. N. Supervisor
(CHC)
PN (PHC)
LHV/HS
ANM
Director, Nursing Services
Dy. Asst. Director, Nursing Services
Assistant Dist. Nsg. Officer
(Hosp. & Nsg. Edu)
Dy. Director, Nursing Services
Asst. Director, Nursing Services
Assistant Dist. Nsg. Officer
(Community)
LHV

The above recommended organisational set up will need full administrative and financial
support of the government. It will look after the overall nursing components, development of
nursing standards, norms, policies, ethics, recruitment, selection and placement roles__ for both
hospitals and community health nursing, development in speciality nursing, higher education in
nursing, and research. These will promote professional autonomy and accountability.
NATIONAL RURAL HEALTH MISSION
The National Rural Health Mission (NRHM) has been launched with a view to bringing
about dramatic improvement in the health system and the health status of the people, especially
those who live in the rural areas of the country..
To achieve these goals NRHM will:
 Facilitate increased access and utilization of quality health services by all.
 Forge a partnership between the Central, state and the local governments.
 Set up a platform for involving the Panchayati Raj institutions and community in the
management of primary health programmes and infrastructure.
 Provide an opportunity for promoting equity and social justice.
The Vision of the Mission
 To provide effective healthcare to rural population throughout the country with
special focus on 18 states, which have weak public health indicators and/or weak
infrastructure.
 18 special focus states are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal
Pradesh, Jharkhand, Jammu and Kashmir, Manipur, Mizoram, Meghalaya, Madhya
Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh.
 To rise public spending on health from 0.9% GDP to 2-3% of GDP, with improved
arrangement for community financing and risk pooling.
 To undertake architectural correction of the health system to enable it to effectively
handle increased allocations and promote policies that strengthen public health
management and service delivery in the country.
 To revitalize local health traditions and mainstream AYUSH into the public health
system.

The Objectives of the Mission
 Reduction in child and maternal mortality.
 Universal access to public services for food and nutrition, sanitation and hygiene and
universal access to public health care services with emphasis on services addressing
women‘s and children‘s health and universal immunization.
 Prevention and control of communicable and non-communicable diseases, including
locally endemic diseases.
 Access to integrated comprehensive primary health care.
 Population stabilization, gender and demographic balance.
 Revitalize local health traditions & mainstream AYUSH.
 Promotion of healthy life styles.
The core strategies of the Mission
 Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and
manage public health services.
 Promote access to improved healthcare at household level through the female health
activist (ASHA).
 Health Plan for each village through Village Health Committee of the Panchayat.
 Strengthening sub-centre through better human resource development, clear quality
standards, better community support and an untied fund to enable local planning and
action and more Multi Purpose Workers (MPWs).
 Provision of 30-50 bedded CHC per lakh population for improved curative care to a
normative standard. (IPHS defining personnel, equipment and management standards, its
decentralized administration by a hospital management committee and the provision of
adequate funds and powers to enable these committees to reach desired levels)
District and Block levels.
Programmes
 Reproductive and Child Health Programme – II (RCH-II) and the Janani Suraksha
Yojana (JSY) launched.
 Polio eradication programme intensified – cases reduced from 134 in 2004-05 to 63 (up
to now).

 Accelerated implementation of the Routine Immunization programme taken up. Catch up
rounds taken up this year in the States of Bihar, Jharkhand and Orisaa.
 Ground work for introduction of JE vaccine completed.
 Ground work for Hepatitis vaccines to all States completed.
 Auto Disabled Syringes introduced throughout the country.
 State Programme Implementation Plans for RCH II appraised by the National Programme
Coordination Committee set up by the Ministry. Funds to the extent of 26.14% i.e. Rs.
1811.74 core have been released under NRHM Outlay.
Mission on nursing education:
The Mission would support strengthening of Nursing Colleges wherever required, as the
demand for ANMs and Staff Nurses and their development is likely to increase significantly.
Special attention would be given to setting up ANM training centers in tribal blocks which are
currently para-medically underserved by linking up with higher secondary schools and existing
nursing institutions.
ORGANISATION OF THE HEALTH CARE SYSTEM
Public sector
Public agencies are financed with tax monies, thus these are accountable to the public. The
public sector includes official (governmental) agencies and voluntary agencies.
Organization of the public health system
The public health system is organised in too many levels in the
 Federal,
 State,
 Local systems.
THE FEDERAL SYSTEM:
Federal Government has the responsibility for the following aspects of health care.
At the federal level, the primary agencies are concerned with health are organized under the
Department of Health and Human Services (DHHS).

 Providing direct care for certain groups such as Native Americans, military personnel,
and veterans.
 Safeguarding the public health by regulating quarantines and immigration laws and the
marketing food, drugs and products used in medical care.
 Prevents environmental hazards, gives grantsin aids to states, local areas and individuals
and supports research.
 Administration of social security, social welfare and related programmes
Organization and Functions of Nursing Services and Education at National, State,
District, and Institutions: Hospital and Community
Organization and functions of nursing services and education At centre/ national level
Organization of health care at centre level is done by three structures these are
1) Union ministry of health and family welfare
2) Centre council of health
3) Centre family welfare council
Functions:
The functions which are performed by the department of health and through DGHS are given in
the union list and concurrent list and these are as under:
1. Conducting health and morbidity surveys, planning and organizing health programmes
with active participate of state governments, co-ordination of health care activities
through central health council, consultative committee of parliament, statutory bodies
etc.; appraisal of health schemes and feed back in order to maintain uniformity, norms
etc.
2. Maintenance of international health relations, administration of port health and
quarantine laws..
3. Administration of central health institutions, training colleges, laboratories and hospitals,
4. Promotion and maintenance of appropriate standards of education in medical, nursing,
dental, pharmaceutical and ancillary health personnel through statutory bodies.
5. Promotion of medical and public health research.
6. Establishing and maintenance of drug standards,
7. Health intelligence.
8. Central bureau of health intelligence was set up in 1961 for collection, complication,
analysis and evaluation of information.
9. Maintenance of a central medical library.

Central family welfare council
This department mainly deals with FW matters. Secretary with support of team members, plan
co-ordinates, evaluates and supervises the implementations of FW programme in the state and
co-ordinates the activities and the functions of the technical divisions of the FW department like
 Programme appraisal co-ordination and training and sterilization division
 Technical operation division
 Maternal child health division
 Evaluation and intelligence division
Centre council of health
Health is a state subject. The union government has mainly an advisory, guiding and
coordinating function. The main functions of the council are as under:
 To consider and recommend broad lines of policy on all matters of health like, primary
health care, medical care, nutrition, environmental health, health education etc.
 To make proposal for legislation in the field of medical and public health matters
 To lay down the pattern of development in the country as a whole
 To make recommendations regarding distribution of available grants-in-aid
Apart from Governmental actions, Nursing education and services are organized by Indian
nursing council and other statutory bodies in national level.
AT STATE LEVEL
State ministry of health and family welfare
They have political responsibilities, responsibilities towards their constituencies as per
their political agenda, and responsibilities for administration and management of health and
family welfare services in their state.
Health secretariat
It is the official organ of the ministry. Major function of the secretariat include helping
minister in
 Formulation, review and modification of board policy outlines
 Execution of policies programmes etc.
 Coordination with government of India and other state governments
 Control for smooth and efficient functioning of administrative machinery.

State health directorate
 Providing curative and preventive services
 Provision for control of milk and food sanitation
 Assumes for total responsibility for taking all steps in the prevention of any outbreak of
communicable diseases specially during festivals and special seasons
 Establishment and maintenance of central laboratories for preparation of vaccines, etc
 Promotion of health education
 Collection, tabulation and publication of vital statistics
Apart from governmental actions it will be organized by state nursing councils and universities
Functions of university are
 Organize the courses
 Plan for the examinations
 Setting question papers
 Planning the examination date
 Plan the curriculum
AT DISTRICT LEVEL
At district level health organisation is maintained by taluks or block, their main function
is, to plan and implement community development programmes.
Panchayati raj system is a local self governing system in rural area which work parallel
to official structure of administration. It consists of three –tier structure of rural local self
government.
Gram sabha- it is comprised of all the adult men and women of the village. This body
meets at least twice in a year and discusses important issues and considers proposals pertaining
to various developmental aspects including health matters
Gram Panchayat- it is the executive organ of the gram sabha. Its main function is
overall planning and development of the villages. The Panchayat secretary has been given
powers to function for wide areas such as maintenance of sanitation and public health, socio
economic development of villages.
Panchayat samiti- it is responsible for the block development programme. The funds for
the development activities are processed through Panchayat samiti. The block development
officer and his/her technical staff extend assistance and guidance to gram Panchayats in carrying
out developmental activities in their villages.

INSTITUTIONAL LEVEL –
AT HOSPITAL
Organization of nursing services and education
 Director of nursing
Nursing services must function under a senior competent nursing administrator –
variously called as director of nursing, nursing superintendent, principal matron, or matron-in-
chief. She is responsible to the hospital administrator for overall programme and activities of
nursing care of all patients in the hospital. Nursing programme is administered by her through
appropriate planning of services, determining nursing policies in collaboration with hospital
management and nursing procedures in collaboration with nursing staff, giving general
supervision, delegation of responsibility, coordination of interdepartmental nursing activities‘,
and counseling the hospital administration on nursing problems.
She has a dual role: the first one is the administrative responsibility towards hospital
administration, and the second one is the coordinating of all professional activities of nursing
staff with those of medical staff.
The role of the nursing superintendent starts in a new hospital from helping to establish
the overall goals, policies and organization, and facilities to accomplish these goals in the most
effective and efficient manner. The functional elements of the role of nursing superintendent
includes the following
 Formation of the aims, objectives and policies of nursing services as an integral part of
hospital service
 Staffing based on nursing requirements in relation to accepted standard of medical care
 Planning and directing nursing services
 Maintaining supplies and equipments
 Budgeting
 Records and reports
 Nursing supervisor
Each department or clinical division, e.g. Medical, surgical, obstetrical, operation
theatres, outpatient department, nurseries, etc. should have a supervisor. As they may be more
than one nursing unit in each division or department, supervisors have a general administrative
and coordinating function within their respective division. However, supervisors will also have
limited clinical functions
 Head nurse / nursing tutor
A head nurse is assigned to a nursing unit, or ward, or a section of department. She works
under the general direction of the supervisor of the division.

 Staff nurse / clinical instructor
Staff nurses are employed at the ‗floor‘ level for carrying out skilled bedside nursing.
This is the real work force of the hospital upon whose competency, state of training and
dedication depend the success of the nursing department.
 Student nurse
Students nurse cannot be employed on nursing duties except under supervision of fully
qualified staff nurses.
Policies and procedures
In order that a good standard of nursing care be maintained, the nursing superintendent
should develop written policies and procedures to serve as a guides for nurses of the various
units of the hospital. Important topics that should be incorporated are as follows
 Organization
 Status and relationship
 Responsibilities
 Staffing pattern, shift pattern
 Departmental functions
 Requisitioning of supplies
 Utilization, care and maintenance of equipment
 Nursing procedures, coordination with domestic services
 Handling of the patients clothing and valuables
 Isolation technique
Functions
Of hospital in nursing services and education
 As a basic function, to assist the individual patient in performance of those activities
contributing to his health or recovery that he would otherwise perform unaided has had
the strength will, or knowledge.
 As an extension of the above basic function, to help and encourage the patients to carry
out the therapeutic plan initiated by the physician
 As a member of health team, to assist other members of the team to plan and carryout the
total programme of care

AT COMMUNITY
PHCs (Primary Health Care)
Introduction
The PHC is the first contact point between the village community and the medical
officer. These are established and maintained by the state government under minimum needs/
basic minimum services programme. It acts as a referral unit for six sub centre and has 4-6 beds.
A PHC covers population of 30000 in plain area and 20000 in hilly remote and tribal area. The
activities of PHC‘s involve curative, preventive, promotive and family welfare services. The
number of PHC‘s functioning in the country is 22975.
Definition
Primary health centre is the basic structural and functional unit of public health services
for rendering primary health care in peripheral areas.
Elements of PHC
e- Ensure safe water supply
l- Locally endemic disease control
E- Education/ expanded programme on immunization
m- Maternal and child health
e- Environmental sanitation
n- Nutritional services
t- Treatment of minor aliments
s- School health services
Standards of PHC
The IPHHS for PHCs has been prepared keeping in view the resources available with respect to
functional requirement for PHCs with minimum standards such as-
 Building
 Man power
 Instrument
 Equipments
 Drugs
 Other facilities

The standards prescribed are , a PHC covering 20000-30000 population with six beds on well the
block level PHC are ultimately going to be upgraded as CHC with 30 beds of providing
specialized services.
The objectives of IPHS for PHCs are:-
 To provide comprehensive primary health care to the community through the PHC
 To achieve and maintain an acceptable standards of quality of care
 To make the services more responsible and sensitive to the needs of the community
Minimum requirements are:-
The assured services cover all the essentials of preventive, promotive, curative and rehabilitative
primary health care. This implies a wider range of services that includes
 Medical care
 Maternal and child health care
 Full rage family planning services including counseling and appropriate referral for
couples having infertility
 MTP services
 Health education for prevention and management of malnutrition, anemia and vitamin A
deficiency and co-ordinates with ICDS
 School health services
 Adolescent health care
 Disease surveillance and control of epidemics
 Collection and reporting of vital events
 Promotion of sanitation
 Testing water quality
 Nutritional health programme
 Training health workers
 Training of ASHA

Staffing pattern
The man power that should be available in the PHC is as follows
STAFF EXISTING RECOMMENDED
Medical officer 1 3(at least 1 female)
AYUSH practitioner - 1
Accountant manager - 1
Pharmacist 1 2
Nurse midwife(staff) nurse 1 5
Health worker 1 1
Health educator 1 1
Health assistant (m/f) 2 2
Clerks 2 2
Laboratory technician 1 2
Driver 1 OPTIONAL / vehicle
may be from out side
Class IV 4
Major role of nurse in PHC
 Facilitative role
 Developmental role
 Clinical role
 Supportive role
Functions of PHC
 Medical care
 Maternal and child health
 Control of communicable diseases

 Collection and reporting of vital statistics
 Immunization services
 Improvement in environmental sanitation
 School health programmes
CHCs (community health centres)
Introduction
The community health centres are established and maintained by state government under
MNP/BMS programme. It has 30 indoor beds with x-ray labour room, operation theatre, and
laboratory facilities. It is managed by four medical specialists i.e. surgeon, physician,
gynecologist and pediatrician. On 31st
march 2003, 3076 CHC were established each covering a
population of 80000 to 1.20 lakh.
Definition
Community health centres are the nonprofit community governed health organizations
that provide primary health care, health promotion and community development services, using
them inter disciplinary terms of health providers.
Principles
 Excellence
 Innovations
 Accountability
 Collaboration
 Accessibility
 Integrity
 Environment
Elements
 Primary care
 Illness prevention
 Health promotion
 Community capacity building
 Service integration
Standards of CHC
In order to provide quality care in CHCs IPHS are being prescribed to provide optimal expert
care to the community and achieve and maintain an acceptable standards of quality of care.
These standards would help to monitor and improve the functioning of CHCs.
CHCs has to provide the following services like

 Care of routine and emergency cases in surgery
 Care of routine and emergency cases in medicine
 24 hour delivery services
 Essentials of emergency obstetric care.
 Full range of family planning services including laparoscopic services
 Safe abortion services
 New born care
 Routine and emergency care of sick children
 Other management of medical and accidental conditions
 All the national health programmes should be delivered through CHCs
PLANNING PROCESS
HEALTH IN FIVE YEARS PLANS
INTRODUCTION
Five years plan is mechanism to bring about uniformity in policy formulation in programmes of
national importance
The specific objectives of the health programme, during Five years plan, are as follows:
1. Control & eradication of major communicable diseases.
2. Strengthening of basic health services through the establishment of the PHC & sub
enters.
3. Population control.
4. Development of health manpower resources.
For the purpose of planning the health sectors has been divided in two following sub sectors.
1. Water supply & sanitation.
2. Control of communicable diseases.
3. Medical education, training & research.
4. Medical care including hospitals, dispensaries & PHCs.
5. Public health services.
6. Family planning.
7. Indigenous system of medicine.
FIRST FIVE YEAR PLAN (1951 – 1956)
The first Indian Prime Minister, Jawaharlal Nehru presented the first five-year plan to the
Parliament of India on 8 December 1951. The first plan sought to get the country's economy out
of the cycle of poverty. The plan addressed, mainly, the agrarian sector, including investments in

dams and irrigation. The agricultural sector was hit hardest by the partition of India and needed
urgent attention.[2]
The total planned budget of 206.8 billion was allocated to seven broad areas:
1) Irrigation and energy
2) Agriculture and community development
3) Transport and communications
4) Industry
5) Social services
6) Land rehabilitation
7) Other sectors and services
The specific objectives were;
1. Provision of water supply & sanitation.
2. Control of malaria.
3. Preventive health care of the rural population.
4. Health services for mother & children.
5. Education & training in health.
6. Self sufficiency in drug & equipments.
7. Family planning & population control.
During this plan period the public sector outlay was Rs. 2356 crore of which Rs. 140 crore were
allotted for health programs.
SECOND FIVE YEAR PLAN (1956-1961)
The second five-year plan focused on industry, especially heavy industry. Unlike the First
plan, which focused mainly on agriculture, domestic production of industrial products was
encouraged in the Second plan, particularly in the development of the public sector.
The plan followed the Mahalanobis model, an economic development model developed by
the Indian statistician Prasanta Chandra Mahalanobis in 1953. The plan attempted to determine
the optimal allocation of investment between productive sectors in order to maximize long-run
economic growth.
The specific objectives were;
1. Establishment of institutional facilities to serve as a basis from which service could be
render to the people both locally & surrounding territory.
2. Development of technical man power through appropriate training programmes.
3. Intensifying measures to control widely spread communicable disease.

4. Encouraging active campaign for environmental hygiene.
5. Provision of family planning and other supporting services.
During this plan period the public sector outlay was Rs. 4,800 crore of which Rs. 225 crore were
allotted for health programs.
THIRD FIVE YEAR PLAN (1961-1966)
The third plan stressed on agriculture and improving production of rice
Many primary schools were started in rural areas. In an effort to bring democracy to the
grassroots level, Panchayat elections were started and the states were given more development
responsibilities.
State electricity boards and state secondary education boards were formed. States were made
responsible for secondary and higher education.
The specific objectives were in tuned with the 1st
& 2nd
five years plan except that integration of
public health with maternal & child welfare, nutrition & health education was planned.
During this plan period the public sector outlay was Rs. 7,500 crore of which Rs. 341.8 crores
were allotted for health programs.
FOURTH FIVE YEAR PLAN (1969-1974)
At this time Indira Gandhi was the Prime Minister. The Indira Gandhi government nationalized
Green Revolution in India advanced agriculture
Certain objectives of the Mudaliar committee were the base for this plan in relation to health.
1. To provide an effective base for health services in rural areas by strengthening the PHCs.
2. Strengthening of sub-division & district hospitals to provide effective referral services
for PHCs,
3. Expansion of medical & nursing education & training of Para –medical personnel to meet
the minimum technical man power requirements.
During this plan period the public sector outlay was Rs. 16,774 crore of which Rs. 1,156 crore
FIFTH FIVE YEARS PLAN (1974-1979)
Stress was laid on employment, poverty alleviation, and justice. The plan also focused on self-
reliance in agricultural production and defense. In 1978 the newly elected Morarji Desai
government rejected the plan. Electricity Supply Act was enacted in 1975,

The emphasis of the plan was on removing imbalance in respect of medical facilities &
strengthening the health infrastructure in rural areas.
Specific objectives to be pursued during the plan were:
1. Increase accessibility of health services to rural areas.
2. Correcting regional imbalance.
3. Further development of referral services.
4. Integration of health, family planning & nutrition.
5. Intensification of the control & eradication of communicable diseases especially malaria
& smallpox.
6. Quantitative improvement in the education & training of health personnel.
During this plan period the public sector outlay was Rs. 37,250 crore of which Rs. 3,277 crores
The sixth plan also marked the beginning of economic liberalization. Price controls were
eliminated and ration shops were closed. This led to an increase in food prices and an increase in
the cost of living.
Family planning was also expanded in order to prevent overpopulation. In contrast to China's
strict and binding one-child policy, Indian policy did not rely on the threat of force. More
prosperous areas of India adopted family planning more rapidly than less prosperous areas,
which continued to have a high birth rate.
SEVENTH FIVE YEAR PLAN (1985-89)
The main objectives of the 7th five year plans were to establish growth in the areas of increasing
economic productivity, production of food grains, and generating employment opportunities.
The thrust areas of the 7th Five year plan have been enlisted below:
 Social Justice
 Removal of oppression of the weak
 Using modern technology
 Agricultural development
 Anti-poverty programs
The objectives were
1. Eliminate poverty & illiteracy by 2000

2. Achieve near full employment secure satisfaction of the basic needs of food, cloth,
shelter
and provide health for all.
3. To provide an effective base for health services in rural areas by strengthening the PHCs.
4. universal immunization programme
5. Promotion of voluntary acceptance of contraceptives
During this plan period the public sector outlay was Rs. 1.80.000 crores of which Rs. 3,392
crores were allotted for health programs.
Period between 1989-91
P.V. Narasimha Rao was the twelfth Prime Minister of the Republic of India and head of
Congress Party
1989-91 was a period of political instability in India and hence no five year plan was
implemented. Between 1990 and 1992, there were only Annual Plans.
EIGHTH FIVE YEAR PLAN (1992-97)
India became a member of the World Trade Organization on 1 January 1995.This plan can be
termed as Rao and Manmohan model of Economic development. The major objectives included,
containing
1. population growth,
2. poverty reduction,
3. employment generation,
4. strengthening the infrastructure,
5. Institutional building,tourism management,
6. Human Resource development,
7. Involvement of Panchayat raj,
8. Nagarapalikas,
9. N.G.O‘s and
10. Decentralization and people's participation.
It is based on the national health policies.
1. Human development is the ultimate goal of this plan.
2. Employment generation, population control literacy, education, health, drinking water &
provision of adequate food &basic infrastructure.
3. Towards health for the underprivileged‖ was the of the aim of this plan.
The PHCs were strengthened staff vacancies, by supplying essential equipment &drugs.

AIDS control program was initiated during this plan.
NINTH FIVE YEAR PLAN (1997-2002)
Ninth Five Year Plan India runs through the period from 1997 to 2002 with the main aim of
attaining objectives like speedy industrialization, human development, full-scale employment,
poverty reduction, and self-reliance on domestic resources.
Background of Ninth Five Year Plan India: Ninth Five Year Plan was formulated amidst the
backdrop of India's Golden jubilee of Independence.
The main objectives of the Ninth Five Year Plan India are:
 to prioritize agricultural sector and emphasize on the rural development
 to generate adequate employment opportunities and promote poverty reduction
 to stabilize the prices in order to accelerate the growth rate of the economy
 to ensure food and nutritional security
 to provide for the basic infrastructural facilities like education for all, safe drinking water,
primary health care, transport, energy
During this plan, vertical health program were integrated horizontally with general health
services.
The Reproductive & child health program was improved under following guidelines;
1. Decentralize RCH to the level of PHCs.
2. Base planning for RCH services on assessment of the local needs.
3. Meet the needs of contraceptives
4. Involve the general practitioners & industries in family welfare work.
TENTH FIVE YEAR PLAN (2002-2007)
 Reduction of poverty ratio by 5 percentage points by 2007;
 Providing gainful and high-quality employment at least to the addition to the labour
force;*All children in India in school by 2003; all children to complete 5 years of
schooling by 2007;
 Reduction in gender gaps in literacy and wage rates by at least 50% by 2007
This plan has laid down the following targets
 Bring down the decadal growth rate by 16.2% in the decade from 2001 to 2011.

 Reduce infant mortality rate to 35/1000 live births by 2007 & to 28/1000 live births by
2012
 Reduce maternal mortality rate to 2/1000 live births by 2007 & 2/1000 live births by
2012.
To achieve the above, the government is planning to do the following
1. Restructure existing health infrastructure.
2. Upgrade the skills of health personnel
3. Improve the quality of reproductive & child health‘
4. Improve logistic supplies.
5. carry out the research on nutritional deficiency
6. Promote rational drug use.
ELEVENTH PLAN (2007-2012)
1. Income & Poverty
o Create 70 million new work opportunities.
o Reduce educated unemployment to below 5%.
o Raise real wage rate of unskilled workers by 20 percent.
2. Education
o Reduce dropout rates of children from elementary school from 52.2% in 2003-04
to 20% by 2011-12
o Develop minimum standards of educational attainment in elementary school, and
by regular testing monitor effectiveness of education to ensure quality
o Increase literacy rate for persons of age 7 years or above to 85%
3. Health
o Reduce infant mortality rate to 28 and maternal mortality ratio to 1 per 1000 live
births
o Reduce Total Fertility Rate to 2.1
o Provide clean drinking water for all by 2009 and ensure that there are no slip-
backs
o Reduce malnutrition among children of age group 0-3 to half its present level

4. Women and Children
o Raise the sex ratio for age group 0-6 to 935 by 2011-12 and to 950 by 2016-17
o Ensure that at least 33 percent of the direct and indirect beneficiaries of all
government schemes are women and girl children
o Ensure that all children enjoy a safe childhood, without any compulsion to work
5. Infrastructure
o Ensure electricity connection to all villages and BPL households by 2009 and
round-the-clock power.
o Ensure all-weather road connection to all habitation with population 1000 and
above (500 in hilly and tribal areas) by 2009, and ensure coverage of all
significant habitation by 2015
o Connect every village by telephone by November 2007 and provide broadband
connectivity to all villages by 2012
o Provide homestead sites to all by 2012 and step up the pace of house construction
for rural poor to cover all the poor by 2016-17
6. Environment
o Increase forest and tree
o Attain WHO standards of air quality in all major cities by 2011-12.
o Treat all urban waste water by 2011-12 to clean river waters.
o Increase energy efficiency by 20 percentage points by 2016-17.
I. Various health and family welfare committees
1. Bhore committee
In 1946, the recommendations and guidance provided by the Bhore Committee formed
the basis for organization of basic health services in India. The report was submitted to
the government.-side was the focal point of these recommendation
The Bhore Committee made two types of recommendations;
a) A Comprehensive blue print for the distant future (20 to 40 years from then) and the
smallest service unit was to be Primary Health Unit, serving a population of 10,000 to
20,000
b) A short-term scheme covering 2 to 5 years period from then with emphasis on setting up
30 bedded hospitals, one for every two Primary Health Care

The country – side was the focal point of these recommendations. Other
recommendations were:
 Formation of village health committee to secure active cooperation and support in the
development of health program.
 Provision of Doctors of future who should be ―Social Doctor‖, combines both
curative and preventive of the public.
 Formation of District Health Board for each district with district health officials and
representatives of the public.
 To ensure suitable housing, sanitary surroundings, safe drinking water supply
elimination of unemployment and lay special emphasis on preventive work.
2. Mudaliar committee 1962
In 1959, the Government of India appointed another committee known as ―Health Survey
and Planning Committee popularly known as Mudaliar Committee under the
Chairmanship of Dr. A.L mudaliar.
Recommendations:
a) Consolidation of advances made in the first two-year plans
b) Strengthening of the district hospital with specialist services
c) Regional organizations in each state
d) Each primary health centre not to serve more than 40,000 populations.
e) To improve the quality of health care provided by primary health centres
f) Integration of medical and health services on the pattern of Indian Administrative
service.
3. Chadah Committee, 1963
Under the chairmanship of Dr. M.S. Chadah, Government of India appointed a committee
to study the arrangement necessary for the maintenance phase of the National Malaria
Eradication Programe.
Recommendations
1. Vigilance operations in respect of the NMEP should be the responsibility of the
general health services (e.g.) PHC.
2. The vigilance operations should be should be done through monthly home visits by
basic workers (Junior Health Assistant male)
3. Now each Junior Health Assistant Male to cover 3 – 5000 population

4. Mukherjee Committee, 1965
Under the chairmanship of Shri Mukerji, the then secretary of health to the Government
of India was appointed to review the strategy for the family planning program.
Recommendations
 To have separate staff for the family planning program.
The family planning assistants were to undertake family planning duties only
The basic health workers were to be utilized for purposes other than family planning.
To delink the malaria activities from family planning of it‘s that the later would receive
undivided attention of its staff.
Mukherjee Committee, 1966
Multiple activities of the mass programmes like family planning, small pox, leprosy,
trachoma, etc. were making it difficult for the states to undertake these effectively because of
shortage of funds. A committee of state health secretaries, headed by the Union Health
Secretary, Shri Mukherjee, was set up to look into this problem.
5. Jungalwalla Committee, 1967
Under the Chaimanship of Dr. Jungalwalla Director, National Institute of Health
Administration and Education, New Delhi was appointed to examine the various
problems of service conditions of doctors. This committee is known as the committee on
integration of Health Services.
Recommendation
1. The main steps recommended towards integration were
a) Unified cadre
b) Common Seniority
c) Recognition of extra qualifications
d) Equal pay for equal work
e) No private practice and good service conditions
6. Kartar Singh committee, 1973
The Government of India constituted a committee in 1922, known as the committee on
multipurpose workers under Health and Family Planning, under the Chairmanship of
kartar Singh, Additional Secretary, Ministry of Health and Family Planning, Government
of India.

Recommendations
 The Present Auxiliary Nurse Midwives to be replaced by the newly designated ―Female
Health Workers‖ and the present day Basic Health Workers, malaria surveillance
workers, vaccinators, health education assistants (Trachoma)and the family planning
health assistants to redesignated by ―Male Health Workers‖.
 The program has to be introduced in areas where malaria is in maintenance phase and
smallpox has been controlled and later to other areas.
 One primary health centre for 50,000 populations.
 Each PHC should be divided into 16 sub centers and each covers 3,000 to 35, 00
population.
 Each sub centre to be staffed by a male and female health worker.
 One male health supervisor to supervise 3 to 4 male health workers and one female health
supervisor to supervise the work of 4 female health workers.
 The lady health visitors to be designated as female health supervisors.
 The doctor in charge of a primary health centre should have the overall in charge of all
the supervisors and health workers in the area.
7. Shrivastav Committee, 1975
The Government of India in the Ministry of Health and Family Planning had in
November 1974 set up a ‗Group on Medical Education and Support Manpower‘
popularly known as Shrivastav Committee.
Recommendations
 Creation of bands of paraprofessional and semiprofessional health workers from within
the community itself (e.g. school teachers, postmasters, gram sevaks) to provide simple
promotive, preventive and curative health services needed by the community.
 Establishment of 2 cadres of health workers, namely multipurpose health workers and
health assistants between the community level workers and doctors at PHC.
 Development of a ‗Referral Services Complex‘ by establishing proper linkages between
PHC and higher level referral services.
 Establishment of a Medical and Health Education Commission for planning and
implementing the referrals needed in health and medical education on the lines of the
University Grants Commission.

8. Balaji Committee 1986-19877
The Ministry of Health and Family welfare, Government of India, following the adoption
of the National Policy on education, 1986, set-up a committee on Health Manpower,
Planning, Production and Management in 1986 under the chairmanship of Prof. JS Balaji,
Professor of Medicine, AIIMS, and New Delhi
Recommendations
 To formulate a National Policy on education in Health Services
 To prepare curriculum for schoolteachers this should constitute a holistic approach
including social, moral, health and physical education.
 Health service statistics needs to be improved in quality
 To utilize the services of Indian system of medicine viz. Homeopathy, in the area of
National Health Program.
 Health related components to be included in IX, X Grades
 Continuing education program for the health personnel.
 Health manpower requirements for nursing personnel.
NATIONAL HEALTH POLICY - 2002
Introduction
National Health Policy was last formulated in 1983, and since then there have been
marked changes in the determinant factors relating to the health sector. Some of the policy
initiatives outlined in the NHP-1983 have yielded results, while, in several other areas, the
outcome has not been as expected.
Current scenario
Financial resources: The public health investment in the country over the years has been
comparatively low, and as a percentage of GDP has declined from 1.3 percent in 1990 to 0.9
percent in 1999. The aggregate expenditure in the Health sector is 5.2 percent of the GDP. Out of
this, about 17 percent of the aggregate expenditure is public health spending, the balance being
out-of-pocket expenditure.
Equity: In the period when centralized planning was accepted as a key instrument of
development in the country, the attainment of an equitable regional distribution was considered
one of its major objectives.
Delivery of national public health programmes
 Extending public health services

 Policy of devolving programmes and funds in the health sector through different levels of
the Panchayati Raj Institutions.
 Need for specialists in ‗public health‘ and ‗family medicine‘
 Use of generic drugs and vaccines
 Urban health, Mental health, Women‘s health
 Information, education and communication
 Health research and National disease surveillance network
 Health statistics and Medical ethics
 Enforcement of quality standards for food and drug
 Regulation of standards in para medical disciplines
 Environmental and occupational health
 Providing medical facilities to users from overseas
 Globalization on the health sector
Objectives
 The main objective of this policy is to achieve an acceptable standard of good health
amongst the general population of the country.
 Decentralized public health system by establishing new infrastructure in deficient areas,
and by upgrading the infrastructure in the existing institutions.
 Ensuring a more equitable access to health services across the social and geographical
expanse of the country.
 Emphasis will be given to increasing the aggregate public health investment through a
substantially increased contribution by the Central Government.
 Strengthen the capacity of the public health administration at the State level to render
effective service delivery.
NHP-2002 - Policy prescriptions
 Financial resources
 Equity
 Delivery of national public health programmes
 The state of public health infrastructure
 Extending public health services
 Role of local self-government institutions
Need for national health policy
 Population stabilization
 Medical and Health Education
 Providing primary health care with special emphasis on the preventive, promotive and
rehabilitative aspects
 Re-orientation of the existing health personnel

 Practitioners of indigenous and other systems of medicine and their role in health care
AYUSH
The Indian Systems of Medicine and Homoeopathy (External website that opens in a new
window) (ISM&H) were given an independent identity in the Ministry of Health and Family
Welfare in 1995 by creating a separate Department of Ayurveda, Yoga and Naturopathy, Unani,
Siddha and Homoeopathy (External website that opens in a new window) (AYUSH) in
November 2003.
The infrastructure under AYUSH sector consists of 1355 hospitals with 53296 bed capacity,
22635 dispensaries, 450 Undergraduate colleges, 99 colleges having Post Graduate Departments,
9,493 licensed manufacturing units and 7.18 lakh registered practitioners of Indian Systems of
Medicine and Homoeopathy in the country.
Budget: An outlay of Rs.775 crore has been allocated for the Department during the Tenth Five-
year Plan. The Plan allocation for 2006-07 is Rs. 381.60 crore.
Subordinate Offices
 Pharmacopoeial Laboratory for Indian Medicine (PLIM)
 Homoeopathic Pharmacopoeial Laboratory (HPL)
 Ayurved Hospital, Lodhi Road, New Delhi
National Population Policy of India
Population Policy pursues to achieve following Socio-Demographic goals by 2010:
 Address the unmet needs for basic reproductive and child health services, supplies and
infrastructure.
 Make school education up to age 14 free and compulsory, and reduce dropouts at primary and
secondary school levels to below 20 percent for both boys and girls.
 Reduce infant mortality rate to below 30 per 1000 live births.
 Reduce maternal mortality ratio to below 100 per 100,000 live births.
 Achieve universal immunization of children against all vaccine preventable diseases.
 Promote delayed marriage for girls, not earlier than age 18 and preferably after 20 years of
age.
 Achieve 80 percent institutional deliveries and 100 percent deliveries by trained persons.
 Achieve universal access to information/counseling, and services for fertility regulation and
contraception with a wide basket of choices.
 Achieve 100 per cent registration of births, deaths, marriage and pregnancy.

UNIT II
Management  Functions of administration
 Planning and control
 Co-ordination and delegation
 Decision making – decentralization basic
goals of decentralization.
 Concept of management
Nursing
management
 Concept, types, principles and techniques
 Vision and Mission Statements
 Philosophy, aims and objective
 Current trends and issues in Nursing
Administration
 Theories and models
 Application to nursing service and
education

Management: Refer unit 1
Functions of administration: Refer unit 1
PLANNING AND CONTROL
Planning
Planning means to decide in advance what is to be done. It charts a course of actions for the
future. It is an intellectual process and it aims to achieve a coordinated and consistent set of
operations aimed at desired objectives.
Essentials of good planning
 Yields reasonable organizational objectives and develops alternative approaches to meet
these objectives.
 Helps to eliminate or reduce the future uncertainty and chance.
 Helps to gain economical operations.
 Lays the foundation for organizing.
 Facilitates co-ordination.
 Helps to facilitate control.
 Dictates those activities to which employers are directed.
Controlling
Controlling can be defined as the regulation of activities in accordance with the
requirements of plans.
Steps of control:
o The control function, whether it is applied to cash, medical care, employee morale
or anything else, involves four steps.
1. Establishments of standards.
2. Measuring performance
3. Comparing the actual results with the standards.
4. Correcting deviations from standards.

CO-ORDINATION AND DELEGATION
CO-ORDINATION
Definitions
Co-ordination is the integrating process in an orderly pattern of group efforts in an organization
toward the accomplishment of a common objective.
Co-ordination is the orderly arrangement of group efforts to provide unity of an action in pursuit
of common purpose.
Co-ordination is the orderly synchronization of efforts to provide the proper amount, timing and
directing of execution resulting in harmonious and unified actions to a stated objective. (NEW
MAN,1953)
Characteristics
 Group effort: The financial, human and technical resources are properly organized and
co-ordinate.co-ordination transcends and permeates all managerial functions.
 Unity of action: Co-ordination applies to the group effort, not individual effort, co-
ordination stress the unity of effort and unity of action.
Common purpose
 Effective co-ordination is good management. Co-ordination is not a one-shot deal.
 It is a never ending process of ensuring the achievement of organizational goals
effectively.
Important features of co-ordination
 Co-ordination is a integrity process.
 If subdivision of work is in escapable, co-ordination becomes mandatory.
 Undue confusion is a symptom of poor co-ordination.
 Co-ordination is a process. It is a process of achieving integration among different
organizational units.
 Unity of effort is the heart of co-ordination problem. The idea that co-ordination is a
fixed entity that either exists or does not exist is totally unrealistic.co-ordination is
present in all organizations but in varying degrees.
 The chief objective of co-ordination is a common purpose.
Principles of co-ordination
Co-ordination is a process whereby an executive develops an orderly pattern of group effort
among his subordinates and secures unity of action in the pursuit of common objectives. Co-

ordination is the continuous and dynamic process and emphasizes unity of efforts of achieve the
desired objectives. Co-ordination the managerial responsibility.
1. Principle of direct contact: co-ordination can be achieves by direct contact among the
responsible people concerned. Co-ordination can be easily obtained by direct
interpersonal relationships and direct personal communications.
2. Principle of early stages: co-ordination should start from the very beginning of planning
process. At the time of policy formulation and objective setting.
3. Reciprocal relationships: As the third principle: all factors in a situation are reciprocally
related, in other words all the parts influence and are influenced by other parts. For
example when A works with B and he is turn works with C and D, each of the four finds
himself influenced by others influenced by the people in the total situation.
4. Principles of self co-ordination: in this when a particular department affects other
function or department or function in turn affected, may not have direct control over the
other department that is influencing the said department.
Importance of co-ordination
Co-ordination is crucial factor in the survival of any enterprise.
It resolves conflicts between line and staff inter-department, intra-departmental conflicts
and restores harmony in operations.
It results in the accomplishment of organizational goals
It helps to increase the effectiveness of management
Co-ordination helps to increase the effectiveness of management in the following ways
Co-ordination pulls all the function and activities together
Co-ordination brings unity of action and direction. it resolves effectively the dangerous
conflicts between individual and organizational goals.
Activities are dividing and sub-divide in organizations.
Modern organizations are considered as open system these open systems are
characterized by information flows, resource flows, and the flow of activities.
Co-ordination ensures the smooth flow of resources into productive units and brings
required quality output.

Techniques to achieve co-ordination
1. Co-ordination by rules or procedures
In the work that need to be accomplished is highly predictable and hence can be planned in
advance, a manager can specify a head of time what actions his subordinating the routine
rescuing activities, rules and procedures are helpful which specify in detail a head of time, what
courses of action the subordinates should take if some situation should arise.
2. Co-ordination by targets or goals
Most of the managers assign specific goals/ targets to their subordinates facilitate co-ordination.
3. Co-ordination through hierarchy
Rules, regulations and procedures as well as the goals apart, managers also use the chain of
command to achieve co-ordination. When situations arise the specified rules or targets do not
cover that, subordinates are trained to bring the problem to their concerned manager. Co-
ordination through the hierarchy works well as long as the number of problems that must be
brought to the boss is not great.
4. Co-ordination through departmentalization
Departmentalization also serves as a technique to bring about effective co-ordination. Some
forms of departmentalization also facilitate co-ordination better than do others. a matrix
approach means each project has the continuous and undivided attention of its own project
manager and the project team.
5. Using a staff assistant for co-ordination
To make his job of coordinating easier, a manager may hire an assistant. When subordinate
brings a problem to him, the assistant can comic the information on the problem, research the
problem, provide alternative solutions available. This increases, undoubtedly, the manager‘s
ability to handle the problems and coordinate the work of his subordinates.
6. Using a liaison for coordination
In some big organizations where the volume of contacts between two departments grows, many
managers appoint a special liaison person to facilitate coordination.
7. Using committee for coordination
Another sound technique of coordination is to from committee for understanding various
functions and problems. Committees are increasingly useful for coordinating, planning and
executing programs and controlling the various activities..

8. Using independent integrators for coordination
In some special circumstances, independent integrator may be recruited by organizations. An
independent integrator‗s job is to coordinate the activities of several interdependent
departments..
9. Conferences
Conferences at regular intervals also ensure better coordination. Conferences provide adequate
platform for discussion of various problems being encountered by different departments.
10. The techniques of communication
To promote coordination, communication system must be perfect. It must be well designed.
Communication is an artery through which the decisions flow top to bottom and reports flow
from bottom to top.
11. Miscellaneous
Other coordinating techniques include :grouping the similar activities, reorganization of
departments to ensure coordination, cross functioning of the departments, project management
organization hierarchy, planning techniques, creation of certain staff positions, periodical staff
meetings ect.
Types of co-ordination
Coordination can be classified into two broad categories, one on the basis of its shape in the
organization and other on the basis of its scope and coverage. On the former basis, it can be
classified into vertical and horizontal coordination and on, the latter basis, into internal and
external coordination.
1. Vertical and horizontal coordination
The term vertical coordination is used when coordination is to be achieved between various links
or different levels of the organization vertical coordination is needed to ensure that all the levels
in the organization act in harmony and in accordance with organizational policies and
programmers. It is the function of the top executives to bring about this co-ordination. Vertical
coordination is secured through delegation of authority and with the help of directing and
controlling.
The term ―horizontal coordination‖ is used when coordination has to be achieved between
departments on the same level in the management hierarchy. Thus, when coordination is brought
between production department, sales department, personnel department etc it is said to be
horizontal coordination.

2. Internal and external coordination
Coordination may be internal or external to be organization. Coordination is internal when it is
achieved between different departments, sections, and units of an enterprise. It is both vertical
and horizontal.
The various factors with whom it has interaction include government, customs, supplies and
competitors. An enterprise has to keep proper coordination with these. Such type of coordination
is known as external co-ordination and it is essential for the survival of the enterprise. External
coordination also involves interaction with other business, economic and research institutions to
have the benefits of latest information and technological advances.
DIFFICULTIES OF CO-ORDINATION
Lack of coordination and understanding between and among individuals, groups, and
departments.
lack of good interpersonal relations
failure in accomplishing objectives according to time and work schedule
Lack of direction and consequently aimless individual efforts.
Functioning of departments in the organization as watertight compartments.
Lack of initiative and loyalty towards the organization.
DELEGATION
Delegation is defined as transferring of responsibility to subordinates on behalf of the manager.
It is an act through which a manager gives authority to others to attain certain assignments.
Salient Features:
1. Not to delegate total authority
2. Not to delegate authority which he himself does not possess
3. Should be only for organisational purpose and not personal purpose
4. It does not imply reduction in power
Characteristics:
1. Delegation of authority can be exercised only by higher authority
2. Delegation can be of any kind
3. Delegation does not mean transfer of final authority
4. Does not involve surrender of power
Kinds of delegation:
1. Full delegation
2. Partial delegation

3. Conditional delegation
4. Formal delegation
5. Informal delegation
Principles of delegation:
1. Should be written and specific
2. Authority and responsibility should be equal
3. Should be properly planned and exercised
4. Right person should be chosen
5. Good reporting system should be established
6. Should have certain objectives to get certain results
7. Superiors should be ready to give support and guidance
8. Overall responsibility lies with the superior
Symptoms of poor delegation
1. Dissatisfied subordinates
2. Disorganized effort
3. Long queue in front of boss office
4. Boss always busy
5. Boss carrying big suitcase
6. Work never completed in time
7. Constant time pressure
8. Hold up of activities due to pending orders from boss
Decision making- decentralization basic goals of decentralization.
Definition
 Decision making is a systematic process of choosing among alternatives and putting the
choice in to action. -Lancaster and Lancaster
 Decision making is a necessary component of leadership, power, influence, authority and
delegations. -John 1993
 Decision making process is a conscious, intellectual activity involving judgment, evaluation
and selection from among several alternatives. -According to Claude

Types of decision making
There are 4 managerial decisions
a. Mechanistic decision b. Analytical decision
c. Judgmental decision d. Adoptive decision
Mechanistic decision
 Routine and repetitive in nature
 It usually occurs in a situation involving a limited number of decision variables where the
outcome of each alternative is known.
 Tools used for these kinds of decisions are charts, list, decision tree etc.
Analytical decision
 This decision helps to solve the complex problems.
 It involves a problem with a large number of decision variables where the outcome of
each decision alternatives can be computed.
 Computational techniques involve linear programming and statistical analysis.
Judgmental decision
 Decision involves a problem with a limited number of decision variables but the out of
the decision alternatives are unknown.
 These types of decision are useful in marketing investment and to solve the personal
problems.
Adaptive decision
 Decisions involving a problem with a large number of decision variables where outcomes
are not predictable.
 Such ill structured problems require contribution of many people with diverse technical
background. Eg. Research finding.
1. Nursing Administration decision making

According to Ann Bill Taylor
a. Non routine decision: made by directors of nursing. The out of the problem will be
unpredictable. Eg. Changing ways of organizing for the delivery of nursing care.
b. Routine decision: Routine decision: made by mid level and low level managers, the
outcome will be predictable. Eg. Assigning the duty roster, assign the security laws.
Generally decisions are broadly divided into two categories:
1. Typical, routine, unimportant decisions
2. Important, vital or strategic decisions
Routine decisions: Involve no extraordinary judgment, analysis and authority, since they are
dealing with less important problems. Routine decisions demand power to select the shortest
path, within the given means and ends.
Strategic decisions: Aim at determining or changing the means and ends of the enterprise. They
require a thorough study, analysis and reflective thinking on the part of administrators. Strategic
decisions are usually taken by top managers, while routine decisions are made mostly by lower
level managers.
DECISION STRATEGIES
A strategy is an artful or cleaver plan for applying technique in pursuit of a goal. Before
selecting any method of decision manager should adopt a decision strategy. Some strategy suited
for some type of problems than others, they are;
1. Optimizing: It is an approach in which an individual analyze a problem, determines desired
out comes, identifies possible solutions, predict the consequences of each actions, and select
the courses that yields the greatest amount of preferred outcomes.
2. Satisfying: It is an approach, where by an individual chooses a problem solutions, and then
select best of remaining options.
3. Mixed scanning: making a decision that satisfies to remove least promising solutions, and
then select best of remaining options.
4. Opportunistic: making a decision for the solution chosen by problem identifier.

5. Do nothing: taking decision after waiting for the storm to pass.
6. Eliminate critical limiting factor: making a decision by removing most powerful obstacle
to success.
7. Maxima: an optimistic approach in which, while assuming the highest possible p ay off
from use of any action the individual chooses that action alternative that will yield the
largest pay off.
8. Mini-regret: an approach designed to minimize the surprise resulting from any action
decision by selecting the action alternative that will yield a result midway between the most
desired and the least desired out comes.
9. Precautionary: making a decision by choosing the action that will maximize gain of
minimize loss regardless of opponents actions. It is useful when the manager engaged in a
zero sum conflict with another.
10. Evolutionary: while taking a decision individual has to make series of small changes
leading towards goal. It is based on the assumption that subordinates can better adjust to
series of small changes than a quantum leap.
11. Chameleon: taking a decision by making vague plan, adjusted to changing circumstances.
It consists of farming management decision in general terms, so that they can be interpreted,
differently at different times.
Time and basis for decision making
There are six important bases for decision making which are referred to as aids to
decision making and they include experience, authority, facts, intuition, research, analysis and
experimentation.
1. Experience: Experience is the most important and valued basis for making decisions.
Experience gives the administrator the requisite vision, that trains him to apply his
knowledge to the best of its use and that helps him to recognize the crucial factors from
unnecessary details.

2. Authority: Provides an important basis for enabling managers to take quick and sound
decisions.
3. Facts: Provide the solid basis for decision making. Decisions become wrong only when
adequate facts are not available on the problem. The computer technology has been
introduced for supplying greater facts to operating managers.
4. Intuition: It is the residuary basis for covering up deficiencies in other three bases of
decision making. It includes guess work, and common sense views.
5. Research and analysis: These are the most effective basis for choosing among alternatives.
It helps in finding out relationships among the other important variables.
6. Experimentation: This provides another means by which various alternatives can be
evaluated. Since experimentation becomes and expensive basis for decision making in many
cases, it is used sparingly for indicating the best course of actions in problems like policy
formation, product development, introduction of new organizational technique etc.
Factor affecting decision making
Internal factors
 Decision makers physical and emotional status
 Personal characteristics and values
 Past experience and interest
 Knowledge and Attitude
 Self awareness and courage
 Energy and creativity
 Resistance to change
 Sensitivity and flexibility
External factors
 Cultural environment
 Philosophical environment
 Social back ground

 Time
 Poor communication
 Cooperation
 Coordination
Steps in decision making
1. Making the diagnosis
2. Analysing the problem
3. Searching alternative solutions
4. Selecting best possible solution
5. Putting the decision into effect
6. Following up the decision
1. Making the diagnosis
The first step is to determine what the real problem is?. If the problem is not ascertained
correctly at the beginning, money and effort spent on the decision making will be a waste. The
original situation will not come under control. But new problems will start from this incorrect
appraisal of the situation.
2. Analyzing the problem
The problem should be thoroughly analysed to find out adequate background information
and data relating to the situation. This analysis may provide the manager with some revealing
circumstances that will help him to gain an insight into the problem. The whole approach should
be based around the important factors. Only pertinent and closely connected factors are selected,
as dictated by the principle of the limiting or strategic factor.
3. Searching alternative solution
After anodizing the problem attempts are made to find alternative solutions to the
problem. In the absence of alternatives decision making process will become.
4. Selecting best possible solution

Selection of one best course of action among the several alternatives developed; require
an ability to draw distinctions between tangible and intangible factors as well as facts and
guesses. The four criteria have been suggested by Dracker in selecting the best solution.
1. Proportion of risk to the expected gain.
2. Relevance between the economy of effort and the possibility of results.
3. The time considerations that meet the needs of the situation.
4. The limitation of recourses.
Instead of picking the best solution managers have to really on a course of action that is
satisfactory enough under the existing circumstances and limitations.
5. Putting the decision in to effort
The decisions can be made effective through the action of other people. In order to
overcome the opposing on the part of employee‘s managers can make three important
preparations.
a. Communication of decisions
b. Securing employee acceptance
c. The timing of decisions
6. Follow up the decision
As a safe guard against the incorrect decisions managers are required to a system of
follow up care of the decisions so as to modify them at the earliest.
Decision making authorities
1. Individual
2. Group
3. Committees

Individuals as decision makers
The autocratic manager‘s fears that decisions made by others may be more costly, less
effective and represents a threat to his/ her position. There are mainly 3 behavioural
characteristics that influence the decision making.
 Perception of the problem: it is affected by ones previous experience and value system.
 Personal value system: basic convictions about what is right, good or desirable.
 The role theory: it predicts how actions will be performed in certain roles and how it will
be affected certain circumstances. Specific behaviour associated with position constitutes
roles.
Group factors in decision making
Group comprises two or more people who share common interest and come together to
accomplish an activity through face to face interaction. Commitment to the decision and to the
implementation is important and may be increased by participation in the decision making
process.
Advantages of group participation
 Increasing self expression, innovation and development.
 Increases the commitment.
Disadvantages of group participation
 Change in the participants may create problems.
 Few people may dominate in the group.
 Members may become more interested in arguments and winning than finding a solution.
 The decisions can be most acceptable but not optional.
Committee Aspects in Decision Making
A committee a group of people chosen to deal with a particular topic or problem. It can
be formal or informal committee. A committee appointed to collect data analyze finding make
recommendations is an ‗ad hoc committee‘.

Advantages of decision making by committee
 Time consuming
 Expensive
 Indecisiveness can be result in the adjournment of the committee.
 Pressure for unanimity discourages creativity from the members.
Models of decision making
1. The Normative Model
2. The Decision Tree Model
3. The Descriptive Model
4. The Strategic Model
5. Optimizing Model
6. Satisfying Model
1. The Normative Model
This model is at least 200 years old. It is assumed to maximize satisfaction and fulfils the
―perfect knowledge assumption‖ that‖ in any given situation calling for a decision, all possible
choices and the consequences and potential outcome of each are known.‖ Seven steps are
identified in this analytically precise model:
a. Define and analyze the problem.
b. Identify all available alternatives.
c. Evaluate the pros and cons of each alternative.
d. Rank the alternatives.
e. Select the alternative that maximizes satisfaction.
f. Implement.
g. Follow up.

The normative model for decision making is unrealistic because of its assumption that there are
clear-cut choices between identified alternatives.
Vroan and Yelton‟s Normative M odel
They define decision making as a social process and emphasis how mangers work rather
than should behave in their normative way. It is used when information is rather than should
behave in their normative way. It is used when information is objective, the problem is structured
or routine, and options are known and predictable. They identified 5 alternative decision making
process:
A- Autocratic
C – Consultative
G – Group
I – First variant
II – Second variant
AI – making decision by yourself using information available to you at that time.
AII – obtain necessary information from your subordinates then decide on a solution to your
problem. But subordinates will be unaware about the problem.
CI - shares the problem with subordinates individually, and gets their ideas and suggestions.
Then you make a decision that may or may not reflect your subordinates influence.
CII- you share the problem with subordinates as a group, together you generate and evaluate
alternatives and attempt to reach agreement on a solution. You do not try to influence the group
to adopt your solutions but are willing to accept and to implement any solution that has the
support of the entire topic.
GI – is applicable only in more comprehensive models.
Vroan identified 7 rules that do most of the work of the model. Three rules protect the decision
and quality and four rules protect the acceptance.
 The information rule: If the quality of decision is important and the leader doesn‘t poses
adequate information to solve the problem then AI is eliminated from the feasible set.

 The goal congruence rule: if the quality of decision is important and the subordinates do
not share the organizational goals to be obtained in solving the problem then GII is
eliminated.
 The unstructured problem rule: If the quality of decision is important and the leader
doesn‘t poses adequate information to solve the problem and if the problem is
unstructured then eliminate AI, AII, and CI.
 The acceptance rule: If the acceptance of the decision by the subordinates is critical for
the effective implementation, if it is uncertain that an autocratic decision made by the
leader would receives the acceptance then AI, AII are eliminated from the feasible set.
 The conflict rule: if the acceptance of the decision is critical and if it is uncertain that an
autocratic decision made by the leader would receives the acceptance and subordinates
are likely to be in conflict over the appropriate solution then AI, AII, CI is eliminated
from the feasible set.
 The fairness rule: if the quality of the decision is unimportant, acceptance is critical, and
an uncertain to result from an autocratic decision. AI, AII, CI and CII are eliminated.
 The acceptance priority rule: if acceptance is critical, not assured by an autocratic
decision and if subordinates can be trusted then AI, AII, CI, and CII are eliminate.
2. The Decision Tree Model
Various adaptations of decision tree analysis are found in the literature; the essential
elements described in the 1960s are standard. All factors considered important to a decision can
be represented on a decision tree. Vroom arranged answers to seven diagnostic questions in the
form of a decision tree to identify types of leadership style used in management decision making
models. The questions focus on protecting the quality and acceptance of the decision and deal
with adequacy of information, goal congruence, structure of the problem, acceptance by
subordinates, conflict, fairness, and priority for implementation.
Magee and Brown depict decision trees as starting with a basic problem and use branches
to represent ―event forks‖ and ―action forks.‖ The number of branches at each fork corresponds
to the number of identified alternatives. Every path through the tree corresponds to a possible
sequence of actions events, each with its own distinct consequences. Probabilities of both

positive and negative consequences of each action and event are estimated and recorded on the
appropriate branch.
A1
A2
A3
Alternatives A4
Chance events Probable consequences
3. The Descriptive Model
Simon developed the descriptive model based on the assumption that the decision maker
is a rational person looking for acceptable solutions based on known information. This model
allows for the fact that many decisions are made with incomplete information because of time,
money, or people limitations, and the cause of time, money, or people limitations, and the fact
that people do not always make the best choices. Simon wrote that few decisions would ever be
made if we always sought optimal solutions. Instead, he contended, we identify acceptable
alternatives. Steps in the descriptive model are as follows:
a. Establish acceptable goal.
b. Define subjective perceptions of the problem.
c. Identify acceptable alternatives.
d. Evaluate each alternative.
e. Select alternative.
f. Implement decision.
g. Follow up.
Decision point 1

The descriptive model may lend itself well to nurses faced with daily decision making
that must be completed rapidly and with significant consequences. Steps in the model are not
unlike those in the familiar nursing process, although the sequencing is different. Readers may
readily identify conditions in their own environments similar to those described by Simon and
see immediate application of this model. Lancaster and Lancaster illustrated the use of this
model for nursing administrators.
4. The Strategic Model
Strategic decision making usually relates to long-range planning. As an example,
hospitals are beginning to merge, and certainly nursing departments will be affected. Among the
decisions that will be made are the need for one top manager or department head versus two or
more, whether to decentralize and eliminate middle managers, and what maximize the use of
scarce resources and provide for their efficient use.
Nagelkerk and Henry used a model designed by Mintzberg, Raisinghani, and Teoret (the
MRT model) to design and test the nature of strategic decision making that entailed substantial
risk. They worked with chief nurse executives employed in six acute care hospitals with 400 or
more beds each.
Supporting Activities
In decision making
Identifying
the Problem
Selecting
the Single
Best Choice
Developing
Potential
Solutions

In applying this model, participants used mixed scanning of general and specific
information from subordinates to identify complex problems. To develop potential solutions they
gathered facts from hospital documents. They made their selection of the single best solution by
 Screening solutions using predetermined criteria
 Identifying the costs and benefits as nearly as possible, and
 Selecting the single best solution.
It was concluded that top managers make these final choices using intuition, formal
analysis, and knowledge of organizational politics. In making good choices, top managers do
extensive planning, communicating, and politicking.
5. Optimizing Model
Decision maker select the solution that maximally meet the objective for a decision.
Usually this process involves assessing the pros and cons of each known outcomes as well as
listing benefits and costs associated with each option. The goal is to select the most ideal
solution. This process is most expedient and may be the most appropriate when time is an issue.
6. Satisfying Model
Decision maker selects the solution that minimally meets the objective for a decision. It is
more conservative method compared to an optimizing approach. This process is most expedient
and may be the most appropriate when time is an issue.
Tool of decision making
1. Judgemental technique
2. Operational research technique
3. Delphi technique
4. Decision tree
1. Judgmental technique
a) This is the oldest technique and subjective in decision making.
b) Based on past experience and intuition about future.

c) Useful in making routine decision.
d) Cheap and not time consuming.
e) Hazardous due to a chance for taking wrong decision.
f) Rarely used in large capital commitments.
2. Operational Research Technique (OR)
It can be defined as the analysis of decision problem using scientific method to provide
manager the needed quantitative information in making decision.
a) Operational research makes the decision analytic, objective and quantitative based.
b) Steps of OR technique
 Construction of mathematical model that pinpoints the important factor in the
situation.
 Definition of criteria to be used for comparing the relative merits of various
possible courses of action.
 Procuring empirical estimates of the numerical parameters in the model that
specify that particular situation to which it is applied.
 Carrying out through the mathematical process of finding and series of action
which will give optimal solution.
Types of Operational Research Technique
1. Linear programming: Uses linear mathematical equations to determine the best way to use
limited resources to achieve maximum results. This technique is based on the assumption
that a linear relationship exists between the variables and the limits of variation can be
calculated. Linear programming is a sophisticated short cut technique in which computers
can be used. Three conditions must be existing before linear programming must be utilized.
a. Either a maximal or a minimal value is sought to optimize the objective. The value may be
expressed in terms of cost or quantity.
b. The variables affecting the goal must have a linear relationship. The ratio of change in one
variable to the changes in the other variable must be constant.

c. Constraints to the relationship of the variable exist.
It can be used to determine a minimal cost nutrition diet or determine a class size, class
hours, and instructors in school of nursing.
2. Queuing theory: It deals with waiting lines or intermittent servicing problems. It balances
the cost of waiting versus the prevention of waiting by increasing the services. A group of
items waiting to receive service is known as a ‗queue‘. By decreasing or eliminating the
waiting line to reduce waiting line cost, there is an increase in cost of labor and physical
facilities.
3. Games theory: In normal games, each player or group of player tries to choose a course of
action which will frustrate opponent‘s action and help in winning the game. The same will
apply in the context of business by maximize his loss.
4. Programme evaluation and review technique (PERT): PERT is a network system model
for planning and control under certain conditions. It involves identifying the key activates in
a project, sequencing the activities in a flow diagram, and assessing the duration for each
phase of work.
a. It is appropriate for project work that involves extensive research and development.
b. Helps to predict time.
c. Helps to determine priorities.
d. Use of recourses can be considered when setting priorities.
e. Assignment can be changes temporarily.
f. Overtime or temporary help can be given to facilitate the activity flow.
g. Can manipulate the time required to move from one event to another.
5. Critical path method (CPM):
Closely related to PERT. Critical path method calculates a single time estimate for each
activity, the longest possible time. CPM is useful where the cost is a significant factor.

6. Computers in decision making:
In management information system computers can be used for various activities like
patient classification system, supplies and material management system, staff scheduling,
policy and procedure changes and announcements, patient charges, budget information and
management, personal records, statistical reports, administrative reports and memos etc.
3. Delphi technique
It allows members who are dispersed over a geographic area to participate in decision
making without meeting face to face. This is possible through the use of questionnaire. The
members will return the questionnaires anonymously; the results of the first questionnaire are
centrally compiled and sent to each member. Again the members are asked for suggestions.
This process continues until the consensus is reached. Little changes usually occur after the
second round.
 The Delphi technique is free from others influence.
 Doesn‘t require physical presence.
 Appropriate for scattered group.
 But it is true consuming.
4. Decision trees
A decision tree is a graphic method that can help the supervisor in visualizing the
alternatives available, outcomes, risk and information needs for a specific problem over a
period of time. It helps to see the possible directions that actions may take from each decision
point and to evaluate the consequences of a series of decisions. The process begins with a
primary decision having at least two alternatives. Then the predicted outcome of each
decision considered and the need for further decision is contemplated.
Advantages of decision making
1. It is characterized by order and direction that enables managers to determine where they
are.
2. Provide a frame work data gathering which is relevant to the decision.

3. Allows application of previous knowledge and experience that minimize errors and
improve quality of patient care and work of an organization.
4. Increase manager‘s confidence and ability in making decision.
DECENTRALIZATION
Introduction
Decentralization is the division of activities by forming departments. In nursing service,
departmentalization aims on attaining a better quality of patient care through benefits derived
from specialist nurses. Departmentalization aims to provide better arrangements, control of
facilities, equipments and materials required to perform the necessary service.
The nursing service administrator should explicitly define the standards, policies, and
scope of decision to be undertaken by top administration and those to be handled by departments
and their subunits.
Decentralization versus Centralization
The term centralized and decentralized refer to the degree to which an organization has
spread its lines of authority, power, and communication.
The centralization tends to concentrate decision making at the top level of the
organization, whereas decentralization disperses decision making and authority throughout
decision making and authority throughout and further down the organizational hierarchy. The
centralization and decentralization can be thought of as two theoretical extremes of one
continuum. In other words the decentralization is the extent of authority is passed down to lower
levels in the organization. The centralization is the extent to which authority is retained at the top
of the organization.
Complete centralization complete decentralization
Authority decentralization
Authority not delegated

Definition of decentralization
Decentralization is the dispersion or delegation of responsibilities and the authority to
lower levels of an organization. Institution makes use of both centralization & decentralization.
Top management needs a positive attitude towards decentralization and they need competent
personal to whom they can delegate authority.
Decentralized structure
The decentralized structure is flat in nature and organizational power is spread out
throughout the structure. These are few layers in the reporting structure, and managers have a
broad span of control. Communication patterns are simplified and problems tend to be addressed
with ease and efficiency at the level at which they occur. Employees have autonomy and
increased job satisfaction within this type of structure.
Dec
Decentralization (Flat, Horizontal, Participatory) Structure
Flat organizational structures are characteristic of decentralized management.
Decentralization refers to the degree of which authority is shifted downward within an
organization to its divisions, services, and units. Decentralization is delegating decision making
In nursing, as in other organizations, delegation fosters participation, teamwork, and
accountability. A first line manger with delegated authority will contact another department to
solve a problem in providing a service. The first line manager does not need to go to his or her
department head of the other service, creating a communication bottleneck. The people closest to
the problem solve it, resulting in efficient and cost effective management.
Nursing Administrator
Maternity
supervisor
Pediatric
supervisor
Surgery
supervisor
s
Nurse Nurse Nurse Nurse Nurse Nurse

Research conducted on Magnet hospitals found the most of the hospitals has a
decentralized structure in which nurses had a feeling of control over their unit work environment.
Porter O‘Grady identified the following conditions as essential for effective decentralization:
 Freedom to function effectively
 Support from Peers and leaders
 Concise and clear expectations of the work environment
 Appropriate resources
Advantages and limitations of decentralization
Advantages
The advantages of decentralization are as follows:
1. Relieves top manager from burden of managing.
2. Encourages subordinates to undertake responsibility.
3. More freedom to managers.
4. Increases motivation of subordinates.
5. Enhances competition among various departments/units.
6. Helps setting up of profit centres.
7. Promotes development of general managers.
8. Prepares mangers for rapid change in the organization.
Limitations
The limitations of decentralization are as follows:
1. Maintenance of uniform policy throughout organization becomes difficult.
2. Increases complexity of coordination.
3. May lead to loss of control by superior level managers.
4. May be limited by inadequate control techniques.
5. May be constrained by inadequate planning.

6. Limited by inadequate training.
7. Limited by inadequate number of qualified personnel at lower level.
8. It may be limited by external factors like; government regulations, taxation policy of
government, etc.
Concepts of management
The concept of management is not fixed. It has changing according to time and circumstances.
The concept of management has been used in integration and authority etc.
The concept of management.
The concept of management is not fixed. It has changing according to time and circumstances.
The concept of management has been used in integration and authority etc. Different authors on
management have given different concepts of management. The main concepts of management
are as follows:
Functional Concept:
According to this concept 'management is what a manager does'. The man followers of this
concept are Louis Allen, George R. Terry, Henry Fayol, E.F.L. Brech, James L. Lundy, Koontz
and O. Donnel, G.E Milward, mcfarland etc. The functional concept as given by some of the
authors is given below:
I. Louis Allen, "Management is what a manager does."
II. James L. Lundy, " Management is principally the task of planning, coordinating, motivating
and controlling the effort of others towards a specific objective. Management is what
management does. It is the task of planning, executing and controlling."
III. George R. Terry, "Management is a distinct process consisting of planning, organizing,
activating and controlling performed to determine and accomplish the objective by the use of
human beings and other resources."
IV. Howard M. Carlisle, "Management is defined as the process by which the elements of a
group are integrated, coordinated and/or utilized so as to effectively and efficiently achieve
organizational objectives."
V. Henry Fayol, "To manage is to forecast, and plan, to organize, to command, to coordinate and
to control."

'Getting Things Done Through Others' Concept:
According to this concept, 'Management is the art of getting things done through others'.
It is very narrow and traditional concept of management. The followers of this concept are
Koontz and O Donnell, Mooney and Railey, Lawrence A. Appley, S. George, Mary Parker Follet
etc. Under this concept, the workers are treated as a factor of production only and the work of the
manager is confined to taking work from the workers. He need not do any work himself. Modern
management experts do not agree with this concept of management. Some of these authors have
explained this concept in the following words:
I. Mary Parker Follet, "Management is the art of getting things done through others."
II. Harold Koontz, "Management is the art of getting things done through and wit people in
formally organized groups. It is the art of creating and environment in which people can perform
as individuals and yet cooperate towards attaining of group goals.
III. J.D. Mooney and A.C. Railey, "Management is the art of directing and inspiring people."
Leadership and Decision-making Concept:
According to this concept, "management is an art and science of decision-making and
leadership." Most of the time of managers is consumed in taking decisions. Achievement of
objects depends on the quality of decisions. Similarly, production and productivity both can be
increased by efficient leadership only. Leadership provides efficiency, coordination and
continuity in an organization. Leadership and decision-making concept as given by some authors
is given below:
I. Donald J. Clough, "Management is the art and science of decision-making and leadership".
II. Ralph, C. Davix, "Management is the function of executive leadership anywhere."
III. Association of Mechanical Engineers, U.S.A., "Management is the art and science of
preparing, organizing and directing human efforts applied to control the forces and utilize the
materials of nature for the benefit to man."
IV. F.W. Taylor, "Management implies substitution of exact scientific investigation and
knowledge for the old individual judgment or opinion, in all matters in the establishment."
Productivity Concept:
According to this concept, "management is an art of increasing productivity."
Economists treat management as an important factor of production. According to them,
"Management is also a factor of production like land, labor, capital and enterprise." The main
followers of this concept of management are John F. Mee, Marry Cushing Niles, F.W. Taylor
etc. The productivity concept, as given by the authors is given below:

I. Jon, F. Mee, "Management may be defined as the art of securing maximum prosperity with a
minimum of effort so as to secure maximum prosperity and happiness for both employer and
employee and give the public the best possible service."
II. F. W. Taylor, "Management is the art of knowing what you want to do in the best and
cheapest way."
III. Marry Cushing Niles, "Good management achieves a social objectives with the best use of
human and material energy and time and with satisfaction of the participants and the public.
Universality Concept:
According to this concept, "Management is universal". Management is universal in the sense that
it is applicable anywhere whether social, religious or business and industrial. The followers of
this concept are Henry Fayol, Lawrence A. Appley, F.W. Taylor, Theo Haimann etc. According
to-
I. Henry Fayol, "Management is an universal activity which is equally applicable in all types of
organization whether social, religious or business and industrial".
II. Megginson, "Management is management, whether it is in Lisbon, or in London or in Los
Angeles."
III.Theo Haimann, "Management principles are universal. It may be applied to any kind of
enterprises, where the human efforts are coordinated."
Management is principally the task of planning, coordinating, motivating, and controlling the
efforts of others towards a specific objective. -James lundy 1963
Management is the creation and control of technological and human environment of an
organization in which human skill and capacities of individuals and groups find full scope for
their effective use in order to accomplish the objective for which an enterprise has been set up. It
is involved in the relationship of the individual, group, the organization and the environment.
-A dasgupta 1969
Management is a good planning, organizing directing, co ordinating and controlling to eliminate
chaos, errors and waste and get better utilization of manpower and materials.
-George A Melresh
Management is the process and agency which directs and guides the operations of an
organization on the realizing established aims.

NURSING MANAGEMENT
MISSION STATEMENTS
A Mission Statement defines the organization's purpose and primary objectives. Its prime
function is internal – to define the key measure or measures of the organization‘s success – and
its prime audience is the leadership team and stockholders. Mission statements are the starting
points of an organisation‘s strategic planning and goal setting process. They focus attention and
assure that internal and external stakeholders understand what the organization is attempting to
accomplish.
Dimensions of Mission statements:
According to Bart, the strongest organizational impact occurs when mission statements contain 7
essential dimensions.
 Key values and beliefs
 Distinctive competence
 Desired competitive position
 Competitive strategy
 Compelling goal/vision
 Specific customers served and products or services offered
 Concern for satisfying multiple stakeholders
 The mission statement of an; organization describes the purpose for which that
organization exists.
 Mission statements provide information and inspiration that clearly and explicitly outline
the way ahead for the organization. They provide vision.
 Individuals want productive and meaningful lives .therefore, the purpose of the
organization and of each of its units should be defined a teamwork approach should be
properly trained: and all individuals within the organization should be treated with
respect.
 Organizational purpose moves and guides the organization toward a perceived goal.
 Many writers indicate that the purpose or mission statement should be created from
mission statement should be properly trained and all individual s within the organization
should be treated with respect.
 Organizational purpose moves and guides the organization toward a perceived goal.
 The mission or purpose statement incorporates the culture of the organization, including
strong leadership, rules and regulations, achievement of goals, and the notion that people
are more important than work.

 Employees who participate in developing the vision statement believe in their own
abilities and are more committed to the organization.
 The vision statement is shared companywide so that employees live the vision.
 The mental exercise of creating one is more meaningful than the contents of the statement
itself. Vision, values, mission or purpose statements are meaningful only to the creators.
VISION
 Employees who participate in developing the vision statement believe in their own
abilities and are more committed to the organization than employees who do not
participate.
 The vision statement is shared companywide so that employees may live the vision. It is
updated to keep pae with technology and trends. A vision statement is sometimes.
 The mental exercise of creating one is more meaningful than are the contents of the
statement itself.
 Vision values, mission, or purpose statements are meaningful only to the creators.
 Translated for the community, these statements place value on the way nurses care for
people.
 It follows that ethnic populations are considered in developing vision and values
statements for nursing entities. Nursing education teaches the meaning of values such as
tolerance and compromise.
 Examples of values are informality, creativity, honesty, quality, courtesy, and caring.
Philosophy
 Cost effectiveness
In management or administration of any enterprises for organization, the quality,
quantity, timing and cost of the necessary to reach the objective of the enterprises are
interrelated factor which must be given constant attention.
 Execution and control of work plan:
One of the greatest possible contributors to wastage of our precious recourses, whether at
the local or national level, is the failure of those at any level of administration, and at all
stages in the management of the activity, to base all decision on verifiable facts.
 Delegation of responsibility and authority:
The delegation of responsibility and authority is an important aspect of successful
administration, to place the responsibility for decision at the lowest possible
organizational level in order to attain decision as speedily as possible.
 Human relation and good morale:
Since the function of administration is to attain an established objective through the
management of people, administration if deeply concerned with human relation. Good
morale of the staff is essential to the success of any organization.

 Effective communication:
Effective communication are essential for all aspect of effective administration .staff
must be adequately and correctly informed about plan, methods ,schedules, problems
events and progress.
 Flexibility:
Administrators must be completely flexible to meet the changing needs of the
situation.
TRENDS IN NURSING ADMINISTRATION
I. Historical and
II. Educational trends
I. HISTORICAL
 Late nineteenth century.
 Beginning of twentieth century
 Early twentieth century to 1946
 The post independence period
LATE NINETEENTH CENTUR. The states of nursing that today had its beginning in
madras around the 17‘s in the 19TH
century. This started with training for women for
improving nursing in military hospitals.
BEGINNING OF TWENTIETH CENTURY: The trend set in the late 19th
century
found its effect in the period .by the start of this century we find establishment of nursing
training by the start of this century we find establishment of nursing training centers.
1905: The association of nursing superintend was formed .
The missionary nurses were meeting has members of the medical missionary
association of India set up by the missionary doctors in 1905.
1908: The association of nursing of superintends broadened its scope and the trained
nurses‘ and association of India (TNAI) was found this year.
1909-1912: SAW The publication of nursing journals of India this provided a forum for
sharing of ideas and experience.

Filling the need for systematic preparation of nurses for better patients care services from
1909 the north India board was set up by the missionary nurses and are the medical
association of India in 1911.
The early 20th
century to 1946
1926: The first nurses registration at was enacted in madras presidency.
1934: The Bengal nurses act was enacted for the nurses midwives and health visitors of
undivided Bengal.
1936: The mid-India board of education was formed in 1934 and was affiliated to
Christian nurses league in 1936.
1939: By this time we need all the provinces in India except Assam had nursing councils
1920-1940: It will be interest for you to know that during 1920 to 1940 nursing was
lapping forward in the Weston countries nurses in India to did not want to lag behind.
1940-1946: The Second World War ravaged the world during this period. For obvious
regions expansions‘ of military and civil hospitals took place during the war years.
1943: Commissioned rank was given to the Indian military nursing systems.
1941 -46: During the period the state nursing services with standardized pay scales and
terms of services were established in madras in UP (1944)
1946: The university nursing programmed leading to bachelors degrees in nursing were
lunched at the college of nursing ,Delhi and Christian medical college Vellore under delhi
and madras university respectively.
1947: We earned our independence on august 15th
in 1947. Two nations were also burned
in this date, this brought on foreseen change in its wake, which has responsible for
bringing many human in to the field of nursing.
1949: The first meeting of India nursing council was held
1950: This also replaced the various junior grade courses in nursing and midwifery in the
standardized courses shorter and simpler than the sinuous nursing and senior midwifery
courses
1953: The registering nurses trained in countries were no reciprocal registration existed,
and maintained Indian nurses register.

1963: A WHO assisted technical project was undertaken at the INC revise general
nursing midwifery.
1965: A WHO publication on guide for schools of nursing in India came out this year.
This period also saw the formation of many commissions and commits to recommended
nurses for improving the health care delivery systems
1. The health service development committee
2. The health serving planning committee
3. The committee to review conditions of service.
4. Chad‘s committee
5. Mukerjee committee.
6. Mukerjee committee.committe
7. Jungalwala karthar singh committee.
8. Srivasthav committee.
Educational trends
 FMHW Programme :
1. Meant to work at sub centers.
2. Main thrust: MCH service, implementing intervention of national health
programme.
3. Including IMR, MMR child mortality rates.
 Old ANM programme
1. Meant to meet the demands generalized service
 GNM programme
 Bachelor‟s degree programme .
 Post certificate diploma programme in
1. Public health nursing
2. Psychiatric nursing
3. Pediatric nursing
4. Cancer nursing
5. Nursing education and administration
6. Other nursing specialities

 M.Sc.
 M Phil
 PhD programmes
1. University of Delhi.
2. Jawaharlal Nehru University.
3. Calcutta university
4. MGR university of health science, madras
5. Madras university
6. IGNOU
7. RGUHS
8. MANGALORE UNIVERSITY
9. SNDT university
10.Punjab university, Chandigarh
11.MAHE- maniple
 Central institutions.
1. AIIMS ,New Delhi
2. All India institute of hygiene and public health, Calcutta
3. PGI, Chandigarh
4. IPGMER, Pondicherry
5. MAHE, maniple
6. NIMHANS, Bangalore.
7. NIHFW, New Delhi.
ISSUES IN NURSING ADMINISTRATION
A. Profession of NSG :
The issue related to nursing are.
 Status of nursing in society in the health care delivery system.
 Values reflected in our nursing performances.
 Attitude, human approach.
 Quality in nursing vis-vis education and practice.
 Unique function of nursing.
 Different levels of nurses that we need in our country.
 Define and delineation of nursing functions at the different level.

B. Nursing education :
 Taken in to consideration the national health policy goals and
programme‘s
 Shifted its emphasis from traditional to community health oriented
approach and re-oriented nursing circular accordingly.
 Be making sincere efforts to prepare nurses for the job they are
accepted to perform in their work field in terms of appropriate skills,
knowledge and right attitude and the desired behaviour patterns
reflecting the values for caring and at the level of .
 Been preparing nurses keeping in the status and countries health
needs in minds.
 Made studies on our west countries nursing training needs and
training load.
C. Nursing practice :
 In the community setting and
 In the institutional setting at the level of primary, secondary, and
tertiary levels of care.
 Are nurses as matter of policy conceited in all matters related
decisions area for nursing practice?
 Can it be said that nursing service rendered reflect quality of nursing
care do there have the necessary back up support from the system for
performing the way they are required to perform.
 Are the nurses aware of the shift of emphasis on the primary health
care approach.
D. Nurse themselves:
 Long hours of duties with very little time for recreation.
 Non availability of health care programme of nurses.
 Pressure from influence people
 Non involvement of nurses in nursing matters.
 Poor pay structures.
 Lack of security and safety.
 Non availability of basic communities like toilet facility, in
residential accommodation of community nurses.

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

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

2) Gantt Henry I. Gantt (1861-1910):
Gantt was concerned with problems related to efficiency. He contributed to scientific
management by refining the previous work of Taylor than introducing new concepts.
1. He studied the amount of work planned or completed on one axis to the time
needed or taken to complete a task on the other axis.
2. Gantt also developed a task and bonus remuneration plan whereby workers
received a guaranteed day‘s wages plus a bonus for production above the standard
to stimulate higher performance.
3. Gantt recommended to select workers scientifically and provided with detailed
instructions for their tasks.
4. He argued for a more Humanitarian approach by management, placing emphasis
on service rather than profit objectives.
5. He recognized useful non –monetary incentives such as job security and
encouraging staff development.
3) Emerson (1853-1936):
His emphasis was on conservation and organizational goals and objectives.
He defined principles of efficiency related to:
1. Interpersonal relations and to system in management.
2. Goals and ideas should be clear and well-defined as the primary objective is to
produce the best product as quickly as possible at minimal expense.
3. Changes should be evaluated-management should not ignore ―commonsense‖ by
assuming that big is necessarily better.
4. ―Competent counsel ―is essential.
His theory explains about
1. Management can strengthen discipline or adherence to the rules by justice, or
equal enforcement on all records, including adequate, reliable and immediate
information about the expenses of equipment and personnel should be available as
a basis for decisions.
2. Dispatching or production scheduling is recommended.
3. Standardized schedules, conditions and written instructions should be there to
facilitate performance.
4. ―Efficiency rewards ―should be given for successful completion of tasks.
5. Emerson moved further beyond scientific management to classic organizational
theory.
4. Charles Babbage (1792-1871): Charles Babbage ,a scientist mainly interested in
mathematics, contributed to the management theory by developing the principles of cost
accounting and the nature of relationship between various disciplines. Charles

Babbage laid the foundation for much of the work that later come to be known as
scientific management. He concentrated on production problems and stressed the
importance.
1) Division and assignment of work on the basis of skill and
2) The means of determining the feasibility of replacing manual operations with
automatic machinery.
B. CLASSIC ORGANIZATIONAL THEORY:
Importance of classic organization theory:
 The classic administration-organization thinking began to receive attention in
1930.
 Organization is viewed as whole rather than focusing solely in production.
 The concepts of scalar levels, span of control, authority, responsibility,
accountability, line staff relationships, decentralization, and
departmentalization become prevalent.
Three pioneers of Classic organizational theory:
1) Henry Fayol (1841-1925):
Fayal was a French industrialist known as father of the management process
school concerned with management of production shops. He studied the functions of
managers and concluded that management is universal.
Functions of management:
1. Planning policies, programs and procedures.
2. Organization based on hierarchy of authority
3. Directing the business in order to gain optimum return from all workers.
4. Coordination, signifying harmony in activities of the organization and to
facilitate its working
5. Control, the errors of the functionaries of organization and ensure that such
errors do not occurs.
Fayol divided all the work carried out in a business enterprise into the following
categories.
1. Technical activities (production, manufacture, etc)
2. Commercial activities (buying, selling, personnel, and industrial relations)
3. Financial activities( to have optimum use of capitals)
4. Security activities(production of property and persons)
5. Managerial activities(planning organizing, commanding, directing, coordination
control, communication, motivation .leadership)

Principles by which good organization can be recognized. They are as follows:
1. The number of organization units should be the minimum needed to cover the
major enterprise functions.
2. All related functions should be combined within one unit.
3. The number of levels of authority should be kept to a minimum.
4. There should be room for initiative with the limit of his assigned authority.
5. Functions should be assigned so as to minimize cross relations between
organizational units.
6. No more employees should report to a superior than he can effectively direct and
coordinate.
2) Max Webber theory (1864-1920):
He is German psychologist. He earned the title of father of organizational theory.
His emphasis was on rules instead of individuals and on competencies over favoritism.
His conceptualization was on bureaucracy, structure of authority that would facilitate the
accomplishment of organizational objectives:
The three basis for authority:
1. Traditional authority, which is accepted because it seems things have always been
that way such as the rule of a king in a monarchy.
2. Charisma, having a strong influential personality.
3. Rational legal authority which is considered rational in formal organizations
because the person has demonstrated the knowledge, skills and ability to fulfill the
position.
3) James Mooney Theory (1884-1957):
Moony believed that management to be the technique of directing people and
organization the technique of relating functions. Organization is managements
responsibility.
Four universal principles:
1. Coordination and synchronization of activities for the accomplishment of goal.
2. Functional affects the performance of one‘s job description.
3. Scalar process organizes level of commands.
4. Arrange authority in to a higher Archie.
Consequently people get their right to command from their position in the
organization.

C. HUMAN RELATION THEORY:
The human relations movement began in 1940s.
 Focused on the effect that the individuals have on the success or failure of an
organization.
 Classic organization and management theory concentrated on the physical
environment fail to analyze the human element.
Instead of concentrating on the organizations structure, managers encourage workers to
develop their potentials and help them meet their needs for
 Recognition
 Accomplishment
 Sense of belonging
1). Follett theory (1868-1933):
1. Follett stressed the importance of coordinating the psychological and sociological
aspects of management in 1920s.
2. She perceived the organization s a social system and management as a social
process.
3. Indicated that legitimate power is produced by a circular behaviour where by
superiors and subordinates mutually influence one another.
4. The law of the situation dictates that a person does not take orders from another
person but from the situation.
2). Lewin theory (1890-1947):
1. Lewin focused on the Group dynamics.
2. He maintained that groups have personalities of their own: composites of the
member‘s personalities.
3. He showed that group forces can overcome individual interests.
D. BEHAVIORAL SCIENCE THEORY:
Emphasis is on:
1. Use of scientific procedures to study the psychological,
2. Sociological,
3. Anthropological aspects of human behaviour in organization.
Behavioural Science Indicated:
1. The importance of maintaining a positive attitude toward people,
2. Training managers,
3. Fitting supervisory actions to the situation,

4. Meeting employees needs.
5. Promoting employees sense of achievement,
6. Obtaining commitment through participation in planning and decision making.
1) Douglas McGregor‟s Theory (1932):
McGregor‘s is the father of the classical theory of management which termed
theory. He developed the managerial implications of Maslow‘s theory. He noted that
one‘s style of management is dependent on ones philosophy of humans and categorized
those assumptions as theory X and theory Y.
Theory X
1. The manager‘s emphasis is on the goal of organization.
2. The theory assumes that people dislike work and avoid it.
Consequence of theory X
 Workers must be directed
 Controlled
 Coerced
 Threatened
So that organizational goals can be met.
According to theory X
1. Most people want to be directed and to avoid responsibility because they have
little ambition.
2. They desire security.
Managers who accept the assumption of theory X
1. Will do the thinking and planning with little input from staff associates.
2. They will delegate little, supervise closely.
3. Motivate workers through fear ad threats
4. Failing to make use of the workers potentials.
Theory Y
It is focuses on goal.
1. People do not inherently dislike the work and that work can be a source of
satisfaction.
2. Workers have the self direction and self control necessary for meeting their
objectives.
3. Will respond to the rewards for the accomplishment of those goals.

Managers who believe in this Y theory:
1. Will allow participation
2. They will delegate
3. Give general supervision than close supervision
4. Support job enlargement
5. Use positive incentives such as praise and recognition.
They believe that under favourable conditions: people seek responsibility and display
imagination, unity and creativity. According to theory Y human potentials are only
partially used.
2).Rensis Likert‟s theory:
Dr Rensis Likert has studied human behaviour within many organisations. After
extensive research, Dr. Rensis Likert concluded that there are four systems of
management. According to Likert, the efficiency of an organisation or its departments is
influenced by their system of management. His theory of management is based on his
work at the University of Michigan‘s institute for social research.Likert categorised his
four management systems as follows;
He identified three variables in organizations.
1. The casual variable includes leadership behaviour.
2. The intervening variables are perceptions, attitudes and motivations.
3. The end results variables are measures of profits, costs and productivity.
Factors measured by likert scale
The scale measures several factors related to leadership behaviour process:
 Motivation
 Managerial
 Communication
 Decision making process
 Goal setting
 Staff development
Four types of management system according to likert, effcets on the management
systems:
a). Exploitive-authoritative:
1. He associates the first system with the least effective in performance.
2. Managers show less confidence in staff associates and ignore their ideas.
3. Consequently staff associates do not feel free to discuss their jobs with their
managers

b). Benevolent- authoritative:
1. Staff associates ideas are sometimes sought, but they do not feel free to discuss
their jobs with the manager.
2. Top and middle management are responsible for setting goals.
3. There is minimal communication. Mostly downward and received with suspicion.
4. Decisions are made at the top with some delegation.
c). Consultative system:
1. The manager has substantial confidence in staff associates.
2. Their ideas are usually sought.
3. They fell free to discuss their job with the manager.
4. Goal setting is fairly general.
5. It has limited accuracy and accepted with some caution.
6. Broad policy is set at the top level.
7. There are decisions making throughout organization.
8. Control functions are delegated to lower level where.
9. Reward and self guidance are used.
10.There is some resistance from informal groups in the organization.
d) Participative group:
Group Participative is the most effective performance. Managers have complete
confidence in their staff associates. Their ideas are always sought, and they feel
completely free to discuss their jobs with the manager. Goals are set at all levels. There is
a great deal communication- upward, downward, and later that is accurate and received
with open mind.
E. MODERN MANAGEMENT THEORIES:
The modern era is characterized by trends in the management through viz:-
1. Microanalysis of human behaviour, motivation, group dynamics leadership
leading to many theories of organization.
2. The macro search for fusion of the many systems in business organization-
economic social technical political and quantitative methods in decision- making.
Modern management theories era can be father classified as the three streams viz:
1. Quantitative approach
2. System approach
3. Contingency approach
Indicating further refinement, extension and synthesis of all the classical and neo-
classical approaches to management.

1. Quantitative approach: Management science refers to the application of Quantitative
methods to management. Management science has an interdisciplinary basis in other
words management science is a combination and interaction of different scientists.
2. System approach:-according to system approach the organization is the unified,
purposeful systems composed of interrelated parts and also interrelated with its
environment. Each unit must mesh/ interact with the organization as a whole, each
manager most interact/ communicate and deal with executives of other unites and the
organization itself must also interact with other organizations and society as whole.
An open system model
Ludwing Von Bertanffy:
Bertanffy, a biology is credited with coining the general system theory. His contention
were that it was possible to develop a theoretical framework for describing relationship in
the real world and different disciplines with similarities could be developed into a general
systems model. The similarities were:
1. Study of organization
2. State of equilibrium
3. Openness of all systems and their influence o the environment and environment
influence on the system.

3. Contingency approach:
 The contingency approach can be described as the behavioural approach.
 Contingency theory does not prescribe the application of certain management
principles to any situation.
 Contingency theory is recognition of the extreme importance of individual
manager performance in any given situation.
 It rests on the extent of manager power and control over a situation and the degree
of uncertainty in any given situation.
 The role of management in the contingency approach is to develop an appropriate
management solution for any given organizational environment.
 It is principally directed at the management practitioner seeking to control a
distinct Organizational environment.
Luther Gulick:
He was influenced by Taylor and Fayol. He used Fayal‘s five elements of
administration viz.Planning,Organizing,Command,Coordination and Control as a
frame work for his neutral principles. He condensed the duties of administration into a
famous acronym‖POSDCORB‖.Each letter in the acronym stands for one of the seven
activities of the administrator as given below:
 Planning (P): working out the things that need to be done and the methods for
doing them to accomplish the purpose set for the enterprise.
 Organising (O): establishment of the formal structure of authority through which
work subdivisions are arranged, designed and coordinated for the defined
objective.
 Staffing (S): the whole personnel function of bringing in and training the staff, and
maintaining favourable conditions of work.
 Directing (D): continuous task of making decisions and embodying them in
specific and general orders and instructions, and serving as the leader of the
enterprise.
 Coordinating (CO): all important duties of interrelating the various parts of the
work.
 Reporting (R): keeping the executive informed as to what is going on, which
includes keeping himself and his subordinates informed through records, research
and inspection.
 Budgeting (B): all that goes with budgeting in the form of fiscal planning,
accounting and control.
Luther Gulick was very much influenced by Fayal‘s 14 basic elements of administration
in expressing his principles of administration as follows:

1. Davison of work or specialization
2. Bases of departmental organization
3. Coordination though hierarchy
4. Deliberate coordination
5. Decentralization
6. Unity of command
7. Staff and line
8. Delegation
9. Span of control
Lyndal urwick:
Lyndal urwick also one of the among classical theorist, attached more important to the
structure of organization than the role of the people in the organization.
Lyndal urwick concentrated his efforts on the discovery of principles and identified eight
principles of administration applicable to all organization as given below:
1. The ―principle of objective‖-that all organizations should be an expression of a
purpose.
2. The ―principle of correspondence‖-that authority and responsibility must be co-
equal.
3. The ―principle of responsibility‖-that the responsibility of higher authorities of the
work of subordinates is absolute.
4. The ―scalar principle‖-that a paramedical type of structure is build up in an .
5. The ―principle of span control‖-
6. The ―principle of specialization‖-limiting ones work to single function.
7. The ―principle of coordination‖-
8. The ―principle of definition‖-clear prescribed of every duty.
4. Critical theory versus critical thinking:
Steffy and Grimes note that a strict natural science approach to social science is native,
since subjective or qualitative analysis is important to quantitative research. This holds
true for management and, consequently for nursing management. The authors suggest a
critical theory approach to organizational science rather than a phenomenological or
hermeneutic approach.
Phenomenological approach uses second order constructs ―interpretations of
interpretation. ―The nurse manager would interpret the meaning of nursing of nursing
management experience or observations and arrive at a nursing management theory from
aggregate of meanings.

Hermeneutic approach is the art of textual interpretation. She would consider the specific
context and historic dimensions of data collected, and would reflect on the relationship
between theory and history.
Critical theory: Critical theory is an empirical philosophy of social institutions. It is
translated into practice by decision makers, in these case nurse managers. It includes
organizational development, management by objectives or results, performance appraisal,
and other practice- oriented activities performed by managers.
Aims:
 To critique the ideology of scientism, ―the institutionalized form of reasoning
which accepts the idea that the meaning of knowledge is defined what the sciences
do and thus can be adequately explicated through analysis of sciencetific
producers.
 ‗To develop an organizational science capable of changing organizational
processes. ―it is used the practice of clinical nursing and nursing management.
Critical thinking: Concept analysis is advocated as a strategy for promoting critical
thinking. The rudiments of critical thinking: recalling facts, principles, theories, and
abstractions to make deductions, interpretations, and evaluations in solving problems,
making decisions, and implementing changes. Concept analysis uses critical thinking to
advance the knowledge base of nursing management as well as nursing practice.
Definition: critical thinking is reflecting on a situation, a plan an event under the rule of
standards and antecedent to making a decision.
(Mackenzie)
Critical thinking is both a philosophical orientation toward thinking and a cognitive
process characterized by reasoned judgment and reflective thinking.
(Jones and brown)
Abraham H. Maslow (1908-1970)
• Receiving his doctorate in psychology, Abraham Maslow was the first psychologist to
develop a theory of motivation based upon a consideration of human needs.

Maslow‟s theory of human needs has three assumptions
Factor within Person
Maslow‘s need hierarchy
– Physiological. The need for food, drink, shelter and relief from pain
– Safety and Security. The need for freedom from threat, that is, the security from
threatening events or surroundings.
– Belongingness, Social and love. The need for friendship affiliation interaction
and love
– Esteem. The need for self-esteem and for esteem from others
– Self- Actualization. The need for fulfill oneself by making maximum use of
abilities skills and potential.
Human needs are never
completely satisfied
Human behaviour is
purposeful and is motivated
by need satisfaction.
Hierarchical structure of
importance from the lowest to
highest

Douglas McGregor (1906-1964)
• McGregor is the other major theorist associated with the Human Relations School of
management.
• McGregor believes there are two basic kinds of managers. One type of manager, Theory
X, has a negative view of employees assuming they are lazy, untrustworthy and incapable
of assuming responsibility while the other type of Manager,
• Theory Y, assumes employees are trustworthy and capable of assuming responsibility
having high levels of motivation.
Herzberg‟s two factor theory:
This theory was developed in 1959.It is based on realisation that work motivation and
job-satisfaction are two dimensions that influence the productivity of an employee.
Herzberg‘s finding that good working conditions, adequate salary, good physical
facilities, good human relation, quality of supervision might contribute to job satisfaction,
of employees, which are‖ hygiene‖ factors. Whereas factors like recognition of work
done, status, opportunities for growth, challenging task, play an important role in creating
work motivation for employees, which are the motivation factors.ltter, many authors
interpreted that all the motivation factors described by Herzberg do not give equal
amount of satisfaction to all employees.
Implications of management theories in nursing:
1. Taylor‘s theory can be implemented in nursing to study complexity of care and
determine staffing needs and observe efficiency and nursing care.
2. Nurses can utilize Emerson‘s theory of early notion of the importance of
objectives setting in an organization.
3. Nurses should be aware of the managerial tasks as defined by Fayol: Planning,
Organizing, Directing, Coordinating and Controlling.
4. The theory of human relations of Follett and Lewin emphasise the importance for
nurse managers to develop staff to their full potential and meeting their needs for
recognition, accomplishment and sense of belonging.
5. Mc Gregon and Likert support the benefits of positive attitudes towards people,
development of workers, satisfaction of their needs and commitment through
participation.

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

PLANNING
INTRODUCTION
Planning is a deliberative, systematic phase of the nursing process that involves decision
making and problem solving. In planning the nurse refers to the client‘s assessment data and
diagnostic statements for direction and formulating client goals and designing the nursing
strategies required to prevent, reduce or eliminate the client‘s health problems.
ROGRAM EVALUATION AND REVIEW TECHNIQUE (PERT)
Meaning
The program evaluation & review technique (PERT) was developed by the Special Projects
Office of the U.S. Navy and applied to the planning &control of the Polaris Weapon system in
1958. It worked then, it still works; and it has been widely applied as a controlling process in
business & industry.
PERT uses a network of activities. Each activity is represented as a step on chart. It is an
important tool in the timing of decisions. In simplest form of PERT, a project is viewed as a total
system and consisting of setting up of a schedule of dates for various stages and exercise of
management control, mainly through project status reports on this progress.
Program Evaluation & Review Technique includes:
1. The finished product or service desired
2. The total time & budget needed to complete the project or program.
3. The starting date & completion date.
4. The sequence of steps or activities that will be required to accomplish the project or program.
5. The estimated time & cost of each step or activity.
Steps for accomplishing the project are:
a. The optimistic time: This occasionally happens when everything goes right.
b. The most likely time : It represents the most accurate forecast based on normal developments.
c. The pessimistic time: This is estimated on maximum potential difficulties.

Calculation of the ―critical path‖ , the sequence of the events that would take the greatest
amount of time to complete the project or program by the planned completion date. The reason
this is the critical path because it will leave the least slack time.
USES
Why should nurse managers use the PERT system for controlling?
1. It forces planning and shows how pieces fit together.
2. It does this for all nursing line managers involved.
3. It establishes a system for periodic evaluation & control at critical points in the program.
4. It reveals problems & is forward- looking.
5. PERT is generally used for complicated & extensive projects or programs.
6. Many records are used to control expenses and otherwise conserve the budget.
These include personnel staffing reports, overtime reports, monthly financial reports and
others. All these reports should be available to nurse managers to help them monitor, evaluate,
and adjust the use of people and money as a part of the controlling process.
Modern and Philips enlist the advantages of PERT:
1. It encourages logical discipline in planning, scheduling and control of project.
2. It encourages more long range & detailed project planning
3. It provides a standard method of documenting and communicating project plans, schedules,
and time and cost- performance.
4. It identifies the most critical elements in the plan, thus focusing management attention .i.e.
most constraining on the schedule.
5. It illustrates the effects technical procedural changes on overall schedules.
GANTT CHARTS
Early in this century Henry L. Gantt developed the Gantt Chart as a means of
controlling production. It depicted a series of events essential to the completion of a project or
program . It is usually used for production activities.
Figure shows a modified Gantt chart that could be applied to a manager nursing administration
program or project. The 5 major activities that the nurse administrator has identified are
segments of a total program or project.

It could be applied to a project such as implementing a modality of primary nursing or
implementing case management.
These are possible nursing actions for a project:
1. Gather data
2. Analyze data
3. Develop a plan
4. Implement the plan.
5. Evaluation, feedback, and modification
Figure is an only an example .Application of these controlling process by nurse managers
would be specific to the project or program, and the time elements for the various activities
would vary with each. Also these 5 major activities with estimated completion times. The nurse
manager‘s goal is to complete each activity or phase on or before the projected date.
MBO (Management by Objectives)
Management by objectives (MBO) is a process whereby superiors &
subordinates jointly identify the common objectives ,set the results that should be achieved by
subordinates, asses the contribution of each individual, and integrate individuals with the
organization so as to make best use of organizational resources.
Definition
―MBO is a comprehensive managerial system that integrates many key
managerial activities in a systematic manner, consciously directed toward the effective &
efficient achievement of organizational objectives.‖
―MBO is a result centered, non-specialist, operational managerial process for the
effective utilization of material, physical & human resources of the organization by integrating
the individual with the organization & organization with the environment.‖
Objectives of MBO:
1. To measure and judge performance
2. To relate individual performance to organizational goals
3. To clarify both the job to be done and the expectations of accomplishment
4. To foster the increasing competence & growth of these subordinates
5. To enhance communication between superior and subordinates
6. To serve as a basis for judgments about salary and promotion
7. To stimulate the subordinates motivation and
8. To serve as a device for organizational control and integration.

Characteristics of MBO
1. MBO is an approach & philosophy to management & not merely a technique.
2. On the other hand, MBO is likely to affect every management technique. MBO
employs several technique but it is not merely the sum total of these techniques. It is a
way of thinking about management.
3. MBO is bound to have some relationship with every management technique. Certain
degree of overlapping is there. In fact often MBO provides the stimulus for the
introduction of new techniques of management & enhances the relevance & utility of
the existing ones.
4. The basic emphasis of MBO is an objectives.MBO is also concerned with
determining what these results & resources should be. This MBO tries to match
objectives & resources.
5. The MBO is characterized by the participation concerned managers in objective
setting, the performance reviews, and his performance.
6. Periodic review of performance is an important feature of MBO.
7. Objectives in MBO provide guidelines for appropriate systems procedures.
Steps in process of MBO
1. Setting of Organizational Purpose & Objectives
2. Identify the Key Result Areas(KRAs)
3. Establishment of the objectives of the supervision
4. Recommending objectives for the subordinates by the superiors.
5. Setting subordinates objectives
6. Periodic review of the performance of the subordinates.
7. Review of the performance by the superiors.
8. Final review of performance by the superiors.
9. Performance appraisal by superiors.
10. Providing feedback to the top level.

Steps of MBO
1. Setting Goals
1. Top managers formulate the overall organizational goals
2. Middle managers work with first line managers to set goals
3. This strengths organization‘s overall goals and commitment.
2. Planning
During action planning, managers decide in the who, what, whom, and how‖ detail
needed to achieve each objective.
Implementing plans
1. To control their performance managers must be allowed to implement plans in their own
way.
2. Element of self control
Reviewing performance
 Managers review the performance of the people by supervisor
 Evaluate the plans to achieve individual & group goals
 Discuss how can these obstacles be removed.
MBO Process Cycle

Benefits of MBO
1. Better management of organization
i. Clarity of objectives
ii. Role clarity
iii. Periodic feedback of performance.
iv. Participation by managers in the management process
v. Realization that there is always scope for improvement of performance in every
situation.
2. Clarity in organizational action
3. Personnel satisfaction
4. Basis for organizational change.
Limitations of MBO
1. Time and cost
2. Failure to teach MBO philosophy
3. Problems in objective setting
4. Emphasis on short- term objectives
5. Inflexibility
6. Frustration
Pre requisites for installing MBO program
1. Purpose of MBO
2. Top management support
3. Training for MBO
4. Participation
5. Feedback for self direction & self control
6. Other factors:-
i. Implementing MBO at lower levels
ii.MBO & Salary Decision
iii. Conflicting objectives.

VENTURE PLANNING
Venture Planning is a personal assessment of your feelings and the feasibility of a
venture. Venture Planning answers the question, should I be doing this and why? The Venture
Feasibility process examines seven key factors in any venture.
Venture Planning
It is not about writing a Business Plan. Sometimes a business plan is not needed. Venture
Planning does not require detailed funding, source analysis, professional opinions, entity
formation or detailed market analysis. Venture Planning is development of a means of comparing
various business models, usually through financial modeling to answer the following questions:
 Which venture concept produces the most sales, the best margins, the highest net profit
and the lowest breakeven?
 Which model requires the least investment by entrepreneurs and others?
 Which concept requires equity as opposed to debt financing?
 Which produces the highest "Return on Investment" and the best liquidity?
 Which model requires the entrepreneur to give up the least equity?
Identify and quantify the risks involved with execution of each model.
Venture Formation involves all of the following stages:
 Idea - Concept Development - Venture Development - Monitoring Progress - Initiating
New Changes - Venture Feasibility Analysis - Business or Operational Plan - Budget vs.
Actual - New Plans.
There are four keys to good venture planning:
 Focus on one venture at a time in one business area at a time.
 Discover the opportunity first, and then evaluate how to exploit it.
 Develop three cases good, bad & likely for each scenario of a venture concept.
 Identify what type of venture you want. Each type has an entirely different model,
implementation and end result. Each demands a different entrepreneurial approach and
each requires different management and style.
There Are 11 Keys to a Good First Venture
1) Founder's alignment with the mission.
2) Guaranteed or qualified customers.
3) Lifestyle of High Profit smaller business.

4) Routine concept.
5) Available product.
6) Advantageous Cash Flow.
7) Supportive local environment.
8) Neutral State and Federal Environment.
9) Equity Control.
10) Relevant Experience.
11) Low Overhead.
Emerging venture areas in nursing that needs planning
There often occurs a crisis situation in the healthcare set- up when nurses try to defend existing
models of practice instead of embracing change. In order to gain successful planning of good
ventures, we should examine the existing realities (traditional), and analyze and adapt to the
changing context of nursing practice. Some of the traditional realities are;
 Institution based care
 Process oriented
 Procedure driven
 Based on mechanical and manual intervention
 Provider driven
 Treatment based
 Reflective of late stage intervention
 Based on vertical clinical relationships
According to Porter-O‘ Grady (2003), the emerging realities for nursing practice for this century
will be;
o Mobility based on multiple settings
o Outcome driven
o Best- practice oriented
o Emphasized by technology and minimally invasive intervention
o User driven
o Health based
o Geared for early intervention
o Based on horizontal clinical relationships

Functions of good nurse manager
A nurse manager‘s functions include the following;
 The nurse administrator needs to know the plans and programs of the health facility
administrator and of other departments in which personnel contribute to the joint effort of
providing health care services.
 Should be a participatory , voting member of all committees of the institution including
those dealing with budgeting, planning, credentialing, auditing, utilization, infection
control, patient care improvement, library or any other committees concerned with
nursing services, nursing activities and nursing personnel.
 Should develop a marketing operational plan based on the overall view of the agency
problems and activities.
 Marketing plan should include gathering and analysis of data related to product or service
 Operational plan consist of pinpointing possible strengths, weaknesses, problems and
opportunities.
 Before launching a venture, a control plan is made to measure performance of
implementation of venture within a time frame.
 Selected and trained personnel will be assigned to compare expected results with actual
results for making corrections in all elements of plan and its implementation in future.
PLANNING FOR CHANGE
Change occurs over time, often fluctuating between intervals of change then a time of
settling and stability. Change management entails thoughtful planning and sensitive
implementation, and above all, consultation with, and involvement of, the people affected by the
changes. If you force change on people normally problems arise. Change must be realistic,
achievable and measurable. These aspects are especially relevant to managing personal change.
Definition
 Planning: ―Planning refers to thinking ahead of time and formulation of preliminary
thoughts‖.
 Planned change: ―Planned change entails planning and application of strategic actions
designed to promote movement towards a desired goal‖.
o ―Planned change is a change that results from a well thought out and deliberates
effort to make something happen. It is the deliberate application of knowledge
and skills by a leader to bring about a change‖.
Tappen, 1995
 Change agent: ―A change agent is one who generates ides, introduces the innovation,
and works to bring about the desired change‖.

Change agent
A change agent is someone who deliberately tries to bring about a change or innovation,
often associated with facilitating change in an organization or institution. To some degree,
change always involves the exercise of power, politics, and interpersonal influence. It is critical
to understand the existing power structure when change is being contemplated.
A change agent must understand the social, organizational, and political identities and
interests of those involved; must focus on what really matters; assess the agenda of all involved
parties; and plan for action. The change agent should have the following qualities;
 The ability to combine ideas
 The ability to energize others
 Skills in human relations
 Integrative thinking
 Flexibility modify ideas
 Persistent, confident and has realistic thinking
 Trustworthy
 Ability to articulate a vision, and
 Ability to handle resistance.
Assumptions regarding change
 Change represents loss. Even if the change is positive, there is a loss of stability. The
leader of change must be sensitive to the loss experienced by others.
 The more consistent the change goal is with the individual‘s personal values and beliefs,
the more likely the change is to be accepted. Likewise the more difficult the goal is from
the individual‘s personal values; the more likely it is to be rejected.
 Those who actively participate in change process feel accountable for the outcome.
 Timing is important in change. With each successive change in a series of changes,
individual‘s psychological adjustment to the change occurs more slowly. And for this
reason the leader of change must avoid initiating too many changes at once.
The key principles driving the elements of the Change Management are:
1. Targeted Commitment Levels
2. Executive Ownership
3. Visible, sustained sponsorship
4. Deployment/Implementation Support and Monitoring

5. Employee Support
6. Post Deployment Preparation
Strategies for planned change
In general, three categories of change models exist: empirical-rationale, power-coercive, and
normative-educative model. (Bennis, Benne and Chin [1969], The planning of change)
Rationale- empirical:
This strategy emphasizes reason and knowledge. People are considered rational beings
and will adopta change if it is justified and in their self- interest. Here the change agent‘s role is
communicating the merit of the change to the group. If the change is understood by the group to
be justified and in the best interest of the organization, it is likely to be accepted. This strategy is
useful when little resistance to change is expected. It is assumed that once if the knowledge and
rationales are given, people will internalize the need for change and value the result.
Normative- re-educative:
This is based on the assumption that group norms are used to socialize individuals. The
success of this approach often requires a change in attitude, values, and/ or relationships. This
strategy is most used when the change is based on culture and relationships within the
organization. The power of the change agent, both positional and informal, becomes integral to
the change process.
Power- coercive:
This approach is based on power, authority, and control. Desired change is brought about
by political or economic power. It requires that the change agent have the positional power to
mandate the change. The outcome of change is often based either on follower‘s desire to please
the leader or fear of the consequences for not complying with the change. This strategy is
effective for legislated changes, but other changes using this strategy are often short- lived.
Barriers to change and strategies to overcome
It is important to identify all potential barriers to change, to examine them contextually
with those affected by proposed change, and to develop strategies collectively to reduce or
remove the barriers.
Change requires movement, which as physics indicates, is a kinetic activity that that
requires energy to overcome resistance.

Barrier Discussion Strategy
Desire to remain in
our comfort zone
Those who become increasingly attached to a
familiar way of doing things (comfort zone)
often view change as an unwelcome disruption.
Rational- empirical
strategies
Inadequate access to
information
Lack of information, inability to read and
understand the available resources.
Rational- empirical
strategy
Lack of shared vision Lack of widespread involvement, input, and
ownership of change will cripple a change
effort.
Normative- re-
educative strategy
Lack of adequate
planning
Involving individuals in planning gives a sense
of control and decreases their resistance to
change.
Rational- empirical
and normative- re-
educative strategies
Lack of trust Trust in the change agent and ability of self to
bring about change is necessary.
Rational- empirical
and normative- re-
educative strategies
Resistance to change Co-operation and involvement of the whole
team will only bring effective and lasting
changes.
Normative- re-
educative strategy
Poor timing or
inadequate time
planned
Poor timing and lack of planning can fail to
bring desired change.
Introducing change
at a time when
people are ready to
change guarantees
success
Fear that power,
relationships, or
control will be lost
Every change represents potential for loss to
someone.
Normative- re-
educative strategy
Amount of personal
energy needed for
change may be great
Sometimes change is desired, but people are not
willing to do what is necessary to effect the
change.
Slow the change
process and give
time to catch- up and
energize

Types of changes
Hohn (1998) identified four different types of change: Change by exception, Incremental
Change, Pendulum Change and Paradigm Change.
 Change by Exception: This occurs when someone makes an exception to an existing
belief system. For instance, if a client believes that all nurses are bossy, but then
experiences nursing care from a much modulated nurse, they may change their belief
about that particular nurse, but not all nurses in general.
 Incremental Change: A change that happens so gradually, that an individual is not aware
of it.
 Pendulum Changes: Are changes that result in extreme exchanges of points of view.
 Paradigm Change: Involves a fundamental rethinking of premises and assumptions, and
involve a changing of beliefs, values and assumptions about how the world works.
Change Theories in Nursing
Change theories are used in nursing to bring about planned change. Planned change
involves, recognizing a problem and creating a plan to address it. There are various change
theories that can be applied to change projects in nursing. Choosing the right change theory is
important as all change theories do not fit every change project. Some change theories used in
nursing are Lewin‘s, Lippitt‘s, and Havelock‘s theories of change. The characteristics of change
theories are;
 Problem identification
 Plan for innovation
 Strategies to reduce innovation
 Evaluation plan
Kurt Lewin‟s change theory:
The theoretical foundations of change theory are robust: several theories now exist, many
coming from the disciplines of sociology, psychology, education, and organizational
management. Kurt Lewin (1890 – 1947) has been acknowledged as the ―father of social change
theories‖ and presents a simple yet powerful model to begin the study of change theory and
processes. He is also lauded as the originator of social psychology, action research, as well as
organizational development.
"Unfreezing" involves finding a method of making it possible for people to let go of an old
pattern that was counterproductive in some way. In this stage, the need for change is recognized,
the process of creating awareness for change is begun and acceptance of the proposed change is
developed

"Moving to a new level" involves a process of change--in thoughts, feelings, behavior, or all
three, that is in some way more liberating or more productive. The need for change is accepted
and implemented in this stage.
"Refreezing" is establishing the change as a new habit, so that it now becomes the "standard
operating procedure." Without some process of refreezing, it is easy to backslide into the old
ways.The new change is made permanent here.
Lewin also created a model called ―force field analysis‖ which offers direction for
diagnosing situations and managing change within organizations and communities.
According to Lewin‘s theories, human behavior is caused by forces – beliefs,
expectations, cultural norms, and the like – within the "life space" of an individual or society.
These forces can be positive, urging us toward a behavior, or negative, propelling us away from
a behavior.
―Driving Forces‖- Driving forces are those forces affecting a situation that are pushing in a
particular direction; they tend to initiate a change and keep it going. In terms of improving
productivity in a work group, pressure from a supervisor, incentive earnings, and competition
may be examples of driving forces.
―Restraining Forces‖- Restraining forces are forces acting to restrain or decrease the driving
forces. Apathy, hostility, and poor maintenance of equipment may be examples of restraining
forces against increased production.
―Equilibrium‖ - This equilibrium, or present level of productivity, can be raised or lowered by
changes in the relationship between the driving and the restraining forces. Equilibrium is reached
when the sum of the driving forces equals the sum of the restraining forces.
Lippitt‟s phases of change theory:
Lippitt‟s theory is based on bringing in an external change agent to put a plan in place to
effect change. There are seven stages in this theory. The first three stages correspond to Lewin's
unfreezing stage, the next two to his moving stage and the final two to his freezing change. In
this theory, there is a lot of focus on the change agent. The third stage assesses the change
agent‘s stamina, commitment to change and power to make change happen. The fifth stage
describes what the change agent‘s role will be so that it is understood by all the parties involved
and everyone will know what to expect from him. At the last stage, the change agent separates
himself from the change project. By this time, the change has become permanent.
The seven phases shift the change process to include the role of a change agent through the
evolution of the change.
• Phase 1:Diagnose the problem

• Phase 2:Assess the motivation and capacity for change
• Phase 3:Assess the resources and motivation of the change agent(commitment the
change, power, and stamina)
• Phase 4:Define progressive stages of change
• Phase 5: Ensure the role and responsibility of the change agent is clear and understood
(communicator, facilitator, and subject matter expert.
• Phase 6:Maintain the change through communication, feedback, and group coordination
• Phase 7:Gradually remove the change agent from the relationship, as the change becomes
part of an organizational culture.
Havelock's change model:
Havelock's change theory has six stages and is a modification of the Lewin's theory of
change. The six stages are building a relationship, diagnosing the problem, gathering resources,
choosing the solution, gaining acceptance and self renewal. In this theory, there is a lot of
information gathering in the initial stages of change during which staff nurses may realize the
need for change and be willing to accept any changes that are implemented. The first three stages
are described by Lewin's unfreezing stage the next two by his moving stage and the last by the
freezing stage.
John P Kotter's 'eight steps to successful change'
John Kotter's highly regarded books 'Leading Change' (1995) and the follow-up 'The
Heart Of Change' (2002) describes a helpful model for understanding and managing change.
Each stage acknowledges a key principle identified by Kotter relating to people's response and
approach to change, in which people see, feel and then change: Kotter's eight step change model
can be summarized as:
 Increase urgency - inspire people to move, make objectives real and relevant.
 Build the guiding team - get the right people in place with the right emotional
commitment, and the right mix of skills and levels.
 Get the vision right - get the team to establish a simple vision and strategy focus on
emotional and creative aspects necessary to drive service and efficiency.
 Communicate for buy-in - Involve as many people as possible, communicate the
essentials, simply, and to appeal and respond to people's needs. De-clutter
communications - make technology work for you rather than against.
 Empower action - Remove obstacles, enable constructive feedback and lots of support
from leaders - reward and recognize progress and achievements.

 Create short-term wins - Set aims that are easy to achieve - in bite-size chunks.
Manageable numbers of initiatives. Finish current stages before starting new ones.
 Don't let up - Foster and encourage determination and persistence - ongoing change -
encourage ongoing progress reporting - highlight achieved and future milestones.
 Make change stick - Reinforce the value of successful change via recruitment,
promotion, and new change leaders. Weave change into culture.
General considerations for planning change
 Secure and maintain commitment to change
 Define and communicate desired end state
 Identify critical success factors
 Establish targets and prioritize activities
 Develop a theme
 Understand why the change is desired/ required
 General considerations for planning change
 Secure and maintain commitment to change
 Define and communicate desired end state
 Identify critical success factors
 Establish targets and prioritize activities
 Develop a theme
 Understand why the change is desired/ required
Nurse Leader (manager) as role model for Planned Change
 Implement a comprehensive and coordinated change management program: Discover,
develop, detect.
 Identify ―change agents‖ and engage people at all levels in the organization.
 Ensure the message comes from the top, and executives and line managers are
―walking the talk.‖
 Make change visible with new tools and/or environment.
 Ensure clear, concise, and compelling communication.
 Integrate change goals with day-to-day activities, e.g., recruiting, performance
management, and budgeting.
 Address short-term performance while setting high expectations about long-term
performance.
 Help management avoid attempts to short circuit the change management process.

 Foster change in people‘s attitudes first, then focus on change in processes, then
change in the formal structure.
 Manage both supporters and champions, as well opponents and possible detractors.
 Accept that all people go through the same steps – some faster, some slower – and it
is not possible to skip steps.
 Build a safe environment that enables people to express feelings, acknowledge fears,
and use support systems.
 Acknowledge and celebrate successes regularly and publicly!
Mistakes by a leader manager
 Fail to provide visible support and reinforce the change with other managers.
 Do not take the time to understand how current business processes would be affected by
change.
 Delayed decision-making, which leads to low morale and slow project progress.
 Are not directly or actively involved with change project.
 Fail to anticipate the impact on employees.
 Underestimate the time and resources needed
 Abdicate ownership of the project to another manager.
 Fail to communicate both the business reasons for the change and the expected
outcome to employees and other managers
 Change the project direction mid-stream
 Do not set clear boundaries and objectives for the project
Organizational ageing
The organization has to undergo progress through certain developmental stages within
the organizational structure termed organizational ageing. The young organization is
characterized by high energy, movement and constant change and adaptation; while the aged
organizations will have established ‗turf boundaries functioning in an orderly and predictable
fashion, and are focused on rules and regulations. In any type of ageing, organizations must find
a balance between chaos and stagnation. Some areas that undergo restructuring during an
organizational ageing are;
• leadership changes
• organizational restructuring
• outsourcing and offshoring
• new technologies and tools
• new competitors and markets

INNOVATIONS IN NURSING
Introduction
Change is a natural social process of individuals, groups, organizations and society. The
source of change originates inside and outside health care organizations. Change today is
constant, inevitable, pervasive and unpredictable, and varies in rate and intensity, which
unavoidably influences individuals, technology and systems at all levels of the organization.
Creativity and innovation
Creativity is defined as ‗artistic or intellectual inventiveness.‘
Innovation is defines as ‗introduction of something new. ‗These definitions suggest that the
terms are interchangeable. A person could say that creativity is the mental work or action
involved in bringing something new into existence, while innovation is the result of that effort.
A constant flow of new ideas is needed to procure new products, services, processes,
procedures and strategies for dealing with the change occurring in every sphere of endeavour:
technology social system, government and everyday living. Innovation is the key to survival and
growth of health care and nursing.
Change, innovation and creativity are comparison terms but can also be differentiated.
Changes occur when the system is disrupts; innovation uses changes to create new and different
approaches to resolve an issue and develop new products or procedures. (Huber 1996).
Systemic innovations according to (Drucker 1992) require willingness to look on changes
as an opportunity. Innovations do not create change. Successful innovations are accomplished by
exploiting the change not forcing it.
Process of Innovation
The process of the innovation may include several steps. They are:
 Assessment
It is the first step of process and it requires a look at both the strength and
problems. An administrator must focus on what is specific content requirement the
expected outcome. Specific content requirement changes often in the health care, as new
technologies and research bring new knowledge needs.
 Defining objectives
It is the second step. The administrator should search for research or technique
that could address the identical needs. Asking the peers for the suggestion is also helpful.
This is the place where the creativity begins. It is important to look at many different
ways to address the learning objectives before selecting one.

 Planning
Once a strategy has been selected the third step, planning is important.
Understand who the stakeholders are and what their investment is in the status quo or in
change can be helpful in planning the strategies to bring them on board. Many stake
holders do not like the changes and will resist the new approaches. Using the change
theory it can assist in demonstrating the needs and provide information that can make
resistors more amenable to change. It‘s important to take time to develop a support for
the strategy. In more complex strategies it may be important to bring other
administrators.
 Gaining support for the innovation
Some strategies require little or resources to implement where as others require
significant physical and financial resources. If resources are needed then gaining support
for the accusation of those resources are essential. Grants can provide good funding
sources but require time and effort to secure and may be for a limited time.
Administrative support may be required but administrators may also be an excellent
resource to tap to discuss the potential funding or acquisitions of the physical resource.
 Preparing faculty members for the innovation
Rehearsal time may be required or additional education may be required. Planning
sufficient for those activities will increase everyone‘s comfort level with this process.
This is the time where everyone agrees how the strategy will be in run. Use of perception,
validate and clarification can be a valuable tool.
 Implementing the evaluation
In this step it is hope that the things will be going well, but flexibility may be
required if problems arise. Sometimes unintended consequences, such as surfacing of
emotional issues can occur. Administrator should be alert to the need for the follow up or
referral if problem arise.
 Evaluating the outcome
It is the final step of the process. It may be possible to measure short term
attainment goals. A strong evaluation process provides an opportunity to evaluate the
outcome of the change.
Sources of innovation
Seven sources for innovative ideas have been identified by (Drucker 1992)

Four sources are found internally within the institutions are:
 Unexpected outcomes: Situation presents themselves that require different methods to
be adopted. Knowing what is happening in an institution allows an individual to prepare
for the impending changes.
 Incongruous circumstances: Disruptions occur that require change to be made
discrepancies exists between the reality as it is and reality as it is assumed to be.
 Innovations made on the process needs: Procedures and policies need to be altered to
respond to the new regulations, policies or law.
 Changes in structure: Organizational changes require changes in method of the
operations.
Three sources are outside the institutions:
 Change in the demographics: Alteration in the community statistics such as age and
income levels affect the organizational operations.
 New information or knowledge: New technological knowledge requires change in
practice.
 Change in perception, taste and meaning: Shifts in demographics, technologies and
social needs create different ways of looking at the situation.
Steps in Innovation adoption
 Knowledge: Aware of new information and possible significance to practice.
 Persuasion: Positive attitudes about importance and utility of new knowledge.
 Decision: Trial use of new information to test relevance to practice.
 Implementation: Change of care setting to facilitate use of the innovations.
 Confirmation: Gathering of evidence to confirm appropriateness of using the
innovations.
Theories
Planned change using linear approaches
Theories for planned change
Six phases of planned change
Havelock (1973) is credited with this planned change model
Key idea: Change can be planned, implemented and evaluated in six sequential stages. The
model is advocated for development of effective change agents and use as a rational problem
solving process. The six stages are:-
1. Building a relationship
2. Diagnosing the problem

3. Acquiring relevant resources
4. Choosing the solution
5. Gaining acceptance
6. Stabilizing the innovation and generating self renewal
Application to practice: Useful for low level, low complexity change.
Seven phases of planned change
Lippitt, Watson and westly (1958) are credited with this planned change model
Key idea: change can be planned, implemented and evaluated in seven sequential phases.
Ongoing sensitivity to forces in the change process is essential. The seven phases are:
1. The client system become aware of the need for the change
2. The relationship is developed between the client system and change
3. The change problem is defined
4. The change goal are set and options for achievements are explored
5. The plan for the change is implemented
6. The change is accepted and stabilized
7. The change entities redefine their relationship
Application to practice: Useful for low level, low complexity change.
Innovation – decision process
Rogers (1995) is credited with formulating this process.
Key idea: Change for an individual occurs over five phases when choosing to accept or reject an
innovation/idea. Decision is to not accept the new idea may occur at any five stages. The change
agent can promote acceptance by giving information about benefits and disadvantages and
encouragement. The five stages are:
1. Knowledge
2. Persuasion
3. Decision
4. Implementation and
5. Confirmation
Application to practice: Useful for individual change.

Nonlinear change
Chaos theory
Organization can no longer rely on rules, policies, and hierarchies to get work
accomplished in flexible ways. According to the chaos theory perspectives because of rapidly
changing nature of human and world factors health organizations cannot control long term
outcomes. The assertion of chaos theory are that ‗organization are potentially chaotic‘(thietat and
Forgues, 1995). In other words, ‗order emerges through fluctuations and chaos‘. Organization
will experience periods of stability interrupted with periods of intense transformation.
Response to change / Human side of change
The human side of the managing change refers to staff responses to change that either
facilitate or interfere with change process. Responses to all or part of the change process by
individuals and group may vary from full acceptance and willing participation to open rejection.
Responses may be categorized behaviourally or emotionally. Some nurses may manifest their
dissatisfaction visibly; others may quietly accommodate the change. Some individuals
consistently reject any new thinking or way of doing things. The initial response to change may
be, but not always, reluctance and resistance. Resistance and reluctance are common when the
change threaten the personal security. Eg: -Changes in the structure of an agency can result in
changes of position for personnel.
The change agent‘s recognition of the ideal and common patterns of the individuals
behaviour responses to change can facilitate an effective change process (Rogers 1983).
The responses and brief descriptions are as follows:
 Innovators thrive on change, which may be disruptive to the unit stability.
 Early adopters are respected by their peers and thus are sought out for advice and
information about innovations/changes.
 Early majority prefer doing what has been done in the past but eventually will accept the
new ideas.
 Late majority are openly negative and agree to change only after most others have
accepted the change.
 Laggards prefer keeping tradition and openly express their resistance to new ideas.
 Rejecters oppose change actively.
General characteristics of effective change agents
 Is a respected member of the organization (insider) or community (outsider).
 Possesses excellent communication skills.
 Understands change process.

 Knows how group functions.
 Is trusted by others.
 Participates actively in change processes.
 Processes expert and legitimate power.
Principles characterizing effective change implementation
 The recipients of change feel they own the change.
 Administrators and other key personnel support the proposed change.
 The recipients of change anticipate benefit from the change.
 The recipient of change participates in identifying the problem warranting a
change.
 The change holds interest for the change recipients and other participants.
 Agreements exist within the work group about the benefit of the change.
 The change agents and recipients of change perceive a compatibility of values.
 Trust and empathy exist among the participants of the change process .
 Revision of the change goal and process is negotiable.
 The change process is designed to provide regular feedback to its participants.
Challenges met by the change leaders
Mc Daniels (1996) advocates that change leaders in healthcare organizations meet
the challenges of managing by applying 12 recomendations:
1. Dispense with controlling and planning.
2. Operate on the margin between order and disorder.
3. Develop new organizations with the help of everyone.
4. Allow individual autonomy.
5. Encourage information sharing among staffs.
6. Promote staffs knowledge of others work.
7. Stimulate open learning through discussion generating ‗creative tension‘.
8. Considering the organization structure as dynamic.
9. Help staffs discover their goals.
10. Encourage cooperation not competition.
11. Approach work from smarter view, not harder.
12. Uncover values continuously to form organization wide visions.
*****

Unit IV
ORGANISATION  Concept , principles, objectives, Types and theories,
Minimum requirements for organisation,
Developing an organizational Structure, levels,
organizational Effectiveness and organizational
Climate,
 Organizing nursing services and patient care:
Methods of patient
 assignment- Advantages and disadvantages,
primary nursing care,
 Planning and Organizing: hospital, unit and
ancillary services(specifically central sterile supply
department, laundry, kitchen, laboratory services,
emergency etc)
 Disaster management: plan, resources, drill, etc

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

Importance of organization
 It increases managerial efficiency .
 It ensures an optimum use of human efforts through specialization and also make use of
all resources , determines needs for innovative and new technologies in terms of cost
effectiveness and accomplish objectives.
 It places a proportionate and balanced emphasis on various activities.
 It facilitates coordination in the enterprises.
 It provides scope for training and developing managers.
 It helps to consolidate growth and expansion of the institution/enterprise.
 It invites creative and innovative ideas.
 It prevents the growth of laggards, wire pullers or other forms of corrupters
Principles of organization
According to Ms. T.K.Adranvala
• Division of labor
• Hierarchy of authority
• System for co-ordination and control
• Span of control – it depends on ,
-Unity of objectives
-Division of work &specialization
-Job description
-Unity of command
-Principle of adequate authority
-Span of supervision
According to BT Basavanthappa
There are six principles of organization as follows:
1. Hierarchy
2. Span of control
3. Integration vs. disintegration
4. Centralization vs. decentralization
5. Unity of command
6. Delegation

According to Russell C. Swansburg & Richard J. Swansburg
 Principle of chain of command
 Principle of unity of command
 Principle of span of control
 Principle of specialization
Theories of organization
Definition :
 Organizational theory (OT) is the study of organizations for the benefit of identifying
common themes for the purpose of solving problems, maximizing efficiency and
productivity, and meeting he needs of stakeholders
Types of organizational theories
1)Classical
organization
theory
2)Neoclassical
theory
3)Modern theories 4)Individual
processes
a)Taylor‟s
scientific
management
approach
a)The systems
approach
a)Motiv
ational
theory
b)Weber‟s
bureaucratic
approach
b)Socio-technical
approach
b) Role theory
c)Administrative
theory
c)The contingency or
Situational approach
c)Personality
theory

TYPES OF ORGANIZATIONAL THEORIES
1) Classical organization theory
a) Taylor‘s scientific management approach
b) Weber‘s bureaucratic approach
c) Administrative theory
2) Neoclassical theory
3) Modern theories
a) The systems approach
b) Socio-technical approach
c) The contingency or situational approach
4) Individual processes:
a) Motivational theory
b) Role theory
c) Personality theory
1) Classical organization theories (Taylor, 1947; Weber, 1947; Fayol, 1949) deal
with the formal organization and concepts to increase management efficiency.
• Taylor presented scientific management concepts,
• Weber gave the bureaucratic approach, and
• Fayol developed the administrative theory of the organization.
A) Taylor's scientific management approach
 Is based on the concept of planning of work to achieve efficiency, standardization,
specialization and simplification.
 Taylor suggested that, to increase productivity was through mutual trust between
management and workers,

Taylor developed the following four principles of scientific management for improving
productivity:
1. Science, not rule-of-thumb Old rules-of-thumb should be supplanted by a scientific
approach to each element of a person's work.
2. Scientific selection of the worker Organizational members should be selected based on
some analysis, and then trained, taught and developed.
3. Management and labor cooperation rather than conflict Management should
collaborate with all organizational members so that all work can be done in conformity
with the scientific principles developed.
4. Scientific training of the worker Workers should be trained by experts, using scientific
methods.
B) Weber's bureaucratic approach
Weber (1947) based the concept of the formal organization on the following principles:
1. Structure: In the organization, positions should be arranged in a hierarchy, each with a
particular, established amount of responsibility and authority.
2. Specialization: Tasks should be distinguished on a functional basis, and then separated
according to specialization, each having a separate chain of command.
3. Predictability and stability The organization should operate according to a system of
procedures consisting of formal rules and regulations.
4. Rationality: Recruitment and selection of personnel should be impartial.
5. Democracy: Responsibility and authority should be recognized by designations and not
by persons.
C) Administrative theory
The elements of administrative theory (Henri Fayol, 1949) relate to accomplishment of tasks,
and include
 Principles of management,
 The concept of line and staff,
 Committees and
 Functions of management.

i) Principles of management
• Division of work
• Authority and responsibility
• Discipline
• Unity of command
• Unity of direction:
• Subordination of individual interest to general interest
• Remuneration of personnel
• Centralization
• Scalar chain
• Order
• Equity
• Stability of tenure of personnel
• Initiative
• Esprit de corps
b) The concept of line and staff :
 The concept of line and staff is relevant in organizations which are large and require
specialization of skill to achieve organizational goals.
 Line personnel are those who work directly to achieve organizational goals.
 Staff personnel include those whose basic function is to support and help line personnel.
c) Committees :
• Committees are part of the organization.
• Members from the same or different hierarchical levels from different departments can
form committees around a common goal.
• They can be given different functions, such as managerial, decision making,
recommending or policy formulation.
• Committees can take diverse forms, such as boards, commissions, task groups or ad hoc
committees.
• Committees can be further divided according to their functions.
• For e.g. In agricultural research organizations, committees are formed for research, staff
evaluation or even allocation of land for experiments
d) Functions of management
• Fayol (1949) considered management as a set of ,
-Planning, Organizing, Training, Commanding and Coordinating functions.
• Gulick and Urwick (1937) also considered organization in terms of management
functions such as,
- Planning, Organizing, Staffing, Directing, Coordinating, Reporting and Budgeting.

2) Neoclassical theory
• Classical theorists recognized the importance of individual or group behavior and
emphasized human relations.
• Based on the Hawthorne experiments, the neoclassical approach emphasized social or
human relationships among the operators, researchers and supervisors
• Productivity increases as a result of high morale, which was influenced by the amount of
individual, personal and intimate attention workers received.
Principles of the neoclassical approach
• The individual :An individual is not a mechanical tool but a distinct social being, with
aspirations beyond mere fulfillment of a few economic and security works. Individuals
differ from each other in pursuing these desires. Thus, an individual should be recognized
as interacting with social and economic factors.
• The work group: The neoclassical approach highlighted the social facets of work
groups or informal organizations that operate within a formal organization. The concept
of 'group' and its synergistic benefits were considered important.
• Participative management :Participative management or decision making permits
workers to participate in the decision making process. This was a new form of
management to ensure increases in productivity.
3) Modern theories
• It is based on the concept that the organization is a system which has to adapt to changes
in its environment.
• Notable characteristics of the modern approaches to the organization are:
1. A systems viewpoint
2. A dynamic process of interaction
3. Multileveled and Multidimensional
4. Multi motivated
5. Probabilistic
6. Multidisciplinary
7. Descriptive
8. Multivariable
9. Adaptive

a) The Systems Approach:
• The systems approach views organization as a system composed of
interconnected - and thus mutually dependent - sub-systems
• Sub-systems can have their own sub-sub-systems.
• A system can be perceived as composed of some components, functions and
processes (Albrecht, 1983).
The organization consists of the following three basic elements (Bakke, 1959):
(i) Components :
· the individual,
· the formal and informal organization,
· patterns of behavior emerging from role demands of the organization,
· role comprehension of the individual, and
· the physical environment in which individuals work.
(ii) Linking processes-
• Communication:
Is a means for eliciting action, exerting control and effecting coordination to link decision
centers in the system in a composite form.
• Balance :
Is the equilibrium between different parts of the system so that they keep a harmoniously
structured relationship with one another.
• Decision analysis:
Decisions may be to produce or participate in the system.
Decision to produce depends upon the attitude of the individual and the demands of the
organization.
Decision to participate refers to the individual's decisions to engross themselves in the
organization process. That depends on what they get and what they are expected to do in
participative decision making.
(iii) Goals of organization:
The goals of an organization may be growth, stability and interaction.

Interaction implies how best the members of an organization can interact with one another to
their mutual advantage.
b) Socio-technical approach
• The socio-technical systems approach is based on the premise that every organization
consists of the people, the technical system and the environment (Pasmore, 1988).
• People (the social system) use tools, techniques and knowledge (the technical system) to
produce goods or services valued by consumers or users (who are part of the
organization's external environment).
• Therefore, an equilibrium among the social system, the technical system and the
environment is necessary to make the organization more effective.
c) The contingency or situational approach
• The situational approach is based on the belief that there cannot be universal guidelines
which are suitable for all situations.
• Organizational systems are inter-related with the environment.
• The contingency approach suggests that different environments require different
organizational relationships for optimum effectiveness, taking into consideration various
social, legal, political, technical and economic factors
4) Individual Processes
a) Motivational Theory
• Motivation drives behavior; it is the force behind an individual‘s decision to commit or
not commit to certain acts or behaviors.
• An individual calculates an ―E‖ (energy, enthusiasm, effort) the product of need, and
prediction for likelihood of achieving the desired results.
• When a person enters into a contract with an organization some calculation will be made
in regards to the individual‘s ―E‖ put forth.
• Organizations also put forth an ―E‖, either by resources alone (salary), or by other items
such as prestige and stature. This exchange sets the limits of a physical and
―psychological contract‖ between the organization and the person

• Management must carefully consider how to maintain or adjust the psychological
contract in order to keep the person a productive member of the team.
c) Role Theory
 In an organization roles can help to clearly define boundaries between individuals .
 Organizations need to acknowledge that its employees manage many roles and that
problems or conflicts can arise and create tensions that can change the ability of the
individual to reach their goals.
 Organizations should be sure to support their team members in meeting new roles by
giving time for transition, or offering training and support.
 When role conflict arises the organization can nurture employee‘s ability to relieve
tension by allowing time to devote to caring for roles outside the office.
d) Personality Theory
• Personality is the unique and enduring traits, behaviors and emotional characteristics in
an individual.
• Personality can either aid or hinder meeting work goals dependent on fit.
For e.g. Personality types are Type a vs. Type B
• Type A personalities are competitive, impatient, seekers of efficiency and always seem to
be in a hurry.
• Type B personalities are laid back and possess more patience and emotional stability, but
tend to be less competitive.
• In a work environment Type A‘s tend to be more productive in the short term and pursue
more challenging work. However, they also have a greater tendency towards health risks
and are less likely than Type B‘s to be in top executive positions.
• Organizations can play a role in developing their staff for success. Workshops, seminars,
even book clubs that focus on developing EQ an strengthen organizational success.
• Allowing for a diverse set of experiences, with appropriate support can maximize and
expand the capabilities of each employee.

Minimum requirements for organization
Clarity:
• Nurses need to know
-Where they belong,
-Where they stand in relation to the quality and quantity of their performances
-Where to go for assistance.
Economy:
• Nurses need as much self-control of their work as they can possibly be given.
• They need to be self motivating .
• There should be the smallest possible number of overhead personnel necessary to keep
the division and units operating and well maintained.
Direction of vision-
• Nurse managers must direct their vision and that of their employees
-toward performance,
-toward the future and
- toward strength.
Decision making-
• Nurses should be organized to make decisions on the right issues and at the right levels.
• They should be organized to convert their decisions into work and accomplishments.
Stability and Accountability-
• Nurses should be organized to feel community belongingness .
• They can adapt to show objectives requiring changes in their functions and productivity.
Perception and Self renewal-
• Nursing services should be organized to produce future leaders.
• The organizational structure should produce continuous learning for the job each nurse
holds and for promotion.

TYPES OF ORGANIZATIONAL STRUCTURE
1) Tall or Centralized Structure.
2) Flat or Decentralized Structure.
3) Matrix Structure.
4) Adhocracy Structure.
5) Shared Governance.
Tall or Centralized Structure
• A Tall organization is named so because a chart of its relationship appears tall and
narrow.
• It is also called Centralized, because most of the decision making authority and power is
held by few persons in central positions.
e.g. In an acute care hospital, the nursing position would be that of the chief nursing
officer, with 2 or 3 assistants.

ADVANTAGES DISADVANTAGES
 Enables an individual to
be an expert in the
narrow area over which
he or she is responsible.
 Because the supervisor
has fewer people to
supervise, close
supervision is possible.
 The top level authority
are the primary decision
makers and have a great
deal of control over
actions of others.
 The most skilled
individuals may end
up doing nothing but
supervising, whereas
those less capable do
the actual tasks.
 Those who are
closely supervised
may feel stifled and
even mistrusted
sometimes.
 Communication is
difficult because it
may pass through
many layers.
 Implementation of
decisions may
excessively delay.
Flat or Decentralized Structure
• The chart of relationships shows few levels and a broad span of control.
• Decision making is commonly spread out among many people and those closest to the
situation are given wide latitude in determining appropriate actions.

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

• This resulted in the organization of areas around product lines (which focuses on end
product of health care) and service line (represents the tasks required to accomplish the
delivery of the product)
A team approach to projects or
problems brings together wide
expertise and often generates
more creative solutions
Leadership conflict
There is flexible use of human
resources
Lack of understanding of
roles and expectations
The team members learn more
about one another‟s concerns and
thus improves working
relationships, functional
integration
Confusion, Conflict and
Ambiguity
Communication is also improved
by close contact with all
organizational groups.
Time allocation between
working for team and
working for department
may become an issue.

Adhocracy Structure
 This type of structure uses teams of specialists who are organized to complete a
particular project or task.
 These groups are referred to as project team or task force.
 It is composed of highly specialized professionals, the work is delegated by a director
to members of the project team who provide particular expertise.
Shared Governance
• It represents a professional practice model in which the nursing staff and nursing
management are both involved in making decisions as opposed to having the decisions
made at an administrative level only.
Implementations Of Shared Governance:
President

• It requires the staff nurses participate in professional development designed to increase
the nurse‘s understanding of decision making, team building, group dynamics, leadership
and budgeting.
• Disadvantages:
• Time involved in shared governance is costly to organizations.
• Its cost effectiveness in terms of patient outcomes is questioned sometimes.
ORGANIZATIONAL EFFECTIVENESS
• The product or output of an organization is termed organizational effectiveness (O.E).
• There should be a relationship between organizational effectiveness and performance
(O.P).
• Nurse Managers define the goals and provide the resources for both the organizational
effectiveness and organizational performance.
For e.g-
The dimensions include:
Patient satisfaction with care
Family satisfaction with care
Staff satisfaction with work
• Staff satisfaction with rewards , intrinsic and extrinsic
• Staff satisfaction with professional development – career, personal and educational
• Staff satisfaction with organization
• Management satisfaction with staff.
• Community relationships.
• Organizational
Nurse administrators control these dimensions of organizational effectiveness.
• The organization is effective or productive when the people are performing care that
meets client‘s needs and for which employees have a sense of accomplishment.

An organization can be shaped through:
 Job enlargement that is qualitative- meaningful, interesting, and intellectually rewarding.
 Making the structure more manageable. Increasing clinical nurses autonomy reduces the
organization's size.
 Increasing the span of control of the manager.
 Shortening the hierarchy.
 Involving the employees in participation.
 Decentralization.
 Increasing the employee‘s stake in his or her own performance.
 Increasing creativity while maintaining fiscal responsibility.
 Replacing direction and control with advice.
 Meeting employees need.
ORGANIZATIONAL CLIMATE
• It is the emotional state and the perceptions and feelings shared by members of the
system.
• It can be formal, relaxed, defensive, cautions, accepting, trusting etc.
• It is the employee‘s subjective impression or perception of their organization.
• It relates to the personality of an organization and can be changed.
Organizational climate, defined differently by many researchers and scholars, generally refers to
the degree to which an organization focuses on and emphasizes:
• Innovation
• Flexibility
• Appreciation and recognition
• Concern for employee well-being
• Learning and development
• Citizenship and ethics

• Quality performance
• Involvement and empowerment
• Leadership
Sociological dimensions of organizational climate:
• Clarity in specifying certification of the organizational goals and policies. This is
facilitated by smooth flow of information and management support of employees.
• Commitment to goal achievement through employee involvement.
• Standards of performance that challenge promote pride and improve individual
performance.
• Responsibility for one's own work fostered and supported by managers.
• Teamwork- a sense of belonging, mutual trust and respect.
Environmental dimensions of climate:
• It includes
-Room attractiveness
-Illumine
-Shape of the furniture
Practicing nurses wants a climate that will give them
-Job satisfaction
-Good working conditions
-High salaries
-Opportunities for professional growth
-Career development experiences that will help them to determine and direct their
professional futures.
-Administrative support that includes adequate staffing and shift options
-To develop their self esteem through self actualization.
Hellriegel and Slocum (2006) explain that organizations can take steps to build a more positive
and employee-centered climate through:

• Communication – How often and the types of means by which information is
communicated in the organization
• Values – The guiding principles of the organization and whether or not they are modeled
by all employees, including leaders
• Expectations – Types of expectations regarding how managers behave and make
decisions
• Norms – The normal, routine ways of behaving and treating one another in the
organization
• Policies and rules - These convey the degree of flexibility and restriction in the
organization
• Programs – Programming and formal initiatives help support and emphasize a
workplace climate
• Leadership – Leaders that consistently support the climate desired
Role of Nurse Managers In Organizational Climate
• Nurse Managers should emphasize management tasks or activities that stimulate
motivation in nursing employees.
• Nurse Managers should establish a management strategy to support new nurses and
involve them in decision making.
• Nurse Managers should establish a climate in which discipline is applied fairly and
uniformly.
• Nurse manager will work to establish an organizational climate that provides
-Incentives for clinical nurses,
-Places them on committees,
-Is creative and equitable in all staffing matters;
-Emphasizes pride,
-Promotes participation,
-Rewards seniority and achievements,
-Reduces boredom and frustrations.
• Nurse Managers need management education and training.
(Nurse managers and practicing nurses can work together to manage the work and the work
environment so that energy channeled into accomplishing personal and organizational goals.)

Activities to promote positive organizational climate
• Developing the organization's mission, philosophy, vision , goals and objectives
statements with input from practicing nurses , including their personal goals.
• Establishing trust and openness through communication that includes prompt and
frequent feedback and stimulates motivation.
• Providing opportunities for growth and development, including career development and
continuing education programs.
• Promoting team work.
• Asking practicing nurses to state their satisfactions and dissatisfactions during meetings
and conferences and through surveys.
• Marketing the nursing organization to the practicing nurses, other employees and the
public.
• Analyzing the compensation system for the entire organization and structuring it to
reward competence, productivity and longevity.
• Promoting self esteem, autonomy, and self fulfillment for practicing nurses including
feelings that their work experiences are of high quality.
• Emphasizing programs to recognize practicing nurses contributions to the organization.
• Assessing needed threats and punishments and eliminating them.
• Providing job security with an environment that enables free expression of ideas and
exchange of opinions.
• Being inclusive in all relationships with practicing nurses.
• Helping practicing nurses to overcome their short comings and to develop their strengths.
• Encouraging and supporting loyalty, friendliness, and civic consciousness.
• Developing strategic plans that include decentralization of decision –making and
participation by practicing nurses.
• Being a role model of performance desired of practicing nurses.

ORGANIZING NURSING SERVICES AND PATIENT CARE
INTRODUCTION
―A hospital may be soundly organized, beautifully situated and well equipped, but if the
nursing care is not of high quality the hospital will fail in its responsibility.‖
ORGANIZING NURSING SERVICES
Meaning of nursing service and nursing service administration
Nursing Service
Nursing service is the part of the total health organization which aims at satisfying the
nursing needs of the patients/community. In nursing services, the nurse works with the members
of allied disciples such as dietetics, medical social service, pharmacy etc. in supplying a
comprehensive program of patient care in the hospital.
Nursing service administration
Nursing service administration is a complex of elements in interaction and is organized to
achieve the excellence in nursing care services. It results in output of clients whose health is
unavoidably deteriorating, maintained or improved through input of personnel and material
resources used in a process of nursing services.
DEFINITION OF NURSING SERVICE
WHO expert committee on nursing defines the nursing services as the part of the total
health organization which aims to satisfy major objective of the nursing services is to provide
prevention of disease and promotion of health.
OBJECTIVES OF NURSING SERVICE
The first component of nursing service administration is the planning and it should be
based on clearly defined objectives. The objectives of nursing service department are as follows:
Objectives in relation to Patient care
The primary emphasis is on total patient care that is:
 To give highest possible quality care in terms of total patients need which include
physical, psychological, social, educational and spiritual needs by collaborating with
other health tem members.
 To assist the physician in providing medical care to the patients.
 To provide preventive and rehabilitative services.
 To provide round the clock nursing care to all the patients.
 To render timely and appropriate nursing service to emergency patients.
 To provide cost effective quality care as per the needs of patients.

 Confidentiality and privacy of each patient should be maintained.
 Constant monitoring and evaluating is of utmost importance to improve patient care
continuously.
Objectives in relation to Education
 Planning of education and training programme for nurses are must for professional
growth and development needs through in-service education and research support.
 To provide regular staff development, in-service education and guidance services for all
members of nursing staff.
 To conduct regular orientation programme for new entrants and for those have been on
the job for a long time.
 To conduct training for operating procedure of latest gadgets and on handling
sophisticated bio-medical equipment.
Objectives in relation to Administration and Organization
 To make regular supervision through rounds.
 To ensure that the essential equipment is provided in functional status for nursing care
services.
 To provide regular flow of essential supplies to render quality nursingcare.
 To have a proper system of rotation of staff, provision for annual leave and days off for
the nursing staff without hampering patient care.
 Establish a communication system for nursing personnel, other health worker, patients,
health authorities, government authorities and public.
 Ensure that each nurse identifies her job responsibilities and accountability.
 Counseling for health personnel, patients and the public.
 The formulation of policies, standards, goals of nursing service, education and practice.
 Maintaining proper documentation of the personnel employed in nursing service.
Objectives in relation to Research
 Establish a system for collection of essential information, research and studies concerning
all aspects of nursing.
 To contribute in research programme conducted by hospitals and by other health
personnel.
 To encourage and support the nurse to conduct research projects/ activities.
Objectives in relation to Performance appraisal
 Appraise the performance of nursing service personnel regularly against set standards and
performance indicators objectively with a view to maintain quality-nursing services.

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

The director of nursing service is delegated the authority and responsibilities for
organizing and administrating the nursing services in hospital. It is her duty to institute the
essential characteristics of good nursing services in her institute such as:
Purposes and objectives of the nursing service:
The purposes should be in accordance with the hospital philosophy regarding patient
care and approved by administration. It must characterize the principles of excellence in
service, in practice and leadership. Objectives are specific, practical, attainable,
measurable and understandable to all the nursing staff.
Plan of organization:
Every hospital has the basic system of coordination of vast number of activities
i.e. the Director of Nursing service, she is responsible for maintaining standards for
patient care in terms of quality nursing service must be familiar with the formal
organizational structure of the hospital and its relationship in various department and
their functions. The plan of organization should indicate inter as well as intra-department
relationship. The plan also should indicate area of responsibility and to whom and for
whom each person is accountable and the channels of communication.
Written statement of purposes and objectives of nursing
services
Plan of organization
Policy and administrative manuals
Nursing practice manual
Nursing service budget
Master staffing pattern
Nursing care appraisal plan
Nursing service administrative meetings
Adequate infrastructure facilities, supplies and equipment
Written job description & job specifications
Personnel records
Personnel policies
Health services
In–service education
Co-ordination
Advisory committee

Policy and administrative manuals:
The policy and procedure manual are required for the operation of the hospital.
Policies are established within the department to guide the nursing staff, which includes
duty hrs, rules and regulations etc. These are periodically revised and reviewed at regular
intervals.
Nursing practice manual:
This the written procedure available as evidence of the standards of performance
established by nursing service organization for safe and effective practice after taking
into consideration the best use of available resources. Liberal use of diagram and
precautions in nursing manual helps to keep instruction direct and exact. The advantages
are ensure economy of time effort & material and provides basis for training for new
personnel to acquire knowledge and current skill.
Nursing service budget:
It is required for personnel budget, 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.
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.
ORGANISATION OF NURSING SERVICES:
DIRECTOR (hospital) DIRECTOR OF HEALTH
SERVICE
Chief Nursing Officer Asst. Director of Health Service
Nursing Superintendent Nursing Superintendent Grade-I
Deputy Nursing Superintendent Nursing Superintendent Grade-II
Assistant Nursing Superintendent Head Nurse
Ward Sister - Clinical Supervisor Staff Nurse
Staff nurse Student nurse
ORGANIZING NURSING SERVICE AT VARIOUS LEVELS
The organization of nursing service varies from institution to institution.
Organizational set-up at Directorate General of Health Services

DGHS
Addl.DG (PH) Addl.DG (N) Addl.DG (M)
ADG ADG ADG
(Community Nsg service) (Nsg-education & research) (Hospital Nsg service)
DADG DADG DADG
Community & Nsg officer Principal Nsg.Supdt
PHN Supervisor Senior Tutor Dy.Nsg.Supt
PHN Tutor Asst.Nsg.Supt
LHV Clinical Instructor Ward sister
ANM Staff Nurse
Organizational set-up of Nursing Service at Central Level
Secretary, Health
Director Nursing Service
Joint/Deputy Director Nursing services
ADNS ADNS ADNS
DADNS DADNS DADNS
DADNS DADNS DADNS
Dist. Nsg officer DADNS Nsg.Supdt
PH. Nsg officer Principal Dy.Nsg.Supt
PHN at PHC Senior Tutor Asst.Nsg.Supt

LHV Tutor Ward sister
ANM Clinical Instructor Staff Nurse
Organizational set-up of Nursing Service at State Level
Director Nursing Services
Deputy Director Nursing Services
Assistant Director Nursing Services
Deputy Assistant Director Nursing Services
DMO DNO DHO
ADNO (Hosp&Nsg.Edu) ADNO (Community)
Nsg Supt/Dy.Nsg.Supt Principal tutor Dist.PNO
Asst.Nsg.Supt Tutor PHN Supervisor (CHC)
Ward Sister Clinical Instructor PHN (PHC)
Staff Nurse LHV
ANM
KEYS:
 DGHS - Director General of Health Services
 Addl. DG (PH) - Additional Director General (Primary Health)
 Addl. DG (M) - Additional Director General (Medical)
 Addl. DG (N) - Additional Director General (Nursing )
 ADG - Assistant Director General
 DADG - Deputy Assistant Director General
 PHN - Primary Health Nurse
 LHV - Lady Health Visitor
 ANM - Auxiliary Nurse Midwives
 ADNS - Assistant Director Nursing Service
 DADNS - Deputy Assistant Director Nursing Service
 DMO - Director of Medical Office
 DNO - Director of Nursing Office
 DHO - Director of Health Office

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

♪ Welfare
♣ Responsible for health and welfare of nursing staff.
♣ Ensures annual and periodical health examination and maintenance of health
records.
♪ Conferences
♣ Responsible for organizing and conducting staff meeting of the nursing staff once
in three months.
♣ Holds conference in nursing care problems and discuss policies as regards to
working conditions, working hrs and other facilities.
♪ Supervision
♣ Supervises nursing care given to the patients and all nursing activities within the
nursing unit.
♣ Supervises the work of all paramedical staff of the hospital.
♪ Records and Reports
♣ Maintains various records such as duty roster nursing staff, day off book, personal
bio-data, leave plan, staff conference book, courses file etc.
PROBLEMS AND CHALLENGES FACED BY THE NURSE ADMINISTRATOR
♠ Lack of adequate training.
♠ Problem of personnel management.
♠ Inadequate number of nursing staff.
♠ Shortage of trained manpower.
♠ Lack of motivation.
♠ No involvement in planning.
♠ No career mobility.
♠ Poor role model.
♠ No research scope.
♠ Professional risk/hazards.
♠ No autonomy in nursing activities.
Day to day problem in nursing services
♠ Shortage of nurses.
♠ Lack of motivation.
♠ Negative attitude.
♠ Lack of training.
♠ Lack of team approach.
♠ Inactive participation of program
♠ Lack of interpersonal relationship
♠ Less involvement in patients care by the nursing supervisors.
♠ Lack of supervision.

ORGANIZING PATIENT CARE
The overall goal of nursing is to meet the patient nursing needs with the available
resources for providing smooth day and night 24 hrs quality care to patients and to honor his
rights. To ensure that nursing care is provided to patients, the work must be organized. A
Nursing Care Delivery Model organizes the work of caring for patients. The decision of which
nursing care delivery model is used is based on the needs of the patients and the availability of
competent staff in the different skill levels. For organizing function to be productive and
facilitate meeting the 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.
OR
 The prevention, treatment and management of illness and the preservation of mental and
physical well-being through the services offered by the medical and allied health
professions.
PATIENT CLASSIFICATION SYSTEMS
Patient classification system (PCS), which quantifies the quality of the nursing care, is
essential to staffing nursing units of hospitals and nursing homes. In selecting or implementing a
PCS, a representative committee of nurse manager can include a representative of hospital
administration. The primary aim of PCS is to be able to respond to constant variation in the care
needs of patients.
Characteristics
 Differentiate intensity of care among definite classes.
 Measure and quantify care to develop a management engineering standard.
 Match nursing resources to patient care requirement.
 Relate to time and effort spent on the associated activity.

 Be economical and convenient to repot and use.
 Be mutually exclusive, continuing new item under more than one unit.
 Be open to audit.
 Be understood by those who plan, schedule and control the work.
 Be individually standardized as to the procedure needed for accomplishment.
 Separate requirement for registered nurse from those of other staff.
Purposes
◘ The system will establish a unit of measure for nursing, that is, time, which will be used
to determine numbers and kinds of staff needed.
◘ Program costing and formulation of the nursing budget.
◘ Tracking changes in patients care needs. It helps the nurse managers the ability to
moderate and control delivery of nursing service
◘ Determining the values of the productivity equations
◘ Determine the quality: once a standards time element has been established, staffing is
adjusted to meet the aggregate times. A nurse manager can elect to staff below the
standard time to reduce costs.
Components
The first component of a PCS is a method for grouping 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 in
preparing
Cannot feed self but is
able to chew and
swallowing
Cannot feed self
any may have
difficulty
swallowing
Grooming Almost
entirely self
sufficient
Need some help in
bathing, oral hygiene …
Unable to do much for
self
Completely
dependent
Excretion Up and to
bathroom
alone
Needs some help in
getting up to bathroom
/urinal
In bed, needs bedpan /
urinal placed;
Completely
dependent
Comfort Self
sufficient
Needs some help with
adjusting position/ bed..
Cannot turn without
help, get drink, adjust
position of extremities
…
Completely
dependent
General
health
Good Mild symptoms Acute symptoms Critically ill
Treatment Simple –
supervised,
simple
dressing…
Any Treatment more
than once per shift,
foley catheter care,
I&O….
Any treatment more
than twice /shift…
Any elaborate/
delicate procedure
requiring two
nurses, vital signs
more often than
every two hours..
Health
education &
teaching
Routine
follow up
teaching
Initial teaching of care
of ostomies; new
diabetics; patients with
mild adverse reactions
to their illness…
More intensive items;
teaching of
apprehensive/ mildly
resistive patients….
Teaching of
resistive patients,

MODES OF ORGANIZING PATIENT CARE / METHODS OF PATIENT
ASSIGNMENT
The most well known means of organizing nursing care for patient care delivery are,
Case method or Total patient care
Functional nursing
Team nursing
Modular or district nursing
Progressive patient care
Primary nursing
Case management
Each of these basic types has undergone many modifications, often resulting in new
terminology. For example, primary nursing has been called case method nursing in the past and
is now frequently referred to as a professional practice model. Team nursing is sometimes called
partners in care or patient service partners and case managers assume different titles, depending
on the setting in which they provide care. When closely examined most of the newer models are
merely recycled, modified or retitled versions of older models. Choosing the most appropriate
organizational mode to deliver patient care for each unit depends on the skill and expertise of the
staff, the availability of registered professional nurse, the economic resources of the organization
and the complexity of the task to be completely.
CASE METHOD
Features:
It was the first type of nursing care delivery system. In this method, nurses assume total
responsibility for meeting all the needs of assigned patients during their time on duty. It involves
assignment of one or more clients to a nurse for a specific period of time such as shift. The
patient has a different nurse each shift and no guarantee of having the same nurses the next day.
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.
Merits:
♣ The nurse can attend to the total needs of clients due to the adequate time and proximity
of the interactions.
♣ Good client nurse interaction and rapport can be developed.
♣ Client may feel more secure.

♣ RNs were self-employed.
♣ Work load can be equally divided by the staff.
♣ Nurse‘s accountability for their function is built-it.
♣ It is used in critical care settings where one nurse provides total care to a small group of
critically ill patients.
Demerits:
♠ Cost-effectiveness.
♠ The greater disadvantage to case nursing occurs, when the nurse is inadequately trained
or prepared to provide total care to the patient.
♠ Nurse may feel overworked if most of her assigned patients are sick.
♠ She/he may tend to ‗neglect‘ the needs of patient when the other patients ‗problem‘ or
‗need‘ demands more time.
FUNCTIONAL NURSING
Features:
This system emerged in 1930s in U.S.A during WWII when there was a severe shortage
of nurses in US. A number of Licensed Practice Nurses (LPNs) and nurse aides were employed
to compensate for less number of registered nurses (RNs) who demanded increased salaries. It is
task focused, not patient-focused. In this model, the tasks are divided with one nurse assuming
responsibility for specific tasks. For example, one nurse does the hygiene and dressing changes,
whereas another nurse assumes responsibility for medication administration. Typically a lead
nurse responsible for a specific shift assigns available nursing staff members according to their
qualifications, their particular abilities, and tasks to be completed.
RN
Medication Nurse
RN
Treatment Nurse
LPN
Vital signs Nurse
UAP
Hygiene
Nurse
Patients assigned to the team
Charge Nurse

Merits:
♣ Each person become very efficient at specific tasks and a great amount of work can be
done in a short time (time saving).
♣ It is easy to organize the work of the unit and staff.
♣ The best utilization can be made of a person‘s aptitudes, experience and desires.
♣ The organization benefits financially from this strategy because patient care can be
delivered to a large number of patients by mixing staff with a large number of unlicensed
assistive personnel.
♣ Nurses become highly competent with tasks that are repeatedly assigned to them.
♣ Less equipment is needed and what is available is usually better cared for when used only
by a few personnel.
Demerits:
♠ Client care may become impersonal, compartmentalized and fragmented.
♠ Continuity of care may not be possible.
♠ Staff may become bored and have little motivation to develop self and others.
♠ The staff members are accountable for the task.
♠ Client may feel insecure.
♠ Only parts of the nursing care plan are known to personnel.
♠ Patients get confused as so many nurses attend to them, e.g. head nurse, medicine nurse,
dressing nurse, temperature nurse, etc.
TEAM NURSING
Features:
Developed in 1950s because the functional method received criticism, a new system of
nursing was devised to improve patient satisfaction. Care through others became the hallmark of
team nursing. Team nursing is based on philosophy in which groups of professional and non-
professional personnel work together to identify, plan, implement and evaluate comprehensive
client-centered care. In team nursing an RN leads a team composed of other RNs, LPNs or LVNs
and nurse assistants or technicians. The team members provide direct patient care to group of
patients, under the direction of the RN team leader in coordinated effort. The charge nurse
delegates authority to a team leader who must be a professional nurse. This nurse leads the team
usually of 4 to 6 members in the care of between 15 and 25 patients. The team leader assigns
tasks, schedules care, and instructs team members in details of care. A conference is held at the
beginning and end of each shift to allow team members to exchange information and the team
leader to make changes in the nursing care plan for any patient. The team leader also provides
care requiring complex nursing skills and assists the team in evaluating the effectiveness of their
care.

Advantages:
♣ High quality comprehensive care can be provided to the patient
♣ Each member of the team is able to participate in decision making and problem solving.
♣ Each team member is able to contribute his or her own special expertise or skills in caring
for the patient.
♣ Improved patient satisfaction.
♣ Feeling of participation and belonging are facilitated with team members.
♣ Work load can be balanced and shared.
♣ Division of labour allows members the opportunity to develop leadership skills.
♣ There is a variety in the daily assignment.
♣ Nursing care hours are usually cost effective.
♣ The client is able to identify personnel who are responsible for his care.
♣ Barriers between professional and non-professional workers can be minimized, the group
efforts prevail.
Disadvantages:
♠ Establishing a team concept takes time, effort and constancy of personnel. Merely
assigning people to a group does not make them a ‗group‘ or ‗team‘.
♠ Unstable staffing pattern make team nursing difficult.
♠ All personnel must be client centered.
♠ There is less individual responsibility and independence regarding nursing functions.
♠ The team leader may not have the leadership skills required to effectively direct the team
and create a ―team spirit‖.
♠ It is expensive because of the increased number of personnel needed.
Charge Nurse RN
Team Leader RN Team Leader RN
RN NA
LPN NA LPN
RN
Group of Patients Group of Patients

♠ Nurses are not always assigned to the same patients each day, which causes lack of
continuity of care.
♠ Task orientation of the model leads to fragmentation of patient care and the lack of time
the team leader spends with patients.
MODULAR NURSING
Features:
Modular nursing is a modification of team nursing and focuses on the 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:
♣ Nursing care hours are usually cost-effective.
♣ The client is able to identify personnel who are responsible for his care.
♣ All care is directed by a registered nurse.
♣ Continuity of care is improved when staff members are consistently assigned to the same
module
♣ The RN as team leader is able to be more involved in planning & coordinating care.
♣ Geographic closeness and more efficient communication save staff time.
♣ Feelings of participation and belonging are facilitated with team members.
♣ Work load can be balanced and shared.
♣ Division of labor allows members the opportunity to develop leadership skills
♣ Continuity care is facilitated especially if teams are constant.
♣ Everyone has the opportunity to contribute to the care plan.
Demerits:
♠ Costs may be increased to stock each module with the necessary patient care supplies
(medication cart, linens and dressings).
♠ Establishing the team concepts takes time, effort, and constancy of personnel.
♠ Unstable staffing pattern make team difficult.
♠ There is less individual responsibility and autonomy regarding nursing function.
♠ All personnel must be client centered.
♠ The team leader must have complex skills and knowledge.

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

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

Advantages:
♣ Primary Nursing Care System is good for long-term care, rehabilitation units, nursing
clinics, geriatric, psychiatric, burn care settings where patients and family members can
establish good rapport with the primary nurse.
♣ Primary nurses are in a position to care for the entire person-physically, emotionally,
socially and spiritually.
♣ High patient and family satisfaction
♣ Promotes RN responsibility, authority, autonomy, accountability and courage.
♣ Patient-centered care that is comprehensive, individualized, and coordinated; and the
professional satisfaction of the nurse.
♣ Increases coordination and continuity of care.
Disadvantages:
♠ More nurses are required for this method of care delivery and it is more expensive than
other methods.
♠ Level of expertise and commitment may vary from nurse to nurse which may affect
quality of patient care.
♠ Associate nurse may find it difficult to follow the plans made by another if there is
disagreement or when patient‘s condition changes.
♠ It may be cost-effective especially in specialized units such as the ICU.
♠ May create conflict between primary and associate nurses.
♠ Stress of round the clock responsibility.
♠ Difficult hiring all RN staff
♠ Confines nurse‘s talent to his/her own patients.
Patients
Total patient care 24 hrs/day
Communicates with
supervisors
Consults with physician
or other healthcare
providers
Associate (days)
when primary nurse is
not available
Associate (afternoon)
When primary nurse is
not available
Associate (evenings)
when primary nurse is
not available
PRIMARY
NURSE

CASE MANAGEMENT
Features:
The case manager (RN or social worker with managerial qualification) is assigned
responsibility of following a 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 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.
♥ Serving as a liaison with third party payers in planning the client‘s care.
Merits:
♣ Case management provides a well coordinated care experience that can improve the care
outcome, decrease the length of stay, and use multiple disciplines and services efficiently.
♣ Provides comprehensive care for those with complex health problems.
♣ It seeks the active involvement of the patient, family and diverse health care professionals

Demerits:
♠ Nurses identify major obstacles in the implementation of this service, financial barriers
and lack of administrative support.
♠ Expensive
♠ Nurse is client focused and outcome oriented
♠ Facilitates and promotes co-ordination of cost effective care
♠ Nursing case management is a professionally autonomous role that requires expert
clinical knowledge and decision making skills.
FACTORS INFLUENCING THE QUALITY PATIENT CARE
Many variable factors influence the number of nurses needed on a ward in order to render a
high quality of patient care.
◘ The total number of patient to be nursed
◘ The degree of illness of patients (physical dependency)
◘ Type of service: medical, surgical, maternity, pediatrics and psychiatric
◘ The total needs of the patients
◘ Methods of nursing care
◘ Number of nursing aids and other non professional available, the amount and quality of
supervision available
◘ The amount, type and location of equipment and supplies
◘ The acuteness of the service and the rate of turnover in patients according to the degree or
period of illness.
◘ The experience of the nurses who are to give the patient care.
◘ The number of non-nurses who involve in the patient care, the quality of their work, their
stability in service.
◘ The physical facilities
◘ The number of hours in the working week of nurses and other ward personnel and the
flexibility in hours
◘ Methods of performing nursing procedures
◘ Affiliation of the hospital with the medical school
◘ Methods of assignment-individual, team or functional method
◘ The standards of nursing care.

PLANNING AND ORGANIZING HOSPITAL UNITS AND ANCILLARY SERVICES
(SPECIFICALLY CSSD, LAUNDRY, KITCHEN, LABORATORY SERVICES,
EMERGENCY DEPARTMENT)
Planning and organization of hospital units:
A hospital is responsible to render an essential service. In fulfilling this responsibility, hospital
planning should be guided by certain universally acknowledged principles. The principles are
usually irrespective of the level of planning, i.e. whether at national level, state level or
individual hospital level.
Aims of hospital planning:
 To enlarge the existing hospital by introducing new facilities.
 To increase utilization of hospital facilities.
 To increase population coverage
 To increase productivity of hospital
 Modernization of the already existing facilities
 To reduce the cost of operations and maximize efficiency of services.
Guiding principles in planning:
Patient care of high quality: it can be achieved by the hospital through adopting following
measures:
a. Provision of appropriate technical equipments and supplies.
b. An organizational structure that assigns responsibility and requires accountability
for various functions within the organization.
c. A continuous review of adequacy of care provided by physicians, nursing staffs
and paramedical personnel.
Effective community orientation: this should be achieved by the hospital by adopting
following measures:-
a. A governing board made up of persons who have demonstrated concerns for
community and leadership ability.
b. Policies that assure availability of services to all people.
c. Participation of the hospital in community programmes to provide preventive
care.
Economic viability: this is achieved by adopting measures like:-
a. A corporate organization that accepts responsibility for sound financial
management in keeping with desirable quality of care.
b. A planned programme of expansion based solely on demonstrated community
need.
c. An annual budget plan that will permit the hospital to keep pace with times.
Orderly planning: orderly planning should be achieved by the hospital by following:-

a. Acceptance by the hospital administrator of primary responsibility for short and
long-range planning with support and assistance from competent financial,
organizational and functional advisors.
b. Preparation of a functional programme that describes the short range objectives
and facilities, equipments and staffing necessary to achieve them.
Sound architectural plan: it is achieved by the following:-
a. Selection of a site large enough to provide for future expansion and accessibility
of population.
b. Recognition of the need of uncluttered traffic patterns within for movement of
staff, patients and visitors and efficient transportation of supplies.
Medical technology and planning: development in medical technology is taking place so
rapidly that now the use of sophisticated technology determines the professional status.
Classification of hospitals:
Hospitals in general are classified into two categories depending upon the agencies which
finance them:
1. Government or public hospitals: they are managed by government services, either central
or state or public, municipal or departmental bodies that are financed from the overall
budget for public services.
2. Non-government hospitals: they are managed by individuals, charitable organizations,
religious groups, industrial undertakings etc.
On the basis of ownership patterns, non-governmental hospitals are classified as:
 Private (personal)
 Partnership
 Private (family) trust
 Public charitable trust
 Cooperative society
 Private limited company
 Public limited company
Hospital planning process:
i. Conceptualization of hospital: here the imagination or idea of the originator takes into a
practical shape, and compares his dreams with the existing hospitals of country or outside
world, tries to fit dreams into any such project.
ii. Support groups: once the idea is developed, the entrepreneur, discuss project, and then
finds support groups to join hands and complete the project.
iii. Temporary organization and securing funds: a group should be formalized called as a
hospital trust, which must be registered under the society‘s act or companies act. The
originator is the chairman and others are members who are assigned different tasks.

A detailed work out as to how much capital will be required for establishing the hospital.
iv. Geographical, environmental and miscellaneous factors:
Meteorological information: temperature, rainfall, humidity
Geographical information: existing road and rail communications, susceptibility to
quakes/floods, building height restrictions due to proximity of airports.
Miscellaneous availability: trained manpower, water, sewage disposal.
v. Hospital design:
 Bed planning: it should be realized that the hospitals are not only utilized by the
population in the vicinity but also will constitute the indirect population in the larger
catchment area. About 85% bed occupancy is considered optimum.
 Hospital size: as a very large hospital of 1000 beds or more becomes extremely unwidely
to operate, and a small hospital of 50 or less are not profitable. From functional efficiency
point of view, it is advisable to plan two separate hospitals of 400 beds, each with a scope
of future expansion, rather than a single one of 800 beds.
 Land requirements: in rural and semi-urban areas, plentiful land may be available
permitting the hospital to grow horizontally, whereas in urban areas there will always be
great premium on land and only avenue will be a vertical growth.
No. of beds Land in acres Storey of building
50 beds 10 acres Single storey
100 beds 15-20 acres -do-
200 beds 20-25 acres Double storey
500 beds 55-70 acres 3-5 storey
700 beds 80-90 acres 4-6 storey
1000 beds 90-100 acres 6-9 storeys
 Public utilities: the national building code of ISI suggests 455 liters of water per
consumer per day (LPCD) for hospitals up to 100 beds and 340 LPCD for hospitals of
100 beds and over.

Additional availability of water in case, staff quarters and nurse‘s hostel are a part of
hospital campus. The hospital sewage disposal is connected to the public sewage disposal
system, otherwise it needs to build and operate its own sewage disposal plant.
It is preferable that power supply should be available on a multi-grid instead of uni-grid
system in general use, to ensure a continuous supply of electricity to hospital at all times.
Electricity requirement is 1 KW per bed per day2
.
 Approval of plan by the local authorities: once the detailed plan has been formulated,
the local bodies are consulted and persuaded for approval of plans.
vi. Circulation routes: the utility and success of hospital plans depend on the circulation
routes on hospital site and within building. there are two types of circulation in the
hospital :-
Internal circulation: the circulation space involves corridors, stairways and lifts.
Corridors with less than 8 ft. Width are not desirable in hospitals and protective corner
beading is a necessity in hospital corridors.
External circulation: only one entrance to the hospital for vehicular traffic from the main
road is desirable. the entrance and exit points should be wide enough to take two lanes of
traffic, one entry for clarity of all visiting traffic and one exit for security from
administrative viewpoint.
vii. Distances, compactness, parking and landscaping: distances must be minimized for all
movements of patients, medical, nursing and other staff, for supplies aiming at minimum
of time and motion.
Functional efficiency depends on the compactness of the hospital which is achieved by
constructing multistoried as they are convenient due to compactness as compared to
horizontal development of hospital which demands more land involving extra costs and
installation of services, roads, water supply, sewage etc.
One car parking space per 2 beds is desirable in metropolitan towns, lesser in smaller
urban areas while much less in semi-urban and rural areas. Separate parking for 3-
wheelers and scooters, employees and staff parking areas separate from public parking
should be considered.
viii. Zonal distribution and inter-relationship of departments: the departments which come in
close contact with the public (e.g. outpatient department, emergency and casualty) should
be isolated from the main in patient areas and allotted areas closer to the main entrance.
The supportive services like X-ray and laboratory services need to be located near the
OPD‘s. From the main entrance should be main inpatient zone consisting of ICU, wards,
OT and delivery suit. The other supportive and clinico-administrative department in the
hospital consists of hospital stores, kitchen and dietary department, pharmacy etc. these
departments should be preferably grouped around a service core area.

ix. Gross space requirements: gross total area (building gross)-780-1005 sq ft, add walls,
partitions: 95-125 sq ft. a building gross square footage figure includes everything a
building‘s perimeter viz. stairs, corridors, wall thickness and mechanical areas.
On average, space will be required for a reception and enquiry counter in the main
waiting area near the OPD entrance. The bed distribution is calculated as:
Bed:population= A x S x 100
365 x PO
Where, A= number of in-patient admissions per thousand population per year
S= average length of stay (ALS)
PO= percentage occupancy
Bed distribution among various specialties will vary from hospital to hospital and
conforms to following range:
Medical: 30-40%
Surgical: 25-30%
Obstetrical: 15-18%
Pediatric: 10-12%
Miscellaneous: 10-15% (including eye and ENT)
x. Climatic consideration in design: in very hot climate buildings need to be cooled in
summer by artificial means. Some natural cooling can be achieved by building
orientation and design. The building should be open, and oriented in such a way that even
a slight breeze can pass through the building to cool its insides. Another way is to keep
thick walls and small windows where the thick walls absorb the heat during day and
dissipates during night, and small windows minimize the amount of radiated heat
entering the building.
xi. Equipping a hospital: hospital equipment covers a broad range of items necessary for
functioning of all services. the universal application of equipment in the hospital can be
classified as:
Physical plant: it includes lifts, refrigeration and air-conditioning, incinerators, boilers,
kitchen equipments, mechanical laundry, central oxygen etc.
Hospital furniture and appliances: beds, stretchers, trolleys, bedside lockers, movable
screens, operation tables, instrument trolleys etc.
General purpose furniture and appliances: it includes office machines (typewriters,
calculators, filing system, and computers), office furniture, crockery and cutlery.
Therapeutic and diagnostic equipments: it includes equipments for general use (BP
instruments, suction machines, glassware washers etc.) and equipment interacting with

patients during diagnostic and therapeutic procedures ( defibrillators, X-ray machines
etc.)
xii. Cost evaluation of construction of hospital: the most common method of estimating the
cost is on the basis of per bed cost. It will also vary in type of facilities the hospital
provides, like teaching, training and research facilities.
Outpatient department:
Outpatient department is the one where all patients except those who require emergency
treatment, come for service in the hospital.
Planning and organization of the OPD:
Location: it should be easily accessible to those who come for outside, and should be a separate
wing for OPD attached to the hospital accessible from the main entrance to the hospital with
direct approach from the main road.
Space: the space requirement will depend upon the land available and location of the hospital.
Generally 0.66-1 sq ft area per annual outpatient attendance should be provided for OPD. If there
are 3 lakhs visit in a year, the total space requirement for OPD will be 2-3 lakh sq ft or 4.5-6.8
acres.
Size: the size of OPD depends upon the volume of attendance, clinics provided and extent of
facilities like blood bank, emergency department.
Zones of OPD:
 FUNCTIONAL ZONE: this zone is mainly used by the patients attending the OPD,
attendants and relatives. This area includes parking area, entrance hall, waiting space,
enquiry and registration, and medical social services.
 ADMINISTRATIVE ZONE: this zone is required in a large hospital to plan, organize,
supervise, evaluate and co-ordinate the facilities being provided. the various functional
units of this zone are
 Office of the OPD in-charge
 Administrative control nurses station
 Cash counters
 Medical record room
 DIAGNOSTIC AND SUPPORTIVE ZONE: the various functional units in this area are:
 Clinical laboratory
 Imaging section
 AMBULATORY ZONE: This is a zone where the patients come in direct contact with
the doctors and paramedical staff for consultancies, advice and treatment. it includes units
like:
 Clinics for various medical disciplines

 Pharmacy
 Treatment room
 Minor OT
 STAFF ZONE: this zone is used exclusively by the staff members only. It includes duty
rooms, stores, housekeeping and conference room.
Functional management:
 OPD timings: it is recommended that OPD shall work 6 days in a week with facilities of
morning and evening clinics. The morning timings is usually from 8am-12 pm, whereas
the evening hours shall be from 3pm to 5 pm, and specialty clinics from 2 pm to 4pm.
overcrowding and waiting time of the patients and relatives must be minimized.
 Records: a unit record system combining both in-patients record and continuous out
patient record is recommended.
 Public relations: public complaints can be minimized and defused through public
relations, the entire staff of OPD including public relations persons should act as agents.
 Facilities in OPD:
 The waiting lines should have enough furniture so that patients don‘t have to
stand in queues but can sit comfortably.
 The general procedure and rules should be painted on boards or walls for the
public.
 The registration area should be easily recognized and reachable.
 Health education messages can be promoted through TV-VCR system, closed
circuit TV and also to reduce the boredom of the waiting patients and their
relatives in OPD.
 Staffing of OPD: It includes the medical staff (consultant, professor, senior lecturers,
medical officers, residents, junior and senior should be available), nursing staff (usually
one nurse/OPD/clinic), paramedical staff (for injection room, dressing room, registration
and MRD), receptionists and medico social worker.
Planning and organization of Wards:
A ward is the most important part of hospital where the sick persons are kept for supervised
treatment. It is also a nodal point for research in medicine and nursing field, training and
teaching of medical, nursing and paramedical personnel.
Types of wards:
a. General wards: in these wards, patients with non-specific ailments, requiring no life
saving care are admitted. The nurse patient ratio of 1:5 in big wards, and catering to the
patient‘s routine investigation, treatment and care needs.
b. Specific wards: these include patients admitted for specific care due ti illness or social
reasons. It includes:

 Emergency ward
 Intensive care unit
 Intensive coronary care unit
 Nursery
 Special septic nursery
 Burns ward
 Post operative ward
 Post natal ward
c. Units with specialist nursing, treatment and equipment: wards like burn ward, transplant
ward functions at national or regional centers where particular service skills are
concentrated.
Ward planning:
 Physical facilities: it includes:
 Size of ward: size of the ward depends on- types of patient (an area of 100-120 sq
ft/bed is required and smaller rooms of 2-4 beds are preferable), requirement of
ward staff (a small ward will have same requirement throughout the day, helped
by a head nurse and a clerk for administrative and clerical responsibilities)
 Patient housing area: this is an area where patients are kept for treatment.
 The area per bed within the ward is 80 sq ft/bed but in acute ward it is 100
sq ft/bed
 Space left between two rows of bed is 5 ft.distance between two beds is
31/2
to 4 ft.
 Clearance between wall and side of bed is 2ft.
 Length of bed is 6‘6‖, width of the bed is 3‘.
Size of rooms:
 Single bed room should have a size of 125 sq ft/bed
 2 bed room 160 sq ft/bed
 ICU 120-150 sq ft/bed
 Obstetrics and orthopedics 120 sq ft/bed
 support service area: this section of ward includes:
 Nursing station/duty room: it should be located at such a place that the
time taken by a nurse for moving from one place to another is limited.
Centralize location is desirable.

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

Rigg‘s unilateral ward
Rigg‘s bilateral ward
Ward management: it is the optimal utilization of the ward resources to produce maximum
output, namely care and comfort of patients. It includes:
 Strategic management: responsibility of giving a strategic direction to a ward lies
within the nursing unit set up in each ward. Strategy formulation for ward has to
be done in the context and parameters defined by the strategy, direction, resources
and constraints of hospital.
 Operational management: whereas strategic management gives an anchor and
direction, operational management works towards the strategy. The responsibility
of operational management of a ward rests with the ward head nurse/ nursing unit
with the help of other ward personnel like ward clerk. It includes objectives of
providing comfort and good care to the patients and long term objective of
improvement and establishment of systems in functioning of the ward.
Central Sterile Supply Department (CSSD):
Definition of CSSD: A CSSD is a department that furnishes all supplies required for the nursing
units and departments of a hospital- theatres, wards, out-patient and casualty departments with
complete, sterile equipment ready and available for immediate treatment of patients.

These supplies include sterile linens, sterile kits, operating room packs, needles, syringes and
other medical surgical supplies. In addition, the personnel in this department clean, inspect,
repair, assemble, wrap and sterilize special treatment trays for various nursing units.
Planning and organizational consideration of CSSD:
Planning of CSSD: the CSSD should be planned in all hospitals above 100 beds. Theatre sterile
supply unit (TSSU) is to meet emergent and large requirement of OT and is established inside
OT complex. In large hospitals like 500 beds and above, TSSU is established in addition to the
CSSD in service area.
Bed size of the hospital Location of CSSD
Up to 100 beds In operation theatre
100-500 beds CSSD centrally located in service area
Above 500 beds CSSD in service area and a separate unit for
OT to be called theatre sterile supply unit (
TSSU).
The following areas are to be provided in CSSD:
i. Equipment storage room
ii. Receiving counter and clean up room
iii. Needles and syringes processing room
iv. Gloves assembling room with rubber goods processing room
v. Clean work area including sterilizers
vi. Sterile storage area and issue counter
vii. gauze and dressing assembly area
Percentage distribution of the space is as follows:
 Clean area including sterilization- 40%
 Sterile storage area-15%
 Equipment storage-14%
 Fluids, needles and syringes- 14%
 Receiving and clean up area-12%
 Glove processing area-5 to 7%
 Additional 25% space located for future expansion

Layout:
 Location should be where the most rapid means of transportation of supplies and
equipment is possible.
 There should be avoidance of back tracking of sterile goods.
 There should be a continuous flow of equipment from the receiving counter to the
dispensing counter.
 The contamination of sterile goods should be avoided.
 Sterilizing area should be the last area before the sterile storage and dispensing counter.
 The receipt and issue counters are separated by a corridor to avoid contamination.
Separation of sterilized items by a partition or corridor
Area requirements:
It is recommended that the area of 1.64 sq.m/bed for a CSSD would be appropriate up to 400
bedded hospitals, and for more than 400 beds an area of 1 sq.m/bed would be sufficient.
The manual of IGNOU has recommended following functional area for a 100 bedded hospitals:
Facilities In sq.meter
entrance
10.50
lockers
7.00
Staff change room
7.00
Dirty receipt and disassembly
7.00
Washing, disinfection and decontamination
17.50
assembly
10.50
Linen processing
10.50
sterilization
14.00
Sterile storage
21.00
distribution
10.50
Counter of receipt of
used items
Decontamination and
cleaning area
Processing
Packing of items
Sterilization
Sterilized items store
Distribution point

Trolley wash
7.00
Trolley bay
10.50
Bulk store
17.50
Duty room
3.50
toilet
3.50
Total per 100 bed hospital
164.50
Staffing pattern:
One CSSD worker per 30 beds plus one supervisor is recommended. In 200-300 beds hospital,
you need 10-15 persons. Staff for 1000 bedded hospitals is:
Supervisor – 1(senior most and trained technician)
Asst. Supervisor- one of the senior technician
Technicians – 6 (promoted attendants)
Sweepers- 15
Clerk- 1
Equipments and materials required:
 Hot and cold running water
 Cleaning brushes and jet water gadgets
 Ultrasonic washers
 Hot air oven for drying instruments and sterilization
 Globe processing unit
 Instrument sharpener like needle sharpening machines
 Stem sterilizers and boiler for steam
 Autoclaves of various sizes including gas autoclave
 Testing equipment
 Chemicals to clean materials
 Wall fixtures like sinks, taps
 Trolleys for supply of sterilized items and separate trolleys for collection of used items
are needed
Methods of sterilization:
Sterilization is a process of freeing an article from all living organisms including bacteria,
fungus, using dry or wet heat, chemicals or irradiation.
a. Steam sterilization: autoclaving is the commonest method
b. Hot air sterilization: Vaseline and oils cannot be sterilized with steam. these items are
exposed to hot air to 160-1800
c for 40 minutes.
c. Gas sterilization with ethylene oxide

d. Sub atmospheric pressure sterilization with formalin: it is meant to disinfect instruments
like endoscopes. the temperature required is 900
c for 10-30 minutes.
e. Chemical sterilization with activated glutaraldehyde
f. Gamma irradiation sterilization: it is used for disposable goods but is a costly method.
g. Formaldehyde steam sterilization
Inventory management:
i. Stock: to ensure the availability of sterilized items to the hospital units, five times the
average daily requirements. The replacement and procurement of condemned items
should be laid out so that situation of ‗stock out‘ can be avoided.
ii. Issue of materials: the principle of ‗first in- first out‘ ensures proper rotation of supplies
in CSSD and prevents any item from being kept for longer time so that its sterilization
date expires.
iii. Distribution of sterile items: the method that can be used for distribution of sterile items
are:
 Grocery system: in case CSSD is open 24 hrs, wards and departments can send
requisition to CSSD and stock is supplied accordingly.
 CSSD is open for limited hours:
 Clean for dirty exchange system: one clean item is provided for each item
in the ward used.
 Milk round system: it includes daily topping up of each ward/ department
stock level to a pre determined level decided by users.
 Basket system: a basket with daily requirement of ward is changed
everyday irrespective sterile items used or not, and the items of the whole
basket is sterilized every day.
 In case the items are to be stocked in wards, the date of sterilization is written on
each item so that the unused items are returned to CSSD for re-sterilization after
72 hrs.
iv. Quality control methods:
 Routine temperature/pressure and holding time testing of each autoclave.
 Steam clox is also very handy and reliable. Changes color from brown to green
 Heat/time, moisture sensitive tapes may be used in same way as that of steam
clox
 Random samplings of sterilized items are also tested in laboratory
 Culture of wall/floor and scrapings.

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

Floor area/space requirement:
According to Dr. Mc Gibony, the area for a laundry for a teaching hospital in India should be at
least 5800 sq.ft.
Physical layout:
1. Straight through flow: the planning of the building and installation of equipment in a
straight flow from the dirty end to the clean end.
2. U-flow: where the dirty and clean ends are in the same direction.
3. Gravity flow: this takes advantage of the underground, with dirty end at the top and clean
end at the bottom.
Laundry is divided into two distinct areas:
 Dirty area: it comprises of
 Reception of solid linen
 Sorting of soiled linen into suitable quantities for processing
 Clean area: it comprises of
 drying
 finishing
 discharge
 a barrier wall between the clean and dirty area is desirable
Schematic design of functional areas:
Reception of dirty
linen and storage
room
Decontamination and sluice
room
Boiler room
Toilet Washer
Laundry
manager
Staff room Store of
detergent
Store of spare
linen
Linen mending Hydro extractor
Issue area Storage of
clean linen
Pressing and
laundering
Drier

Ancillaries:
Laundry manager‘s office
Stores
Tailoring bay
Worker‘s rest room
Toilet
Boiler room
Material and decor:
 The route of soiled linen from the using points to the laundry and the flow of clean linen
from laundry to the using points should be planned as to minimize the possibility of
contamination of clean linen.
 The laundry should be grouped into specific separate areas.
 Laundry manager‘s office should be located as centrally as possible to properly supervise
the entire laundry operations.
 The walls should have large vision panels to allow full view of each area.
 A toilet, locker and shower facilities should be provided in the soiled linen receiving,
sorting and washer loading room and clean linen processing room.
 Supply storage room should be adjacent and connected to the soiled linen receiving,
sorting and washer loading room.
 Sufficient space should be provided for the storage of one week‘s supply of detergents,
bleaches and others.
 The floor for the laundry should have smooth, slip resistant and water proof surface, the
walls should have a smooth washable surface free from all corners, edges or projections
which create maintenance problems.
 Utility services like piping, electrical wiring should be designed and sized with
appropriate consideration for future expansion.
 The steam supply system should be designed to deliver steam to the equipment in right
quantity at a desired temperature.
 Hot water should be available at 1800
F by the pipeline to the laundry at the required
temperature from the boiler room.
 The power supply to the laundry is usually 220 or 440 volts in three phases , four wire
alternative system and must be accessible
 Lighting should be free of glare and shadows.
 Fire extinguishers should be located in the laundry near the clean linen and the processing
areas.
 There is a need for flow of drains in the sorting and washing areas.
 Ventilation system must be able to provide a comfortable environment for the workers.

 Sewing and mending room should be located near to the clean linen and pack preparation
room.
Laundry management:
The management of laundry contributes to morale of the staff and patients with fresh laundered
linen:
a. Sequence of operation:
Collection of laundry by laundry staffs in trolley with clean and dirty linen
separately and is sorted out as soiled, infected and foul linen to avoid nosocomial
infection.
Disinfection is done using disinfectants for infected linens.
Sluicing and washing: sluicing is done for foul linen in sluice machine and then the
linen along with those that are disinfected are put in washer for cleaning.
Hydro-extractor: it is then put in extractor for removing extra water.
Drier tumbler: the linens are put for drying.
Pressing: the linens are pressed
Mending: the torn linen is sent for repair or condemnation and replacement.
Repaired linen is again washed in washer and washing cycle after that is to be
completed.
Distribution to ward is done by laundry staff after it is ready for use.
b. Linen distribution system:
 Topping up: in this, the ward is given certain number of stock of linen based on
24 hours requirement and shortfall of linen due to use is topped up by the laundry
staff everyday and used ones are collected.
 ‗Clean for dirty‘ exchange: the issue of clean linen to exchange number of pieces
of dirty linen.
 Exchange trolley system: this is expensive and not used in India. In this, total
trolley is supplied which has 24 hours requirement and next day fresh trolley is
supplied with same number of pieces and old trolley is taken back to laundry
irrespective as how many pieces have been used and linen is brought and washed.
c. Quality control of laundry services: the quality assurance of laundry should be developed
since laundry is important from where infection can be transmitted to other patients,
which should be seen by the hospital infection control committee.
d. Policies and procedures:
 Collection and distribution system of linens with periodicity to each ward and
department.
 Detailed instruction about handling infected and foul linen.
 Charter of duty of each person handling laundry and training schedule of staffs.
 Sluicing and disinfection procedures.

 Operation of laundry machines.
 Maintenance and service contracts of machines.
 Provision of detergents
 Procedure for condemnation of linen and procurement of new linen
 Fire safety drills and fire extinguishing measures
 Record of distribution, collection, inventory of detergents and linen
procured/condemned.
 Security arrangements for laundry.
 Regular physical verification of linen and fixing responsibility of any type of loss.
Kitchen services:
A hospital dietary service includes most importantly a production unit that converts raw material
into palatable food. The preparation and distribution of food from store to spoon has many
challenges for the administration such as proper preparation, cost accounting, pilferage and
wastage.
Functions of dietary services:
The dietary services cater for the following:
therapeutic diet
in-patient catering
diet counseling
education and training
Staff requirements:
Category of employees Beds
100 200 300 500 750
Chief dietician - - - - 1
Senior Dietician - - - - 1
Dietician - - - 1 1
Asst. dietician 1 2 3 5 7
Steward - - 1 1 1
Storekeeper(ration) - - - 1 1
Storekeeper(general) - - - 1 1

Clerk/typist - - - 1 1
Head cook 1 1 1 2 2
Therapeutic cooks - - 2 2 3
Cooks 4 6 8 10 16
Asst. cook 6 14 20 28 32
Cleaners, waiters 4 4 6 8 10
Store attendants - 1 1 2 2
Sweepers 1 1 2 2 3
Fig. 1 shows staff requirement
Location and space requirement:
Location: the dietary department should be located on the ground floor near wards where the
diets need to be taken and also accessible to road as supplies are to be carried to storage area.
Space requirement:
Hospital kitchen is divided into number of divisions which have a particular activity. The broad
areas are supplies receiving area, storage area, cooking area, pots and pan wash, garbage
disposal, LPG stove and refrigeration facilities, housekeeping, dietician, steward offices and
circulation area.
Following space requirements are recommended for different size of hospitals:
 200 beds or less: 20 sq ft per bed
 200-400 beds: 16 sq ft per bed or 18 sq ft per bed
 500 beds and above: 15 sq ft per bed
Functional areas in department:
a. Recipient area: this is the place where all provisions are off loaded. these are checked for
right quality and quantity, hence area should have unloading points, ramps, trolleys and
weighing scales.
b. Storage area: this area where the provisions are categorized and stored in separate areas.
the areas should have enough shelves and bins:
 Dry provisions like flour, dal, sugar, oil etc.
 Fresh provisions like vegetables, milk, butter, meat etc.

Office store
keeper
They are further divided based on temperature requirements:
 items to be stored at room temperature like onion, potato etc
 Items require cool temperature (8-100
c is maintained) for which walk-in cooler
can be provided to store milk, eggs, butter etc.
 Deep fridge where temperature is below 00
c fish and meat should be stored.
c. Day store: it is an area where provisions for one days cooking issued to the cooks are
stored.
d. Preparation area: it is an area where provisions are cleaned, washed, soaked; meat is
chopped, cut and sliced etc. the items like kneader, weighing scale, slicer etc has to be
provided.
e. Cooking area: it should have pressure cooker, cooking range oven etc.
f. Service area: the food is put in service pots in trolleys and if it is a centralized distribution
system, it is put in service trays, with specifying the name of patients.
g. Washing area: this is meant for washing cooking and service pots, hence should have
liberal hot and cold water.
h. Disposal area: the area where all garbage and left over food is collected for disposal.
Fig 2. - The figure explains the layout of kitchen
Walk-in cold
store
Dry store Fresh store
Recipient area of
provisioning
Preparation area
Dry store
Cooking area
Trolley+ pot wash
area
Distribution area and service
Wards
Dietician
Supervisor
Staff room
Staff toilet

Distribution of diet:
a. Centralized service: the food is set in individual tray centrally at dietary department
including therapeutic diet of patients and are transferred to wards in trolleys and served to
the patients.
b. Decentralized service: the food is sent to wards and served as per the need of the patient.
Dietary store management:
 Storage of food items: for dry storage, the temperature should be 700
c, with adequate
ventilation has to be insured. The storing shelves, bins should be placed 10‖ above the
floor.
 Purchase of food products: the items can be purchased from open market or through
calling tenders. The items to be purchased should have AG MARK OR IDI. For this, an
internal purchase committee may be constituted by the hospital administration.
 Equipment planning: equipment purchase depends on the objectives and basic functions
of the department, workload and availability of the personnel, and quality standards.
Modern gadgets like mixer grinders, pressure cookers, dish washers etc. Should be a part
of hospital kitchen.
 Financial control:
 The first thing to be done for an effective financial control is to control the labor
costs.
 Menu planning should be done in such a way that it reduces the inventory,
selection of items common to many areas of patient care, reduced handling,
wastage, use of automation or more equipment requiring less operational staff are
some measures that can be put to practice for an effective financial control.
Laboratory services:
The basic function of laboratory services is:
 To assist doctors in arriving at or confirm a diagnosis and to assist in the treatment and
follow-up of patients.
 The laboratory not only generates prompt and reliable reports, and also functions as store
house of reports for future references.
 It also assists in teaching programmes for doctors, nurses and laboratory technologists.
 It carries out urgent tests at any part of day or night.
Functional divisions:
The hospital laboratory work generally falls under the following five divisions:
a. Hematology
b. Microbiology
c. Clinical chemistry/ biochemistry

d. Histopathology
e. Urine and stool analysis
Functional planning:
It covers the following activities:
 Determining approximate section wise workload.
 Determining the services to be provided.
 Determining the area and space requirement to accommodate equipment, furniture and
personnel in technical, administrative and auxiliary functions.
 Dividing the areas into functional units i.e. Hematology, biochemistry, microbiology etc.
 Determining the number of work stations in each functional units.
 Determining the major equipments and appliances in each unit.
 Determining the functional location of each section in relation to one another, from the
point of view of flow of work and technical work considerations.
 Identifying the electrical and plumbing requirements for each area/ work station.
 Considering utilities i.e. lighting, ventilation, isolation of equipments or work stations.
 Working out the most suitable laboratory space unit, which is a standard module for work
areas.
Organization:
 Location: it is preferable to have hospital laboratory planned on the ground floor and so
located that it is accessible to the wards. In large hospitals, the entry of outpatients to the
laboratory can be obviated by opening a sample collection counter in the outpatient
service area itself.
 Outpatient sample collection: it should be located in the outpatient department itself. The
design of this area should include waiting room for patients, venepuncture area and
specimen toilets separately for male and female patients, along with provision of
containers with appropriate preservatives and keeping record of each patient.
 Area/space: in a small hospital, the laboratory facility consists of a room in which all the
routine urinalysis, hematology and clinical chemistry investigations are carried out. As
the hospital size increases, the requirement of technical and administrative services also
increases with the necessity for departmentalization of the laboratory. The requirement of
space for the laboratory consists of :-
 Primary space: this space is utilized by technical staff for the primary task of
carrying professional work.
 Secondary space: it is utilized for all supportive activities.
 Administrative space, i.e. Offers for the pathologists and others, staff toilets etc.
 Circulation space: it is the space required for uncluttered movement of personnel
and materials within the department between various technical work stations,
rooms, stores and other auxiliary and administrative areas.

 Laboratory space unit (LSU): it is a module of space and all calculations for
technical work areas and some auxiliary area are based on LSU. For allocation of
primary space, one of the most suitable sizes of a LSU is one measuring 10‘ x 20‘
giving a LSU module of 200 sq. ft. a rectangular module is functionally more
efficient because in the same overall space, it can accommodate longer runs of
benching due to its longer perimeter.
 Layout: structural flexibility should be achieved by use of movable or adjustable
benching systems in association with an installation of service mains that has been
designed to permit the repositioning of outlets.
 Administrative and auxiliary areas: the administrative area (the area is the central
collection point for receiving specimens and is the reception and interaction area for
patients and hospital staffs) is separated from the technical work area so that the non-
laboratory personnel need not enter the technical areas.
 Reception and sample collection: this is the area should be well ventilated and lighted,
should have a chair where the patient can sit in comfort and where his arm can be
stretched for the phlebotomy, a bed where the patient can lie down for pediatric
collection or aspiration cytology.
 Bar-coding system for samples: this system is used to trace the samples. The sample is
received and then bar coded, and then sent to processing area. This protects patient
identity.
 Specimen toilet: it is provided for the collection of urine and stool specimens.
 Pathologist office: it is so placed that the pathologist can have an easy access to the
technical areas particularly histopathology unit.
 Glass washing and sterilizing unit: small labs collect blood in bottles that are washed and
reused. This is partitioned into washing and sterilizing area, containing sterilizer, pipette
washer and sinks.
 Report issue: the reports should be issued in printed format. The hospital lab software can
be made as per the requirement of the hospitals.
 Utility services: it includes water, gas and compressed air systems. Piping systems should
be easily accessible for maintenance and repairs with minimum disruption of work. For
safety purpose and to facilitate repairs, each individual piping system should be identified
by color, coding or labeling.
 Internal design and fitments:
a. Work benches: the height of the work bench on which the technicians sit while
working (revolving stools) vary from 75-90 cm depending upon the height of the
workers.
b. Lighting: natural light should be used to the fullest. Each work bench should be
provided with adequate electric points especially fluorescent fixtures that give
uniform illumination and minimize heat.

c. Storage: each laboratory bench length should have storage space for reagents,
chemicals, glass wares and other items, provided in the form of under bench
drawers, cupboards etc.
d. Partitions: it may be required between some laboratory spaces.
e. Air conditioning: whole or at least histopathology section of the laboratory
should be air conditioned due to accumulation of formalin vapors or else a
powerful exhaust system should be installed.
f. Working surface/ flooring: the surface of work benches should be resistant to
heat, chemicals, stain proof and easy to clean. Floor should be easy to clean, and
not slippery. Flexible vinyl flooring is preferred for laboratory floor coverings.
Staffing: the hospital laboratory services should be under the control and direction of
a doctor with qualifications in pathology or a PG degree in the new discipline of
―laboratory medicine‖.
Number of personnel: staff requirement of laboratory technicians can be worked out
empirically on the basis of generally accepted norm which is about 30 tests per day
per technician.
Equipment:
Some of the core instruments that are needed are:
 Colorimeters/ spectrophotometers: they were used in old days, are now
replaced by new auto-analyzers these days.
 Auto analyzers: it is used maximum in biochemistry works.
 Cell counter: it gives a more complete blood picture. The principle of the
instrument is to pass the cells through a thin capillary.
 Centrifuge
 Refrigerators
 Pressure sterilizers
 Pipette washers
 Analytical balance
 Semi auto analyzer
 ELISA reader
 Blood gas analyzer
 PCR instrument
 Flow cytometer
Emergency services:
An emergency department must be developed as a mini hospital within a hospital i.e.
Independent and self sufficient in day to day working.
Planning and organizational considerations:
1. Location: there are two essential location requirements:

 It must be on ground floor and easily accessible to both ambulatory and ambulance
patients, and there should be minimal separation between it and radiology department.
 Secondly, the emergency department should have ready access to the acute patient care
areas, eg. Operation theatre, ICU, blood bank etc.
Emergency department must be designed; usually 1000 sq.ft is required for daily patient load of
100 patients.
2. Stretcher, trolley, wheelchair store: a store for stretcher, trolley and wheelchairs should
be located adjacent to the entrance.
3. Ambulance attendants, police, mass media room: an equipped room of about 10 m2
near
the entrance hall with attached toilet serves the needs of above personnel.
4. Work area: it should be spacious with enough room for personnel and patients.
5. Waiting area for emergency department patients: the main function of this is to be the
passageway to patient examination and treatment area.
6. Waiting area for relatives: patient relatives should not be allowed in the work areas of
emergency department. Waiting room with recreational facilities may be provided.
7. Visitor‘s toilet: it should be provide near the main waiting space.
8. Nurse‘s station and administrative office: this should be next to the entrance and manned
on 24 hr. basis. It should be provided with multiple telephones, bulletin board with duty
roster of doctors on call and directive pertaining to the emergency department should be
displayed. Nurses work room should be well stocked with drugs, IV fluids.
9. Examination and treatment area: this area should always be in readiness to receive
patients at all times, and should consist of a large room and number of separate smaller
rooms for examination and treatment. It should be well illuminated space with oxygen
supply, resuscitation equipment, suction, portable X-ray, electrocardiographs, and
Boyle‘s apparatus.
10. Equipment:
 Stretchers
 On-the wall oxygen unit
 On-the wall suction unit
 BP apparatus, otoscope, stethoscope, opthalmoscope etc.
 Spot lights
 Utility table
 Airways and resuscitation bags
11. Resuscitation room: the patient is to be stabilized in this room before shifting to treatment
or recovery room, or to ICU or nursing unit. It should be well equipped with resuscitation
equipment, ECG machine and X-ray viewing screening with facility for performing
minor operative procedures.
12. Operation room: a self sufficient operation room to serve patients who need minor
surgery and no admission or who are critically ill etc. in emergency department.

13. Fracture room: a separate fracture room equipped similar to OT and additional facilities
for reduction of closed fractures under local anesthesia can be planned with hospitals
with turnover of emergency patients in excess of 15,000 per annum.
14. Plaster room: it is needed for treatment of fractures and application plasters.
15. Care of burns: a separate room with 20 m2
area should be reserved for immediate care of
burn patients. An observation ward of about 6-8 beds for patients to be kept under
observation overnight or 24 hrs.
16. Isolation room: for obstetric patients, pediatric patients.
17. Other rooms: these should be planned based on the local needs:
 Room for dead bodies
 Pantry-7 m2
 Storage space
 Utility and soiled linen room-7 m2
 Cleaners room-house keepers room 4m2
 Change room duty rooms 9m2
 Conference room and reference library 8m2
Staffing pattern:
 Full time emergency physicians, especially trained in emergency medicine
 A well staffed emergency department needs 8 nurse shifts of 8 hours each per 100
daily patients‘ visits. Additional staff nurses is required if there is observation
ward attached.
 For registration and records, usually 3 clerks work in day and afternoon shift,
and one during night.
 Security should be available round the clock
 Public relations and social worker should be available to take care of the anxious
and disturbed patients and their relatives.
Medico-legal aspects of emergency department:
a. Negligence: it is the breach of duty owed by a doctor to his patients to exercise
reasonable care/skills resulting in some bodily, mental or financial disability.
b. Duty to treat all: according to the recent supreme court decision, no doctor can refuse
giving first aid treatment to accident victims or any other patients.
c. Problem areas in emergency department:
Consent to treatment: a written consent must be obtained from the patient to treat
him, with the patient‘s knowledge regarding procedures.
Medical records: medical records and proper record keeping are high priority in
any hospital. Proper documentation of patient‘s case history with informed
consent is necessary.

Reporting to authorities: all medico-legal cases e.g. Assault and battery, child
abuse, accidents etc. Should be reported to proper authorities e.g. Police. The
cases of AIDS and venereal diseases should be reported to health authorities.
DISASTER MANAGEMENT
DEFINITION
Disaster is ―any occurrence that causes damage, economic disruption, loss of human life and
deterioration of health and health service on a scale sufficient to warrant an extraordinary
response from outside the affected community or area‖. (WHO)
―Disaster can be defined as an overwhelming ecological disruption, which exceeds the capacity
of a community to adjust and consequently requires assistance from outside. -Pan American
Health Organisation(PAHO)
Disaster is an event, natural or manmade, sudden or progressive, which impacts with such
severity that the affected community has to respond by taking exceptional measures. -W. Nick
Carter
CLASSIFICATION OF DISASTERS
Disasters are commonly classified according to their causes into two distinct categories:
 Natural disaster
 Man-made disaster
Natural disasters
 Metrological disaster: Storms (Cyclones, typhoons, hurricanes, tornados, hailstorms,
snowstorms), cold spells, heat waves and droughts.
 Typological Disaster: landslides, avalanches, mudflows and floods.
 Telluric and Teutonic (Disaster originate underground): Earthquake, volcanic
eruptions and tsunamis (seismic sea waves).
 Biological Disaster: communicable disease, epidemics and insect swarms (locusts).
Man Made Disasters
 Warfare: conventional warfare (bombardment, blockade and siege) and non-conventional
warfare (nuclear, chemical and biological).
 Civil disasters: riots and demonstration.
 Accidents: transportation (planes, trucks, automobiles, trains and ships); structural
collapse (building, dams, bridges, mines and other structures); explosions and fires.
 Technological failures: A mishap at a nuclear power station, leak at a chemical plant
causing pollution of atmosphere or the breakdown of a public sanitation.

PRINCIPLES OF DISASTER MANAGEMENT
 Prevent the disaster
 Minimize the casualties
 Prevent further casualties
 Rescue the victims
 First aid
 Evacuate
 Medical care
 Reconstruction
READINESS FOR DISASTER
Readiness for disaster involves two aspects:
1. Resource for readiness.
2. Disaster pre planning.
1. Resources for readiness:
 RED CROSS: Its primary concern in a disaster situation is to provide relief for human
suffering in the form of food, shelter, clothing, medical care, and occupational rehabilitation
of victims.
 COMMUNITY AND LOCAL GOVERNMENT: It shares the responsibility in clearing rubble,
maintaining law and order, determining the safety of a structure of habitation, repairing
bridges, resuming transportation, maintaining sanitation, providing safe food and drinking
water, etc.
 CIVIL DEFENCE SERVICES: The civil defense and its medical facility programmers provide
for shelters, establishing communication linkage, post disaster services, assistance to affected
community in the area of health, sanitation, maintaining law and order, fire fighting, clearing
debris, prevention and control of epidemic of various diseases etc.
2. Disaster pre-planning: It is important to make the best possible use of the resources.
Some of the pre-planning aspects for disaster related to medical care as follows:
 HOSPITAL DISASTER PLANING: Depending upon the hospital‘s location and size, it
mobilizes its resources to manage any disaster. It should provide for immediate action in the
event of:
i. An internal disaster in hospital itself eg. fire, explosion, etc.
ii. Some minor external disaster.
iii. Major external disaster.
iv. Threat of disaster.
v. Disaster in neighboring communities/country.

 EVACUATION: There is usually a system which on order of the medical superintendent, is
activated : eg.
i. Percentage of evacuation (discharge) of the patient from the hospital.
ii. Addition of extra beds.
iii. Preparation of emergency ward.
iv. Such facilities should be near to X-ray, operation theatre, central supply, medical store,
etc.
 ORDERLY FLOW OF CASUALITY: It is important to minimize confusion in receiving
causalities. A team of well qualified physician and nurses at the reception itself sorts out
causalities and make quick decisions of the treatment.
i. Additional nursing staff volunteers may be called and posted.
ii. Services of all departments of the hospital should be well integrated in the disaster plan
viz. dietary department, laundry, public works department (PWD), engineering unit, etc.
iii. The planning should also take into consideration other aspects like traffic control, types of
medical records to be maintained, standardization of emergency medical tags, public
information centers, controlled dissemination of information without or with minimum
distortion, preparation of emergency supplies kept ready, all ambulance kept ready,
arrangement of additional vehicles.
 COMMUNICATION SYSTEM: Additional communication system should be planned. It is
also important to keep the hospital informed about the inflow of the casualties from the scene.
THE DISASTER MANAGEMENT CYCLE
1. DISASTER EVENT: This refers to the ―REAL TIME‖ event of the hazard occurring and
affecting elements of risk.
2. RESPONSE AND RELIEF: This refers to the first stage response to any calamity, which
include setting up control rooms, putting the contingency plan in action, issue warnings,
evacuating people to safe areas, rendering medical aid to the needy, etc.
3. RECOVERY: It has three overlapping phases of emergency relief rehabilitation and
reconstructing.
4. DEVELOPMENT: Evolving economy and long-term prevention/disaster reduction
measures like construction of houses capable of withstanding the onslought of heavy rains,
wind speeds and shocks of earthquakes.
5. REDUCTION AND MITIGATION: Protective or preventive actions that lessons the scale
of impact. Minimizing the effects of disaster. Eg. building codes and zoning, vulnerability
analyses, public education.
6. PREPAREDNESS: Includes the formulation and development of viable emergency plans,
of the warning system, the maintenance of inventories and the training of personnel.

DISASTER
IMPACT
RESPONSE
RECOVERY
DEVELOPMENT
PREVENTION
MITIGATION
PREPAREDNESS
TRIAGE
The word triage is derived from French word ―trier‖ which means sorting or choosing.
Objectives of triage
An effective triage system should be able to achieve the following:
 Ensure immediate medical intervention in life threatening situations.
 Expedite the care of patents through a systematic initial assessment.
 Ensure that patients are prioritised for treatment in accordance with the severity of their
medical condition.
 Reduce morbidity through early medical intervention.
 Improve public relations by communicating appropriate information to friends and
relatives who accompany patients.
 Improve patients flow within emergency departments and/or disaster management
situation.
 Provide supervised learning for appropriate personnel.

Principles of triage
The main principles of triage are as follows:
 Every patient should be received and triaged by appropriate skilled health-care professionals.
 Triage is a clinic-managerial decision and must involve collaborative planning.
 The triage process should not cause a delay in the delivery of effective clinical care.
Triage system
Triage consists of rapidly classifying the injured on the bases of severity of their injuries and the
likelihood of their survival with prompt medical intervention
1. GOLDEN HOUR
A seriously injured patient has one hour in which they need to receive Advanced Trauma Life
Support. This is referred to as the golden hour
2. IMMEDIATE OR HIGH PRIORITY
Higher priority is granted to victims who‘s immediate or long term prognosis can be dramatically
affected by simple intensive care.
Immediate patients are at risk for early death
They usually fall into one of two categories. They are in shock from severe blood loss or
they have severe head injury
These patients should be transported as soon as possible
3. DELAYED OR MEDIUM PRIORITY:
 Delayed patients may have injuries that span a wide range
 They may have severe internal injuries, but are still compensating
Delayed patients have:
 Respirations under 30/minutes
 Capillary refill under 2 seconds
 Can do-follow simple commands
4. MINOR OR MINIMAL OR AMBULATORY PATIENTS
Patients with minor lacerations, contusions, sprains, superficial burns are identified as
―minor/minimal‖

5. EXPECTANT OR LEAST PRIORITY
 Morbid patients who require a great deal of attention with questionable benefit have the
lowest priority.
 Patients with whom there are signs of impending death or massive injuries with poor
likelihood of survival are labeled as expectant
Color code
 Red indicate high priority treatment or transfer
 Yellow signals medium priority
 Green indicate ambulatory patients
 Black indicates dead or moribund patients
HOSPITAL DISASTER PLAN
The hospital is an integral part of the society and it has great role to play in the disaster
management. Every hospital big or small, public or private has to prepare a disaster plan, and
must learn to activate the disaster plan at the hour of need. Disasters in the hospital perspective
can be grouped into two categories:
1. Internal Hospital disasters like fire, building collapse, terrorism, etc
2. External disasters like earthquakes, floods, etc
OBJECTIVES OF HOSPITAL DISASTER PLAN
1. Preparedness of staff, optimising of resources and mobilisation of the logistics and
supplies within short notice
2. To make community aware about the hospital disaster plan and benefits of plan
3. Training and motivation of the staff
4. To carry out mock drills
5. Documentation of the plan and making hospital staff aware about the various steps of the
plan
DESIGNING OF HOSPITAL DISASTER PLAN
1. Disaster management committee:
The hospital disaster management committee is the decision making body for formulation of
the policy and plan for disaster management. It constitutes the following members.
a. Director of the hospital
b. HOD of accidents and emergency services
c. All heads of the departments

d. Nursing superintendent
e. Hospital administrator
f. Representatives of the staff
2. Functions of the disaster management committee- The functions of the committee are:
a. To prepare a hospital disaster plan for the hospital
b. To prepare departmental plan in support of the hospital plan
c. Assign duties to the staff
d. Establishment of criteria for emergency care
e. To conduct, supervise and evaluate the training programmes
f. To supervise the mock drills
g. Updating of plans as need arises
h. Organise community awareness programmes, through mass media
i. Assist in information, education, communication (IEC) programmes in respect of the
disaster preparedness, prevention and management.
3. Role and functions: The effective implementation of the program will depend upon clarity of
the plan, role and functions of the different members and the staff. They are:
a. Disaster co-ordinator: The co-ordinators role will be:
o Organising
o Communicating
o Assigning duties
o Deployment of staff
o Taking key decisions
b. Administrator: The responsibilities of the administrator is to execute the authority
through the departmental heads
c. Departmental heads: Development of departmental plans
d. Nursing superintendent : deployment of nursing staff
e. Medical staff: specific role of rendering medical care both pre-hospital and hospital care
f. Nursing staff: nursing care and support critical care
4. Important departments
The important department of the hospital have to play a key role in the disaster management.
a. Accident and emergency department
b. Operating department
c. Critical care units
d. Radiology departments
e. Laboratory
f. Bloodbank

5. Support areas
Prompt supply of drugs, linen and surgical items, fluids are required in the hospital and due
care has to be taken to incorporate the role and function of following units.
a. Laundry
b. CSSD
c. Dietary department
d. Housekeeping services
e. Medical records
f. Public relations
g. Communications
h. Transportation
i. Mortuary
j. Medic-social worker
k. Engineering department
l. Security and safety services
m. Media relations
DISASTER DRILL
Definition
A disaster drill is an exercise in which people simulate the circumstances of a disaster so that
they have an opportunity to practice their responses.
Features
On a basic level, drills can include responses by individuals to protect themselves, such as
learning how to shelter in place, understanding what to do in an evacuation, and organizing
meet up points so that people can find each other after a disaster.
Disaster drills handle topics like what to do when communications are cut off, how to deal
with lack of access to equipment, tools, and even basic services like water and power, and
how to handle evacuations.
It also provides a chance to practice for events such as mass casualties which can occur during
a disaster.
Regular disaster drills are often required for public buildings like government offices and
schools where people are expected to practice things like evacuating the building and assisting
each other so that they will know what to do when a real alarm sounds.
Community-based disaster drills such as whole-city drills provide a chance to practice the full
spectrum of disaster response. These drills can include actors and civilian volunteers who play
roles of victims, looters, and other people who may be encountered during a disaster, and
extensive planning may go into such drills. A disaster drill on this scale may be done once a
year or once every few years.

Benefits
 Used to identify weak points in a disaster response plan
 To get people familiar with the steps they need to take so that their response in a disaster
will be automatic.
ROLE OF NURSES IN DISASTER MANAGEMENT
I. In disaster preparedness
1) To facilitate preparation with community
For facilitating preparation within the community, the nurse can help initiate updating disaster
plan, provide educational programmes & material regarding disasters specific to areas.
2) To provide updated record of vulnerable populations within community
The nurse should be involved in educating these populations about what impact the disaster can
have on them.
3) Nurse leads a preparedness effort
Nurse can help recruit others within the organization that will help when a response is required.
It is wise to involve person in these efforts who demonstrate flexibility, decisiveness, stamina,
endurance and emotional stability.
4) Nurse play multi roles in community
Nurse might be involved in many roles. As a community advocate, the nurse should always seek
to keep a safe environment. She must assess and report environmental hazards.
5) Nurse should have understanding of community resources
Nurse should have an understanding of what community resources will be available after a
disaster strikes and how community will work together. A community wide disaster plan will
guide the nurse in understanding what should occur before, during and after the response and his
or her role in the plan.
6) Disaster Nurse must be involved in community organization
Nurse who sects greater involvement or a more in-depth understanding of disaster management
can be involved in any number of community organizations such as the American Red Cross,
Ambulance Corps etc.
II. In disaster response
1) Nurse must involve in community assessment, case finding and referring, prevention, health
education and surveillance

2) Once rescue workers begin to arrive at the scene, immediate plans for triage should begin.
Triage is the process of separating causalities and allocating treatment based on the victim‘s
potential for survival.
o Higher priority is always given to victim‘s potential who have life threatening injuries but
who have a high probability of survival once stabilized.
o Second Priority is given to victims who have injuries with systemic complications that are
not yet life threatening but who can wait up to 45-60 minutes of treatment.
o Last priority in given to those victims who have local injuries without immediate
complications and who can wait several hours for medical attention
3) Nurse work as a member of assessment team
Nurse working as members of an assessment team have the responsibility of give accurate feed
back to relief managers to facilitate rapid rescue and recovery.
4) To be involved in ongoing surveillance
Nurse involved in ongoing surveillance uses the following methods to gather information –
interview, observation, physical examination, health and illness screening surveys, records etc.
III. In disaster recovery
1) Successful Recovery Preparation
Flexibility is an important component of successful recovery preparation.
Community clean up efforts can incure a host of physical and psychological problems. Eg.
Physical stress of moving heavy objects can cause back injury, severe fatigue and even death
from heart attacks.
2) Health teaching
The continuing threat of communicable disease will continue as long as the water supply remains
threat and the relieving conditions remain crowded. Nurses must remain vigilant in teaching
proper hygiene and making sure immunization records are up to date.
3) Psychological support
Acute and chronic illness can be exacerbated by prolonged effects of disaster. The psychological
stress of cleanup and moving can bring about feelings of severe hopelessness, depression and
grip.
4) Referrals to hospital as needed
Stress can lead to suicide and domestic abuse. Although most people recover from disasters,
mental distress may persist in vulnerable populations. Referrals to mental health professionals
should continue as long as the need exists.

5) Remain alert for environmental health
Nurse must also remain alert for environment health hazards during recovery phase of a disaster.
Home visit may lead the nurse to uncover situations such as lack of water supply or lack of
electricity.
PARAMETERS FOR NURSING PRACTICE
All nurses providing health care at mass gatherings must be competent in the basic principles of
first aid including CPR and use of automated external defibrillator. In addition nurses should
possess the following minimum care competencies.
Nursing assessment
 Perform respiratory airway assessment
 Perform a cardiovascular assessment including vital signs, monitoring for signs of shade.
 Perform an integumentary assessment, including burn assessment
 Perform a pain assessment.
 Perform a trauma assessment from head to toe
 Perform a mental status including Glasgow coma scale
 Know the indications of intubation

Unit V
Human Resource
for health
 Staffing
 Philosophy
 Norms: Staff inspection unit(SIU), Bajaj
Committee, High power committee, Indian
nursing council (INC)
 Estimation of nursing staff requirement-
activity analysis
 Various research studies
 Recruitment: credentialing, selection, placement,
promotion
 Retention
 Personnel policies
 Termination
 Staff development programme
 Duties and responsibilities of various category of
nursing personnel
 Applications to nursing service and education

HUMAN RESOURCES FOR HEALTH
Introduction
Organization is the formal structure of authority calculated to define, distribute and
provide for the co-ordination of the tasks as contribution to the whole. When the aims of the
organization properly design the planning of its institutions and its functional standard, it will
have identified the kind and numbers of personnel it needs.
STAFFING
Definition
Staffing is the systematic approach to the problem of selecting, training, motivating and
retaining professional and non professional personnel in any organization.
It involves manpower planning to have the right person in the right place and avoid ―Square peg
in round hole‖.
Philosophy
Components of the staffing process as a control system include a staffing study, a master
staffing plan, a scheduling plan, and a nursing management information system (NMIS).
NMIS includes these five elements;
1. Quality of patient care to be delivered and its measurement.
2. Characteristics and care requirements of patients.
3. Prediction of the supply of nurse power required for components 1 &2.
4. Logistics of the staffing program pattern and its control.
5. Evaluation of the quality of care desired, thereby measuring the success of the staffing
itself.
Philosophy of staffing in nursing
Nurse administrators of a hospital nursing department might adopt the following philosophy.
1. Nurse administrators believe that it is possible to match employee‘s knowledge and
skills to patient care needs in a manner that optimizes job satisfaction and care
quality.
2. Nurse administrators believe that the technical and humanistic care needs of critically
ill patients are complex that all aspects of that care should be provided by
professional nurses.

3. Nurse administrative believe that the health teaching and rehabilitation needs of
chronically ill patients are so complex that direct care for chronically ill patients
should be provided by professional and technical nurses.
4. Should believe that believe that patient assessment, work quantification and job
analysis should be used to determine the number of personnel in each category to be
assigned to care for patients of each type (such as coronary care, renal failure, etc.,).
5. Should believe that a master staffing plan and policies to implement the plan in all
units should be developed centrally by the nursing heads and staff of the hospital.
6. Should the staffing plan should be administrated at the unit level by the head nurse, so
that can change based on unit workload and workflow.
Objectives of staffing in nursing
1. Provide an all professional nurse staff in critical care units, operating rooms, labor,
delivery unit, emergency room.
2. Provide sufficient staff to permit a 1:1 nurse-patient ratio for each shift in every critical
care unit.
3. Staff the general medical, surgical, Obsteritic and gynecology, pediatric and psychiatric
units to achieve a 2:1 professional –practical nurse ratio.
4. Provide sufficient nursing staff in general medical, surgical, Obsteritic, pediatric and
psychiatric units to permit a 1: 5 nurse-patient ratio on a day and after noon shifts an
d1:10 nurse –patient ratio on the night shift.
NORMS OF STAFFING(S I U- staff inspection unit)
Norms
Norms are standards that guide, control, and regulate individuals and communities. For
planning nursing manpower we have to follow some norms. The nursing norms are
recommended by various committees, such as; the Nursing Man Power Committee, the High-
power Committee, Dr. Bajaj Committee, and the staff inspection committee, TNAI and INC. The
norms has been recommended taking into account the workload projected in the wards and the
other areas of the hospital.
All the above committees and the staff inspection unit recommended the norms for
optimum nurse-patient ratio. Such as 1:3 for Non Teaching Hospital and 1:5 for the Teaching
Hospital. The Staff Inspection Unit (S.I.U.) is the unit which has recommended the nursing
norms in the year 1991-92. As per this S.I.U. norm the present nurse-patient ratio is based and
practiced in all central government hospitals.
Recommendations of S.I.U:
1. The norms for providing staff nurses and nursing sisters in Government hospital is given
in annexure to this report. The norm has been recommended taking into account the
workload projected in the wards and the other areas of the hospital.

2. The posts of nursing sisters and staff nurses have been clubbed together for calculating
the staff entitlement for performing nursing care work which the staff nurse will continue
to perform even after she is promoted to the existing scale of nursing sister.
3. Out of the entitlement worked out on the basis of the norms, 30%posts may be sanctioned
as nursing sister. This would further improve the existing ratio of 1 nursing sister to 3.6.
staff nurses fixed by the government in settlement with the Delhi nurse union in may
1990.
4. The assistant nursing superintendent are recommended in the ratio of 1 ANS to every 4.5
nursing sisters. The ANS will perform the duty presently performed by nursing sisters
and perform duty in shift also.
5. The posts of Deputy Nursing Superintendent may continue at the level of 1 DNS per
every 7.5 ANS
6. There will be a post of Nursing Superintendent for every hospital having 250 or beds.
7. There will be a post of 1 Chief Nursing Officer for every hospital having 500 or more
beds.
8. It is recommended that 45% posts added for the area of 365 days working including 10%
leave reserve (maternity leave, earned leave, and days off as nurses are entitled for 8 days
off per month and 3 National Holidays per year when doing 3 shift duties).
Most of the hospital today is following the S.I.U.norms. In this the post of the Nursing Sisters
and the Staff Nurses has been clubbed together and the work of the ward sister is remained same
as staff nurse even after promotion. The Assistant Nursing Superintendent and the Deputy
Nursing Superintendent have to do the duty of one category below of their rank.
BAJAJ COMMITTEE, 1986
An "Expert Committee for Health Manpower Planning, Production and Management"
was constituted in 1985 under Dr. J.S. Bajaj, the then professor at AIIMS.
Manpower is one of the most vital resources for the labour intensive health services industry.
Health for all (HFA) can be achieved only by improving the utilization of these resources.
Major recommendations are:-
1. Formulation of National Medical & Health Education Policy.
2. Formulate on of National Health Manpower Policy.
3.Establishment of an Educational Commission for Health Sciences (ECHS) on the lines of
UGC.

4.Establishment of Health Science Universities in various states and union territories.
5.Establishment of health manpower cells at centre and in the states.
6.Vocationalisation of education at 10+2 levels as regards health related fields with appropriate
incentives, so that good quality paramedical personnel may be available in adequate numbers.
7.Carrying out a realistic health manpower survey.
In relation to nursing, the Bajaj Committee recommended staffing norms for nursing manpower
requirements for hospital nursing services and requirements for community health centres and
primary health centres on the basis of calculations as follow:
Hospital Nursing Services-
1. Nursing superintendents. 1:200 beds
2. Deputy nursing superintendents 1:300 beds
3. Departmental nursing 7:1000 + 1 Addl:1000 beds
(991 x 7 + 991)
4. Ward nursing 8:200 + 30% leave reserve
supervisors/sisters
5. Staff nurse for wards 1:3 (or 1:9 for each shift)
+30 leave reserve
6. For OPD, Blood Bank, X-ray,
Diabetic clinics, CSR, etc 1:100 (1:5 OPD)
+30% leave reserve
7. For intensive units 1:8 (1:3 for each shift)
(8 beds ICU/200 beds) + 30% leave reserve
8. For specialized deptts and
clinics, OT, Labour room 8:200 + 30% leave reserve

Community Nursing Service
Projected population - 991,479,200 (medium assumption) by 2000 AD
1 Community Health Centre - 1,000,00 population
1 Primary Health Services - 30,000 population in plain area
1 Primary Health Services - 20,000 population in difficult areas
1 Sub-centre - 5000 population in plain area
1 Sub-centre - 3000 population for difficult area
It also requires nursing manpower to cater to the needs of the rural community as follows:
Manpower requirements by 2000 AD:
 Sub-centre ANM/FHW 323882
 Health supervisors /LHV 107960
 Primary Health Centres PHN 26439
 Community health centre Nurse-midwives 26439
 Public health nursing supervisor 7436
 Nurse-midwives 52,052
 District public health nursing officer 900
In additional to the above, 74361 Traditional Birth Attendants will be required.
HIGH POWER COMMITTEE ON NURSING AND NURSING PROFESSION (1987-
1989)
High power committee on nursing and nursing profession was set up by the Government
of India in July 1987, under the chairmanship of Dr. Jyothi former vice-chancellor of SNDT
Women University, Mrs. Rajkumari Sood, Nursing Advisor to Union Government as the
member-secretary and CPB Kurup, Principal, Government College of Nursing, Bangalore and
the then President. TNAI is also one among the prominent members of this committee. Later on
the committee was headed by Smt. Sarojini Varadappan, former Chairman of Central Social
Welfare Board.
The terms of reference of the Committee are:
 To look into the existing working conditions of nurses with particular reference to the
status of the nursing care services both in the rural and urban areas.

 To study and recommend the staffing norms necessary for providing adequate nursing
personnel to give the best possible care, both in the hospitals and community.
 To look into the training of all categories and levels of nursing, midwifery personnel to
meet the nursing manpower needs at all levels o health services and education.
 To study and clarify the role of nursing personnel in the health care delivery system
including their interaction with other members of the health team at every level of health
service management.
 To examine the need for organised nursing services at the national, state, district and
local levels with particular reference to the need for planning service with the overall
health care system of the country at the respective levels.
 To look into all other aspects, the Committee will hold consultations with the State
Governments.
ECOMMENDATIONS OF HIGH POWER COMMITTEE ON NURSING AND
NURSING PROFESSION
Working conditions of nursing personnel
1. Employment
Uniformity in employment procedures to be made. Recruitment rules are made for all categories
of nursing posts. The qualifications and experience required or these be made thought the
country.
2. Job description
Job description of all categories of nursing personnel is prepared by the central government
to provide guidelines.
3. Working hours
The weekly working hours should be reduced to 40 hrs per week. Straight shift should be
implemented in all states. extra working hours to be compensated either by leave or by extra
emoluments depending on the state policy .nurses to be given weekly day off and all the gazetted
holidays as per the government rules.
4. Work load/ working facilities
 Nursing norms for patient care and community care to be adopted as recommended by the
committee.
 Hospitals to develop central sterile supply departments, central linen services, and central
drug supply system. Group D employees are responsible for housekeeping department.
 Policies for breakage and losses to be developed and nurses not are made responsible for
breakage and losses.

5. Pay and allowances
Uniformity of pay scales of all categories of nursing personnel is not feasible. However special
allowance for nursing personnel, i.e.; uniform allowance, washing, mess allowance etc should be
uniform throughout the country.
6. Promotional opportunities
The committee recommends that along with education and experience, there is a need to
increase the number of posts in the supervisory cadre, and for making provision of guidance and
supervision during evening and night shifts in the hospital.
-Each nurse must have 3 promotions during the service period.
-Promotion is based on merit cum seniority.
-Promotion to the senior most administrative teaching posts is made only by open selection.
-In cases of stagnation, selection grade and running scales to be given.
7. Career development
Provision of deputation for higher studies after 5 yrs of regular services be made by all
states. The policy of giving deputation to 5 -10 % of each category be worked out by each state.
8. Accommodation
As far as possible, the nursing staff should be considered for priority allotment of
accommodation near to work place. Apartment type of accommodation is built where
married/unmarried nurses can be allowed to live. Housing colonies for hospital s must be
considered in long run.
9. Transport
During odd hours, calamities etc arrangements for transport must be made for safety and security
of nursing personnel.
10. Special incentives
Scheme of special incentives in terms of awards, special increment for meritorious work for
nurses working in each state/district/PHC to be worked out.
11. Occupational hazards
Medical facilities as provided by the central govt. by extended by the state govt to nursing
personnel till such times medical services are provided free to all the nursing personnel. Risk
allowance to be paid to nursing personnel working in the rural $ urban area.
12. Other welfare services
Hospitals should provide welfare measures like 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.
4. Post certificate B.Sc. Nursing degree to be continued to give opportunities to the existing
diploma nurses to continue higher education.
5. Master in nursing programme to be increased and strengthened.
6. Doctoral programme in nursing have to be started in selected universities.
7. Central assistance be provided for all levels of nursing education institutions in terms of
budget( capital and recurring)
8. Up gradation of degree level institutions be made in a phased manner as suggested in report.
9. Each school should have separate budget till such time is phased to degree/vocational
programme. The principal of the school should be the drawing and the disbursing officer.
10. Nursing personnel should have a complete say in matters of selection of students. Selection
is based completely on merit. Aptitude test is introduced for selection of candidates.
11. All schools to have adequate budget for libraries and teaching equipments.
12. All schools to have independent teaching block called as School Of Nursing with adequate
class room facilities, library room, common room etc as per the requirements of INC.

Continuing Education and Staff Development
 Definite policies of deputing 5-10% of staff for higher studies are made by each state.
Provision for training reserve is made in each institution.
 Deputation for higher study is made compulsory after 5 yrs.
 Each nursing personnel must attend 1 or 2 refresher course every year.
 Necessary budgetary provision be made.
 A National Institute for Nursing Education Research and Training needs to be established
like NCERT, for development of educational technology, preparation of textbooks, media, /
manuals for nursing.
NURSING SERVICES: HOSPITALS/INSTITUTIONS (URBAN AREAS)
Definite nursing policies regarding nursing practice are available in each institution.
These policies include:
a) Qualification/recruitment rules
b) Job description/job specifications
c) Organizational chart of the institutions
d) Nursing care standards for different categories of patients.
1. Staffing of the hospitals should be as per norms recommended.
2. District hospitals /non teaching hospitals may appoint professional teaching nurses in the
ratio of 1; 3 as soon as nurses start qualifying from these institutions.
3. Students not to be counted for staffing in the hospitals
4. Adequate supplies and equipments, drugs etc be made available for practice of nursing. The
committee strongly recommends that minimum standards of basic equipment needed for
each patient be studied , norms laid down and provided to enable nurses to perform some
of the basic nursing functions . Also there should be a separate budget head for nursing
equipment and supplies in each hospitals/ PHC. The NS and PHN should be a member of
the purchase and condemnation committee.
5. Nurses to be relieved from non -nursing duties.
6. Duty station for nurses is provided in each ward.
7. Necessary facilities like central sterile supplies, linen, drugs are considered for all major
hospitals to improve patient care. Also nurses should not be made to pay for breakage and
losses. All hospitals should have some systems for regular assessment of losses.
8. Provision of part time jobs for married nurses to be considered. (min 16-20hrs/week)
9. Re-entry by married nurses at the age of 35 or above may also be considered and such
nurse be given induction courses for updating their knowledge and skills before
employment.

10. Nurses in senior positions like ward sisters, Asst. nursing superintendents, Deputy NS;
N.S must have courses in management and administration before promotions.
11. Nurses working in speciality areas must have courses in specialities. Promotion
opportunities for clinical specialities like administrative posts are considered for
improving quality nursing services.
The committee recommends that Gazetted ranks be allowed for nurses working as ward sister
and above (minimum class II gazetted). Similarly the post of Health Supervisor (female) is
allowed gazetted rank and district public health nurse be given the status equal to district
medical/ health officers.
Community Nursing Services
 Appointment of ANM/LHV to be recommended.
- 1 ANM for 2500 population (2 per sub centre)
- 1 ANM for 1500 population for hilly areas
- 1 health supervisor for 7500 population (for supervision of 3 ANM's)
- 1 public health nurse for 1 PHC (30000 population to supervise 4 Health
Supervisors)
- 1 Public Health Nursing Officer for 100000 population (community health centre)
- 2 district public health nursing for each district.
 ANM/LHV promoted to supervisory posts must undergo courses in administration and
management.
 Specific standing orders are made available for each ANM/LHV to function effectively in
the field.
 Adequate provision of supplies, drugs etc are made.
Norms recommended for nursing service and education in hospital setting.
1. Nursing Superintendent -1: 200 beds (hospitals with 200 or more beds).
2. Deputy Nursing Superintendent. - 1: 300 beds ( wherever beds are over 200)
3. Assistant Nursing Superintendent - 1: 100
4. Ward sister/ward supervisor - 1:25 beds 30% leave reserve
5. Staff nurse for wards -1:3 ( or 1:9 for each shift ) 30% leave reserve
6. For nurses OPD and emergency etc - 1: 100 patients ( 1 bed : 5 out patients) 30% leave
reserve
7. For ICU -1:1(or 1:3 for each shift) 30% leave reserve
For specialized departments such as operation theatre, labour room etc- 1: 25 30% leave reserve.

INDIAN NURSING COUNCIL (INC)
The Indian Nursing Council is an Autonomous Body under the Government of India and
was constituted by the Central Government under the Indian Nursing Council Act, 1947 of
parliament. It was established in 1949 for the purpose of providing uniform standards in nursing
education and reciprocity in nursing registration throughout the country. Nurses registered in one
state were not registered in another state before this time. The condition of mutual recognition by
the state nurses registration councils, called reciprocity was possibly only if uniform standards of
nursing education were maintained.
Functions of Indian Nursing Council.
 To establish and monitor a uniform standard of nursing education for nurses midwife,
Auxiliary Nurse-Midwives and health visitors by doing inspection of the institutions.
 To recognize the qualifications under section 10(2)(4) of the Indian Nursing Council
Act, 1947 for the purpose of registration and employment in India and abroad.
 To give approval for registration of Indian and Foreign Nurses possessing foreign
qualification under section 11(2) (a) of the Indian Nursing Council Act, 1947.
 To prescribe the syllabus & regulations for nursing programs.
 Power to withdraw the recognition of qualification under section 14 of the Act in case
the institution fails to maintain its standards under Section 14 (1)(b) that an institution
recognized by a State Council for the training of nurses, midwives, auxiliary nurse
midwives or health visitors does not satisfy the requirements of the Council.
 To advise the State Nursing Councils, Examining Boards, State Governments and
Central Government in various important items regarding Nursing Education in the
Country.
THE EXISTING NORM BY INC WITH REGARD TO NURSING STAFF FOR WARDS
AND SPECIAL UNITS:
Staff nurse Sister(each
shift)
Departmental sister/ assistant nursing
superintendent
Medical ward 1:3 1:25 1 for 3-4 weeks
Surgical ward 1:3 1:25 1 for 3-4 weeks

Orthopedic ward 1:3 1:25 1 for 3-4 weeks
Pediatric ward 1:3 1:25 1 for 3-4 weeks
Gynecology ward 1:3 1:25 1 for 3-4 weeks
Maternity ward
including newborns
1:3 1:25 1 for 3-4 weeks
ICU 1:1(24 hours) 1
CCU 1:1(24 hours) 1
Nephrology 1:1(24 hours) 1 1 department sister/assistant nursing
superintendent for 3-4 units clubbed
together
Neurology & and
neurosurgery
1:1(24 hours) 1
Special wards- eye,
ENT etc.
1:1(24 hours) 1
Operation theatre 3 for 24 hours
per table
1 1 department sister/asst nursing
superintendent for 4-5 operating
rooms
Casuality and
emergency unit
2-3 staff nurses
depending on the
number of beds
1 1 department sister/assistant nursing
superintendent
Staffing pattern according to the Indian Nursing Council (relaxed till 2012)
Collegiate programme-A
Qualifications and experience of teachers of college of nursing-
1. Professor-cum-Principal
 Masters Degree in Nursing
 Total 10 years of experience with minimum of 5 years of teaching experience
2. Professor-cum- Vice Principal
 Masters Degree in Nursing
 Total 10 years of experience with minimum of 5 years in teaching

3. Reader/Associate Professor
 -Masters Degree in Nursing
 Total 7 years of experience with minimum of 3 years in teaching
4. Lecturer
 Masters Degree in Nursing with 3 years of experience.
5. Tutor/Clinical Instructor
 M.Sc.(N) or B.Sc. (N) with 1 year experience or Basic B.Sc. (N) with post basic
diploma in clinical specialty
For B.Sc. and M.Sc. nursing:
Annual intake of 60 students for B.Sc. (N) and 25 for M.Sc. (N) programme
B.Sc. (N) M.Sc. (N)
Professor cum principal
1
Professor cum vice
principal
1
Reader/Associate
professor
1 2
Lecturer
2 3
Tutor/clinical instructor
19
Total
24 5
One in each specialty and all the M.Sc. (N) qualified teaching faculty will participate in both
programmes.
Teacher-student ratio = 1:10
GNM and B.Sc. (N) with 60 annual intake in each programme
1
Professor cum vice
principal
1
Reader/Associate
professor
1
Lecturer
4
35
Total
42

Basic B.Sc. (N)
Admission capacity
Annual intake
40-60 61-100
1 1
Professor cum vice
principal
1 1
Reader/Associate
professor
1 1
Lecturer
2 4
19 33
Total
24 40
Teacher student ratio= 1:10 (All nursing faculty including Principal and Vice principal)
Two M.Sc (N) qualified teaching faculty to start college of nursing for proposed less than or
equal to 60 students and 4 M.Sc (N) qualified teaching faculty for proposed 61 to 100 students
and by fourth year they should have 5 and 7 M.Sc (N) qualified teaching faculty respectively,
preferably with one in each specialty.
Part time teachers and external teachers:
1.
Microbiology
2.
Bio-chemistry
3.
Sociology.
4.
Bio-physic
5.
Psychology
6.
Nutrition
7.
English
8.
Computer
9.
Hindi/Any other language
10.
Any other- clinical discipliners
11.
Physical education

The above teachers should have post graduate qualification with teaching experience in
respective area
School of nursing-B
Qualification of teaching staff-
1. Professor cum principal
M.Sc. (N) with 3 years of teaching experience or B.Sc.(N)
basic or post basic with 5 years of teaching experience.
2.
Professor cum vice
principal
M.Sc. (N) or B.Sc. (N) (Basic)/Post basic with 3 years of
teaching experience.
3. Tutor/clinical instructor
M.Sc. (N) or B.Sc. (N) (Basic) / Post basic or diploma in
nursing education and Administration with two years of
professional experience.
For School of nursing with 60 students i.e. an annual intake of 20 students:
Teaching faculty
No. required
Principal
1
Vice-principal
1
Tutor
4
Additional tutor for interns
1
Total
7
Teacher student ratio should be 1:10 for student sanctioned strength
ESTIMATION OF NURSING STAFF REQUIRMENTS- ACTIVE ANALYSIS AND
RESEARCH STUDIES
INTRODUCTION
Staffing is certainly one of the major problems of any nursing organization, whether it be
a hospital, nursing home, health care agency, or in educational organization. Estimation of staff
requirements is important for rendering good and quality nursing care
Patient Classification Systems
Patient classification system (PCS), which quantifies the quality of the nursing care, is
essential to staffing nursing units of hospitals and nursing homes. In selecting or implementing a

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

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

Calculating Staffing Needs
The following are the hours of nursing care needed for each level patient per shift:
Category I Category II Category III Category IV
NCHPPD for
Day shift
2.3 2.9 3.4 4.6
NCHPPD for
P.M (Evening)
shift
2.0 2.3 2.8 3.4
NCHPPD for
night shift
0.5 1.0 2.0 2.8
A guide to staffing nursing services
1. Projecting Staffing Needs
Some steps to be taken in projecting staffing needs include:
1. Identify the components of nursing care and nursing service.
2. Define the standards of patient care to be maintained.
3. Estimate the average number of nursing hours needed for the required hours.
4. Determine the proportion of nursing hours to be provided by registered nurses and
other nursing service personnel
5. Determine polices regarding these positions and for rotation of personnel.
2. Computing number of nurses required on a Yearly Basis
1. Find the total number of general nursing hours needed in one year. Average patient
census X average nursing hours per patient for 24 hours X days in week X weeks in
year.
2. Find the number of general nursing hours needed in one year which should be given
by registered nurses and the number which should be given by ancillary nursing
personnel.
a. Number of general nursing hours per year X percent to be given by registered
nurses.
b. Number of general nursing hours per year X percent to be given be ancillary
nursing personnel.

Computing number of nurses assigned on weekly basis
1. Find the total number of general nursing hours needed in one week. Average patient
censes X average nursing hours per patient in 24 hours X days in week.
2. Find the number of general nursing hours needed in the week which should be given by
registered nurses and the number which could be given by ancillary nursing personnel.
a. Number of general nursing hours per week X percent to be given by registered
nurses.
b. Number of general nursing hours per week X percent to be given by ancillary nurses.
One method for determining the nursing staff of a hospital
1. To determine the number of nursing staff for staffing a hospital involves establishing the
number of work days available for service per nurse per year.
Example: Analysis of how the days are used;
Days in the year 365
Days off 1 day/week 52
Casual leave 12
Privilege leave 30
1 Saturday /month 12
Public Holidays 18
Sick Leave 8
Total non-working days 132
Total working days /nurse/year 233
So 1 nurse = 233 working days /year
Example, 20 nurse means 20X233= 4660 hours
4660/365= 12.8 (13).
2. Work load measurement tools
Requirement for staffing are based on whatever standard unit of measurement for
productivity is used in a given unit. A formula for calculating nursing care hours per
patient day (NCH/PPD) is reviewed.
NCH/PPD = Nursing hours worked in 24 hours
Patient Census

As a result, patient classification systems (PCS), also known as workload management or patient
acuity tools, were developed in the 1960s.
Important Factors of staffing
There are 3 factors: quality, quantity, and utilization of personnel.
Quality and Quantity:
This factor depends on the appropriate education or training provided to the nursing personnel
for the kind of service they are being prepared for i.e., professional, skilled, routine or ancillary.
Utilization of personnel: Nursing personnel must be assigned work in such a way that her/his
knowledge and skills learnt are based used for the purpose she was educated or trained.
Other factors affecting staffing
1. Acutely Ill : Where the life saving is the priority or bed ridden condition which might
require 8-10 hours / patient /day ie., direct nursing care in 24 hours or nurse patient ratio
may have to be 1:1, 2:1,3:1…
2. Moderately Ill: here 3.5 HPD are required in 24 hours or nurse patient ration of 1:3 in
teaching hospitals and 1:5 non-teaching hospitals.
3. Mildly Ill: this required 1-2 HPD and for such patients 1:6 or 1:10.
4. Fluctuation of workload: workload is not constant.
5. Number of medical staff: In PHC , 30,000 to 50,000 population getting care from 3 to 4
medical staff but only 1 PHN gives care for all… like in hospital the ratio is vary from
medical and nursing staff.
Modified approaches to nurse staffing and scheduling
Many different approaches to nurse staffing and scheduling are being tried in an effort to
satisfy needs of the employees and meet workload demands for patient care. These include
game theory, modified workweeks (10 or 12hours shifts), team rotation, premium day, weekend
nurse staffing .Such approaches should support the underlying purpose, mission, philosophy and
objectives of the organization and the division of nursing and should be well defined in a staffing
philosophy, statement and policies.
Modified work week: This using 10 and 12 hour shifts and other methods are common place.
A nurse administrator should be sure work schedules are fulfilling the staffing philosophy and
policies, particularly with regard to efficiency. Also, such schedules should not be imposed on
the nursing staff but should show a mutual benefits to employer, employees and the client
served.
 One modification of the worksheet is four 10 hour shifts per week in organized time
increments. One problem with this model is time overlaps of 6 hours per 24 –hour day.
The overlap can be used for patient –centered conference, nursing care assessment and
planning and staff development. It can be done by hour or by a block of 3-4 hours.

Starting and ending time for the 10 hours shifts can be modified to provide minimal
overlaps, the 4- hour gap being staffed by part-time or temporary workers
 A second scheduling modification is the 12 hour shift, on which nurses work even shifts ,
on which nurses work seven shift in 2 weeks: three on , four off: four on, three off . They
work a total 84 hours and are paid of overtime. Twelve hour shifts and flexible staffing
have been reported to have improved care and saved money because nurses can better
manage their home and personal lives.
 The weekend alternatives: another variation of flexible scheduling is the weekend
alternative. Nurses work two 12 hour shifts and are paid for 40 hours plus benefits. They
can use the weekdays for continued education or other personal needs. The weekend
scheduled has several variations. Nurses working Monday through Friday have all
weekends off.
 Other modified approaches: team rotation is a method of cyclic staffing in which a
nursing team is scheduled as a unit. It would be used if the team nursing modality were a
team practice.
 Premium day weekend: nursing staffing is a scheduling pattern that gives the nurse an
extra day off duty, called a premium day, when he/she volunteers to work one additional
weekend worked beyond those required by nurse staffing policy. This technique does not
add directly to hospital costs.
 Premium vacation night: staffing follows the same principle as does premium day
weekend staffing. An example would be the policy of giving extra 5 working days of
vacation to every nurse who works a permanent night shifts for a specific period of time ,
say 3, 4, or 6 months.
 A flexible role: this programme has enabled the hospitals to better meet the staffing
needs of units whenever workload increases. Since establishment of the resources acuity
nurse position, nurses position, nurse‘s morale has improved because they know short-
term helps is more readily available and will be more equitably distributed among units.
 Cross training: It can improve flexible scheduling. Nurses can be prepared through
cross-training to function effectively in more than one area of expertise. To prevent errors
and incidence job satisfaction during cross training nurses assigned to units and in pools
require complete orientation and ongoing staff development.
Scheduling with Nursing Management Information Systems
Planning the duty schedule does not always match personnel with preferences. This is
one major dissatisfaction among clinical nurses. Posting the number of nurses needed by time
slot and allowing nurses to put colored pins in slots to select their own times can improve
satisfaction with the schedule.
Hanson defines a management information system as ―an array components designed to
transform a collective set of data into knowledge that is directly useful and applicable in the

process of directing and controlling resources and their application to the achievement of specific
objectives‖.
The following process for establishing any MIS:
1. State the management objective clearly.
2. Identify the actions required to meet the objective.
3. Identify the responsible position in the organization.
4. Identify the information required to meet the objective.
5. Determine the data required to produce the needed information.
6. Determine the system‘s requirement for processing the data.
7. Develop a flowchart.
Productivity
Productivity is commonly defined as output divided by input. Hanson translates this definition
into following:
Required staff hours
×100
Provided staff hours
Example
380 hours
X 100 = 95% productivity
400 hours
Productivity can be increased by decreasing the provided staff hours holding the required staff
hours constant or increasing them.
Measurement
In developing a model for an MIS, Hanson indicates several formulas for translating data
into information. He indicates that in addition to the productivity formula, hours per patient day
(HPPD) are a data element that can provide meaningful information when provided for an
extended period of time.
HPPD is determined by the formula
Staff hours
Patient days
For example,
52000
2883
Answer = 18 HPPD

Another useful formula
1. Budget utilization
Provided HPPD
X 100 = budget utilization
Budgeted HPPD
Example
18.03 % so, answer is 112.7% Budget utilization.
16
2. Budget adequacy
Budgeted HPPD X100, this is known as Budget adequacy
Required HPPD
16/18.03= 88.74% budget adequacy.
Nurse Staffing, Models of Care Delivery, and Interventions
Nurse Staffing
Measure
Definition
Nurse to patient ratio Number of patients cared for by one nurse typically specified by job
category (RN, Licensed Vocational or Practical Nurse-LVN or LPN);
this varies by shift and nursing unit; some researchers use this term to
mean nurse hours per inpatient day
Total nursing staff or
hours per patient day
All staff or all hours of care including RN, LVN, aides counted per
patient day (a patient day is the number of days any one patient stays in
the hospital, i.e., one patient staying 10 days would be 10 patient days)
RN or LVN FTEs per
patient day
RN or LVN full time equivalents per patient day (an FTE is 2080 hours
per year and can be composed of multiple part-time or one full-time
individual)

Nursing skill (or
staff) mix
The proportion or percentage of hours of care provided by one category
of caregiver divided by the total hours of care (A 60% RN skill mix
indicates that RNs provide 60% of the total hours of care)
Nursing Care
Delivery Models
Definition
Patient Focused Care A model popularized in the 1990s that used RNs as care managers and
unlicensed assistive personnel (UAP) in expanded roles such as
drawing blood, performing EKGs, and performing certain assessment
activities
Primary or Total
Nursing Care
A model that generally uses an all-RN staff to provide all direct care
and allows the RN to care for the same patient throughout the patient's
stay; UAPs are not used and unlicensed staff do not provide patient care
Team or Functional
Nursing Care
A model using the RN as a team leader and LVNs/UAPs to perform
activities such as bathing, feeding, and other duties common to nurse
aides and orderlies; it can also divide the work by function such as
"medication nurse" or "treatment nurse"
Magnet Hospital
Environment/Shared
governance
Characterized as "good places for nurses to work" and includes a high
degree of RN autonomy, MD-RN collaboration, and RN control of
practice; allows for shared decisionmaking by RNs and managers Jean
Ann Seago, Ph.D.,RN

VARIOUS RESEARCH STUDIES
1. ESTIMATION OF DIRECT COST AND RESOURCE ALLOCATION IN INTENSIVE
CARE: CORRELATION WITH OMEGA SYSTEM.
Department of Public Health & Medical Information, Hôpital Ambroise Parè, Boulogne, France.
Comment in: Intensive Care Med. 1999 Feb;25(2):245-6.
Abstract
OBJECTIVE: An instrument able to estimate the direct costs of stays in Intensive Care Units
(ICUs) simply would be very useful for resource allocation inside a hospital, through a global
budget system. The aim of this study was to propose such a tool.
DESIGN: Since 1991, a region-wide common data base has collected standard data of intensive
care such as the Omega Score, Simplified Acute Physiologic Score, length of stay, length of
ventilation, main diagnosis and procedures. The Omega Score, developed in France in 1986 and
proved to be related to the workload, was recorded on each patient of the study.
SETTING: Eighteen ICUs of Assistance Publique-Hôpitaux de Paris (AP-HP) and suburbs.
PATIENTS: 1) Hundred twenty-one randomly selected ICU patients; 2) 12,000 consecutive
ICU stays collected in the common data base in 1993.
MEASUREMENTS: 1) On the sample of 121 patients, medical expenditure and nursing time
associated with interventions were measured through a prospective study. The correlation
between Omega points and direct costs was calculated, and regression equations were applied to
the 12,000 stays of the data base, leading to estimated costs. 2) From the analytic accounting of
AP-HP, the mean direct cost per stay and per unit was calculated, and compared with the mean
associated Omega score from the data base. In both methods a comparison of actual and
estimated costs was made.
RESULTS: The Omega Score is strongly correlated to total direct costs, medical direct costs
and nursing requirements. This correlation is observed both in the random sample of 121 stays
and on the data base' stays. The discrepancy of estimated costs through Omega Score and actual
costs may result from drugs, blood product underestimation and therapeutic procedures not
involved in the Omega Score.
CONCLUSIONS: The Omega system appears to be a simple and relevant indicator with which
to estimate the direct costs of each stay, and then to organise nursing requirements and resource
allocation.
2. THE IMPACT OF NURSING GRADE ON THE QUALITY AND OUTCOME OF
NURSING CARE.
Carr-Hill RA, Dixon P, Griffiths M, Higgins M, McCaughan D, Rice N, Wright K.
Centre for Health Economics, University of York, UK.

Abstract
The large industry which has grown up around the estimation of nursing requirements for a ward
or for a hospital takes little account of variations in nursing skill; meanwhile nursing researchers
tend to concentrate on the appropriate organisation of the nursing process to deliver best quality
care. This paper, drawing on a Department of Health funded study, analyses the relation between
skill mix of a group of nurses and the quality of care provided. Detailed data was collected on 15
wards at 7 sites on both the quality and outcome of care delivered by nurses of different grades,
which allowed for analysis at several levels from a specific nurse-patient interaction to the shift
sessions. The analysis shows a strong grade effect at the lowest level which is 'diluted' at each
succeeding level of aggregation; there is also a strong ward effect at each of the lower levels of
aggregation. The conclusion is simple; you pay for quality care.
PMID: 7780528 [PubMed - indexed for MEDLINE]
3. IMPACT OF SHIFT WORK ON THE HEALTH AND SAFETY OF NURSES AND
PATIENTS.
Berger AM, Hobbs BB.
College of Nursing, University of Nebraska Medical Center, Omaha, USA. aberger@unmc.edu
Abstract
Shift work generally is defined as work hours that are scheduled outside of daylight. Shift work
disrupts the synchronous relationship between the body's internal clock and the environment.
The disruption often results in problems such as sleep disturbances, increased accidents and
injuries, and social isolation. Physiologic effects include changes in rhythms of core temperature,
various hormonal levels, immune functioning, and activity-rest cycles. Adaptation to shift work
is promoted by reentrainment of the internally regulated functions and adjustment of activity-rest
and social patterns. Nurses working various shifts can improve shift-work tolerance when they
understand and adopt counter measures to reduce the feelings of jet lag. By learning how to
adjust internal rhythms to the same phase as working time, nurses can improve daytime sleep and
family functioning and reduce sleepiness and work-related errors. Modifying external factors
such as the direction of the rotation pattern, the number of consecutive night shifts worked, and
food and beverage intake patterns can help to reduce the negative health effects of shift work.
Nurses can adopt counter measures such as power napping, eliminating overtime on 12-hour
shifts, and completing challenging tasks before 4 am to reduce patient care errors.
4. NURSE STAFFING AND PATIENT, NURSE, AND FINANCIAL OUTCOMES.
Unruh L.
Department of Health Professions, University of Central Florida, Orlando, FL, USA.
lunruh@mail.ucf.edu
Abstract
Because there's no scientific evidence to support specific nurse-patient ratios, and in order to
assess the impact of hospital nurse staffing levels on given patient, nurse, and financial

outcomes, the author conducted a literature review. The evidence shows that adequate staffing
and balanced workloads are central to achieving good outcomes, and the author offers
recommendations for ensuring appropriate nurse staffing and for further research.
Policy Polit Nurs Pract. 2009 Nov;10(4):240-51.
5. AN APPLIED SIMULATION MODEL FOR ESTIMATING THE SUPPLY OF AND
REQUIREMENTS FOR REGISTERED NURSES BASED ON POPULATION HEALTH
NEEDS.
Tomblin Murphy G, MacKenzie A, Alder R, Birch S, Kephart G, O'Brien-Pallas L.
Dalhousie University, Halifax, Nova Scotia, Canada, University of Toronto, Toronto, Ontario,
Canada. gail.tomblin.murphy@dal.ca
Abstract
Aging populations, limited budgets, changing public expectations, new technologies, and the
emergence of new diseases create challenges for health care systems as ways to meet needs and
protect, promote, and restore health are considered. Traditional planning methods for the
professionals required to provide these services have given little consideration to changes in the
needs of the populations they serve or to changes in the amount/types of services offered and the
way they are delivered. In the absence of dynamic planning models that simulate alternative
policies and test policy mixes for their relative effectiveness, planners have tended to rely on
projecting prevailing or arbitrarily determined target provider-population ratios. A simulation
model has been developed that addresses each of these shortcomings by simultaneously
estimating the supply of and requirements for registered nurses based on the identification and
interaction of the determinants. The model's use is illustrated using data for Nova Scotia,
Canada.
J Public Health Manag Pract. 2009 Nov;15(6 Suppl):S56-61.
6. HEALTH HUMAN RESOURCES PLANNING AND THE PRODUCTION OF
HEALTH: DEVELOPMENT OF AN EXTENDED ANALYTICAL FRAMEWORK FOR
NEEDS-BASED HEALTH HUMAN RESOURCES PLANNING.
Birch S, Kephart G, Murphy GT, O'Brien-Pallas L, Alder R, MacKenzie A.
Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario,
Canada. birch@mcmaster
Comment in:
 J Public Health Manag Pract. 2009 Nov;15(6 Suppl):S62-3.

Abstract
Health human resources planning is generally based on estimating the effects of demographic
change on the supply of and requirements for healthcare services. In this article, we develop and
apply an extended analytical framework that incorporates explicitly population health needs,
levels of service to respond to health needs, and provider productivity as additional variables in
determining the future requirements for the levels and mix of healthcare providers. Because the
model derives requirements for providers directly from the requirements for services, it can be
applied to a wide range of different provider types and practice structures including the public
health workforce. By identifying the separate determinants of provider requirements, the
analytical framework avoids the "illusions of necessity" that have generated continuous increases
in provider requirements. Moreover, the framework enables policy makers to evaluate the basis
of, and justification for, increases in the numbers of provider and increases in education and
training programs as a method of increasing supply. A broad range of policy instruments is
identified for responding to gaps between estimated future requirements for care and the
estimated future capacity of the healthcare workforce.
RECRUITMENT CREDENTIALING, SELECTION, LACEMENT& RETENTION
RECRUITMENT
INTRODUCTION:
Recruitment is an important function of health manpower management, which
determines, whether the required will be available at the work spot, when a job is actually to be
undertaken. Recruitment procedures include the process and the methods by which vaccines are
notified, post are advertised, applications are handled and screened, interviews are conducted and
appointments are made.
MEANING:
In a simple term, recruitment is understood as the process of searching for and obtaining
applicants for job, from among whom the right people can be selected.
DEFINITION:
1. According to B Flippo: ―Recruitment is defined as the process of searching for prospective
employees and stimulating them to apply foe job in the organization‖.
2. According to IGNOU Module: ―It is a process in which the right person for the right post is
procured‖.
3. According to Yoder: ―Recruitment is a process to discover the sources of manpower to
meet the requirements of the staffing schedule and to employ effective measures for
attracting that manpower in adequate numbers to facilitate effective selection of an efficient
working force.‖

TYPES OF RECRUITMENT:
There are three types of recruitment:
1. Planned: arise from changes in organization and recruitment policy
2. Anticipated: by studying trends in the internal and external organization.
3. Unexpected: arise due to accidents, transfer and illness.
LIKAGES OF REQUIREMENT TO HUMAN RESOURCE ACQUISITION
The requirement process is concerned with the identification of possible sources of
human resources supply and tapping those resources, the total process acquiring and placing
human resources in the organization. Requirement fails in between different sub process like:
BASIC ELEMENTS OF SOUND RECRUITMENT POLICY:
 Discovery and cultivation of the employment market for post in the public service
 Use of the attractive recruitment literature and publicity
 Use of the scientific tests for determining abilities of the candidate
 Tapping capable candidates from within the services
 Placement program which assigns the right man to the right job.
 A follow up probationally program as an integral process.
PURPOSES AND IMPORTANCE:
 Determine the present and future requirements of the organization in conjunction with the
personnel planning and job analysis activities
 Increase the pool of job candidates with minimum cost
Manpower
planning
Job analysis
Selection
Recruitment Placement

 Help increase the success rate of the selection process reducing the number of obviously
under qualified or over qualified job applicants.
 Help reduce the probability tat the job applicants, once recruited and selected will leave
the organization only after short period of time.
 Meet the 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.
OBJECTIVES OF RECRUITMENT:
To attract people with multi-dimensional skills and experiences that suit the present and
future organizational strategies
To induct outsiders with new perspective to lead the company
To infuse fresh blood at all levels of organization
To develop an organizational culture that attracts competent people to the company
To search or heat hunt/ head pouch people whose skills fit the 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:
Recruitment should be done from a central place. Eg: Administrative officer/Nursing Service
Administration.
1) Termination and creation of any post should be done by responsible officers, eg:
regarding nursing staff the Nursing superintendent along with her officers has to take the
decision and not the medical Superintendent.
2) Only the vacant positions should be filled and neither less nor more should be employed.
3) Job description/ work analysis should be made before recruitment.

4) Procedure for recruitment should be developed by an experienced person
5) Recruitment of workers should be done from internal and external sources
6) Recruitment should be done on the basis of definite qualifications and set standards.
7) A recruitment policy should be followed
8) Chances of promotion should be clearly stated
9) Policy should be clear and changeable according to the need.
SOURCES OF RECRUITMENT:
The sources of recruitment are:
I) Internal sources:
Internal sources include present employees, employee referrals, former employee and
former applicants.
Present employees: promotion and transfers from among the present employees can be good
source of recruitment. Promotions to higher positions have several advantages. They are:
o It is good public relations
o It builds morale
o It encourages competent individuals who are ambitious
o It improves the probability of a good selection, since information of the
candidate is readily available
o It is less costly
o Those chosen internally are familiar with the organization.
However promotions can be dysfunctional to the organization as the advantage of hiring
outsiders who may be better qualified and skill is denied. Promotions also results in breeding
which is not good for the organization.
SOURCES OF
RECRUITMENT
DIRECT
SOURCES
INDIRECT
SOURCES

Another way to recruit from among present employees is the transfer without promotion.
Transfers are often important in providing employees with a broad based view of the
organization, necessary for the future.
Employee referrals: this is the good source of internal recruitment. Employees can develop
good prospects for their families and friends by acquainting with the advantages of a job with the
company, furnishing cards introduction and even encouraging them to apply. This is very
effective because many qualified are reached at very low cost.
Former employees: some retired employees may be willing to come back to work on a part-
time basis or may recommend someone who would be interested in working for the company.
An advantage with these sources is that the performance of these people is already known.
Previous applicants: although not truly an internal source, those who have previously applied
for jobs can be contacted by mail, a quick and inexpensive way to fill an unexpected opening.
Evaluation of internal recruitment:
Advantages:
 It is less costly
 Organizations typically have a better knowledge of the internal candidates‘ skills and
abilities than the ones acquired through external recruiting.
 An organizational policy of promoting from within can enhance employees‘ morale,
organizational commitment and job satisfaction.
Disadvantages:
 Creative problem solving may be hindered by the lack of new talents.
 Divisions complete for the same people
 Politics probably has a greater impact on internal recruiting and selection than does
external recruiting.
II) External sources:
Sources external to an organization are professional or trade associations, advertisements,
employment exchanges, college/university/institute placement services, walk-ins and writer-ins,
consultants, contractors.
 Professional or trade associations: many associations provide placement services for
their members. These services may consist of compiling seekers‘ lists and providing
access to members during regional or national conventions.
 Advertisements: these constitute a popular method of seeking recruits as many
recruiters; prefer advertisements because of their wide reach. For highly specialized

recruits, advertisements may be placed in professional/ business journals. Newspaper is
the most common medium.
Advertisement must contain the following information:
 The job content ( primary tasks and responsibilities)
 A realistic description of working conditions, particularly if they are unusual
 The location of the job
 The compensation, including the fringe benefits
 Job specifications
 Growth prospects and
 To whom one applies.
Employment exchange: Employment exchanges have been set up all over the country in
deference to the provisions of the Employment exchanges (Compulsory Notification of
Vaccination) Act, 1959. The Act applies to all industrial establishments having 25 workers or
more. The Act requires all the industrial establishments to notify the vacancies before they are
filled. The major functions of the exchanges are to increase the pool of possible applicants and to
do preliminary screening. Thus, employment exchanges act as a link between the employers and
the prospective employees.
Campus recruitment: colleges, universities and institutes are fertile ground for recruitment,
particularly the institutes.
Walk-ins, write-ins and Talk-ins: write-ins those who send written enquire. These job-seekers
are asked to complete applications forms for further processing.
Talk-in is becoming popular now-in days. Job aspirants are required to meet the recruiter (on an
appropriated date) for detailed talks. No applications are required to be submitted to the recruiter.
Consultants: ABC consultants, Ferguson Association, Human Resources Consultants Head
Hunters, Bathiboi and Co, Consultancy Bureau, Aims Management Consultants and The Search
House are some among the numerous recruiting agents.
Contractors: Contractors are used to recruit casual workers. The names of the workers are not
entered in the company records and to this extent, difficulties experienced in maintaining
permanent workers are avoided.
Radio Television:
International Recruiting: Recruitment in foreign countries presents unique challenges
recruiters. In advanced industrial nations more or less similar channels of recruitment are
available for recruiters.

MODERN SOURCES OF RECRUITMENT:
 Walk-in
 Consult in
 Tele recruitment: Organizations advertise the job vacancies through World Wide Web
RECRUITMENT PROCESS / STEPS:
As was stated earlier, recruitment refers to the process of identifying and attracting job
seekers so as to build a pool of qualified job applicants. The process comprises five inter-related
stages, via:
FACTORS EFFCTING RECRUITMENT:
All organization, whether large or small, do engage in recruiting activity, though not to
the same extent. This differs with:
1) The size of the organization
2) The employment conditions in the community where the organization is located
3) The effects of past recruiting efforts which show the 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.
STEPS
Planning
Strategy
development
Searching
Screening
Evaluation &
Control

CREDENTIALING
INTRODUCTION
Credentialing is the process of establishing the qualification of licensed professionals,
organizational members or organizations, and assessing their background and legitimacy. Many
health care institutions and provider networks conduct their own credentialing, generally through
a credentialing specialist or electronic service, with review by a medical staff or credentialing
committee. It may include granting and reviewing specific clinical privileges and medical or
allied health staff membership.
DEFINITION
1) Credentialing is the process by which selected professionals are granted privileges to practice
within an organization. In health care organizations this process has been largely confined to
physicians. Limited privileges have been granted to psychologists, social workers and selected
categories of nurses, such as nurse anesthetists, surgical nurses, and midwifes.
Russell C Swan‘s burg
2) Credentialing is the process of establishing the qualifications of licensed professionals,
organizational members or organizations, and assessing their background and legitimacy.
3) A credential is an attestation of qualification, competence, or authority issued to an individual
by a third party with a relevant de jure or de facto authority or assumed competence to do so.
PURPOSE OF CREDENTIALING
The purpose of credentialing is:
1) To prevent a problem before it happens.
2) To research the qualifications and backgrounds of individuals and companies. Credentialing
is also the process of reviewing and verifying information.
SIGNIFIANCE
Credentialing is very significant because it shows that an individual or company
performing a service is qualified to do so. For example: your doctor must have certain credentials
to prescribe medicine to you.
LEGAL PROTECTION
It is a good idea to have credentialing process to protect you and your business from a
lawsuit or other legal problems. For instance, 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).
Facility and Ancillary service Providers: Hospitals , Nursing Homes, Skilled Nursing
Facilities, Home Health, Home Infusion Therapy, Hospice, Rehabilitation Facilities,
Freestanding Surgery Centers, Freestanding Radiology Centers, Portable X-ray Suppliers, End
Stage Renal Disease Facilities, Clinical Laboratories, Outpatient Physical therapy and Speech
Therapy providers, Rural Health Clinics, Federally Qualified Health Centers Orthotic and
Prosthetic providers and Durable Medical Equipment (DME) providers.
COMPOTENTS OF CREDENTIALING
As with physicians, the components of a credentialing system for nurses would be:
1) Appointment: Evaluation and selection for nursing staff membership.
2) Clinical privileges: Delineation of the specific nursing specialties that may be managed
types of illnesses or patients that may be managed within the institution for each member of
the nursing staff.
3) Periodic reappraisal: Continuing review and evaluation of each member of the nursing staff
to assure that competence is maintained and consistent with privileges.

CRETERIA FOR APPOINTMENT:
Criteria for appointments would include proof of licensure, education and training, specialty
board certification, previous experience, and recommendations.
Clinical privileges criteria would include the proof of specialty training and of performance of
nursing procedures or specialty care during training and previous appointments.
PRINCIPLES OF CREDENTIALING ACCORDING TO (ANA)
A report of the Committee for the study of Credentialing in Nursing was made in 1979. It
included fourteen principles of credentialing related to:
1) Those credentialed.
2) Legitimate interests of involved occupation, institution, and general public.
3) Accountability
4) A system of checks and balances
5) Periodic assessments
6) Objective standards and criteria and persons competent in their use
7) Representation of the community of the interests
8) Professional identity and responsibility
9) An effective system of role delineation
10) An effective system of program identification
11) Coordination of credentialing mechanisms
12) Geographic mobility
13) Definitions and terminology
14) Communications and understanding.
SELECTION
INTRODUCTION
“The selection process starts when applications are screened in the personnel department.
Selecting includes interviewing, the 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,
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 be selected for a specific college according to its individual admission
policies and the programme it offers.
The members of the selection committee should include
a) The head of the college of nursing
b) Professor
c) Representative of the local controlling authority
d) Representative of the nursing division of the state
e) An educational psychologist
The procedure for selection should consist of a personal interview of the candidate and
possibly a separate interview with her parents. It may also include tests of previous
achievements, both written and oral, to assess her knowledge of various subjects such as
Arithmetic, English, the regional language and general science and her ability to express herself
orally and in writing. If psychological tests are given, only those devised by experts in their field
should be used.
It should be made clear to them that final acceptance for the course will be subject to a
satisfactory medical report and assessment during the preliminary training period. The college
should make every effort to start the course on the appointed day with the full quota of students.
Only in exceptional circumstances should students be admitted later and in their cases, special
arrangement should be made for them to cope up with the other students.
3. Orientation programme:
After admission an orientation programme is to be conducted to make the students aware
of the college rules, hostel rules and the hospital and the college building and associated parallel
medical education departments. Orientation should be given by a senior faculty of the college of
nursing. Orientation programme may take three to five days.
4. Development of master plan:
When a particular batch is admitted the class teacher may draw a master plan according
to which the whole programme is planned. Date of examinations and periodic evaluation
measures etc are formulated.

5. Parent teachers association:
All parents are enrolled in the parent teachers association and this will help to have a
contact between the family members and teachers. This will help to improve the administration.
Meetings of PTA are held frequently and the parents are kept informed of the students progress.
Before taking any disciplinary actions PTA members are called when students unrest
occurs due to certain problems. Thus parents are also involved in the administration of students.
STEPS IN SELECTION: The steps which constitute the employee selection process are the
following:
I. Interview by personnel department
II. Pre-employment tests-written/oral/practical
III. Interview by department head
IV. Decision of administrator to accept or reject
V. Medical examination
VI. Check of references
VII. Issue of appointment letter.
I. Interviewing:
Interviewing is the main method of appraising an 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:
Interviewing functions of the personnel manager:
The responsibilities of the personnel manager are:
A) To screen the application of the candidate
B) To give information about
a) general nature of work
b) hours of work
c) pay-scale, allowances and starting total salary
d) fringe benefits
e) leave policy
f) ‗brief‘ information about the background of the hospital
g) To discover any differences in the expectations of the hospital and those of the
candidate.
Name and Address of the hospital
INTERVIEW LETTER
Date
Address
Dear
With reference to your application dead ……………… for the post of………………………………………. .
I am pleased to call you for an interview at …………….. on…………………….in the personnel department.
You are required t fill up the enclosed job-application form and bring it with you at the time of the interview.
Please bring your original certificates and certificates and testimonials with you. We look forward to seeing you.
Your sincerely,
( Personnel Manager )
Encl: 1

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

III. Final approval by the head of the hospital:
In some hospitals, the selection committee consists of one person from the personnel
department, the department head/supervisor of the concerned department and one representative
of the head of the hospital. After the interviewing all the candidates, the selection committee
submits its recommendations for approval to the head of the hospital, who is generally the hiring
authority.
In other hospitals, the head of the hospital may prefer to interview all the candidates
himself for the key jobs and leave it to the selection committee for the less vital jobs. In case of
appointment of a department head, one expert is also usually included in the selection committee.
Different hospitals adopt different policies according to their own convenience for the selection
of their employees. Generally this authority lies with the Medical superintendent or
Administrator or Business Manager or Chief Executive who is legally termed the ‗Occupier‘.
IV. References:
The references provided by the applicant should be cross-checked to ascertain his past
performance and to obtain relevant information from his past employer and others who have
knowledge of his professional competence.
The references letters should be brief and should require as little writing as possible by
the person to whom it is sent. If it is directed to a former employer, it should ask for the
following data:
 Date of joining
 Date of leaving
 Job title
 Last salary drawn
 Promotion/demotion, if any
 Unauthorized absentee record
 Reason for termination/ leaving
 Ability to work with others
 Dependability
 Emotional stability
 Health conditions
 Does the employee habitually borrow money?
 Would you re-employ?
 Any other information

V. Medical examination:
The medical examination of a prospective employee is an aid both to the employee and to
the management. The selection of the right type of employee who can give his best and be happy
requires a thorough knowledge of his physical capacities and handicaps. The purpose of the
medical examination is threefold:
a) It is for the protection of the applicant himself to know whether that job will suit him or not
from the medical point of view.
b) It is for the protection of the other employees so that they are not at risk of any communicable
or other disease which the prospective employee may have.
c) It is for the protection of the employer as well, so that he may avoid selecting a wrong person.
The medical examination will eliminate an applicant whose health is below the standard or one
who is medically unfit.
VI. Joining report by the employee:
When new employees reports for joining, he should be given an appointment letter, his
job description and handbook of the hospital. He should be asked to submit his joining report. A
model appointment letter and joining report form are given.
 PLACEMENT
INTRODUCTION:
Placements are a credit bearing part of a degree course and all placements optional. If a
student opts out of a placement or there is no placement available, this means that placement is
not guaranteed.
DEFITION: State of being placed or arranged.
IMPORTANCE PLACEMENTS:
The school of service management believes that taking a placement is one of the most
important decisions you can make in your university carrier. Not only will you benefit from
building personal confidence during your placement year but you will also establish contacts in
your chosen sector which may provide invaluable for graduate opportunity.
IMPORTANCE OF SELECTION AND PLACEMENT:
 To fairly and without any element of discrimination evaluate job applicants in view of
individual differences and capabilities
 To employee qualified and competent hands tat can meet the job requirement of the
organization

 To place job applicants in the best interests of the organization and the individual
 To help in human resources man power planning purposes in organization
 To reduce recruitment cost that may arise as a result of poor selection & placement
exercises.
PLACEMENT TEAM:
Our current placement team consists of a placement coordinator & four academic tutors,
each with specialist knowledge relevant to the degree courses you under the supervision are
studying. These tutors advice and support you throughout your preparation for placement.
 PROMOTION
INTRODUCTION:
The promotion policy is one of the most controversial issues in every organization. The
management usually favors promotion on the basis of merits, and the unions vehemently oppose
it by saying that managements resort to favoritism. The unions generally favor promotions on the
basis of seniority. It is hence essential to examine this issue and arrive at an amicable solution.
DEFINITION:
A change for better prospects from one job to another job is deemed by the employee as a
promotion‖.
FACTORS IMPLYING PROMOTION:
The factors which are considered by employees as implying promotion are:
FACTORS
IMPLYING
PROMOTION
An increase in salary
An increase in
prestige
An upward movement in
the hierarchy of jobs
Additional supervisory
responsibility
A better future

NATURE AND SCOPE OF PROMOTION:
Seniority versus merits: There has been great deal of controversy over the relative values of
seniority and merit in any system of promotion. Seniority will always remain a factor to be
considered, but there be much greater opportunity for efficient personnel, irrespective of their
seniority, to move up speedily if merit is used as the basis for promotions. It is often said that at
least for the lower ranks, seniority alone should be the criterion for promotion. One cannot agree
with this. The quality of work is more important in the lower ranks as in the higher.
There are some who argue against this plea and advocate the merit policy for the following
reasons:
1) They believe that mere length of service evidence only of continued service but are surely
no indication of vast experience.
2) Promotion on the basis of seniority saps the initiative of the employees. Once they realize
that promotions in the organization are on the basis of seniority alone, they lose all
enthusiasm for showing better performance. Therefore, in terms of getting the best out of
employees, the merits of the individual employee will have to be considered.
3) There are individual differences amongst persons working o the same of them are most
efficient, some barely average and some below average. If their differences are not
distinguished and they are uniformly rewarded, all individual will gradually sink to the
level of the below-average employee.
PROMOTION POLICY:
The promotion policy is one of the most controversial issues in every organization. The
management usually favors promotion on the basis of merits, and the unions vehemently
opposite by saying that management resort to favoritism. The unions generally favor promotions
on the basis of seniority. However, in practice, both seniority and ability criteria should be taken
into consideration; but in order to allay the suspicious of the trade unions, there should be written
promotion policy which should be clearly understood by all.
Promotion policy may include the following:
1) Charts and diagrams showing job relationships and ladder of promotion should be prepared.
Those charts and diagrams clearly distinguish each job and connect various jobs by lines and
arrows showing the channels to promotion. These lines and arrows are always based on
analysis of job duties. These charts do not guarantee promotion but do point out various
avenues which exist in an organization.
2) There should be some definite system for making a waiting list after identification and
selection of those candidates who are to be promoted as and when vacancies occur.
3) All vacancies within the organization should be notified so that all potential candidates may
complete.

4) The following eight factors must be the basis for promotion:
 Outstanding service in terms of quality as well as quantity
 Above average achievement in patient care and for public relations
 Experience
 Seniority
 Initiative
 Recognition by employee as a leader
 Particular knowledge and experience necessary for a vacancy and
 Record of loyalty and cooperation
In some instances, it may be possible to use pre-employment test, to determine eligibility for the
vacant position.
5) Though the department heads may initiate promotion of an employee, the final approval
should be with top management because a department head can think only of the
repercussions of the promotion in his department while top management looks at it from the
point of view of the organizations a whole. The personnel department can help at the stage by
proposing the names of prospective candidates out of the existing employees in the
organization and also submit their performance appraisal record of the last few years to the
department head.
6) All promotion should be for a trail period. In case the promoted person is not found capable
of handling the job. Normally, during this trail period, he draws salary at the higher pay-
scale, but it should specially be made clear to him in writing that if his performance is not
found up to the work, he will be reverted to his former post at the former scale.
7) In case of promotion, the personnel department should carefully follow the progress of the
promoted employees. A responsible person of the personnel department should hold a brief
interview with the promoted person and his department head to determine whether
everything is going on well or not. The promotional post should be continued after the
satisfactory report of the department head.
ADVANTAGES OF A SOUND PROMOTION POLICY:
From a scientific management view point, a sound promotion policy has many advantages.
 It provides an incentive to employee to work more and show interest in their work. They
put in their best in their best and aim for promotion within the organization.
 It develops loyalty amongst the employees, because a sound promotion policy assures
them of their promotions if they are found fit.

 It increases satisfaction among the employees.
 It generates greater motivation as they do not have to depend on mere seniority for that
advancement.
 A sound promotion policy retains competent employees, and provides them ample
opportunities to rise further
 It generally results in increased productivity as promotion will be based on an evaluation
of the 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.
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,‖ says 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.

―The stresses of the job can be compounded by responsibilities outside of the workplace.
Hospitals are doing what they can to support nurses on a personal level, which is where
creativity mostly comes into play. From concierge services that help nurses with errands to day
care to flexible scheduling, hospitals are doing whatever it takes to allow nurses to focus on their
work and keep them in their jobs for years to come.
DEFINITION:
Staff choose to stay for long periods within a cost centre, turnover is under is 10% annually.
IMPORTANCE OF STAFF RETENTION:
 The advantages of staff retention are fairly clear. Most importantly perhaps, key skills, ideas,
knowledge and experience remain within your organization. Client relationships and
networks are also preserved in conjunction with all the income that these areas generate.
 Conversely, losing your key employees lays open the possibility that these people will than
assume roles with your direct competitors. As a result those invaluable skills, ideas,
knowledge, experience, relationships and networks are all transferred to another
organization.
 On top of all these there are also direct costs involved in losing key employees. The cost of
replacing such an individual includes advertising, recruitment agency fees and the time spent
conducting actual interview process. Further more it is also worth considering the time and
expense spent on the induction new employees and lost revenue during the recruitment and
bedding in process.
 All though an element of employee churns is both inevitable and healthy. It is nevertheless
clear that retention brings substantial benefits to your organization. Whilst attrition involves
significant direct and indirect financial costs.
PRINCIPLES ANE ELEMNTS OF A HELPFUL PRACTICE AND WORK
ENVIRONMENT:
To foster staff retention, organizations need to develop environments in which nurses
want to work. Among other things, nurses want safe workplaces that promote quality health care.
―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 FOSTER STAFF RETENTION:
1.Respectful collegial
communication and behavior
• Team orientation
• Presence of trust
• Respect for diversity
2. Communication-rich culture • Clear and respectful
• Open and trusting
3. A culture of accountability • Role expectations are clearly defined
• Everyone is accountable
4. The presence of adequate
numbers of qualified nurses
• Ability to provide quality care to meet
client/patient needs
• Work and home life balance
5. The presence of expert,
competent, credible, visible
leadership
• Serve as an advocate for nursing practice
• Support shared decision-making
• Allocate resources to support nursing.
6.Shared decision-making at all
levels
• Nurses participate in system, organizational and
process decisions
• Formal structure exists to support shared
decision-making
• Nurses have control over their practice.
7.The encouragement of
professional practice and continued
growth/ development
• Continuing education/certification is
supported/encouraged
• Participation in professional association
encouraged
• An information-rich environment is supported.
8. Recognition of the value of
nursing‘s contribution
• Reward and pay for performance.
9. Recognition of nurses for their
meaningful contribution to the
practice
• Career mobility and expansion

FIVE CHARACTERISTICS OF SUCCESSFUL RECRUITMENT AND RETENTION
PROGRAMS:
1. Sustained leadership commitment to workforce as a strategic imperative.
2. A culture centred around employees and patients.
3. Work with other organizations to address workforce needs
4. Systematic and structured approach
5. Excellence in human resource practice
PERSONNEL POLICIES
DEFINITION OF PERSONNEL POLICIES
Policy: 1. Statement of predetermined guidelines
2. Policies in general, they are guidelines to help in the safe and efficient achievement of
organizational objectives.
Personnel Policy-
1) A set of rules that define the manner in which an organization deals with a human
resources or personnel-related matter. A personnel policy should reflect good practice, be
written down, be communicated across the organization, and should adapt to changing
circumstances.
2) Personnel policy is an integrated function which encompasses many aspects of the
personnel management.
3) The written statement of an 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.
 The establishment of good personnel policies helps to give the employee a sense
of security and individual worth.
 It gives employee pride and loyalty to the organization for which he/she works.
 Policies that are planned in advance are likely to meet the needs of the
organization better.
2) To the supervisor it is a safeguard in that it relieves her of the responsibility of making a
personal decision which may conflict with decisions given by other supervisors.
 Established personnel policies serve as guides to action so that a great deal of time
is saved by administrational personnel in handling individual cases.
 A well understood clearly written policy saves the time of an employee as well as
the employer.
PHILOSOPHY:
―The nursing service administration of…….. believes that its supreme objective ; the best
possible patient care, can be achieved only by the full cooperation of all who are privileged to
take part in that care‖.
―It seeks to establish a team dedicated to the protection of health and well being of the
patient in an environment that will enable every member of the team to obtain as well as give
satisfaction in his or her work‖.
OBJECTIVES:
1) To employ those persons best fitted by education, skill and experience to perform
prescribed work.
2) Guarantee fairness in the maintenance of the discipline
3) Upgrade and promote existing staff wherever possible.
4) Take all practical steps to avoid excessive hours of work.
5) Ensure the greatest practicable degree of permanent and continuous employment.
6) Maintain standards of remuneration
7) Provide and maintain high level of physical working conditions.

8) Maintain effective methods of regular consultation between administration and
employees.
9) Provide suitable means for the orientation, on the job training and evaluation of
employees.
10) Encourage social and recreational facilities for employees.
11) Develop appropriate schemes for employees welfare.
FUNCTIONS AND TECHNIQUES OF ADMINISTRATION TO MEET THE
OBJECTIVES SPECIFIED BY THE STATEMENT OF POLICY.
SL NO. FUNCTIONS TECHNIQUES
1. Employment
Job analysis, job specifications, time schedules, works
Schedules, manuals, agreed code of regulations, assessment of
personnel
2. Remuneration Job evaluation
3. Health and safety
Physical examination, safety training, accident analysis,
sickness statistics
4. Welfare
Social and recreational programs, rest rooms, canteen, pension
schemes, employers counseling
5. Training On the training, training for leadership
TYPES OF POLICIES
a) Implied Policy:
 It is the policy which is not directly voiced or written but is established by pattern
of decision.
 They may have either favourable or unfavorable effects

 It is the policy neither written nor expressed verbally have usually developed over
time and follow a presendent.
 If you have people who are accountable to you, you 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?‖ If the boss responds by giving an instruction, that
employee will assume that this is how to cope with all similar situations. They
will interpret the instruction in terms of the implied values or the general policy
that would result in the instruction.
b) Expressed Policy:
 These are delineated verbally or in writing.
 Oral policies are more flexible than written ones and can be easily adjusted to
changing circumstances.
 Most of the organization have many written policies that are readily available to
all people and promote consistency in action. It may include:
Formal dress code
Policy for sick leave or vacation time
Disciplinary procedures
ELEMENTS OF PERSONNEL POLICIES STATEMENT
Operating Procedures
The statement details the company's operating procedures, including how employees should
accomplish their assigned tasks; punctuality, work hours, and breaks; payment structure;
personal appearance and dress code; drug and alcohol policies; benefits; and other employee
guidance and responsibilities.

Employee Conduct
The statement defines the company's policies and guidelines about such matters as
professional conduct with other employees and clients.
Equipment Use Regulations
Employee use of office equipment is another key item. If personal or non-work-related use of
computers, telephones, other equipment, and office supplies is prohibited, this should be
outlined.
Professionalism
With an employer personnel policies statement in effect, business owners, managers, and
employees are afforded a greater air of professionalism, according to the National Restaurant
Association's guidelines for writing an employee manual.
Employer Authority
One of the principal functions of an employee statement is that it offers the employer a point
of reference in the event that an employee is reprimanded or terminated, thereby protecting
the employer from wrongful termination lawsuits.
PROCESS OF DEVELOPMENT OF PERSONNEL POLICIES
Every organization should have a complete set of well developed personnel policies before it
begins to function. The existing ones also need to be revised. At times, the policies may be
formulated simultaneously from the top management as well as the lower division management.
The stages and sequences of events in the process of development of policy are:
1) Clarification by top management of philosophy and the objectives of the organization.
2) Analysis of personnel policy requires assessment of relevant facts. Job is delegated to the
committee who through interviews and conferences collect data from inside and outside
the organization.
3) Consultation with staff representatives.

4) Writing the first draft of the policy statement.
5) Further discussion to get the final approval of policies from top management and staff
representatives.
6) Communication of policy statements by means of training session, discussion groups and
staff hand books.
7) Periodic re evaluation and follow up
POLICIES RELATED TO NURSING PRACTICE:
SERVICE STAFFING POLICIES (HOSPITAL)
 Employment- recruitment rules,
qualification
 Job description
 Working hours
 Work load, working facilities
 Vacations
 Holidays
 Sick Leave
 Weekend Off
PROCESS
Communicating the Policy
Discussing the Proposed Policy
Appraising the Policy
Adopting and Launching Policy
Writing the Personnel Policy
Fact Finding
Reporting Of Personnel Policy

 Policies for breakage and losses
 Special allowances- special duty/
hard duty allowance, medical
allowance. The nursing
personnel have demanded a
uniform allowance of Rs 3,000
per month and a nursing
allowance of Rs 1,600 per
month.
 Promotional opportunities
 Career development
 Accommodation
 Transport
 Special incentives
 Occupational hazards
 Rotation To Different Shifts
 Overtime
 Part Time Personnel
 Exchanging Hours
POLICIES RELATED TO NURSING EDUCATION
Policies For College Of Nursing
STUDENTS STAFFS HOSTEL POLICIES
 Admission Policies
 Working Hours
 Attendance
 Uniform
 Medical Facilities
 Internship
 Holidays
 Special Leave
 Withdrawal From
Course
 Discipline
 Recruitment Policies
 Policy On
Termination
 Staff Benefits
 Uniform
 Duty Hours
 Retirement Age
 Permission to meet
only authorized
visitors
 Permission for a
dayout
 Visiting hours
 Permission letter for
outing
 Signing the register
 Disciplinary action
on violation of rules

FACTORS INFLUENCING PERSONNEL POLICY
The following factors will influence determining of personnel policies of an organization:
i) Law of the country: The various laws and labor legislation govern the various
aspects of personnel matters. Policies should be in conformity with the laws of the
country
ii) Social values and customs: there are codes of behavior of any community which
should be taken in account in framing policies.
iii) Management philosophy and values: Management cannot work together for any
length of time without clear broad philosophy and set of values which influence their
actions on matters concerning the work force.
iv) Stage of development: All changes such as size of operations, scale of technology,
innovations, fluctuations in the composition of workforce, decentralization of
authority and change in financial structure influence the adoption of personnel
policies.
v) Financial position of the firm: The personnel policies cost money which will be
reflected in the price of the product. Because of this, prices set the absolute limit to
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
 Helps to give employees a sense of security and individual worth.
 Gives the employees pride and loyalty to the organization for which they work.
 Employees tend to give good service and identify themselves with the goals of the
organization and they want to remain in the organization.
 Are planned in advance and with due consideration on how policy will apply in various
situations to meet the needs of the organization
 As guides to action, save a great deal of time of the administrator.
 A clearly written policy saves the time of the employee as well.
TERMINATION

STAFF DEVELOPMENT PROGRAMME: IN-SERVICE AND CONTINUING
EDUCATION
INTRODUCTION:
Staff development is the process directed towards the personal and professional growth of
nurses and other personnel while they are employed by a health care agency. It is essential for
the upliftment of professional as well as administrative field. Staff development programme
helps in updating the knowledge and practice of professionals. It is applicable not only to the
nursing field but also to all the professional fields.
DEFINITION:
Staff development refers to all training and education provided by an employee to
improve the occupational and personal knowledge, skills and attitude of vested employees.
GOAL:
 To assist each employee to improve performance in his or her present position and to
acquire personal and professional abilities that maximizes the possibility of career
advancement.
NEED FOR STAFF DEVELOPMENT:
 To meet social change and scientific advancement. It causes rapid changes in nursing
knowledge and skills.
 To provide the opportunity for nurses to continually acquire and implement the
knowledge, skills and attitudes, ideas and values essential to maintain high quality
nursing care.
 To meet job related learning needs of the nurse – (eg, continuing education, in-service
education, extramural education and post basic education).
 Fill the gaps between theory and knowledge.
 To achieve personal or professional development eg, promotion.
 To prepare for future tasks or trends.
PRINCIPLES INVOLVED STAFF DEVELOPMENT:
 Activities must base of needs and interest of employees and organization.
 Learning is combination of theory and experience.
 Learning is internal, personal and emotional process.
 Learning involves changes in behavior.
 Learner should be encouraged to contribute in learning process.

 Problem solving approach is well suited because; effective learning takes place when
there is need/problem.
 Positive reward is effective.
 Teaching – learning should be based on educational psychology.
 Learning can be maximized by providing favorable condition.
 Learning is active process i.e., teacher and learner should be active in learning.
 Teaching must satisfy learning needs of an individual.
 Use variety of sources for learning as adult learners have wide range of previous
experience.
STAFF DEVELOPMENT MODEL FOR GOAL ACHIVEMENT OF THE HEALTH
CARE AGENCY, THE NURSE AND THE NURSING PROFESSION
Staff development model is based on the aforementioned philosophical statement, that the
activities within a health care agency are directed towards achieving a high quality care through
the mutual goal oriented efforts of the health care agency, nursing profession and its
practitioners.
This model has three main components.
 Education
 Experience
 Socio-economics
Educational component includes:
The educational component assumes that the nurse is motivated to continue learning
through involvement in educational activities endorse by a health care agency and the nursing
profession. It may take the form of continuing education – in service education and extramural
education or post basic nursing education. Staff nurse is self-motivated for learning. She may
accept any type of staff developmental activity, comes under local agency or outside agency.
 In-service education is referred to an agency based educational activity. It begins with
orientation to the health care agency and to a particular position and continues in the
form of specific skill training related to nursing or more generalized skill training related
to patient care within the context of the health care team.
 Extramural education includes short courses, conferences, seminars and like, which are
planned for group learning, as well as programmed learning and correspondence courses.
 Post basic education refers to formal study at degree-granting institution. It involves full
time commitment to an academic programme leading to university diploma, certificate,
baccalaureate degree, master‘s degree or doctorate degree etc.

Experience:
Nursing practice and experience in daily life are integral parts of staff development.
Planned approach to the daily assignment of nursing responsibilities is both a benefit to the
development of the nurse practitioner and prerequisites to high quality patient care. For quality
care – experiences may be planned or unplanned. Experiences are curricular and co-curricular
and self.
Socio-economic component:
It involves health care agency, the nurse and nursing association in management,
planning, counseling and employee – employer relations.
 The effectiveness of man power planning depends on needs assessment, which is
influenced by the standards set by the nursing profession and the job commitment made
between the health care agency and the nurse.
 Counseling includes career planning as well as performance evaluation for the benefit of
both the health care agency and the nurse.
 Employee-employer relations are reflected in the personal practices, form the basics of
policies underlying staff development in any agency.
The interrelationship of the components provides the framework for purposeful staff
development structured to meet the needs of both a health care agency and the nurse.
TYPES OF STAFF DEVELOPMENT:
Staff development includes formal and informal group and individual training and
education. Staff development activities include the following:
Staff
development
Induction
training
Job
orientation
In service
education
Continuing
education

Induction training (3 days): Is a brief standardized introduction to an agency‘s philosophy,
purpose policies and regulations given to each worker during her or his first two or three days of
employment in order to ensure his or her identification with agency‘s philosophy, goals and
norms.
Job orientation (2- 24weeks): Is an individualized training programme intended to acquaint a
newly hired employee with job responsibilities work place, clients and co-workers.
In-service education(2- 8hours): It is a planned educational experience provided in the job
setting and closely identified with service in order to help the person to perform more effectively
as a person and as a worker.
Continuing education: Is a planned activity directed towards meeting the learning needs of the
nurse following basic nursing education, exclusive of full time formal post basic education.
Extramural education: Is a community based education directed towards meeting the job related
learning needs of the nurse and other personal. Exclusive of full time formal study at a degree
granting institution.
FACTORS INFLUENCING STAFF DEVELOPMENT PROGRAMME
The major factors that determine the administrative structure of an agency-wide staff
development programme are:-
 Administrative philosophy, policies and practices of health care agency
 Policies, practices and standards of nursing and other health professionals
 Human and material resources within the health care agency and community
 Physical facilities within a health care agency and community
 Financial resources within a health care agency and community
FUNCTIONS OF STAFF DEVELOPMENT PERSONNEL:
Personnel assigned to staff development should provide the following consultative
functions for health care agency.
 Determination of the administrative structure of the staff development programme.
 Determination and establishment of organizational methods, policies and procedures for
a staff development programme.
 Determination and establishment of lines of communication for the utilization of
facilities and resources personnel for the staff development programme.
 Determination of organizational and individual staff development needs and priority.
 Development of measurable short and long term objectives for staff development
programmes.

 Promotion, development, implementation and evaluation of programmes to meet these
objectives.
 Planning, co-ordination and utilization of community resources to assist in meeting these
objectives.
 Provision of a consultative service and a resource for information relative to staff
development.
PROGRAMMES FOR STAFF DEVELOPMENT
Orientation Programme
Skill Training Programme
Leadership and management development
Continuing education
1. Orientation Programme:
 Is the process of acquiring anew staff with the existing work environment so that
he/she can relate quickly to his/ her new surroundings.
 It is assigned for new staff. It is given at the initial stage of employment or when a
staff takes new responsibilities.
2. Skill Training Programme:
 Skill training may be a manual or technical skill of doing for people or skill in
dealing and working well with people.
 It provides the nursing staff with the skills and attitude required for job and to
keep them abreast of changing methods and new techniques.
 Often it is the continuation of the orientation programme.
 It is designed to new and older staff.
3. Leadership and management development:
 To improve the managerial abilities of persons at every management level as well
as potential managers to produce the greatest degree of organizational progress.
 It should be begin by establishing agreement among top and middle level
managers as to proper authority, responsibility and accountability for managers at
every level.
 Need can identified by incident reports, turnover rates, patient audits and quality
control reports.
4. Continuing education:
 Formal, organized, educational programme designed to promote the knowledge,
skills and professional attitude of nurses.

OTHER ACTIVITIES OF STAFF DEVELOPMENT
 Make rounds with the physicians
 Attend medical round in a teaching centre
 Visit another hospital to observe their method of patient care
 Attend professional meetings, conferences, etc. and present papers
 Read articles of special interest and report them to staff
BENEFITS OF STAFF DEVELOPMENT:
For the employees:
 Leads to improved professional practice
 Aids in updating knowledge and skills at all levels of organization
 Keep the nurses abreast of the latest trends and developments in techniques
 Equips the nurses with knowledge of current research and developments
 Helps the nurses to learn new and to maintain old competencies
For the organizations/employer:
Keeps the nursing staff enthusiastic in their learning
Develop interest and job satisfaction amongst the staff
Develops the sense of responsibilities for being competent and knowledgeable
Creates an appropriate environment and sound decisions as well as using effective
problem solving techniques
Helps the nurse to adjust to change
Aids in developing leadership skills, motivation and better attitudes
Aids in encouraging and achieving self development and self confidence
Makes the organization a better place to worker
ROLE OF ADMINISTRATOR IN S.D.P
Preceptorship:
 In most of the hospitals have a staff development coordinator who is responsible for
continuing and in-service education programmes. A staff nurse is selected as a preceptor
to assist the new nurse in the unit based on their skill and competence. The role of the
preceptor are:
 As an orienteer
 As a teacher
 As a resource person
 As a counselor
 As a role model and evaluator

IN-SERVICE EDUCAION:
DEFINITION:
1. In service education is defined as a continued programme of education provided by
the employing authority, with the purpose of developing the competences of
personnel in their functions appropriate to the position they hold, or to which they
will be appointed in the service.
2. In-service education is a planned instructional or training programme provided by an
employing agency in the employment setting and designed to increase competence in
a specific area.
3. In-service education is an ongoing on-the-job instruction that is given to enhance, the
worker‘s performance in their present job.
AIM OF IN-SERVICE EDUCATION:
In-service education aims at developing the ability for efficient working and the capacity
for continuous learning, so that one may adapt to changes with judgment and produce profitable
services which become an important tool for the health care of the society and nation.
CONCEPTS OF IN-SERVICE EDUCATION:
In hospital nursing services, it becomes the process of helping the nurse to carry out the
functions with their obligations for nursing services. It helps to develop their skills necessary to
reach the ultimate goals of health agency. i.e. (i) The highest quality of the patient care, and (ii)
to keep abreast of changing technique and use of sophisticated tools and equipment.
Concept
Planned education activities
Provided in a job setting
Help a person‘s
performance effectively
as a personal work
Closely identified with
service

CHARACTERISTICS
 It should be given in job setting
 Every programme should be planned and ongoing
 It should be closely related and identified with service components
 It should help the employees‘ learning and improve her/his knowledge, skills and
attitude.
FACTORS INFLUENCING IN-SERVICE EDUCATION:
The economic, social, medical and technological sciences which affect that society will
affect nursing in-service education. The related factors affect the in-service education
programmes are:-
1. Cost of healthcare – In-service education programme may increase the efficiency of
nursing services, but it adds additional expenditure on health care delivery system.
2. Manpower – In-service education requires need qualified human resources, leads to
increase human resources.
3. Changes in nursing practices – it leads to frequent changes in the programme and in-
service education.
4. Standards of nursing practice
5. Organization of nursing departmental planned approaches is regular.
APPROACHES TO IN-SERVICE EDUCATION:
The pattern of in-service education desired to be:
 Centralized Approach
 Decentralized Approach
 Co-ordinated Approach
1. Centralized Approach: - The in-service curriculum ought to emanate from and be
conducted by nursing personnel in the central administration of the agency. None of the
learners are consulted or participate in planning learning experiences and yet are expected
to attend an in-service offering.
Advantages:
 Budget control
 Evaluation of programme can be facilitated
 Prior decision on resources, people, places and things
 Committees are directed to work on specific problems identified by administration.

Disadvantage:
 It may lead to in reducing spontaneous, interested participation and enthusiasm of
learners.
2. Decentralized Approach: - It is planned by and conducted for the employees of one or
more units. The employees are expected to keep administration informed of their
activities and possibly consult with administration when help is wanted, but the
employees are expected to develop and direct their own learning experiences.
In this approach, control in planning for an in-service is a responsibility of employees and the
qualities which are valued more are self direction, initiative and participation.
Advantages:
 Individuals are working in the same unit and confront problems are common
 Share the responsibilities for meeting the in-service needs
 Proper contribution of the participants is expected
Disadvantages:
 Lack of leadership
 Conflicts
 Inefficiency
 Less or no budget
3. Co-ordinated Approach: - It is a compromise between the centralized and decentralized
patterns in that, while the practicing nurse does indeed carry a large measure of
responsibility for the in-service curriculum, the central administration of nursing
personnel of the agency is responsible for a broad programme which is of importance to
all nursing personnel. This approach involves both nursing administrators and
practitioners in complementary way.
Advantages:
 Mutual co-ordination and assistance to central administration is improved
 Duplication is avoided
 Unity of efforts is maintained
CONTINUING EDUCATION
DEFINITION:
1. Continuing education is ―any extension of opportunities for reading, study and training to
any person and adult following their completion of or withdrawal from full time school
and /or college programmes.‖

2. Continuing education is an ―educational activity, primarily designed to keep the
registered nurses abreast of their particular field of interest and do not lead to any formal
advanced standing in the profession.‖
NEED FOR CONTINUING EDUCATION:
 Respond effectively to the challenge of current social changes.
 To improve the health care, economic and educational opportunities.
 To improve the new health patterns of health care.
 Due to increasing trend towards specialization.
 Due to legislation and its impact on the education of health personnel.
PHILOSOPHY OF CONTINUING EDUCATION:
It has been believed that the system of higher education which provides the basic
preparation or the members of a profession must also provide opportunities for practitioners to
keep abreast of advances in their field.
PLANNING FOR CONTINUING EDUCATION:
Planning is the key stone for the administrative process. Without adequate planning,
continuing education offerings are fragmented, haphazardly constructed, and often unrelated. A
successful continuing education programme is the result of careful and detailed planning.
Effective planning is required at all levels, local, state, regional and national and
eventually international – to avoid duplication and fragmentation of efforts and to help keep at
minimum gap in meeting the continuing education needs of nurses.
THE PLANNING FORMULA:
1. What is to be done?
Get a clear understanding of what your unit is expected to do in relation to the work
assigned to it. Break the unit‘s work into separate jobs in terms of the economical use of
the men, equipment, space, materials and money you have at your disposal.
2. Why is it necessary?
When breaking the units into separate jobs think of the objectives of each job. The best
way to improve any job is to eliminate unnecessary motion, materials etc.
3. How is it to be done?
In relation to each job, look for better ways of doing it n terms of the utilization ofmen,
materials, equipment and money.
4. Where is it to be done?
Study the flow of work and the availability of the materials and equipments best suited
men for doing the job.

5. When is it to be done?
Fit the job into a time schedule that will permit the maximum utilization of men,
materials, equipment and money and the completion of the job at the wanted time.
Provisions must be made for possible delays and emergencies.
6. Who should do the job?
Determine what skills are needed to do the job successfully, select or train the man best
fitted for the job.
STEPS IN THE PLANNING PROCESS:
1. Establishing goals compatible with the purpose or mission of the organization.
2. Deciding upon specific objectives consistent with these goals.
3. Determining the course of action required to meet the specific objectives.
4. Assessing the available resources for establishing the programme.
5. Establishing a workable budget, appropriate for the programme.
6. Evaluating the results at stated intervals.
7. Reassessing he goals and updating the plan periodically.
ROLES AND FUNCTIONS OF ADMINISTRATOR/MANAGER IN STAFF
DEVELOPMENT:
ROLES: He/ she:
 Applies adult learning principles when helping employees learn new skills or information
 Uses teaching techniques that empower staff
 Sensitive to the learning deficits of the staff and creatively minimize these difficulties
 Prepare employees readily regarding knowledge and skill deficits.
 Actively seeks out teaching opportunities
 Frequently assess learning needs of the unit
FUNCTIONS:
 Works with reduction department to delineate shared individual responsibility
 Ensures that all staff are competent for roles assigned
 Ensure that there are adequate resources for staff development
 Assumes responsibly for quality and fiscal control of staff development.
 Provides input in formulating staff development policies

EVALUATION OF STAFF DEVELOPMENT PROGRAM
Staff development is an important part of assisting performance improvement at
organiational, faculty/central department, unit and individual levels. It is therefore important that
the transfer of learning into the workplace is assessed through a process of review and evaluation
so that its success or otherwise can be established and so that we can demonstrate the
contribution learning makes towards overall organisational success.
DEFINITION OF EVALUATION:
Evaluation is the process of finding out how the development or training process has
affected the individual, team and the organization. or
Evaluation is a value judgment on an observation, ―performance test‖ or indeed any data whether
directly measured or inferred
TYPES OF EVALUATION
Formative evaluation: Evaluation that is used to modify or improve a professional development
program is called formative evaluation. Formative evaluation is done at intervals during a
professional development program. Participants are asked for feedback and comments, which
enable the staff developers to make mid-course corrections and do fine-tuning to improve the
quality of the program.
Summative evaluation: Evaluation to determine the overall effectiveness of a professional
development program is called summative evaluation. Summative evaluation is done at the
conclusion of the program. It is collected at three levels: educator practices, organizational
changes, and student outcomes.
LEVELS OF EVALUATION
An Evaluation Framework
The four stages of evaluation are intended to measure: (1) Reaction, (2) Learning, (3) Behavior
and actions, and (4) Results.
 Reaction: Measures how those who participate in professional development activities
react to what has been presented. Although typically characterized as ―the happiness
quotient,‖ participants need to have a positive reaction to a professional development
activity if information is to be learned and behavior is to be changed.
 Learning: Measures the extent that professional development activities have improved
participants' knowledge, increased their skills, and changed their attitudes. Changes in
instructional behavior and actions cannot take place without these learning objectives
being accomplished.

 Behavior: Measures what takes place when the participant completes a professional
development activity. It is important to understand, however, that instructors cannot
change their behavior unless they have an opportunity to do so.
 Results: Measures the final results that occurred because an instructor participated in
professional development activities. Evaluating results represents the greatest challenge
in evaluating professional development approaches
DUTIES OF NURSING AND NON NURSING PERSONALS IN HOSPITAL
INTRODUCTION:
Nursing and non nursing personals in hospitals plays an important role in patient care and
the development of the hospital. Their entire role is very important to improve the standard of
care.
GENERAL ROLE OF REGISTERED NURSES IN HOSPITAL
ADMINISTRATOR:
A hospital administrator is usually an individual responsible for the day to day operational
running of the health care institution. Specific duties include recruitment and retention of
physicians, overseeing quality, improvement of processes for efficient delivery of patient care,
setting standards, oversight of budgets, creating financial and business strategies to assure fiscal
viability and health.
MANAGER:
The nurse plans, gives directions, develops staff, monitors operations, gives rewards fairly,
and represents both staff members and administration as needed. The nurse manages the nursing
care of individuals, groups, families and communities. The nurse manager delegates nursing
activities to ancillary workers and other nurses and supervises and evaluates their performance.
COUNSELOR:
In most organizations counselors' play an important role in the induction of new employees.
At this stage counselors can do much to help new employees. They take new employees round
the hospital, show them different departments and explain their functioning, explains rules and
regulations of hospital and of cafeteria, issue lockers and uniforms, and introduce them to the
administrator and medical superintend.
Counseling helps in reviewing training needs, improving better communication between
employees and employers and helps in solving personal and official problems of employees.
External and internal stress, lack of training, difficulties in job, emotional deprivation etc can be

tackled under employee counseling. Use of counseling methods and skills of the counselor can
be utilized effectively, to create a better harmonious hospital staff environment
Problems to be handled by the Counselor
The problems coming under employee counseling in a hospital setting are
1. Emotional Problem
2. Behavioral Problem
3. Personal Problem
4. Environmental Problem
5. Organizational Problem
1. Emotional Problem
Unpleasant emotions like fear, anger, and jealousy, which are harmful to the well-being and
development of individual employee in hospital setting.
2. Personal Problems
Common personal problems include, housing, transportation, admission of children in
schools etc.
3. Behavioural and Organisational problems
Major organisational problems are lack of group cohesiveness, role conflict, feeling of
inequality, role ambiguity, role over load, lack of supervisory support, constraints of rules and
regulations, job mismatch, inadequacy of role authority, absenteeism, job dissatisfaction, labour
turnover and job stress.
CHANGE AGENT
The nurse initiates changes and assist the client make modifications in the lifestyle to
promote health. This role involves, identifying the problem, assessing the client‘s motivations
and capacities for change, determining alternatives, assessing resources, determining appropriate
helping roles, establishing and maintaining a helping relationship, recognizing phases of the
change process, and guiding the client through these phases.
RESEARCHER
The nurse participates in scientific investigation and uses research findings in practice. The
nurse helps develop knowledge about health and promotion of health over the full life span; care

of person with health problems and disabilities; and nursing actions to enhance people‘s ability
to respond effectively to actual or potential health problems.
CASE MANAGER
The nurse coordinates the activities of other members of health care team, such as nutritionists
and physical therapist, when managing a group of client‘s care.
COLLABORATOR
The nurse works in a combined effort with all those involved in care delivery, for a mutually
acceptable plan to be obtained that will achieve common goals. The nursing initiates nursing
actions within the health team
HEALTH EDUCATORS
Work to encourage healthy lifestyles and wellness through educating individuals and
communities about behaviors that can prevent diseases, injuries, and other health problems.
After assessing their audiences' needs, health educators must decide how to meet those needs.
Health educators have a lot of options in putting together programs. They may organize an event,
such as a lecture, class, demonstration or health screening, or they may develop educational
material, such as a video, pamphlet or brochure. Often, these tasks require working with other
people in a team or on a committee. Health educators must plan programs that are consistent
with the goals and objectives of their employers. For example, many nonprofit organizations
educate the public about one disease or health topic, and, therefore, limit the programs they
issue.
ADVICER:
Specific responsibilities:
1. Act as advisor in Tech-Serve project on matters relating to hospital management improvement
in provincial hospitals, based on previous experience.
2. Contribute to the development of provincial hospital planning and facilitating the
implementation of Standard Based Management in the Provincial Hospitals.
3. Work closely with the other national and international Tech-Serve Hospital Management
Advisors concerning the Tech-Serve Hospital Management Improvement Initiative, reviewing
and developing MOPH policies and active participation in the MOPH Hospital Management
Task Force.
4. Provide technical assistance to EPHS workshops conducted at the provincial and central level
as well as participate in visits to provincial hospitals for purposes of training, conducting quality
standards assessment or preparing necessary workshops of Tech-Serve.

5. Travel regularly to the provincial hospitals for the purpose of supporting, training, and
monitoring the activities of the hospital leadership.
6. Act as a resource to provide models of best practice for hospital management through
research, training, document translation, and any other means as needed.
7. Participate in and sometimes leading quality assurance and performance improvement
activities as required by the hospitals.
8. Collect statistical data as needed for the purposes of monitoring hospital performance and
providing comparative information on hospital performance to peer facilities and MSH.
9. Advocate for external support as needed by the hospitals, both within MSH and at the MOPH
through the Hospital Management Task Force.
10. Any other duties, as requested by the Chief of Party, Program Directors, or Program Manager
for Capacity Building.
ADVOCATOR:
A patient advocate may be charged with a cadre of duties, from gathering information from
doctors and hospitals to helping discuss and decide treatment options.
Some duties of advocator:
 Clarifying treatment and medical options.
 Gathering information.
 Asking specific questions.
 Note taking, to make sure all the appropriate information received from caregivers is
captured and retained.
IMPLEMENTER:
The nurse should implement all of the hospital policies. They should implement patient
care according to their planning.
EVALUATOR:
The nurse evaluator should evaluate staff performance and give feedback about their
work. It helps the staff to improve their knowledge and practice.

DUTIES OF NURSING PERSONALS IN HOSPITAL:
DUTIES OF NURSING SUPERINTENDENT:
A nursing superintendent supervises the nursing staff. The nursing superintendent, who is
also called the director of nursing, is responsible for the running and supervision of a nursing
department. Depending on the size of the facility, she may control subsidiary departments, such
as housekeeping. Nursing superintendents generally report to the hospital director or medical
director of their facility.
Supervise nursing staff
The top priority of a nursing superintendent is to ensure that the nursing staff members are
providing the best care for patients. She makes sure that individual nurses and nurses aides are
carrying out care plans and ensures that communication between shifts happens smoothly and
thoroughly. The superintendent also monitors stock and supplies to make sure that nurses have
the equipment they need to provide quality care.
Oversee hiring and training
The nursing superintendent is responsible for the hiring and training of new staff. She must
search for nurses that complement the existing team, design training programs and make sure
that nursing instructors and trainers are adequately preparing new staff for the workplace. Often
this includes hearing an evaluation of new nurses from the floor staff during the training period.
Patient care
Although the nursing superintendent does not have a high level of direct patient care, she is
responsible for the well-being of patients at the facility. This means that the superintendent must
monitor nurses' care and the attitude and health of the patients. In cases where the family
requests alternate care, the nursing superintendent must hear the request and make the final
decision.
Create work schedules
Each pay period, the nursing superintendent is responsible for setting the work schedules for
the entire department. She must take into account holidays, hear requests for time off, and create
a schedule that gives the appropriate number of hours to each nurse. As part of the process, the
nursing superintendent assigns duties and floor responsibilities to each nurse.

Make disciplinary decisions
In situations where a nurse, nurse's aide, or other staff member is involved in a dispute, the
nursing superintendent must handle disciplinary actions. In extreme cases like patient abuse or
staff coming to work under the influence, the nursing superintendent is responsible for
terminating contracts as needed.
Manage other departments
In a large facility, the nursing superintendent may be responsible for directing the activities
of the housekeeping, linen, and kitchen facilities. She must handle any problems that arise,
communicate with department leaders, and address any supply issues.
Negotiate with vendors
Because the nursing superintendent is responsible for the supply of equipment and medical
necessities, she often negotiates with vendors for the new contracts. In large facilities, a
purchasing manager may handle these duties and report to the superintendent.
DUTIES OF ASSISTANT NURSING SUPERINTENDENT:
Essential Functions/Responsibilities:
1. Take responsibility for a group of activities or subcontractors and manage the work to be
done. Provide liaison between field engineering, estimating, and subcontractors to ensure
compliance of construction with drawings and specifications.
2. Assist in planning work schedule, determining manpower levels, materials quantities,
equipment, requirements, etc. are maintained, including field engineering and construction
activities.
3. Monitor work performance and productivity of crafts to ensure project rules, procedures,
safety requirements, etc. are maintained.
4. Advise senior level supervision and project management of potential problems, work
interferences, schedule difficulties, etc. Assist in circumventing/resolving such problems as
required.
5. Maintain liaison with other departments, i.e., Purchasing, Accounting, Engineering, etc. as
required to support construction schedule. May provide assistance to the Superintendent in
resolving problems.
6. Perform additional assignments per supervisor‘s direction.

DUTIES OF WARD SISTER:
Functions:
A. Clinical Activities:
1. Assesses the situation of given unit in relation to different types of patient‘s care,
facilities provided by the nursing personnel.
2. Identifies the patient‘s need/problem in the unit.
3. Assigns the patient‘s care and others activities to nursing personnel.
4. Evaluates the patient‘s care given by nurses.
5. Attends Doctor‘s round and Matron and Assistant Matron‘s Clinical rounds.
6. Checks and caries out and delegates Doctor‘s instruction and order after round.
7. Participates and refers the patient for rehabilitation therapy.
8. Guides and conducts health education activities to client as required including MCH/FP
disease control and health promotion.
B. Supervisory Activities
1. Guides and supervises all staff for giving bed side nursing care.
2. Maintains regular records, report concerning the patient‘s care.
3. Provides direct guidance and supervision of nursing and non-nursing personnel for the
efficient running of the wards and in carrying out nursing routines, bearing in mind the
individual needs of patients.
4. Encourages motivates, assesses the effectiveness of their own works and develops their
potential for giving good nursing care.
5. Uses the standard guideline and manual for supervision.
C. Administrative Activities
1. Makes duty roaster for 24 hrs coverage in unit of the Hospital.
2. Conducts nursing conference, meeting and individual conference when necessary.
3. Investigates complaints promptly and takes action according to rules and policy of the
hospital.
4. Reports and records absence and sickness of staff including leaves.
5. Maintains cleanliness of the ward and its environment, furniture, equipment, e.g.
ventilation, lighting, heating, noise, odors.
6. Maintains adequate linen, other supplies, requisition for ward stores and repairs, replaces
supplies as necessary.
7. Keeps up-to-date record of drugs and maintains records of its administration.
8. Checks and manages all equipment periodically, to see that it is in good order.
9. Checks daily availability and conditions of emergency equipment and supplies.
10. Maintains inventories, reports, breakages and losses.
11. Helps in Controlling the visitor of patients as needed.
12. Ensures that relatives of very ill patient are allowed to stay with patients when necessary.
13. Accompanies, the Matron on the round and reports to her any important incidents.

14. Informs Matron immediately of any special emergencies or accidents in the ward, and
keeps a written record of nay incidents.
15. Coordinates between Matron and staff in her unit and also with other departments.
16. Takes active part in condemnation of useless materials.
17. Helps Matron for annual plans and budgets in her ward.
18. Delegates responsibilities to the responsible person in her absence.
19. Assist the Matron and Assistant Matron for disaster plan and organization.
D. Educative Activities
1. Identifies the learning need of staff in ward.
2. Plans, conducts and recommends the in-service education and training programme for her
staff.
3. Manages and facilitates the clinical teaching activities for the students and staffs.
DUTIES OF OTHER NURSING PERSONALS:
Duties and responsibilities of Perioperative nurses:
Perioperative registered nurses provide surgical patient care by assessing, planning, and
implementing the nursing care patients receive before, during and after surgery. These activities
include patient assessment, creating and maintaining a sterile and safe surgical environment, pre-
and post-operative patient education, monitoring the patient‘s physical and emotional well-being,
and integrating and coordinating patient care throughout the surgical care continuum.
During surgery, the perioperative registered nurse may assume any of the following
responsibilities:
 Scrub nurse – works directly with the surgeon within the sterile field by passing
instruments, sponges, and other items needed during the surgical procedure.
 Circulating nurse – works outside the sterile field. Responsible for managing the nursing
care within the O.R. by observing the surgical team from a broad perspective and
assisting the team in creating and maintaining a safe, comfortable environment.
RN First Assistant – after completing extensive additional education and training to
deliver direct surgical care, the RN First Assistant may directly assist the surgeon by
controlling bleeding and by providing wound exposure and suturing during the actual
procedure
Diabetes management nurses:
Diabetes Management Nurses are registered nurses who assist patients to
manage diabetes. Their main duty is to educate patients and their families about diabetes and

the self-management skills required. They provide advice on exercise, diet and medication and
monitoring insulin levels. These nurses often work in outpatient clinics and often travel to
hold clinics in regional areas.
 The main duties of a Diabetes Management Nurse include:
-Dealing with complications of patients diagnosed with diabetes mellitus
-Working closely with physicians, pharmacists and other healthcare professionals
-Educating patients of the best practices in improving their health
-Informing patient‘s families on living with diabetes
-Providing advice on diet and exercise
-Advising on injecting medications
-Administering tablets or insulin if the patient is unable
- Monitoring blood glucose levels
Duties and responsibilities of Dermatology nurses:
Those who are suffering from skin disorders or in need of skin care may seek the services
of a dermatology nurse. Dermatology nurses are registered nurses who specialize in treating skin
disorders and may administer treatments for their patients. In some cases, they may prescribe
medication. The nurse may also educate their patients on maintaining healthy skin.
Duties and responsibilities of geriatric nurses:
A geriatric nurse is a registered nurse who specializes in the care of elderly people.
Geriatric nurses must have the same educational background as registered nurses, including a
bachelor's degree from an accredited college or university. Duties of a geriatric nurse, however,
differ from other fields of nursing due to the unique problems that can arise in elderly patients.
Assess Problems
1. Geriatric nurses must be able to assess medical problems of their elderly patients. Often,
it is the geriatric nurse who must decide if his patient can preform every day tasks on her
own. Assessments may be in activities like driving, walking and taking medications.
Communication Skills
2. Geriatric nurses must be able to determine, through both verbal and non-verbal
communication, the health of patients by knowing symptoms, ailments and medications
being taken by patients. Geriatric nurses are the liaison between doctors, patients,
patients' families and other health-care facility workers.
3. Patient Relationships
Geriatric nurses often spend large amounts of time with their patients, causing them to
have close-knit relationships with the patients and their families. Geriatric nurses,

because of the time spent with their elderly patients, must be able to cope with the death
of patients as well as the decline of a patient's mental and physical health.
Duties and responsibilities of Pediatric oncology nurses:
A pediatric nurse works in the pediatric department of a hospital, children's clinics or at
their homes. The basic duties of a pediatric nurse involve performing physical examinations and
giving medicines administrated by the doctor to hospitalized patients. As little children are
usually afraid of medical settings, it is the duty of the pediatric nurse to make them comfortable
with encouraging words, so that they can conduct the necessary tests and treatment procedures
smoothly.
Responsibilities of a pediatric nurse involves taking temperature, blood pressure,
respiratory rate and heart rate of the patient. He/she also has the duty of starting intravenous
medications, performing head to toe examinations and also collecting samples of patient's urine
and stools for laboratory tests.
Ambulatory care nurses:
Provide preventive care and treat patients with a variety of illnesses and injuries in
physicians' offices or in clinics. Some ambulatory care nurses are involved in telehealth,
providing care and advice through electronic communications media such as videoconferencing,
the Internet, or by telephone.
Critical care nurses:
Critical care nurses provide care to patients with serious, complex, and acute illnesses or
injuries that require very close monitoring and extensive medication protocols and therapies.
Critical care nurses often work in critical or intensive care hospital units.
ICU nurses are specialized, trained nurse professionals working with patients who have life-
threatening situations that required an extended hospital stay in an intensive care or critical care
unit of the hospital. The ICU nurse must be skilled to make complex assessments, give the
patient intense therapy and provide intervention care. The nurse may also perform ongoing duties
for a patient in ICU unit during his stay.
Assessment
Individualized assessment is made by the ICU nurse to determine the immediate needs of the
critical care patient. Ongoing assessment is then established to keep tabs on the patient's
condition and make any changes in treatment based on hospital policy, procedure and protocol.
Assessment helps the nurse and other hospital staff determine what plan of action to take in care

of the patient. Assessment also allows the ICU nurse to educate the patient and her family on
what to expect in the days, weeks and months following ICU treatment.
Patient Care
Following doctor or head nurse instructions, the ICU nurse performs treatments and therapies for
the patient. She gives the patient all necessary medication. If the patient lapses into cardiac arrest
or another condition that requires resuscitation, the nurse follow hospital protocols and
administers life-saving techniques. When a patient's condition changes rapidly, the nurse makes
quick decisions to treat the patient effectively. As shift changes occur, it is the nurse's duty to
inform the relief nurse of all patient care information. If the patient requires special procedures,
the ICU nurse acts as an assistant to the doctor or head nurse.
Administrative
Documentation of assessments and drug therapy is recorded by the ICU nurse. She also makes
documentation of physical therapy and other treatments given. The nurse must also keep all
patient clinical records with doctor orders confidentially secure. The ICU nurse must be non-
discriminative and nonjudgmental when dealing with patients.
Emergency or trauma nurses:
Emergency or trauma nurses will work in hospital or stand-alone emergency departments,
providing initial assessments and care for patients with life-threatening conditions.
The main duties of an Emergency / Trauma Nurse include:
- Providing care to patients in an emergency situation
- Administering emergency procedures e.g. code blue and CPR
- Acting fast and thinking on their feet
- Handling complex and difficult situations
- Operating healthcare machines
Transport nurses:
Transport nurses will provide medical care to patients who are transported by helicopter or
airplane to the nearest medical facility.
Holistic nurses:
Holistic nurses will provide care such as acupuncture, massage and aroma therapy, and
biofeedback, which are meant to treat patients' mental and spiritual health in addition to their
physical health.

Home health care nurses:
Home health care nurses will provide at-home nursing care for patients, often as follow-up
care after discharge from a hospital or from a rehabilitation, long-term care, or skilled nursing
facility.
Hospice and palliative care nurses:
Hospice and palliative care nurses work in collaboration with other health providers (such
as physicians, social workers, or chaplains) within the context of an interdisciplinary
team. Composed of highly qualified, specially trained professionals and volunteers, the team
blends their strengths together to anticipate and meet the needs of the patient and family facing
terminal illness and bereavement.
Infusion nurses:
Infusion nurses administer medications, fluids, and blood to patients through injections into
patients' veins. Infusion nurses specialize in administering parenteral fluids, blood & blood
components, pharmacological agents, nutritional solutions and pain medications.
Long term care nurses:
Long term care nurses provide healthcare services on a recurring basis to patients with chronic
physical or mental disorders, often in long-term care or skilled nursing facilities.
Medical surgical nurses:
Surgical nurses are a vital part of the health care team that provides care for patients before,
during and after surgical procedures. They work both inside and outside of the sterile field to
provide both direct patient care and support to the surgical staff.
General Duties
Surgical nurses are RNs who work in the operating, pre-surgical or recovery areas of a
hospital, outpatient surgical center or emergency ward, under the supervision of the operating
physician. They perform many functions that allow surgeries to proceed smoothly, including
preparing patients for surgery, assisting the surgeon during procedures and following up with
patients during recovery.
Recovery nurses
Surgical prep and recovery nurses are RNs who care for individuals before surgery and
during recovery. They prepare patients for surgical procedures by starting intravenous lines,

administering medication, taking a complete health history, completing additional tests such as
blood work, and performing pre-surgical preparations such as shaving.
Scrub Nurses
Scrub nurses are RNs who work within the sterile field to assist the surgeon. The scrub
nurse has scrubbed with antimicrobial soap and is outfitted in a sterile suit. Scrub nurses prepare
the needed instruments and other supplies for surgery and hand them to the surgeon during the
procedure. Typically, scrub nurses acquire their position only after they have gained extensive
nursing experience.
Circulating Nurses
Circulating nurses assist the surgical team in various ways but do not work within the sterile
field. Some of the duties of a circulating nurse include obtaining additional equipment or
instruments for the team, monitoring the condition of the patients, preparing tissue samples for
transport to a lab, and disposing of biohazardous material..
Registered Nurse First Assistants
Registered nurse first assistants (RNFA) have extensive additional training and clinical
experience that qualifies them to assist surgeons by performing basic surgical procedures. An
RNFA must take coursework in perioperative care and surgical procedures and pass the CRNFA
(Certified Registered Nurse First Assistant) professional board exam. Duties of a RNFA may
include suturing, exposing a wound, controlling bleeding and assisting surgeons in holding or
operating other instruments.
Occupational health nurses:
The occupational health nurse role includes:
 The prevention of health problems, promotion of healthy living and working conditions
 Understanding the effects of work on health and health at work
 Basic first aid and health screening
 Workforce and workplace monitoring and health need assessment
 Health promotion
 Education and training
 Counseling and support
 Risk assessment and risk management

Perianaesthesia nurses:
Perianaesthesia nurses provide preoperative and postoperative care to patients undergoing
anesthesia during surgery or other procedure.
Mental health nurses:
Mental health nurses help psychiatrists, psychologists and other mental health professionals
counsel and treat patients with a variety of emotional and psychiatric issues, from substance
abuse oriented problems to paranoid-schizophrenia. Mental health nurses also help with the
dispensing of medication for patients. Psychiatric nurses with an advanced education may be
able to prescribe medication on their own.
Radiology nurses:
Radiology nurses provide care to patients undergoing diagnostic radiation procedures such as
ultrasounds, magnetic resonance imaging, and radiation therapy for oncology diagnoses.
Radiology nurses routinely start or check peripheral i.v.s, assess infusaports, administer
medications, monitor vital signs, suction patients, insert foleys and help patients with their
personal needs.
Rehabilitation nurses:
The goal of the rehabilitation nursing profession is to treat patients who require a broad range
of medical services for their recovery. People who need rehabilitation nursing care may have
suffered from such things as work injuries, car accidents, strokes, head trauma, drug or alcohol
abuse, gunshot wound or other severe trauma. These nurses find work in general hospitals,
rehabilitation centers, drug and alcohol recovery facilities, mental hospitals, senior citizen
facilities, or private homes. Rehabilitation nurses are able to provide a broad range of services
depending on the facility they work in.
Transplant nurses:
Transplant nurses care for both transplant recipients and living donors and monitor signs of
organ rejection.
Addictions nurses:
Addictions nurses care for patients seeking help with alcohol, drug, tobacco, and other
addictions.
Some of the principal duties are:

Oversee detoxification and substitute prescribing programmes;
• Provide support to clients on an individual and group basis;
• Liaise with mental health team, addictions team, psychology dept, social workers, medical staff
and general health team;
• Delivering drug/alcohol education and awareness packages to clients and staff;
• Promoting healthy living and harm reduction initiatives to clients, eg safer injecting;
• Provide support and counseling for blood borne virus testing as required;
• Liaise with community agencies from a client‘s admission through to preparation for and
release from prison.
This post has a diverse range of responsibilities and excellent communication and interpersonal
skills are essential.
Intellectual and developmental disability nurses:
Intellectual and developmental disabilities nurses provide care for patients with physical,
mental, or behavioral disabilities; care may include help with feeding, controlling bodily
functions, sitting or standing independently, and speaking or other communication.
The main duties of an Intellectual and Developmental Disabilities Nurse include:
- Providing care for patients with physical, mental or behavioral disabilities
- Caring for patients of all ages
- Assisting with feeding and controlling bodily functions
- Supporting patients and encouraging them to be independently mobile
- Educating patients and their families of Intellectual and Developmental Disabilities
- Assisting patients with language skills and other forms of communication
Genetic nurses:
Genetic nurses provide early detection screenings, counseling, and treatment of patients with
genetic disorders, including cystic fibrosis and Huntington's disease.
HIV/AIDS nurses:
HIV/AIDS nurses care for patients diagnosed with HIV and AIDS. They should give proper
care, education, psychological support and counseling to the patients.

Oncology nurses:
Oncology nurses care for patients with various types of cancer and may assist in the
administration of radiation and chemotherapies and follow-up monitoring.
The following discussion on the role of the oncology nurse focuses on patient assessment,
patient education, coordination of care, direct patient care, symptom management, and
supportive care. To illustrate how varied the role may be and its importance across the
continuum of cancer care, examples related to the role of the oncology nurse in direct patient
care, symptom management, and supportive care are provided.
Wound, ostomy and continence nurses:
Wound, ostomy, and continence nurses treat patients with wounds caused by traumatic
injury, ulcers, or arterial disease; provide postoperative care for patients with openings that allow
for alternative methods of bodily waste elimination; and treat patients with urinary and fecal
incontinence.
Cardiovascular nurses:
Cardiovascular nurses treat patients with coronary heart disease and those who have had
heart surgery, providing services such as postoperative rehabilitation.
Pre-Operative Responsibilities
Pre-operative care includes evaluating a patient's readiness for surgery by taking a detailed
medical history and performing a complete physical examination. This is followed by ordering
appropriate tests for assessment and prescribing necessary medications for surgery.
Operative Responsibilities
Operative responsibilities include assisting in preparation of the patient by positioning the patient
on the operating room table and applying appropriate draping for the surgical procedure.
Assisting the general operation as needed by a surgeon is also required.
Post-Operative Responsibilities
Post-operative care includes evaluating the patient's recovery process by checking vital signs,
administering intravenous lines, ordering medications and laboratory tests as needed and
monitoring the patient to ensure there are no complications after surgery.

Gynecology nurses:
Gynaecology nurses provide care to women with disorders of the reproductive system,
including endometriosis, cancer, and sexually transmitted diseases.
Nephrology nurses:
Nephrology nurses care for patients with kidney disease caused by diabetes, hypertension, or
substance abuse.
Before dialysis, the nurse assists the patient in seeking information about his disease,
prognoses and treatments. The nurse is responsible for ensuring that appropriate care is available.
Prior to the actual treatment, the nephrology nurse must evaluate if it's safe for treatment to
begin. If the patient has no new acute health issues, the nurse continues with the preparation for
dialysis.
Neuroscience nurses:
Neuroscience nurses care for patients with dysfunctions of the nervous system, including
brain and spinal cord injuries and seizures.
Ophthalmic nurses:
Ophthalmic nurses provide care to patients with disorders of the eyes, including blindness
and glaucoma, and to patients undergoing eye surgery.
Orthopedic nurses:
Orthopedic nurses care for patients with muscular and skeletal problems, including arthritis,
bone fractures, and muscular dystrophy.
Otorhinolaryngology nurses:
Otorhinolaryngology nurses care for patients with ear, nose, and throat disorders, such as
cleft palates, allergies, and sinus disorders.
Respiratory nurses:
The role of respiratory nurses is to promote good pulmonary (lung) health within
individuals, families and communities. By building close relationships with doctors and patients
in their community, respiratory nurses educate the public on the importance of healthy breathing
and proper exercise in people of all ages.

Urology nurses:
Urology nurses care for patients with disorders of the kidneys, urinary tract, and male
reproductive organs, including infections, kidney and bladder stones, and cancers.
A urology nurse cares for patients with urinary tract problems in a hospital, urology clinic, or
private doctor's office. A nurse performs initial evaluations of symptoms, assists doctors with
diagnostic and treatment procedures, and provides expert patient education and counseling
services. Professionals see patients who have urinary tract infections, kidney stones, cancers,
prostatitis, or any of a number of other specific conditions.
Clinical nurse specialist:
Clinical nurse specialists provide direct patient care and expert consultations in one of
many nursing specialties, such as psychiatric-mental health.
Nurse anesthetist:
Nurse anesthetist provides anesthesia and related care before and after surgical, therapeutic,
diagnostic and obstetrical procedures. They also provide pain management and emergency
services, such as airway management.
Nurse midwives:
Nurse midwives provide primary care to women, including gynecological exams, family
planning advice, prenatal care, assistance in labor and delivery, and neonatal care.
Nurse practitioners:
Nurse practitioners serve as primary and specialty care providers, providing a blend of nursing
and healthcare services to patients and families. The most common specialty areas for nurse
practitioners are family practice, adult practice, women's health, pediatrics, acute care, and
geriatrics. However, there are a variety of other specialties that nurse practitioners can choose,
including neonatology and mental health.
Forensics nurses:
Forensics nurses participate in the scientific investigation and treatment of abuse victims,
violence, criminal activity, and traumatic accident.
Main function of a forensic nurse is to collect information about crime and investigate details
about it but it is not the only work that they do. Forensic nurses even provide medication and

relief to the victims of any crime, they even provide counseling to offenders and even children
who at times go off track and start indulging in unethical activities.
Infection control nurses:
An infection control nurse has one primary role, and that is to prevent hospital infections in
their patients by carrying out infection prevention protocols diligently. nurses can play an
important role in controlling and preventing the spread of infectious diseases in health care
facilities. In fact, several nurse duties are aimed solely at infection control.
Nurse educators:
Nurse educators plan, develop, implement, and evaluate educational programs and curricula
for the professional development of student nurses and RNs.
Nurse informaticists:
Nurse informaticists manage and communicate nursing data and information to improve
decision making by consumers, patients, nurses, and other healthcare providers. RNs also may
work as healthcare consultants, public policy advisors, pharmaceutical and medical supply
researchers and salespersons, and medical writers and editors.
Work environment. Most RNs work in well-lit, comfortable healthcare facilities. Home health
and public health nurses travel to patients' homes, schools, community centers, and other sites. .
RNs may be in close contact with individuals who have infectious diseases and with toxic,
harmful, or potentially hazardous compounds, solutions, and medications. RNs must observe
rigid, standardized guidelines to guard against disease and other dangers, such as those posed by
radiation, accidental needle sticks, chemicals used to sterilize instruments, and anesthetics. In
addition, they are vulnerable to back injury when moving patients.
A. Principal (school of nursing, College of Nursing)
Job Summary
Principal, College of Nursing is the administrative head of the College of Nursing, will be
directly responsible to the Director of the Medical Education/Director of Health and Family
Welfare services and responsible for implementation and revision of curriculum for various
courses, and research activities of the college of Nursing.
Duties and Responsibilities
Administration
 Planning

 Develops philosophy and objectives for educational program.
 Identifies the present needs related to educational program.
 Investigates, evaluates and secures resources.
 Formulates the plan of action.
 Selects and organizes learning experience.
Organizing
 Determines the number of position and scope and responsibility of each faculty and staff.
 Analyses the job to be done in terms of needs of education program.
 Prepares the job description, indicate line of authority, responsibility in the relationship and
channels of communication by means of organizational chart and other methods.
 Considers preparation, ability and interest personally in equating responsibility.
 Delegates authority commensurate with responsibility.
 Maintains a plan of work load among staff members.
 Provides an organizational framework for effective staff functioning such as meeting of the
staff, etc.
Directing
 Recommends appointment and promotion based on qualification and experience of the
Individual staff, scope of job and total staff composition.
 Subscribes and encourages developmental aspects with reference to welfare of staff and
students.
 Provides adequate orientation of staff members.
 Guides and encourages staff members in their job activities.
 Consistently makes administrative decision based on established policies.
 Facilitates participation in community, professional and institutional activities by providing
time, opportunity for support for such participation.
 Creates involvement in designing educationally sound program.
 Maintenance of attitude rightly acceptable to staff and learners.
 Provides for utilization in the development of total program and encourages their
contribution.
 Provides freedom for staff to develop active training course within the framework for
curriculum.

 Promotes staff participation in research.
 Procures and maintains physical facilities which are of a standard.
Coordinating
 Coordinates activities relating to the programs such as regular meetings, time schedule,
maintaining effective communication, etc.
 Initiates ways of cooperation.
 Interpretes nursing education to other related disciplines and to the public.
Controlling
 Provides for continuous follow up and revision of education program.
 Maintains recognition of the educational program by accrediting bodies. University, etc,
KNC, INC, etc.
 Maintains a comprehensive system of records.
 Prepares periodic report which revives the progress and problems of the entire program and
presents plans for its continuous development.
 Prepares, secures approval and administrates the budget.
Instruction (Teaching)
 Plans for participating in educational programs for further development.
 Recognizes the needs for continuing education for self and staff provides stimulation of
opportunities for such development.
 Participate as a teacher in the educational program.
Guiding
 Provides for systematic guidance program for staff members and students.
 Encourages studies, research and writing for publication.
 Provides and maintains a program for recruitment, selection and promotion of students.
B.VICE- PRINCIPAL
Financial:
 Assists Principal in carrying out financial activities:
 Planning and revising budget
 Monitoring College expenditure
 In the absence of Principal, performs all the functions
Educational:

 Assists Principal in planning, implementation and evaluation of the programmes.
 Assists Principal in identifying needs for professional development of faculty and
conducting staff development programme.
 Supervises postgraduate students in conducting research.
 Participates in teaching of various educational programmes.
 In the absence of Principal, chairs the assigned committee meetings.
 Supervises all educational programmes in coordination with the coordinators.
 Guides faculty in day-to-day academic activities
Supervisory:
 Shares responsibility with Principal and Professor in supervision of teaching and
nonteaching staff.
 Plans academic staff assignments in consultation with Principal.
 Participates in conduct of orientation programme
 Supervises and guides staff in conducting their activities.
 Writes staff performance report and reviews evaluation report of assigned staff.
 Assists Principal in monitoring students welfare activities e.g. Mess, hostel, Health,
Sports , S.N.A. etc.
 Assists Principal in administration and supervision of library.
Establishment:
 Assists Principal in maintaining rules and regulations in college campus
 Supervises overall functioning of staff and students' hostel.
 Assists Principal in maintaining discipline in the college.
 Assists Principal in reviewing recruitment and promotion policies of teaching and
non-teaching staff.
Interpersonal:
 Assists Principal in maintaining human relation and communication
 Identifies conflict among staff members, initiates solution and reports to Principal
when necessary.
 Communicates with staff in explaining administrative constraints.
 Facilitates guidance and counselling students and staff as per need.
 Any other responsibility assigned by the Principal.
C. PROFESSOR, COLLEGE OF NURSING AND ASSISTANT PROFESSOR
COLLEGE OF NURSING
1. Title: Professor, College of Nursing
Job Summary

The Professor is overall in charge of the department and thereby responsible for administration
teaching activity and guidance of that particular department.
Administration
 Participating in determination of educational purposes and policies.
 Contributes to the development and implementation of the philosophy and purposes of the
educational program.
 Utilizes opportunities through group action to initiate improvement of the educational
program.
 Interprets educational philosophy and policy to others.
 Directs the activities of staff working in the department.
Instruction
 Identifying needs of learners.
 Identifies the needs of the learners in terms of objectives of the program and utilizing records
of previous experience, personal interviews, tests and observations.
 Assists learners and identifying their needs.
 Develops plan for learning experience.
 Participates in the formulation and implementation of the philosophy and objectives program.
 Selects and organizes learning experiences which are in accordance with their objectives.
 Participates in the continuous development and the evaluation of the curriculum.
 Plans within the educational unit, with the nursing services and allied groups.
 Ascertains, selects and organizes facilities, equipment and materials necessary for learning.
Helping the Learners to Acquire
Desirable Attitudes, Knowledge and Skill
 Seeks to create a climate conducive to learning.
 Assists learners in using problem solving techniques.
 Uses varied and appropriate teaching methods effectively.
 Uses incidental and planned opportunities for teaching.
 Encourages learners to assume increasing responsibility for own development.
Evaluating Learner‟s Progress
 Recognizes individual differences in apprasing the learners progress.

 Uses appropriate devices for evaluation.
 Measures and describes quality of performance objectively.
 Helps learners for self evaluation.
 Participates in staff evaluation of learners progress.
Recording and Reporting
 Maintains and uses adequate and accurate records.
 Prepares and channels clear and concise reports.
 Shares information about learner‘s needs and achievements with other concerned with
instruction and guidance.
 Participates in the formulation and maintenance of comprehensive record system.
Investigative Way to improving Teaching
 Measures effectiveness of instruction by use of the
 Increases knowledge and skill in own curriculum area.
 Analyzes and evaluates resources material.
 Devices teaching methods appropriate to objectives and content.
Guidance
 Cooperating in guidance program.
 Shares in planning, developing and using guidance programme.
 Gives guidance within own field of competence.
 Helps the learner with special problems to seek and use additional helps as indicated.
Counseling
 Helps the learner to grow in self – understanding.
 Promotes continuous growth and development towards maturity.
 Continues to develop competence in problem solving process.
 Cooperates in and/or initiates group activities in development and evaluation of studies.
 Utilizes findings of research.
 Makes data available concerning learners and concerning methods of teaching and
evaluation.

1. Assistant Professor, College of Nursing, Title: Assistant Professor, College of
Nursing
Job Summary
The assistant professor usually works under professor and/HOD of the particular department of
specialty and assists him/her in administration, teaching and guidance and counseling and
research activities.
Administration
 Participates in determination of educational purposes and policies.
 Contributes to the development and implementation of the philosophy and purposes of the
total education program.
 Utilizes opportunities through group action to initiate improvement of the total educational
program.
 Interprets educational philosophy and policy to others.
 Directs the activities of staff working in the department.
Instruction
 Identifying the needs of learners.
 Identifies the needs of the learners in terms of the objectives of the program by utilizing
records of previous experience, personal records of previous experience, personal interviews,
tests and observations.
 Assists learners in identifying their needs.
 Develops plan for learning experience.
 Participates in the formulation and implementation of the philosophy and objectives of the
program.
 Selects and organizes learning experience which are in accordance with their objectives.
 Participates in the continue development and evaluation of the curriculum.
 Plans within the educational, with the nursing services and allied groups.
 Ascertains, selects and organizes facilities, equipment and materials necessary for learning.
Helping the Learners to Acquire Desirable Attitudes, Knowledge and skill.
 Seeks to create a climate conductive to learning.
 Assists learners using problem solving techniques.

 Uses varied and appropriate teaching methods effectively.
 Uses incidental and planned opportunities for teaching.
 Encourages learners to assume increasing responsibility for own development.
Evaluative Learning Progress
 Recognize individual differences in appraising the learners progress.
 Uses appropriate devices for evaluation.
 Helps learners for self evaluation.
 Participates in staff evaluation of learners progress.
Recording and Reporting
 Achievement with others concerned with co
 Maintains and uses adequate and accurate records.
 Prepares and channels clear and concise reports.
 Shares information about learner‘s needs and achievement with others concerned with
instruction and guidance.
 Participates in the formulation and maintenance of comprehensive record system.
Investigating Ways Improving Teaching
 Measures effectiveness of instruction by use of appropriate devices.
 Analyzes and evaluates resource material.
 Devices teaching methods appropriate to objectives and content.
Guidance
 Cooperating in guidance program.
 Shares in planning, developing and using guidance program.
 Gives guidance within own field of competence.
 Helps the learners with special problems to seek and use additional help as indicated.
Counseling
 Helps the learner to grow in self understanding.
 Promotes continuous growth and development towards maturity.

Assisting in selection and Promotion of Learners
 Participates in development of criteria for selection and promotion of learners.
Research
 Imitates and participates in studies for the improvement of educational programs.
 Identifies problems in which research is indicated or potentially desirable.
 Cooperates in and/ or initiates group activity in development and evaluation of studies.
 Utilizes findings of research.
 Makes data available concerning learners and concerning methods of teaching and
evaluation.
D. LECTURER, COLLEGE OF NURSING, TITLE: LECTURER, COLLEGE OF
NURSING
Job Summary
He/She works under the direction of the department head and assists him in administration,
instruction and guidance activities.
Instruction
 Identifies the needs of the learners in terms of the program by utilizing the records of
previous experience, personal interviews, tests and observation.
 Assists the learners in identifying their needs.
 Participates in formulation and implementation of the philosophies and objectives of the post.
 Selects and organizes learning experiences which are in accordance with these objectives.
 Plans with the educational unit with nursing service and allied groups.
 Ascertains, selects and organizes facilities equipment and materials necessary for learning.
 Assists the learners in using problem solving process.
 Prepares clear and concise reports.
 Share information about learner‘s needs and achievements with others concerned.
 Measures effectiveness of instruction by use of appropriate devices.
 Devices leaching methods appropriate to objectives and content.

Guidance and Counseling
1. Gives guidance with own field of competence.
2. Helps the learner to grow in self understanding.
Research
 Assist in initiating and participating in studies for the improvement of educational program.
 Identifies the problems in which research is indicated or potentially desirable.
 Make data available concerning learners and concerning methods of teaching and evaluation.
 Cooperate in and/ or initiates group activity in development and evaluation of studies.
 Utilizes the findings of research.
E. SENIOR TUTOR
 Participates in teaching and supervising the courses of undergraduate students.
 Participates in curriculum development , evaluation and revision.
 Guide in research projects for undergraduate students.
 Acts as a Counsellor for staff and students.
 Maintains various records.
 Conducting and participating in department meetings and attending various meetings.
 Participating in Administration activities of department.
F. TUTOR
 Participates in teaching and supervising the courses of undergraduate students.
 Coordinates with the external lecturer for various courses as assigned.
 Participate in the evaluation of students.
 Guide the students in conducting seminars, discussions and presentations etc.
 Maintain students' records.
 Participate in student counselling programmes.
G. CLINICAL INSTRUCTOR
 Demonstrate standards for nursing practice.
 Supervise and teach the students in the clinical fields.
 Participate in evaluation of students.
 Assist the students in conducting health education programme.
 Maintain students' records.
 Participate in the student counselling programmes.
 Participate and promote student welfare activities.

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

DIRECTING
MOTIVATION
INTRODUCTION
Motivation is an action that stimulates an individual to take a course of action, which will
result in an attainment of goals, or satisfaction of certain material or psychological needs of the
individual. Motivation is a powerful tool in the hands of leaders. It can persuade convince and
propel people to act.
DEFINITION
Motivation is defined as…
Motivation is ―an inner impulse or an internal force that initiates and directs the individual to act
in a certain manner to satisfy a need.‖
Motivating force is a need that comes from within an individual, e.g. to make a living, gain status
and respect or to remove a source of frustration (Review of Maslow‘s Hierarchy of Needs).
―Motivation refers to the way in which urges, drives, desires, aspirations, striving or needs direct,
control or explain the behavior of human beings‖. -Dalton E. McFurland,
NEED FOR MOTIVATION:
The nurse manager must realize that nurses have different personalities, work habits, and
what motivates one nurse may not motivate others. Meanwhile, some nurses are skilled,
confident, and capable of self-direction and seem to motivate themselves, while other nurses lack
self-confidence; they do their jobs poorly and have little motivation. The nurse manager is
responsible to motivate the second group and to improve their performance.
Researchers have revealed that job performance is the result of the interaction of two
variables; the ability to perform the task and the amount of motivation.
Job Performance = Ability + Motivation.
Job dissatisfaction:
Job dissatisfaction contributes to higher turnover rates and decreased productivity and
considerable time and money are required to recruit and select a replacement for someone who
leaves the organization, it also takes time to socialize new employee to the organizational
culture, which is expensive time, beside that, other employees will need to carry more load to
cover the needs, and at last the kind of interruptions that results from the loss of this employee.

For all those reasons the manager should be concerned about job satisfaction of employee, and to
do that there is a need to look at the different theories.
TYPES OF MOTIVATORS
1) Intrinsic motivation: Refers to motivation that comes from within the person, driving
him or her to be productive. It is related to a person‘s level of inspiration. The motivation
comes from the pleasure one gets from the task itself or from the sense of satisfaction in
completing or even working on the task rather than from external rewards.
2) Extrinsic motivation: It refers to motivation that comes from outside an individual, i.e.
enhanced by the work environment or external rewards such as money or grades. The
rewards provide a satisfaction and pleasure that the task itself may not provide. An
extrinsically motivated person will work on a task even when they have little interest in it
because of the anticipated satisfaction they will get from the reward. e.g.- reward for a
student would obtain good grade on an assignment or in the class.
TYPES OF MOTIVATION
1) Achievement motivation
It is the drive to peruse and attain goals. An individual with achievement
motivation wishes to achieve objectives and advance up the ladder of success. Hence,
accomplishment is important for his/her own sake and not for the rewards that accompany
it.
2) Affiliation motivation
It is a drive to relate to people on a social basis. Individuals with affiliation
motivation perform work better when they are complimented for their favourable attitude
and co-operation.
3) Competence motivation
It is the drive to be good at something, allowing the individual to perform high
quality work. Competence/skill motivated individuals seek job mastery, take pride in
developing and in using their problem solving skills and strive to be creative when
confronted with obstacles. They learn from their experiences.
4) Power motivation
It is the drive to influence people and change situations. Power motivated people
wish to create an impact on their organisation and are willing to take risks.
5) Attitude motivation
Attitude motivation is how people think and feel. It is their self-confidence, their
belief in themselves and their attitude to life. It is how they feel about the future and how
they react to the past.

6) Incentive motivation
It is where the people are motivated through external rewards. Here, a person or
team reaps a reward from an activity. It is the type of rewards that drive people to work
harder.
7) Fear motivation
Fear motivation coercions a person to act against will. It is instantaneous and gets
the job done more quickly. Fear motivation is helpful in the short run.
Nature of motivation
Unending process: human wants keep changing & increasing.
A psychological concept: deals with the human mind.
Whole individual is motivated: as it is based on psychology of the individual.
Motivation may be financial or non-financial: Financial includes increasing wages,
allowance, bonus, etc.
Motivation can be positive or negative: positive motivation means use of incentives -
financial or non-financial. E.g. of positive motivation: confirmation, pay rise, praise etc.
Negative motivation means emphasizing penalties. It is based on force of fear. Eg.
demotion, termination.
Motivation is goal-oriented behaviour.
Motivation is an internal feeling of an individual. It can‘t be observed directly; we can
observe an individual‘s action and interpret his behavior in terms of underlying motives.
This leaves a wide margin of error. Our interpretation may not reveal the individual‘s true
behavior.
Motivation is a continuous process that produces goal directed behavior. The individual
tries to find alternatives to satisfy his needs.
Motivation is a complex process. Individual may differ in their motivation even though
they are performing the same type of job. For example, if two men are engaged in cutting
stones for constructing a temple, one may be motivated by the amount of wages he gets
and the other by the satisfaction he gets by performing the job.
COMPONENTS OF MOTIVATION
Motivation comprises of three main components:
 Direction
 Effort
 Persistence
We start off by deciding what we want, which is our direction as we know where we want to
go and what we have to achieve. Then we make an effort towards our goal. We start to do things
and we continue our making the efforts for some time and give it everything that we have. Now
comes the part where we have to be persistent with our efforts and keep doing them.

SOURCES OF MOTIVATION
1) Internal or push forces:
 Needs
 For security
 For self-esteem
 For achievement
 For power
 Attitudes
 About self
 About job
 About supervisor
 About organization
 Goals
 Task completion
 Performance level
 Career advancement
2) External or pull forces:
a. Characteristics of the job
 Feedback
 Amount
 Timing
 Work load
 Tasks
 Variety
 Scope
 Discretion
 How job is performed
b. Characteristics of the work situation
 Immediate Social Environment
 Supervisor(s)
 Workgroup members
 Subordinates
 Organizational actions
 Rewards & compensation
 Availability of training
 Pressure for high levels of output
REQUISITES TO MOTIVATE
 We have to be Motivated to Motivate

 Motivation requires a goal
 Motivation once established, does not last if not repeated
 Motivation requires Recognition
 Participation has motivating effect
 Seeing ourselves progressing Motivates us
 Challenge only motivates if you can win
 Everybody has a motivational fuse i.e. everybody can be motivated
 Group belonging motivates
In the initiation, a person starts feeling lacknesses. There is an arousal of need so urgent,
that the bearer has to venture in search to satisfy it. This leads to creation of tension, which urges
the person to forget everything else and cater to the aroused need first. This tension also creates
drives and attitudes regarding the type of satisfaction that is desired. This leads a person to
venture into the search of information. This ultimately leads to evaluation of alternatives where
the best alternative is chosen. After choosing the alternative, an action is taken. Because of the
performance of the activity satisfaction is achieved which than relieves the tension in the
individual.
CREATING A MOTIVATING CLIMATE
As the organization has an impact on intrinsic and extrinsic motivation, it is
important to examine organizational climates or attitudes that influence workers morale and
motivation. Employees want achievement, recognition and feedback, the opportunity to
assume responsibility, a chance for advancement, fairness, good leadership, job security and

acceptance and adequate monetary compensation. All these create a motivating climate and
lead to satisfaction in the work place.
e.g. nurses who experience satisfaction stay where they are, contributing to organization‘s
retention.
STRATEGIES TO CREATE A MOTIVATING CLIMATE
1. Have a clear expectation for workers and communicate effectively.
2. Be fair and consistent when dealing with all employees.
3. Be a firm decision maker.
4. Develop a team work/team spirit.
5. Integrate the staffs needs and wants with the organization‘s interest and purpose.
6. Know the uniqueness of each employee.
7. Remove traditional blocks between the employee and the work to be done.
8. Provide opportunities for growth.
9. Encourage participation in decision-making.
10. Give recognition and credit.
11. Be certain that employees understand the reason behind decisions and actions.
12. Reward desirable behaviour.
13. Allow employees exercise individual judgement as much as possible.
14. Create a trustful and helping relation with employees.
15. Let employees exercise as much control as possible over their work environment.
Leadership Roles and Management Function Associated With Creating A Motivating
Work Climate:-
Leadership Roles:
1. Recognize each worker as unique individual who is motivated by different things.
2. Identifies the individuals and collective value system of the unit and implements a reward
system that is consistent with those values.
3. Listen attentively to individual and collective work values and attitudes to identify unmet
collective needs that can cause dissatisfaction
4. Encourage workers to ―stretch‖ themselves in an effort to promote self growth and self
actualization.
5. Maintains a positive and enthusiastic image as a role model to subordinates in the clinical
setting
6. Encourage mentoring, sponsorship and coaching with subordinates.
7. Develop time and energy to create an environment that is supportive and encouraging to the
discouraging individual.
8. Develop a unit philosophy that recognizes the unique worth of each employee and promote
reward systems that make each employee feel like a winner.

9. Demonstrates through actions and words a belief in subordinates that they desire to meet
organizational goals.
10. Is self- aware regarding own enthusiasm for work and takes steps to motivate self as
necessary.
MEASURES TAKEN BY THE NURSE MANAGER TO FACILITATE NURSES
MOTIVATION: -
The nurse manager while managing the nursing unit will have to choose a combination of the
following measures to facilitate nurses‘ motivation.
1) Act as a Role model (Set a good example):-
a) Set high standards in the units.
b) Maintain a positive attitude towards the work and staff.
c) Be optimistic; in other words, be aware of how difficult the job is and how it can be done.
d) Ask for help when in need.
e) Admit mistakes.
2) Develop and maintain Good Personal Relations:-
a) Use two-way communication.
b) Be friendly, not to criticize staff in front of others and be fair.
c) Keep a sense of humor and avoid getting angry.
d) Try to understand nurses‘ attitudes, likes, dislike their experience, previous training,
problems in their work and needs.
These measures will help in understanding nurses‘ behavior. Understanding is the first step
toward motivating nurses. Trust comes with understanding and it develops slowly based on the
respect and acceptance of the manager. Motivation is based on understanding and trust.
Some guidelines for developing trust:-
a) Apply rules equally and consistently.
b) Avoid favoring some nurses over others, be fair.
c) Share information – show respect for ideas and opinions and confidentiality.
d) Be supportive at all times.
3) Post Each Nurse where she can work best:-
The nurse is more likely to succeed and be motivated if her/his interests and skills are
considered in the assignment. Success is the best motivator.

4) Use a participative style:-
Participation and sharing information will motivate nurses since they feel they are taking part
in decisions. Motivation requires more than physical involvement in a job. It also demands
mental and emotional involvement.
5) Guide, encourage and support continuously:-
Guidance means helping nurses in planning, evaluating their work and in solving work and
personal problems..
Encouragement means helping and reassuring nurses regardless of the type of problems.
Develop a supportive environment by reducing physical stresses associated with the job.
Support means removing obstructions and providing nurses with satisfying work
environment which include personnel and facilities and suitable learning materials needed to do
their job.
Reward Good work:-
a) Give recognition for successful achievement of the job. Praise frequently and informally.
It can be in front of other staff.
b) Reward includes: Pay increase, promotion, training for advancement to a higher level
within a job.
c) Thank you is a type of reward that helps to increase self-confidence.
6) Build team work (Team spirit)
a) Schedule regular meetings.
b) Make nurses feel that their job is important to the success of the team.
c) Integrate the needs and wants of the staff nurses with those of the nursing unit.
d) Think of nurses in the unit as a group and do what is best for them.
7) Provide continuing education:-
Nurses enjoy learning new knowledge and skills or updating the existing knowledge and
skills or taking new responsibilities through continuing education.
SYMPTOMS OF MOTIVATED NURSES:-
1. Show interest, enthusiasm and have a positive attitude.
2. Believe their work is important and work hard.
3. Work well with their supervisors and others.
4. Take part willingly in planning, implementing and evaluating their work.
5. Show responsible behavior.
Strive to find the best way to produce optimal job performance.

THEORIES OF MOTIVATION
The word motivation theory is concerned with the processes that describe why and how
the human behaviour is activated and directed. It is considered as one of the most important areas
of study in the field of organizational behaviour. There are two different categories of motivation
theories- the content theories and the process theories.
A) Content theories of motivation
This is also called as the Need theory. It mainly focuses on the internal factors that
energize and direct human behaviour. Some of the need theories are-
1) Abraham Maslow (1943)
Maslow‘s theory included 5 basic needs in his theory, namely the- The physiological
needs, Safety and security needs, Love needs, self-esteem needs and self-actualization
needs. Maslow suggested that human needs are ordered in a hierarchy from simplex to
complex. Higher level needs do not emerge as motivators until lower needs are satisfied
and a satisfied need no longer motivates behaviour.
 Physiological needs: Food, water, warmth, shelter, sleep, medicine and education, etc.
Once the physiological needs are met, the next level becomes predominant.
 Safety and security needs: These are the needs to be free of physical danger and of the
fear of losing a job, property, food or shelter. It also includes protection against any
emotional harm.
 Social needs: Since people are social beings, they need to belong and be accepted by
others. People try to satisfy their need for affection, acceptance and friendship. After the
lower needs are well satisfied, affiliation or acceptance will emerge as dominant and the
person strives for meaningful social relationship.
 Esteem needs: According to Maslow, once people begin to satisfy their need to belong,
they tend to want to be held in esteem both by themselves and by others. This kind of need
produces such satisfaction as power, prestige status and self-confidence.
 Need for self-actualization: Maslow regards this as the highest need in his hierarchy. It is
the drive to become what one is capable of becoming; it includes growth, achieving one‘s
potential and self-fulfilment. It is to maximize one‘s potential and to accomplish
something.
2) Alderfer ERG theory
ERG theory is similar to Maslow‘s hierarchy of needs. The existence (E) needs are
equivalent to physiological and safety needs; relatedness (R) needs to belongingness,
social and love needs. The growth (G) needs to self-esteem and self actualization- personal
achievement and self-actualization. The major conclusions of this theory are:
In an individual, more than one need may be operative at the same time.

If a higher need goes unsatisfied than the desire to satisfy a lower need intensifies.
When the higher level needs is frustrated; people will regress to the satisfaction of the
lower-level needs. This phenomenon is known as frustration-regression process
3) Frederick Herzberg Two Factor need theory (1966)
Herzberg felt that job satisfaction and dissatisfaction exists on dual scales. Workers are
motivated by two types of needs/factors-
 Needs relating to the work itself called intrinsic/motivation factors (satisfiers):
challenging aspects of the work, achievement, added responsibility, opportunities for
growth and opportunities for advancement
 Needs relating to working conditions called extrinsic/hygiene factors (dissatisfiers):
salary, status, working conditions, quality of supervision, job security and agency policies.
According to Herzberg, the hygiene factors must be maintained in quantity and quality to
prevent dissatisfaction. They become dissatisfiers when not equitably administered,
causing low performance and negative attitudes.
The motivation factors create opportunities for high satisfaction, high motivation and
high performance. Absence of motivation factors causes a lack of job satisfaction.
4) David McClelland(1961)
David McClelland has developed a theory on three types of motivating needs:
 Need for Power
 Need for Affiliation
 Need for Achievement
People with high need for power are inclined towards influence and control. They like to
be at the center and are good orators. They are demanding in nature, forceful in manners and
ambitious in life. They can be motivated to perform if they are given key positions or power
positions.
In the second category are the people who are social in nature. They try to affiliate
themselves with individuals and groups. They are driven by love and faith. They like to build
a friendly environment around themselves. Social recognition and affiliation with others
provides them motivation.
People in the third category are driven by the challenge of success and the fear of failure.
Their need for achievement is moderate and they set for themselves moderately difficult tasks.
They are analytical in nature and take calculated risks. Such people are motivated to perform
when they see atleast some chances of success.
McClelland observed that with the advancement in hierarchy the need for power and
achievement increased rather than Affiliation. He also observed that people who were at the
top, later ceased to be motivated by this drives.

5) McGregor‟s Theory X and Theory Y
Douglas McGregor proposed two different motivational theories- theory X and theory Y.
He states that people inside the organization can be managed in two ways. The first is
basically negative, which falls under the category X and the other is positive, which falls
under the category Y.
Assumptions of theory X:
 Employees inherently do not like work and whenever possible, will attempt to avoid it.
 Because employees dislike work, they have to be forced, coerced or threatened with
punishment to achieve goals.
 Employees avoid responsibilities and do not work until formal directions are issued.
 Most workers place a greater importance on security over all other factors and display little
ambition.
Assumptions of theory Y:
 Physical and mental effort at work is as natural as rest or play.
 People do exercise self-control and self-direction and if they are committed to those goals.
 Average human beings are willing to take responsibility and exercise imagination,
ingenuity and creativity in solving the problems of the organization.
 That the way the things are organized, the average human beings brainpower is only partly
used.
On analysis of the assumptions it can be detected that theory X assumes that lower-order
needs dominate individuals and theory Y assumes that higher-order needs dominate
individuals. An organization that is run on Theory X lines tends to be authoritarian in nature-
―power to enforce obedience‖ and the ―right to command.‖ In contrast Theory Y
organizations can be described as ―participative‖, where the aims of the organization and of
the individuals in it are integrated; individuals can achieve their own goals best by directing
their efforts towards the success of the organization
B) Process theories of motivation
Process theories of motivation provide an opportunity to understand thought processes
that influence behaviour. The major process theories are- Vroom‘s expectancy theory, goal-
setting theory and reinforcement theory.
1) Reinforcement theory
B.F. Skinner‘s theory (1969) suggests that an employee‘s work motivation is controlled
by conditions in the external environment, that is, by designing the environment properly,
individuals can be motivated. Instead of considering internal factors like impressions,
feelings, attitudes and other cognitive behaviour, individuals are directed by what happens in
the environment external to them. Skinner states that work environment should be made
suitable to the individuals and that punishment actually leads to frustration and de-

motivation. Hence, the only way to motivate is to keep on making positive changes in the
external environment of the organization.
Positive behaviour should be reinforced or rewarded as this increase the strength of a
response or induces its repetition. Reinforcers tend to weaken over time and new ones have
to be developed.
Negative reinforcement occurs when desired behaviour occurs to avoid negative
consequences of punishment. Punishment creates negative attitude and can increase costs.
2) Expectancy theory of Vroom
This theory postulates that most behaviours are voluntarily controlled by a person and are
therefore motivated. It focuses on people‘s effort-performance expectancy, or a person‘s
belief that a chance exists for a certain effort to lead to a particular level of performance. This
theory states that motivation depends on three variables-
 Attractiveness: the person sees the outcome as desirable.
 Performance-reward linkage: the person perceives that a desired outcome will result
from a certain degree of performance.
 Effort-performance: the person believes that a certain amount of effort will lead to
performance.
3) J. Stacy Adams Equity theory
Third process theory and focuses on fair treatment. Persons believe that they are being
treated with equity when the ratio of their efforts to rewards equals those of others. Equity
can be achieved or restored by changing outputs, attitudes, the reference person, inputs or
outputs of the reference person or the situation. People have a tendency to use subjective
judgment to balance the outcomes and inputs in the relationship for comparisons between
different individuals. Accordingly,

4) Jeremy Bentham‟s “The Carrot and the Stick Approach”
English philosopher, Jeremy Bentham ideas developed his ideas in the early years of
the Industrial Revolution, around 1800. Bentham‘s view was that all people are self-
interested and are motivated by the desire to avoid pain and find pleasure. Any worker will
work only if the reward is big enough, or the punishment sufficiently unpleasant. With this
view, the ‗carrot and stick‟ approach was built into the philosophies of the age.
This metaphor relates to the use of rewards and penalties in order to induce desired
behaviour. It came from the old story that to make a donkey move, one must put a carrot in
front of him or dab him with a stick from behind. Despite all the research on the theories of
motivation, reward and punishment are still considered strong motivators.
In almost all theories of motivation, the inducements of some kind of ‗carrot‘ are
recognized. Often this is money in the form of pay or bonuses. Even though money is not the
only motivating force, it has been and will continue to be an important one. The trouble with
the money ‗carrot‘ approach is that too often everyone gets a carrot, regardless of
performance through such practices as salary increase and promotion by seniority, automatic
‗merit‘ increases, and executive bonuses not based on individual manager performance.
The ‗stick‘, in the form of fear–fear of loss of job, loss of income, reduction of bonus,
demotion, or some other penalty has been and continues to be a strong motivator. It often
gives rise to defensive or retaliatory behaviour, such as union organization, poor-quality

work, executive indifferences, and failure of a manager to take any risks in decision-making
or even dishonesty. However, fear of penalty cannot be overlooked. Whether managers are
first-level supervisors or chief executives, the power of their position to give or with hold
rewards or impose penalties of various kinds gives them an ability to control, to a very great
extent, the economic and social well-being of their subordinates
5) Goal-setting theory of Edwin Locke
This theory is based on goals as determinants of behaviour. The theory states that when
the goals to be achieved are set at a higher standard than, employees are motivated to
perform better and put in maximum effort. The more specific the goals, the better the results
produced. The goals must be achievable, and their difficulty level must be increased only to
the ceiling to which the person will commit. Goal clarity and accurate feedback increases
security. It revolves around the concept of ―Self-efficacy‖ i.e. individual‘s belief that he or
she is capable of performing a hard task.
6) Arousal/ Cognitive Evaluation theory
Focuses on internal processes that mediate the effects of conditions of work on performance.
This theory states, a shift from external rewards to internal rewards results into motivation. It
believes that even after the stoppage of external stimulus, internal stimulus survives. It relates
to the pay structure in the organization. Instead of treating external factors like pay,
incentives, promotion etc and internal factors like interests, drives, responsibility etc,
separately, they should be treated as contemporary to each other. The cognition is to be such
that even when external motivators are not there the internal motivation continues.
7) Attitude theory
Focuses on favorable attitudes of job satisfaction and job involvement leading to high
performance.
8) Attrition/self-efficacy theory
Focuses on explanations for events or behaviour. Perceptions of self efficacy and self
esteem affect performance.
Motivational theories for Better Nursing Management
The needs of an individual are important motivators. These make the person work with
enthusiasm & interest. The significant individual needs are:
* Need for Power: Which results in a strong desire to influence staff, stimulate them to work,
making them achieve positions of leadership e.g. making the nursing supervisor wholly
responsible to take care of whole ward.

* The need for achievement results in a desire to do something better or more efficiently than
others. People with a high need of achievement have an intense desire for success & equally
intense fear of failure. They want to be challenged, prefer to assume personal responsibility to
get work done and like to work for long hours. Training and orientation (refresher) course
increase this need. All the staff working in a particular area should be given equal chance to
attend the refresher courses related to that particular area.
* Need for affiliation: - Some people derive pleasure from being loved and tend to avoid the pain
of being rejected by social group. They enjoy social relationships, intimacy, empathise and help
others in trouble. There is close intimacy when a staff nurse is allowed to plan and decide patient
care along with ward supervisor.
In order to satisfy the employees, a manger can also use Maslow's Motivation Theory in these
ways:
* Improving physical working conditions to satisfy needs e.g. grilled door and escorts to secure
the nursing staff at night, providing rest rooms for lunch and dinner.
* Increasing the level of training, development and skill in order to meet the self esteem needs
e.g. uniform, leave facilities, vacation to nursing students. If these facilities are inadequate it
harms their self esteem.
* Having congenial social group and peer group interaction to fulfill affiliation needs.
* Placing the person in position which match their self concept to fulfill the self actualization
need.
Job Design
Job design is another motivator to satisfy, signify and give value to employees encouraging them
to perform well.
Koul Jyoti conducted a study on job satisfaction of 126 staff nurses of different hospitals in J&K
State and showed that only 8% were highly satisfied. Maximum satisfaction was found for the
work itself and with the competency of supervision. The areas of best satisfaction were
concerned with material rewards and individual agency. The older age group and experienced
persons were found more satisfied.
Work Environment
There are many conditions in the environment which could possibly effect the motivation of
staff. It is seen by Behaviour Modification Theorist that employees perform positively if
environment is favorable which is made by pay/ reward policies, democratic leadership style,
peer group interaction etc.

To effect the performance of employees, their input (e.g. efforts, training, experience, skill,
education, seniority) should be equitable to their output e.g. pay, rights, benefits, job-status,
status symbol's (vacation, clothing, satisfactory superior).
The employees feel inequity if unrewarded or if given undesirable placement. The employees
always respond to the environment & these responses influence their behaviour. A nursing
Manager can accomplish this by using following motivational techniques.
* Positive Reinforcement: Annual reward for better performance in the form of money,
recognition, praise, promotion etc. Give reward to the most clean and best patient care ward on
Annual days.
* Avoidance Learning: Some staff nurses improve their behaviour in order to avoid criticism of
Nursing. Superintendent or to avoid any disciplinary action against her.
* Punishment: Nursing Superintendent, for example, can withhold reward or promotion so as to
change the behaviour of staff. Scolding in front of others or humiliating should be avoided.
* Be sure to tell a person she / he is doing wrong and what type of behaviour is desired e.g. RT
feeding given with force by use of piston should be corrected and demonstrated so that goes with
gravity.
* Making the staff participate in different activities which give them affiliation, acceptance and
recognition, e.g. in conferences, Nurses'-Day, Hospital Annual Day etc.
* Giving feeling of personal responsibility or keeping interactions. The newly appointed staff
should be left independent but be observed closely.
* Warmth, support and identity motivate the staff to perform better. Every staff member has her
own potential. Respect their individual capabilities. Don't scold if she is performing badly in
other field. Let her develop potential gradually.
PROBLEMS IN APPLYING MOTIVATION THEORIES
This article presents a non-exhaustive account of some problems in applying motivational
theories to the actual conditions of the workplace. It should give readers a general idea of some
of the less effective and more effective methods for motivating employees.
 Reward vs. Punishment
It is generally conceded that while rewards can offer workers a variety of incentives which can
not only motivate them to work harder but also produce feelings of good-will towards
management, punishment often functions only to cultivate feelings of hostility between managers
and workers, which can directly and negatively effect productivity.

 Personal Satisfaction vs. Financial Satisfaction
One of the most successful ways of fostering a productive and motivated workforce is to ensure
that workers are satisfied with their jobs, not just with their pay. It is interesting to note that
people are quite often more concerned with how much they like their job than they are with how
much money they actually make. Making employees feel important in the workplace can make
them feel like part of the team, which makes them feel personally invested in the health of a
business.
 Persuasion vs. Coersion
By appealing to a worker's sentiments and reason a manager can persuade a worker to take
initiative and build their morale, which are internal drivers of motivation. However, by appealing
to fear and coercion a manager may actually cause a decline in internal motivation, leaving
instead feelings of hostility or anxiety which can negatively effect production.
 Knowing Your Workers
Understanding what is important to an individual is endemic for understanding how to motivate
that person effectively. Is an individual motivated by the opportunity to develop professionally or
by the possibility of making more money? Does he or she want more responsibility or more
clearly defined responsibilities? Is it important that he or she see the end-product of their work or
not? Usually, employees are not motivated by just one thing, which can make it difficult to
determine the best strategy for motivation.
 Involvement
One of the top things leading workers to feel productive and motivated in the workplace is
knowing that they have a good management team. When people feel close to their managers they
oftentimes do not want to disappoint, and may even feel the desire to win approval. By being
invested in workers, managers can get workers to feel reciprocally invested in their workplace
and their work. Fostering motivation in the workplace is first and foremost about fostering good
management practices.
METHODS FOR MOTIVATING EMPLOYEES
1. Job rotation: This is also known as cross training. It can be effective for employees that
perform repetitive tasks in the job. This allows the employees to learn new skills by
shifting them from one task to another.
2. Job enlargement: is a motivation technique used for employees that perform a very few
and simple tasks. It increases the number and variety of tasks that the employee performs,
resulting in a feeling of importance
3. Job enrichment: this method increases the employees control over the work being
performed. It allows the employees to control the planning, execution and evaluation of
their own work, resulting in freedom, independence and added responsibility.

4. Flexible time: this allows the employees to choose their own work schedule to a certain
extend.
5. Job sharing: a less common method but very effective in preventing boredom. It allows
employees to share two different jobs
6. Employee involvement: people want to feel like they are a part of something. Letting the
employees to be more active in decision-making related to their job makes them feel
valued and important to the company and increases job motivation.
7. Variable pay programs: merit based pay, bonuses, gain sharing, and stock ownership
plans are some good motivators for employees. They should be offered as an incentive or
reward for outstanding performance.
COMMUNICATION MEANING, PROCESS, PRINCIPLES AND
TECHNIQUES, TYPES, ADVANTAGES, DISADVANTAGES,
INTRODUCTION:
Nurse Managers are required to be aware of the techniques that can help them ensure
effective management of educational/service unit. Communication is one of the most important
activities in the nursing management. It is the foundation upon which the manager achieves
organizational objectives.
MEANING OF COMMUNICATION:
Communication is a process of change. In order to achieve the desired result, the
communication necessarily is effective and purposive.
DEFINITION OF COMMUNICATION:
Communication is a process in which a message is transferred from one person to other
person through a suitable media and the intended message is received and understood by the
receiver.
IMPORTANCE OF COMMUNICATION:
Promotes motivation:
Communication promotes motivation by informing and clarifying the employees about the
task to be done, the manner they are performing the task, and how to improve their performance
if it is not up to the mark.

Source of information:
Communication is a source of information to the organizational members for decision-
making process as it helps identifying and assessing alternative course of actions.
Altering 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. The channel
can be a piece of paper, a communications medium such as radio, or it can be an email. The
channel is the path of the communication from sender to receiver. An email can use the Internet
as a channel.
Receiver:
The Receiver is the party receiving the communication. The party uses the channel to get
the communication from the transmitter. A receiver can be a television set, a computer, or a
piece of paper depending on the channel used for the communication.
Decoding:
Decoding is the process where the message is interpreted for its content. It also means the
receiver thinks about the message's content and internalizes the message. This step of the process
is where the receiver compares the message to prior experiences or external stimuli.
Feedback:
Feedback is the final step in the communications process. This step conveys to the
transmitter that the message is understood by the receiver. The receiver formats an appropriate
reply to the first communication based on the channel and sends it to the transmitter of the
original message.

CHARACTERISTICS OF COMMUNICATION:
1. Clarity:
* One of the most essential characteristics of an impressive communication is "Clarity".
* Use Simple and Sound words, so that listeners can grab it easily.
* Be clear in your thoughts, jumbled and confused mind cannot deliver a good and clear saying.
* Avoid using any technical terms, try to explain in laymen language.
* Use Examples to explain & support complex scenarios.
* Work a little bit on your accent and pronunciation.
2. Aim or Goal:
* At every stage of your talk/communication, don't forget your "Aim or Goal".
* Try to deduce an acceptable stuff by judging Pros & Cons impartially.
* Communicate with a broad and practical mind.
3. Precision:
* Be precise & exact in your approach. Neither be too deep nor be too short.
* Include some good facts acknowledging your topic.
4. Avoid Repeatability, unless required so.
5. Linkage :
* Try to maintain a logic link between your sayings.
* Don't put two opposite faces of coin at a same time.
* Deliver in a structured & planned way.
6. Globalization and Localization:
* Try to explain the broader aspects but not on the cost of local values.
* Aggregation of local values should result into global and broader aspects.
7. Style of Expressing:
* Control various speech parameters like pitch, tone, intensity etc. according to the environment.
* Don't be too fast or too slow.
* Light Humor at the right time is always accepted.
* Look straight & forward. Keep a light smile on your face.

* Avoid using words that show arrogance.
* Feel what you say.
* Avoid being too formal, be natural and practical.
8. Know and Analyze the audiences.
9. Do a good Homework.
10. Dress properly:
* 25% confidence and 25% Respect from audiences comes automatically, if you have dressed up
well.
* Be neat, clean, ironed and polished irrespective of the fact that you have dressed up formally or
informally.
* Do a good hair styling; avoid any casual or unethical looks.
PROCESS OF COMMUNICATION:
All of the 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:
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:
 Communication should be conviction.
 Communication should be appropriate to situation.
 Communication should have objective and purposes.
 Communication should promote total achievement of purposes.
 Communication should represent the personality and individuality of the communication.
 Communication involves special preparation.
 Communication should be oriented to the interest and needs of the receiver.
 Communication through personal contact.
 Communication should seek attention.
 Communication should be familiar.

TECHNIQUES TO IMPROVE THE COMMUNICATION:
 Listening
 Broad openings
 Restating
 Clarification
 Reflection
 Focusing
 Sharing perceptions
 Silence
 Humor
 Informing
 Suggesting
Listening:
An active process of receiving information. The complete attention of the nurse is required
and there should be no preoccupation with oneself. Listening is a sign of respect for the person
who is talking and a powerful reinforce of relationships. It allows the patients to talk more,
without which the relationship cannot progress.
Broad openings:
These encourage the patient to select topics for discussion, and indicate that nurse is there,
listening to him and following him. For e.g. questions such as what shall we discuss today? ―can
you tell me more about that‖? ―And then what happened?‖ from the part of the nurse encourages
the patient to talk.
Restating:
The nurse repeats to the patient the main thought he has expressed. it indicates that the
nurses is listening. It also brings attention to something important.
Clarification:
The 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
On the basis of relationship on the basis of flow on the basis of
expression
Formal informal vertical horizontal verbal non verbal
Downward upward oral written.
ONE-WAY V/S TWO WAY COMMUNICATION:
One-way communication:
The flow of communication is one way from the communicator to the audience. Example
receive method.
Drawbacks are:
 Knowledge is imposed.
 Learning is authoritative.
 Little audience participation.
 No feedback.
 Does not influence human behavior.
Two way communication:
In this both the communicators and the audience take place. The process of communication
is active and democratic. It is more likely to influence behavior than one way communication.

FORMAL V/S INFORMAL COMMUNICATION:
Communication has been classified into formal (follows lines of authority) and informal
(group line) communication.
Formal communication:
It is officially organized channels of communication and it is delayed communication. It is
generally used for all practices purposes. This authoritative, specific, accurate and reaches
everybody. The medium of formal communication may be department meeting, conferences,
telephone calls, interviews, circular etc.
Informal network:
Gossip circles such as friends internet group, like minded people and casual groups.
Communication is very faster here. The informal channels may be more active. It follows
grapewine route. It may be a fact but more in native of rumor. It does not reach every one
informal communications are quite fast and spontaneous.
Physiological communication:
It is a stimulus received by the body immediately the brain receives the information and
transmits to the respective organs through the nervous, where it has to be passed.
Psychic communication:
Extra sensory perception occurs, i.e something which will occur in future. The person
pertains and predicts that in advance is called psychic communication.
Serial communication:
Person to person the message will be passed line a chain. Sender passes the message to one
person, then that receiver passes information to other and so on.
Symbolic communication:
Good communication requires awareness of symbolic communication, the verbal and
nonverbal symbolism used by others to convey meaning.
Visual communication:
The visual forma of communication comprise charts and graphs, pictograms, tables, maps,
posters etc.

VERBAL V/S NONVERBAL COMMUNICATION:
The traditional way of communication has been by word of mouth language is the chief
vehicle of communication. Through it, one can interact with other can be passes through. Direct
verbal communication by word of mouth may be loaded with hidden meanings. The important
aspects if verbal communications are as follows.
Vocabulary:
Communication is unsuccessful if senders and receivers cannot translate each others word
and phrases when a nurses cases for a client who speaks another language an interpret may be
necessary.
Denotative and connotative meaning:
A single word has several meaning. Individuals who use a common language share the
denotative meaning, baseball has the same meaning for everyone who speaks English, but code
denotes cardiac arrest primarily to health care providers.
The connotative meaning is the shade or interpretation of a 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 behavioural due from the receiver.
Intonation:
Tone of voice dramatically affects a meaning. The nurse must be aware of voice line to
avoid sending unintended messages.
Clarity and brevity:
Effective communication is simple, brief and direct. Clarity is achieved by speaking
slowly, enunciating clearly and using, repeating important parts of a message also clarifies
communication.
Brevity is achieved by using short sentences and words that expresses an idea simply
and directly.

Credibility:
Credibility means worthiness of belief, trustworthiness and reliability.
Time and relevance:
Timing is critical in communication. Even though message is clear, poor timing can
prevent it from being effective. Often the best time for interaction is when a client express an
interest in communication. If message are relevant of important to the situation at hand, they are
more effective.
Oral communication:
Oral communication is a transmitting message orally either by meeting the person through
artificial media of communication such as telephone and intercom systems.
Written communication:
It is transmitting message in writing. Written communication can be followed when a
record of communication is necessary.
NON VERBAL COMMUNICATION:
Communication can occur even without word. Non-verbal communication is message
transmission through body language without using words. It includes bodily movements,
positive, facial expression. Silence is non verbal communication. It can speak louder than words.
Personal appearance:
Nurse learn to develop a general impression of clients health and emotion status through
appearance and clients develop a general expression of the 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:
 It is face to face system and hence can be clarified.
 There is an opportunity to ask questions, exchange ideas and clarify meaning.
 It can develop a friendly and co-operative spirit.
 It is easy and quick.
 It is flexible and hence effective.
 It has permanent record for future reference.
 It is less likely to be misunderstood.
 It will have adequate coverage and accuracy.
 Suitable for communicating lengthy messages.
 It is an authoritative communication.
DISADVANTAGES OF COMMUNICATION:
Oral communication:
 The spoken words may be misunderstood.
 The facial expression and tone of voice of the communicator may misled the receiver.
 Not suitable for lengthy communication.
 It requires the art of effective specificity
 It has no record for future reference.

 It requires skill and education for understanding.
 It is also one way communication and hence may not be effective.
 There is no opportunity for the subordinates to ask questions and exchange ideas.
 It may not communicate all aspects.
STRATEGIES OF COMMUNICATION:
Think before you speak:
Think about the purpose of your communication. What do you hope to accomplish with
your words or actions? Are your comments about something you are responsible for doing, such
as parenting or managing someone or about an activity you are doing together with the other
person? Or, is it an opinion about something that is not your business, maybe even something
that the other person has already asked you to stop discussing?
"Before you speak, ask yourself: Is it kind? Is it necessary? Is it true? Does it improve
on the silence?" . Also, think about the structure of your communication.
Listening:
The most effective leaders know when to stop talking and start listening. This is especially
important in three particular situations: when emotions are high, in team situations and when
employees are sharing ideas.
First, listening is crucial when emotions are high. Extreme emotions, such as anger, resentment
and excitement, warrant attention from a personal and a business standpoint. On a personal level,
people feel acknowledged when others validate their feelings. Managers who ignore feelings can
create distance between themselves and their employees, eroding the relationship and ultimately
affecting the working environment.
Questioning:
Many leaders need information but aren't sure how to get it. Similarly, their employees may have
information but don't know how to impart it. Managers can open the lines of communication by
asking good questions. Note that different kinds of questions yield different kinds of results.
Here is a short primer on questioning:
* Closed questions are those that elicit yes/no answers. These are beneficial when a manager
simply needs to check the status of an issue. Has the report been completed? Do you know what
to do? Can you get that to me by Friday? These are examples of closed questions that are
perfectly appropriate in the right situations.
* Open questions are those that elicit longer responses. They are useful almost anytime a
manager wants more than a yes/no answer--for instance, when seeking input from others,

looking for information about a particular topic or exploring a problem. What do you think
would be the best way to go about this? How are you doing on that project? What went wrong?
These kinds of questions give others the chance to give all of the information they have and to
avoid the innumerable consequences that can come when leaders make assumptions without
becoming well-informed.
* Personal questions have a special role in leadership. Inappropriate personal questions can
alienate employees. Asking direct reports if they are dating anyone or why they haven't bought a
house can be perceived as prying, even if the questions are well intended. Appropriate personal
questions, however, can create a sense of camaraderie between employee and boss.
Using Discretion:
Knowing when not to speak as a leader is just as important as speaking. Managers must
understand that the moment they don a new title, they become a leader--one whom others look to
for guidance, direction and even protection. Good leaders adopt a policy of discretion, if not
confidentiality, with their employees. Only then can they develop the trust that is so vital to
productivity.
Confidential situations may arise in a number of areas, personal and professional. Here are some
topics that may warrant discretion:
* An employee is having a direct conflict with another employee.
* An employee is concerned about another employee's conduct.
* An employee's performance has dropped substantially.
* An employee has a health issue or personal problem.
* An employee wants genuine advice on how to excel but doesn't want to be seen as cozying up
to the boss.
Directing
Notice that directing comes last on the list of communication strategies. It may not be the least
important, but it is definitely one to use less often. Many managers direct their employees
because they believe it's the only way to get things done. It is not.
But directing has its place. Directing means giving directions clearly and unequivocally, such
that people know exactly what to do and when. It is best used in times of confusion, or when
efficiency is the most important goal. Although it can be effective, directing also can lead to
complacency on the part of employees who may adopt an "I just do what they tell me" attitude.
Use it sparingly

CHANNELS OF MANAGERIAL COMMUNICATION:
There are four levels of managerial communication:
Downward communication.
Upward communication.
Lateral communication.
Diagonal communication.
Downward communication:
This is the traditional and most used communication, where the management gives orders to
the subordinates at the bottom level to carry out the orders as per the organizational hierarchy.
All the written and oral communication which are carried out from the top management
to the employees by various means in order that the employees carry out their duties in the
organization in achieving its goals.
Upward communication:
Upward communication in the management levels from staff, lower and middle
management personnel and continuous up to the organizational hierarchy. It provides a means
for motivating satisfying personnel by encouraging employees input.
Management
Subordinates
Subordinates
Management
Subordinates
Subordinates

Lateral communication:
Lateral or horizontal communication is referred to the communication which takes place
between the departments or personnel on the same level of the hierarchy.
Diagonal communication:
Diagonal communication occurs between two individuals or departments that are not on
the same level of the hierarchy.
Laboratory x-ray laundry
CSSD
Common means are: unit in-charge ordering diet for the patient, X-ray department informs
appointments given to patients in a particular unit, etc.
Management
Subordinates
Subordinates
Management
Nursing department
Medical department
departm departmen
Pediatrics
Surgical
Medical
Pathology
Surgical unit
Medical unit

BARRIERS OF COMMUNICATION:
Communication barriers create problem of misunderstanding and conflict between men who
live together in the same community, who work together on the same job and even between men
living in the distinct parts of the world who have never seen one another.
Following are the main barriers to overcome:
1. Due to organization structure:
The breakdown or distribution in communication sometimes arises due to:
1. Several layers of management;
2. Long lines of communication;
3. Special distance of subordinates from top management;
4. Lack of instructions for passing information to the subordinates;
5. Heavy pressures of work at certain levels of authority.
2. Due to status and position:
1. The attitude exhibited by the supervisor are sometimes a hurdle in two way
communication. One common illustration is non listening habit. A supervisor may guard
information for:
a. consideration of prestige, ego and strategy.
b. underrating the understanding and intelligence of subordinates.
2. Prejudice among the supervisors and subordinates may stand in the way of a free flow of
information and understanding.
3. The supervisors particularly at the middle level may sometimes like to be in good books of
top management by:
a. not seeking clarification on instructions which are subject to different interpretations; and
b. acting as screen for passing only such information which may please the boss.
3. semantic barriers:
Semantic is the science of meaning. Words seldom mean same thing to two person. Symbols
or
Words usually have a variety of meaning arid the sender and the receiver have to choose
one meaning from among many. If both of them choose the same meaning, communication will
be perfect. But this is not so always because of differences in formal education and specific

situations of the people. Strictly one cannot convey meaning, only one can do it to convey words.
But the same words may suggest quite different meaning to different people, e.g. ‗profits‘ may
mean to management efficiency and growth, whereas to employees it may suggest excess funds
piled up through paying inadequate wages.
4. Tendency to evaluate:
A major barrier to the communication is the natural tendency to judge the statement of the
person or other group. Every one tries to evaluate others from his own point of view or
experience. Communication requires an open mind and willingness to see things through the
eyes of others. Some intelligent brains even complimented him on his excellent style of
imagination.
Heightened emotions:
Barriers may also arise but in specific situations, e.g. emotional reactions, physical
conditions like noise or insufficient light, past experience, etc. when emotions are strong, it is
most difficult to know the frame of mind of the other person or group.
Lack of ability to communicate:
All persons do not have the skill to communicate. Skill in communication may come
naturally to some, but an average man may need some sort of training and practice by way of
interviewing and public speaking, etc.
Inattention:
The simple failure to read bulletins, notices, minutes and reports is a common feature.
With regard to failure to listen to oral communications, it has been seen that non listeners are
often turned off while they are preoccupied with other affairs, like their family problems.
Unclarified assumptions:
This can be clarified by an illustration. A customer send a message that he will visit a
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
 The sell theory
 The minimet theory
The decibal theory:
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.

4. PUBLIC RELATIONS
INTRODUCTION:
Public relation is an essential and integrated component of public policy or service. The
professional public relation activity will ensure the benefit to the citizens, for whom the policies or
services are meant for. An effective public relations can create and build up the image of an individual or
an organization or a nation. At the time of adverse publicity or when the organization is under crisis an
effective public relations can remove the "misunderstanding" and can create mutual understanding
between the organization and the public.
OBJECTIVES:
On completion of the seminar the participant will be able to:
 Explain public relation concept and its importance.
 Explain the importance of organizational image.
 Develop public relation programmes in the hospital.
 Explain about the methods of maintaining public relation in the community.
 Tell about the public relation in an educational institution.
 Understand the role of dean in public relation.
TERMINOLOGIES:
(1) Fortitude: Happening by chance.
(2) Composite: Made up of different part or material.
(3) Humility: Quality of being humble
(4) Persuasive: Able to give good reason for doing something.
DEFINITION OF PUBLIC RELATION:
―Public relation are knowing what the public expects and explaining how administration is
meeting these desires….‖. - John Millet
―Public relation in Government is the composit of all the primary and secondary contacts
between the bureaucracy and citizens and all the interactions of influences and attitudes established in
these contracts‖. - J.L MeCamy,
―Public relation means the development of cordial, equitable and therefore mutually profitable
relations between a business industry organization and the public it serves‖. - W.T. Parry‘
―Public relations are the process whereby an organization analyses the needs and desires of all
interested parties in order to conduct itself more responsively towards them‖. - Rex Harlow,

NEED OF PUBLIC RELATION:
Not many years ago, management decisions took no consideration of public attitudes but today
management cannot ignore the views of employees, and the community in making – policy decisions. It
has been estimated that eighty per cent of the problems confronting management have public relations
implications. Management has to foresee the impact of policy decisions on the opinion of the public.
There is normally four distinct reasons for ever increasing necessity of public relations:
(1) Increased governmental activities.
(2) Population explosion creating communication problems.
(3) Increased educational standards resulting in rise in expectations.
(4) Progress in communication techniques.
Well-executed public relations will
 Increase visibility for the hospital, employees, programs and services.
 Position the hospital as a health care leader and authority within the community or
region.
 Expand awareness of the hospital‘s entire range of programs and services.
 Enhance the hospital‘s image.
 Aid in recruitment and retention of employees.
 Support efforts to raise funds for new programs and services or assist with the passage
of levies and bonds.
 Act as a foundation when negative news about the hospital occurs.
 Boost employee morale.
Functions of public relation:
 Public Relation is establishing the relationship among the two groups
(organization and public).
 Art or Science of developing reciprocal understanding and goodwill.
 It analyses the public perception & attitude, identifies the organization policy with
public interest and then executes the programmes for communication with the
public.
ELEMENTS OF PUBLIC RELATIONS:
A planned effort or management function.
The relationship between an organization and its publics.
Evaluation of public attitudes and opinions.
An 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 employee education,
employee award programs and recognitions, new-hire press releases and newsletters to name a few.
Community relations:
It is the function of actively planning and participating with and within a community for the benefit
of the community and the hospital. Tactics within this category include community events, volunteer
activities and co-sponsorship opportunities with other community organizations. Community relations
may also include fundraising and development activities.
Government relations:
It is a function of relating to government officials and agencies about issues that impact the hospital
and its audiences. Hill climb events in Olympia, letter writing campaigns, and op-ed placements in the
newspaper are often part of government relations.
Media relations:
It is often considered synonymous with public relations, is the function of working with the media
to communicate news. Media relations can be active – seeking positive publicity for a newsworthy topic at
the hospital – or reactive – responding to a news inquiry about a positive or negative story of interest to
the media and its readers or viewers.
PUBLIC RELATION PLAN FOR A HOSPITAL:
Every hospital should have a current public relations plan that outlines goals and desired
outcomes for a period of three to five years. Once a general PR plan is in place, periodic planning and
updating is critical. The plan and its updates will not only help guide employees responsible for public
relations work, but will result in an effective tool to communicate with the board and other staff.
Following are the key elements of an effective PR plan:
Goals:
Public relations goals help direct the strategies and tactics in future public relations endeavors. The
goals should clearly support hospital mission statement. While a mission statement may include what the
hospital wants to accomplish, a public relations goal should be focused on what you want the public to
think and know about the hospital
Examples:
 General Washington Hospital is a community leader committed to providing high quality
health care for the people of Carter, Key and Kangley counties.
 Highland Valley Medical Center provides superior primary care services in a comfortable, safe
environment for people in the Highland Valley region.
 Ivy River Hospital, with its friendly, helpful physicians and nurses, is the most dependable
health care service provider in the state.

Objectives:
Objectives help determine specific outcomes from your public relations efforts. Objectives should be
clear and concise, and include timing.
Examples:
 Increase awareness of the technology and medical advances used at the hospital within Evergreen
County over the next six months.
 Build the reputation of the hospital in the next three to four years as a cornerstone of the
community that provides health care services, jobs and community leadership.
 Encourage renewed interest in specialty hospital services such as childbirth classes over the next
two years.
Target Audiences:
Detail the groups of people that are important to inform or influence, and why.
Examples:
 Patients: They purchase health care services and generate revenue for the hospital.
 Physicians: They use hospital facilities and generate revenue for the hospital. They control where
patients go for care in the hospital or outside of the community.
 Media: They write both positive and negative stories about the hospital, its staff and services. They
have considerable influence and access to all of the 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.
 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. 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.

Operating facility:
The operating efficiency in an organization like, hospital is the outcome of its soundness of
objectives, policies, procedures, programmes and standing orders. The clear cut policy and procedure in
writing and their periodic promulgation to the staff specially, clear order regarding organizational
structure, defining their duties, authorities and accountability of the staff.
The speciality clinics:
The speciality clinics if located proximally are one of the concentrated areas of the OPD services. It
will facilitate mutual interaction of the functionaries and effective protocol among the various specialities
and will in turn save great deal of effort for the patient to move around for multiple consultations, as and
when necessary.
Waiting time:
The waiting time in the OPD is invariably the sore point of public grievances. Introduction of
appointment system, staggering of OPD timings for the registration, punctual attendance by doctors are
some of the remedies which can be introduced to reduce waiting time and have successfully been
implemented in many hospitals.
Delay in Admission:
Anxiety and distress is the result of delays in admission due to long waiting list. In allotting priorities
for admission, hospitals consider the physical state of the patients but forget the social background and as
a result, social emergencies have to wait. Adequate facilities in efficient use of present resources can
resolve this problem to some extent.
Ward Reception:
Patients are generally vulnerable to anxiety and fear on arrival in the ward. The reception they get
tends to leave a deep impression. Prompt reception improves the morale of the patients.
Privacy:
It is normally observed that majority of the patients are dissatisfied with the type of privacy provided
in the ward. Provision of screens around each bed would afford greater privacy. To have the privacy and
at the same time provide the advantage of companionship of other patients in the ward would go a long
way in creating a feeling of warmth and understanding.
Food:
Good food, well prepared and attractively served to patients, makes a very favorable impression.
Presence of dietician or a nurse at the time of service creates good impact on the patients.
Cleanliness:
Cleanliness is much a desired thing in a hospital. It not only enhances the image of the hospital but also
helps in controlling hospital infection. Frequent cleaning and liberal use of detergents and deodorants
eliminates the stink which is most dissatisfying.

Information about Illness:
The most important thing to a patient is to know as to what is wrong with him and how long will it
take to recover. Information in this respect will always be associated with fear, anxiety and thus, will help
in building patients confidence. A doctor or a nurse should be available in the ward during visiting hours
to furnish information regarding illness of the patients to their relatives.
Visitors:
Relatives and friends come rushing to the hospital the moment they learn about the illness of their
near and dear one. This is to show their loyalty, affection and strength of ties. It also satisfies emotional
needs of the patient. The relatives etc. are allowed to visit their patients for a short while. The visiting hour
policy should be more liberal for the visitors to the serious patients and relatives coming from distant
places. Too rigid visiting policy makes the public critical of the hospital.
Complaints and Suggestions:
The best way to deal with complaints is to do everything possible to avoid getting them by
anticipating the problems. In spite of the best intentions of everyone and as it happens everywhere else,
sometimes things go wrong. Any complaint and suggestions should receive prompt attention and wherever
possible remedial actions be taken. Equally important is that whatever action is taken, the same is
communicated to the complaint.
Mortuary and Chaplain Facility:
The disposal of the dead is influenced by religion, social and cultural beliefs and practices. It is
necessary to provide within the hospital or its premises a place to which a dead body can be moved quietly
so that other patients do not get upset. Disposal of dead has a great bearing on public relations of the
hospital. This is a sensitive area for the relatives and friends. Even unintentional neglect or delay may
carry unpleasant impression about the hospital. Utmost care is needed by all members of the staff to
ensure that prompt and proper disposal of the dead is arranged.
NEED FOR PUBLIC RELATION IN THE COMMUNITY:
 The main goal is to raise the standard of care to the highest level.
 To improve the existing channels of communication and to establish new ways of setting-up of
two-way communication.
 To provide the community with the concept of what a hospital and a health centre are.
 To ensure financial support.
 To create mutual understanding and goodwill through proper communication.
 To provide extra services of volunteers.
 To keep in touch with the community to assess their needs.
 To interpret the expectation of the community, their opinion and impression of the hospital to the
top level management.
 In large hospitals relationships can become very impersonal. Project a good image of the hospital
through effective staff performance.
 Public relationship is all about relationships efforts, commitment and activities, which go into
building. The right sort of relationships where there is good public relations, the hospital and
health care are functioning at its best and contribute maximum to which it serves.

METHODS OF MAINTAINING PUBLIC RELATION IN THE COMMUNITY:
There are mainly two methods:
 Operative methods
 Communicative methods
Operative methods:
These methods are essentially connected with every aspect of community operation including
those are carried out by such workmen as health personnel, office personnel, enquiry, media personnel etc.
The fundamental ingredients of community operation are:
i. Cheerful and courteous behavior.
ii. Prompt and efficient treatment.
iii. Clear surroundings and well appearance of the workers.
Some operations of improving operation of primary health care in the community level are:
i. A high quality patient care is the key of good public relation
ii. Adequate physical facility with good functional layout. Waiting room with benches or
chairs, water, refreshment facility in the outpatient department.
iii. To make others happy one must be happy himself. Good morale of workers not only
increases efficiency, but workers with high morale interact in a positive manner with
one another and also with the patients in the community.
iv. Operating efficiency with effective coordination among all clinical departments and
other supportive services stem from good administration, organization structure,
policies, procedures and authority and accountability should be clearly understood by
each staff.
Communicative methods:
These methods employ means of communication in all possible forms to enable the primary
health centre to convey its message to the public. Some of these are also intermixed in a way with intra-
mutual functions of the hospital or health centers and the operative methods may be used in the following
ways:
a. Making the available appropriate information to the patients, their relatives and visitors.
b. A provision to listen to verbal complains instead of insisting on written one.
c. Prompt reply to questions.
d. Provision of suggestion box at appropriate place.
e. Visual communication, film shows, exhibitions and hospital Boucher are to be displayed.
f. Hospital tours can be conducted by the school teachers, students, housewives and members
of 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 judgement, creativity and then critical ability.
Imagination and appreciate others.

Calm and not excitable person.
Ability to take pains.
Lively and inquisitive minds.
Willingness to work long and in constraint atmosphere, whenever necessary especially in
pulse polio campaigns.
Resilient and a sense of humour.
Flexibility and ability to deal with many problems.
Ability to communicate in any languages.
Capable of correcting and subediting others communication.
Loyalty to the organization.
Indicators for assessing public relation in the community:
 Patient-satisfaction surveys.
 General opinion pool.
 Quality of care using checklist.
 Number of complain received.
 Extent of voluntary efforts by the community.
 Turnover of the health staffs.
 Consistency of the attendance of the patients in clinics and health centers.
 Donations.
 Inpatients leaving against medical advice.
 Good recovery: achievement of the health activities.
 Poor recovery and high death rate.
 Vital rates such as IMR, MMR, BR and DR in the area.
 Incidence and prevalence rate of the communicable diseases in the community.
PUBLIC RELATION IN AN EDUCATIONAL INSTITUTION
PUBLIC IMAGE:
An idea or mental picture about the organization by the public.
STEPS FOLLOWED IN PUBLIC RELATION IN EDUCATIONAL INSTITUTION:
The followings are the steps followed in public relation campaign in an educational institution.
i. Listing and prioritizing of information is to be disseminated:
May wish to inform the public:
a) The new policy of the Government or organization.
b) The change in the existing policy.
c) The new scheme promoted.
d) The change in the existing scheme.
Public Relations activity starts with identifying the message to be disseminated and prioritized.

ii. Ascertaining the existing knowledge level or understanding the perceptions of the public:
The organization can check a quick survey among the target group of the public to ascertain the
knowledge level of the issue for which the organization is planning to initiate Public Relations process and
in case of the image it is essential to know whether the image is positive, neutral or negative in terms of
the assessment or in terms of the organization or both.
iii. Communication objectives and prioritize:
Based on the knowledge level or image factor, a communication objective is to be established
which is possible to evaluate and the top management approval is required. For example, communication
objective instead of using the term increasing awareness level about the scheme, it should be specific "By
2005, in the number of families where of the scheme be at least one lakh" so that we can evaluate the
impact.
iv. Message and Media:
After choosing the objective, the content of the message need to be developed. While developing the
message we should keep in mind the media in which we are going to use for disseminating that message.
TV/Visual media may be effective for showing the demonstrating awareness. Training media may be
effective whether the recipient may wish to keep the gap or further reference.
v. Implementation of message and media:
Based on the expected reaching level and target group, the budget is to be prepared and message is
transmitted. through the appropriate media.
vi. Impact assessment:
After release of the message, it is essential to study the impact at interval by interacting with the
target group.
vii. Message redesigned:
In case, the interaction of the target group reveals the message did not reach as expected the
modification in message or media need to be done and the revised message should be disseminated.
TYPES OF PUBLIC RELATION:
Advertising:
The main forms of advertising are------
 Brochures or flyers
 Direct mail
 E-mail messages
 Magazines
 Newsletters
 Newspaper(major)
 Online discussion and chat groups
 Posters and bulletin boards
 Radio and television announcements

Publicity:
Publicity is the spreading of information to gain public awareness for a product, person, service,
cause or organization, and can be seen as a result of effective PR planning.
Propaganda:
Propaganda is a form of communication that is aimed at influencing the attitude of a
community toward some cause or position. Propaganda, in its most basic sense, presents information
primarily to influence an audience and change in their attitude.
Public diplomacy:
Public diplomacy, broadly speaking, is the communication with foreign publics to establish a
dialogue designed to inform and influence. It is practiced through a variety of instruments and methods
ranging from personal contact and media interviews to the Internet and educational exchanges.
Campaign:
Effective public relations require a knowledge, based on analysis and understanding, of all the
factors that influence public attitudes toward the organization. While a specific public relations project
or campaign may be undertaken proactively or reactively to manage some sort of image crisis.
Promotion:
Commercialization of publicity.
Annual reports:
They are ripe with information if they include an overview of your year's activities,
accomplishments, challenges and financial status.
Collaboration or strategic restructuring:
If you're organization is undertaking these activities, celebrate it publicly.
Presentations:
Find ways to give even short presentations, for example, at local seminars, conventions, seminars,
etc. It's amazing that one can send out 500 brochures and be lucky to get 5 people who respond. Yet,
you can give a presentation to 30 people and 15 of them will be very interested in staying in touch with
you.
QUALITIES OF A PUBLIC RELATION OFFICER IN THE EDUCATIONAL INSTITUTION:
 Abundant common sense.
 First class organizing capacity.
 Good judgment and objectivity.
 Imagination ability and ability to appreciate.
 Infinite capacity for taking pain.
 Willingness to work long.
 Be realistic and sense of humor.
 Ability to write and speak English correctly.
 Pleasant voice and ability to speak in public.
 Innovative in ideas.
 Basic understanding about the profession.

 Image building abilities.
 Intelligence, foresight, result oriented approach.
 Media specialization.
 Editorial expertise.
 Insight in research.
ROLE OF DEAN:
Deans are expected to support and promote the highest quality educational programs, research,
public service, and economic development activities of their respective colleges and schools. Each dean
must be an effective advocate for his/her college, both within the University and externally. Deans have
ultimate accountability for their colleges‘ sound management of resources: fiscal, facilities, and human.
They are responsible for collegiate planning, including alignment of plans for educational, research, and
other activities in their colleges. The Deans have direct responsibility for:
Faculty:
The academic dean is responsible for the hiring of most department chairs and faculty selection. She often
acts as a bridge between the academic and bureaucratic sides of education. Often the dean will delegate
responsibility to trusted department heads but still oversee all the activity within each department.
Finance:
The academic dean may also be responsible for fund-raising and financial decisions made in
regard to the school. Because of the complexities of the financial responsibilities of the dean, the job
strongly resembles that of the chief executive officer of a mid-sized business or enterprise.
Course Scheduling and Public Relations:
The academic dean is responsible for overseeing course scheduling and the introduction of new
courses into the curriculum of the school. She also plays an integral role in maintaining good relationship
with alumni and the general public and garnering financial support for the institution. An academic dean
must have excellent social skills, as he is called upon to interact with the public as a representative of the
college or university.
Campus Upkeep and Student Affairs:
The academic dean may also be responsible for much of the decision making in regards to
campus upkeep and the regular care of campus grounds. He delegates the responsibility for care and
upkeep of the grounds, but makes the financial decisions regarding upkeep and general funding allotted to
the physical appeal of the university or college.

Faculty Communication:
Because all faculty report directly to the academic dean, she is often looked to for problem-
solving and conflict resolution. For this reason he must have an active interest in and knowledge of the
academic side of this jurisdiction, as well as a basic understanding of all areas of education. She must
likewise be persuasive, an effectual listener, and collaborative. The authority of the academic dean is
consistently being challenged, and thus she must possess humility, patience, and fortitude.
Fee Accounts:
 Stipulate the fee structure in respective zones under instructions of the management.
 Extending concessions on discretion to students being confirmed, registered or enrolled –
keeping in view merit and other criteria that demand concession.
 Monitor the fee dues of students and educate parents in clearing the same within the time
stipulated.
Public relation with parents:
 Maintain healthy public relations with parents in the interest of the organization.
 Keep in touch with parents of students already studying in your zone.
 Make efforts to identify merit students at the earliest and extend academic support to them.
 Take a feedback from students on the performance of the staff attached to the campuses in your
zone.
 Ask parents of exceptional students for feedback on the performance of respective campuses in
academic and administrative areas.
 Communicate any significant information about campus performance to management and staff
for improvement.
Sick room:
The health of a student is important since it also reflects on the academic performance. A student
in good health can perform up to potential, whereas a student who is ill cannot. Besides, the welfare of a
student studying on residential campus is of primary concern to the organization. It is for this reason that
every residential campus has a Doctor attending to sick students with special rooms to keep them in, and
under the care of Sick-in-charges.
 Monitor the healthcare of students enrolled in the campuses of your zone.
 Ensure that hygiene and sanitation is maintained in the sick room so that the recovery is faster.
 Keep in touch with the Campus Doctor in order to take precautionary measures against
common ailments.
 Ascertain that the parents of students who are sick are informed about the health status of their
wards.

DELEGATION
Introduction
Delegating is a major element of the directing function of nursing management. It
is an effective nurse management competency by which nurse managers get the work
done through their employees. Delegation is part of management; it requires professional
training and development to accept the hierarchical responsibilities of delegation.
Definition
 Delegation can be defined as getting work done through others, or as directing the
performance of one or more people to accomplish organizational goals.
 Delegation is the process of assigning responsibility and authority to co- worker and
ensuring his accountability.
DELEGATION HAS THREE ESSENTIAL ASPECTS OR DIMENSIONS
1. Assignment of duties and task
2. Grant of authority, power, right or permission
3. Creation of accountability
Assignment of duties:
As one person cannot perform all the tasks, he must allocate a part of his to subordinates
for the purposes of accomplishment by them
Grant of authority:
Delegation of authority means division of authority and powers downwards to the
subordinates. If the delegated duty is to be discharged by subordinates, they must be
entrusted with requisite authority for enabling them to make such work performance.
Creation of accountability
Delegation of duties implies accountability from side of subordinates. Because of this
accountability, the manager must keep for himself some reserved authority and duties for
directing, regulating and controlling the course of work undertaken by his subordinates.
PRINCIPLES OF DELEGATION
There are four fundamental principles which serve as guides for effective delegation:
1. Assignment of duties in terms of expected results.
2. Parity of authority and responsibility. While assigning duties to subordinates, there
should be equality of authority and responsibility.

3. Clarification of limits of authority: It is the clear limit of authority that permits
subordinates to exercise initiative to develop their personal capacity through
freedom of action and to know their area of operation.
4. Unity of command: As employee should receive orders from one superior only. So
subordinates should always be placed under the guidance, control and supervision
of one supervisor who will set up work priorities and will arrange for co-
operation.
List of ways or steps for nurse managers to successfully delegate:
1. Train and develop subordinates:
It is an investment .Give them reasons for the task, authority, details, opportunity
for growth, and written instructions if needed.
2. Plan ahead. It prevents problems.
3. Control and coordinate the work of subordinates.
Develop ways of measuring the accomplishment of objectives with
communication, standards, measurements, and feedback to prevent errors. Nursing
employees want to know the nurse manager‘s expectations of them. They
understand expectations from clearly defined jobs, work relationships, and
expected results.
4. Visit subordinates frequently. Spot potential problems of morale, disagreement
and grievance.
5. Coordination to prevent duplication of effort.
6. Solve problems and think about new ideas. Emphasize employees solving their
own problems.
7. Accept delegation as desirable.
8. Specify goals and objectives.
9. Know subordinate‘s capabilities and match task or duty to the employee. Be sure
the employee considers it important.
10.Agree on performance standards. Relate managerial
11.References to employee performance.
12.Take an interest
13.Assess results. The nurse manager should accept the fact that employees will
perform delegated tasks in their own style.
14.Give appropriate tasks.
15.Do not take back delegated tasks.

REASONS FOR DELEGATING
 Assigning routine tasks
 Assigning tasks for which the nurse manager does not have time.
 Problem solving
 Changes in the nurse manager‘s own job emphasis.
 Capability building.
The nurse manager should be careful not to misuse the clinical nurse by
delegating tasks that can be done by non- nurses or non-licensed personnel.
BARRIERS TO DELEGATING
Barriers in the delegator
1. Preference for operating by oneself
2. Demand that everyone ― know all the details‖.
3. ―I can do it better myself‖ fallacy.
4. Lack of experience in the job or in delegating.
5. Insecurity
6. Fear of being disliked
7. Refusal to allow mistakes
8. Lack of confidence in subordinates.
9. Perfectionism, leading to excessive control.
10.Lack of organizational skill in balancing work loads.
Barriers in the delegate
1. Lack of experience
2. Lack of competence
3. Avoidance of responsibility
4. Overdependence on the boss
5. Disorganization
6. Overload of work
Barriers in the Situation
1. One- person – show policy
2. No toleration of mistakes
3. Criticality of decisions
4. Urgency, leaving no time to explain
5. Confusion in responsibilities and authority.
6. Understaffing.

ADVANTAGES OF DELEGATION
 Delegation serves as a vehicle of co-ordination. The various levels of the
organization are used appropriately
 A sound system of delegation tends to develop an increased sense of responsibility
and enhanced potential work capacity of individual employee.
 It reduces the executive burden- It relieves the superior of time- consuming, minor
duties and allows him to concentrate more effectively on major responsibilities of
his own position.
 Delegation minimizes delay when decision have no longer to be referred up the
line.
 As delegation provides the means of multiplying the limited personal capacity of
the superior it is instrumental for encouraging of business.
 Delegation permits the subordinates to enlarge their jobs, to broaden their
understanding and develop their capacity.
 Delegation raises subordinates position in stature and importance and increase
their job satisfaction.
DISADVANTAGES OF DELEGATION
 Frailty of human life
 Eye wash delegation
 Unfamiliarity with art of delegation
 Incapacity of subordinates.
CONFLICT MANAGEMENT
INTRODUCTION
Conflict is generally defined as the internal or external discord that results from
differences in ideas, values, or feelings between two or more people. Because managers have
interpersonal relationships with people having a variety of different values, beliefs, backgrounds,
and goals, conflict is an expected outcome. Conflict is also created when there are differences in
economic and professional values and when there is competition among professionals.
THE HISTORY OF CONFLICT MANAGEMENT
Early in the 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.
Conflict also has a qualitative nature. A person may be totally overwhelmed in one
conflict situation, yet be able to handle several simultaneous conflicts at a later time. The
difference is in the quality or significance of that conflict to the person experiencing it.
MEANING & DEFINITION OF CONFLICT
 Conflict can be defined as an expressed struggle between at least two interdependent
parties, who perceive that incompatible goals, scarce resources, or interference from
others are preventing them from achieving their goals (Wilmot & Hocker, 2001).
 Conflict is related to feelings, including feelings of neglect, of being viewed as taken for
granted, of being treated like a servant, of not being appreciated, of being ignored, of
being overloaded, and other instances of perceived unfairness.
 Conflict management is the process of planning to avoid conflict where possible and
organizing to resolve conflict where it does happen, as rapidly and smoothly as possible.
TYPES OF CONFLICTS
Conflict has been described and studied from the standpoint of its context, or where it
occurs. 3 types of conflicts are
Intrapersonal conflict: an intrapersonal conflict occurs within an individual in situations in
which he or she must choose between two alternatives. Choosing one alternative means that he
or she cannot have the other; they are mutually exclusive. E.g. we might internally debate
whether to complete an assignment that is due the next day or watch a favorite television
programme.
Interpersonal conflict: is conflict between two or more individuals. It occurs because of
differing values, goals, action, or perceptions. For e.g. when you want to go to a science fiction
movie, but your partner may prefer to attend an opera. Interpersonal conflict becomes more
difficult when we are involved in issues relating to racial, ethnic and life style values and norms.
Organizational conflicts: conflict also occurs in organization because of differing perceptions
or goals. Organizational conflicts may be intrapersonal or interpersonal, but they originate in the
structure and function of the organization. Typically, aspects of the organizations style of
management, rules, policies and procedures give rise to conflict..
Two areas responsible for conflict in organizations are role ambiguity and role conflict.

 Role ambiguity occurs when employees do not know what to do, how to do it, or what
the outcomes must be. This frequently occurs when policies and rules are ambiguous and
unclear.
 Role conflict occurs when two or more individuals in different positions within the
organization believe that certain actions or responsibilities belong exclusively to them.
The conflict could relate to competition. E.g. In some hospitals, conflict have existed
between the nurse and the social workers about the responsibility for providing discharge
planning. Both groups see discharge planning as an important aspect of their own care of
the patients.
COMMON CAUSES OF CONFLICT
1. Vertical conflict: Occurs between hierarchical levels
2. Horizontal conflict: Occurs between persons or groups at the same hierarchical level.
3. Line-staff conflict: Involves disagreements over who has authority and control over
specific matters
4. Role conflict: Occurs when the communication of task expectations proves inadequate or
upsetting
5. Work-flow interdependencies: Occur when people or units are required to cooperate to
meet challenging goals.
6. Domain ambiguities: Occurs when individuals or groups are placed in ambiguous
situations where it difficult to determine who is responsible for what.
7. Recourse scarcity: When resources are scarce, working relationships are likely to suffer.
8. Power or value asymmetries: Occurs when interdependent people or groups differ
substantially from one another in status and influence or in values.
CHARACTERISTICS OF CONFLICT
The characteristics of a conflict situation are:
1) At least two parties (individuals or groups) are involved in some kind of interaction.
2) Mutually exclusive goals and mutually exclusive values exist, either in fact or as
perceived by the patients involved.
3) Interaction is characterized by behavior destined to defeat, reduce, or suppress the
opponent or to gain a mutually designated victory.
4) The parties face each other with mutually opposing actions and counteractions.
5) Each party attempts to create an imbalance or relatively favored position of power vis-a-
vis the other.

THE CONFLICT PROCESS
Before managers can or should attempt to intervene in conflict, they must be able to
assess its five stages accurately
1. Latent conflict (also called antecedent conditions).
2. Perceived conflict
3. Felt conflict
4. Manifest conflict
5. Conflict resolution
6. Conflict aftermath.
Latent conflict
The first stage in the conflict process, latent conflict, implies the existence of antecedent
conditions such as short staffing and rapid change. In this stage, conditions are ripe for conflict,
although no conflict has actually occurred and none may ever occur. Much unnecessary conflicts
could be prevented or reduced if managers examined the organisation more closely for
antecedent conditions.
Felt conflict Perceived conflict
Conflict resolution or conflict
management
Manifest conflict
Conflict aftermath
Latent conflict (also
called antecedent
conditions)

Perceived conflict
If the conflict progresses, it may develop into the second stage: perceived conflict.
Perceived or substantive conflict is intellectualized and often involves issues and roles. The
person recognizes it logically and impersonally as occurring. Sometimes, conflict can be
resolved at this stage before it is internalized or felt.
Felt conflict
The third stage, felt conflict, occurs when the conflict is emotionalized. Felt emotions
include hostility, fear, mistrust, and anger. It is also referred to as affective conflict. It is possible
to perceive conflict and not feel it. A person also can feel the conflict but not perceive the
problem.
Manifest conflict
It is also called as overt conflict, action is taken. The action may be to withdraw,
compete, debate, or seek conflict resolution. People often learn pattern of dealing with manifest
conflict early in their lives, and family background and experiences often directly affect how
conflict is dealt with in adulthood.
Gender also may play a role in how we respond to conflict. Men are socialized to respond
more aggressively to conflict, while women are more apt to try to avoid conflicts or to pacify
them. Power also plays a role in conflict resolution. Therefore, the action an individual takes to
resolve conflict is often influenced by culture, gender, age, power position and upbringing.
Conflict aftermath
The final stage in the conflict process is conflict aftermath. There is always conflict
aftermath- positive or negative. If the conflict is managed well, people involved in the conflict
will believe that there position was given a fair hearing. If the conflict is managed poorly the
conflict issues frequently remain and may return later to cause more conflict.
Outcomes of conflict
We often hear people hear about conflict situation resulting in win-win, win-lose and lose-
lose. Filley (1975) identified these 3 different positions or outcomes of conflict.
Win-lose outcome: occurs when one person obtains his or her desired ends in the
situation and the other individual fails to obtain what is desired. Often winning occurs
because of power and authority within the organization or situation.
Lose-lose outcome: in lose-lose situation, there is no winner. The resolution of the
conflict is unsatisfactory to both parties.
Win- win outcome: are of course the most desirable. In these situations, both parties
walk away from the conflict having achieved all or most of their goals or desires.

EFFECTS OF CONFLICT IN ORGANIZATIONS
• Stress
• Absenteeism
• Staff turnover
• De-motivation
• Non-productivity
SIGNS OF CONFLICT BETWEEN INDIVIDUALS
1. Colleagues not speaking to each other or ignoring each other
2. Contradicting and bad-mouthing one another
3. Deliberately undermining or not co-operating with each other, to the downfall of the team
CONFLICT MANAGEMENT
The optimal goal in resolving conflict is creating a win- win solution for all involved.
This outcome is not possible in every situation, and often the 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
 Issues in Question
 Size of the Stakes
 Interdependence of the Parties
 Continuity of Interaction
 Structure of the Parities
 Involvement of Third Parties

Discipline: In using discipline to manage or prevent conflict, the nurse manager must know and
understand the 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.
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.
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 behaviours can be learned with the use of case studies, role playing, and group
discussion.
When they finish their training, assertive nurses will use positive comments to reinforce
expectations that others do their jobs. They will use praise and consideration to promote wellness
and positive individual behaviour. Nurse Managers learn that direct communication of support to
staff members increases staff job satisfaction.
Assertive nurses focus on data and issues when offering constructive cretinism to the
boss or constructive feedback to the staff, which encourages dialogue and produces solutions to
problems rather than conflict. They ask for assistance or delay when it needed.
People generally respond positively to assertion and negatively to aggression; however,
some people respond negatively to assertion.
Assessing the dimensions of the conflict
Greenhalgh has developed a system for assessing the dimensions of conflict. His view is
that conflict may be considered to be managed when it does not interfere with ongoing functional
relationships. Participants in a conflict have to be persuaded to rethink their views. A third party
must understand the situation empathetically from the participants‘ view points. The conflict
may be the result of a deeply rooted antagonistic relationship.
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
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 nonrational arguments, unreasonable stances, impaired communication, or personal
attacks. Such conflicts can be solved with a prestigious, powerful, trusted, and neutral third
mediator, or arbitrator. The inside manager who acts as judge or arbitrator polarizes; inviting a
third party makes it public. Third parties have to be involved when the nurse manager, as party to
a conflict, cannot resolve it.
Dimension
Viewpoint Continuum
Difficult to Resolve Easy to Resolve
Issue in question
Size of stakes
Interdependence of the
parties
Continuity of interaction
Structure of the parties
Involvement of third parties
Perceived progress of the
conflict
Matter of principle
large
Zero sum
Single transaction
Amorphous or fractionalized,
with weak leadership
No neutral third party
available
Unbalanced: One party
feeling the more harmed
Divisible issue
Small
Positive sum
Long-term relationship
Cohesive, with strong
leadership
Trusted, powerful,
prestigious, and neutral
Parties having done equal
harm to each other

TECHNIQUES OR SKILLS FOR MANAGING CONFLICT
Aims: The manager should work on a compromise to stimulate the interaction and involvement
of the parties, another aim of conflict management. Other aims include better decisions and
commitment to decisions that have been made.
Strategies:
There are 5 strategies from conflict management theory for managing stressful situation.
1. Avoidance
2. Accommodation
3. Competition
4. Compromise
5. Collaboration
Avoidance/Avoiding (no winners/no losers):
This isn't the right time or place to address this issue. In the avoiding approach, the
parties involved are aware of a conflict but choose not to acknowledge it or attempt to resolve it.
Avoidance may be indicated in trivial disagreements, when the cost of dealing with the conflict
exceeds the benefits of solving it, when the problem should be solved by people other than you,
when one party is more powerful than the other, or when the problem will solve itself. The great
problem in using avoidance is that the conflict remains, often only to re-emerge at a later time in
an even more exaggerated fashion.
Accommodation/Accommodating (lose/win):
Working toward a common purpose is more important than any of the peripheral
concerns; the trauma of confronting differences may damage fragile relationships.
Cooperating is the opposite of competing. In the cooperating approach, one party
sacrifices his or her beliefs and allows the other party to win. The actual problem is usually not
solved in this win-lose situation. Accommodating is another term that may be used for this
strategy. The person cooperating or accommodating often collects IOUs from the other party that
can be used at a later date. Cooperating and accommodating are appropriate political strategies if
the item in conflict is not of high value to the person doing the accommodating.
Competition/Competing (win/lose):
Associates "winning" a conflict with competition.
The competing approach is used when one party pursues what it wants at the expense of
the others. Because only one party wins, the competing party seeks to win regardless of the cost
to others. Win-lose conflict resolution strategies leave the loser angry, frustrated, and wanting to
get even in the future.

Compromise/Compromising (win some/lose some):
Winning something while losing a little is OK. In compromising, each party gives up
something it wants for compromising not to result in a lose-lose situation, both parties must be
willing to give up something of equal value. It is important that parties in conflict do not adopt
compromise prematurely if collaboration is both possible and feasible.
Collaboration/Collaborating (win/win): Teamwork and cooperation help everyone achieve
their goals while also maintaining relationships.
Collaborating is an assertive and cooperative means of conflict resolution that results
in a win-win solution. In collaboration, all parties set aside their original goals and work together
to establish a supraordinate or priority common goal. In doing so, all parties accept mutual
responsibility for reaching the supraordinate goal. Although it is very difficult for people truly to
set aside original goals, collaborating cannot occur if this 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
Especially in workplace situations, it is necessary to have agreed mechanisms in place for
groups of people who may be antagonistic (e.g. management and workers) to collectively discuss
and resolve issues. This process is often called "collective bargaining", because representatives
of each group come together with a mandate to work out a solution collectively.
2. Conciliation
he dictionary defines conciliation as "the act of procuring good will or inducing a friendly
feeling". It is the synonymous terms that refer to the activity of a third party to help disputants
reach an agreement.
3. Negotiation:
This is the process where mandated representatives of groups in a conflict situation meet
together in order to resolve their differences and to reach agreement. It is a deliberate process,
conducted by representatives of groups, designed to reconcile differences and to reach
agreements by consensus. The outcome is often dependent on the power relationship between the
groups.

4. Mediation:
When negotiations fail or get stuck, parties often call in and independent mediator. This
person or group will try to facilitate settlement of the conflict. The mediator plays an active part
in the process, advises both or all groups, acts as intermediary and suggests possible solution.
5. Arbitration:
Means the appointment of an independent person to act as an adjudicator (or judge) in a
dispute, to decide on the terms of a settlement. Both parties in a conflict have to agree about who
the arbitrator should be, and that the decision of the arbitrator will be binding on them all.
COLLECTIVE BARGANING
INTRODUCTION
Other than the continuing argument about the appropriate education for nurses, collective
bargaining is the most controversial and divisive issue in nursing. Some believe that collective
bargaining reduces the professionalism of nursing; others view it as a mechanism to prevent
employers from exploiting nurses. It has been seen as a complex legal issue, but dealt with by
attorney and other experts specifically trained to handle the problem it presents.
MEANING
Collective bargaining is a process between employers and employees to reach an agreement
regarding the rights and duties of people at work. Collective bargaining aims to reach a collective
agreement which usually sets out issues such as employees pay, working hours, training, health
and safety, and rights to participate in workplace or company affairs.
DEFINITION:
“Collective bargaining is an agreement between a single employer or an
association of employers on the one hand and a labour union on the other, which regulates the
terms and conditions of employment‖
(Tudwig Teller)
―Collective bargaining is a process of discussion and negotiation between two
parties, one or both of whom is a group of persons acting in concest…. More specifically it is the
procedure by which an employer or employers and a group of employees agree upon the
conditions of work‖
(The encyclopaedia of social science)

―Collective bargaining takes place when a number of work people enter into a
negotiation as a bargaining unit an employer or group of employer with the object of reaching
an agreement on conditions of the employment of the work people‖
(According to J.H. Rishardwon)
OBJECTIVES OF COLLECTIVE BARGAINING
Collective bargaining has benefits not only for the present, but also for the future. The objectives
of collective bargaining are:
1. To provide an opportunity to the workers, to voice their problems on issues related to
employment.
2. To facilitate reaching a solution that is acceptable to all the parties involves.
3. To resolve all conflicts and disputes in a mutually agreeable manner.
4. To prevent any conflict/disputes in the future through mutually signed contracts.
5. To develop a conductive atmosphere to foster good organizations relations.
6. To provide stable and peaceful organization (hospital) relations.
7. To enhance the productivity of the organization by preventing strikes lock – out ect.
CHARACTERSTICS OF COLLECTIVE BARGAINING
1. It is a group process, wherein one group, representing the employers, and the
other, representing the employees, sit together to negotiate terms of
employment.
2. Negotiations form an important aspect of the process of collective bargaining
i.e., there is considerable scope for discussion, compromise or mutual give and
take in collective bargaining.
3. Collective bargaining is a formalized process by which employers and
independent trade unions negotiate terms and conditions of employment and the
ways in which certain employment-related issues are to be regulated at national,
organizational and workplace levels.
4. Collective bargaining is a process in the sense that it consists of a number of
steps. It begins with the presentation of the charter of demands and ends with
reaching an agreement, which would serve as the basic law governing labor
management relations over a period of time in an enterprise. Moreover, it is
flexible process and not fixed or static. Mutual trust and understanding serve as
the by products of harmonious relations between the two parties.
5. It a bipartite process. This means there are always two parties involved in the
process of collective bargaining. The negotiations generally take place between
the employees and the management. It is a form of participation.
6. Collective bargaining is a complementary process i.e. each party needs
something that the other party has; labor can increase productivity and
management can pay better for their efforts.

7. Collective bargaining tends to improve the relations between workers and the
union on the one hand and the employer on the other.
8. Collective Bargaining is continuous process. It enables industrial democracy to
be effective. It uses cooperation and consensus for settling disputes rather than
conflict and confrontation.
9. Collective bargaining takes into account day to day changes, policies,
potentialities, capacities and interests.
10.
UNION/LABOUR ORGANIZATION:
An organization in which employees participate for the purpose of
negotiating with the employer about grievances, labour disagreement, wages, hours of work
and conditions of employment.
PREPARATION FOR COLLECTIVE BARGAINING:
 Preparation should begin months before the contract talks.
 Chairperson should be establish and maintain pleasant relationship with union
representatives by treating them courteously in social situations, grievance
hearing.
 Obtain information from other nurse executives about union activities in
neighbouring health agencies.
 Review other labour contracts negotiating in other agencies to determine what
type of demands were made by various worker categories.
 Keep ongoing recording agency‘s employees grievances and analyse these before
negotiation begins.
 Research the wage salary structures of other health agencies in the community
and compare against agencies current wage package.
 Should read the act to identify limitations.
COLLECTIVE BARGAINING PROCESS

Collective bargaining generally includes negotiations between the two parties (employees‘
representatives and 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 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.
2. Discuss: Here, the parties decide the ground rules that will guide the negotiations. A
process well begun is half done and this is no less true in case of collective bargaining.
An environment of mutual trust and understanding is also created so that the collective
bargaining agreement would be reached.
3. Propose: This phase involves the initial opening statements and the possible options that
exist to resolve them. In a word, this phase could be described as ‗brainstorming‘. The
exchange of messages takes place and opinion of both the parties is sought.
4. Bargain: negotiations are easy if a problem solving attitude is adopted. This stage
comprises the time when ‗what ifs‘ and ‗supposals‘ are set forth and the drafting of
agreements take place.
5. Settlement: Once the parties are through with the bargaining process, a consensual
agreement is reached upon wherein both the parties agree to a common decision
regarding the problem or the issue. This stage is described as consisting of effective joint
implementation of the agreement through shared visions, strategic planning and
negotiated change.

STEPS
 Selection of a bargaining agent.
 Certification to contract.
 Contract administration.
 The nurse manager‘s role.
 Decertification.
Selection of bargaining agent:
The process of establishing a union in any setting begins with the selection
of a bargaining agent certified to conduct labour negotiations for a group of individuals. This
process is known as a representative election and is presided over by the national labour
relationship board. For an election occurs, the union must demonstrate that interest is shown by
at least 30% of the employees affected by this action. Once the 30% level is reached, the union
can petition the national labour relations board to conduct an election. At the conclusion of this
meeting the board will have determined three things:
- Who is eligible to participate in the union: - This is problematic issue and not
easily resolved, because registered nurses employed as staff nurses are eligible for
collective bargaining but registered nurses employed as management are not.
- Whether the signatories are employees of the organization.
- A date for union election: - the election is conducted by the board within 45 days,
using a secret ballot. All individuals eligible for represent action by the union are
notified of the election time and date. On Election Day, eligible employees are
asked to choose not only whether they wish to be representatives of the union but
also which union they want to represent.
Many unions represent registered nurses in collective bargaining; therefore the ballot may
contain several choices for the bargaining agent. In addition to various state nurses associations
(SNAs), other major unions representing nurses are:
- American federation of, county and municipal employees (AFSCME).
- Service employee‘s international union (SEIU).
The election outcome is determined by the group receiving a simple majority of the votes
cast. The union winning this election certified to enter into contract negotiations with the
employer.
The process of selecting a bargaining agent produces a tense, emotional climate that
affects everyone in the organization. It is important for both nurse and managers and staff nurses
to remember that during this period, the rules of unfair labour practice apply. Staff nurses also
must be careful that their discussions regarding collective bargaining take place away from the
work site and not on work time.

Certificate to contract:
Certification by the National Labour Relations Board (NLRB) of a union to be the
bargaining agent does mean that a group of people have the right to enter into a contract with an
employer, a concept known as certification to contract.
The actual contract and its provision must be written and voted on by the union
membership a process that may take some time. Issues considered mandatory subjects of
bargaining are rates of pay, wages, hours of employment and grievance procedures.
Additionally, the contract may specify other areas provided that both parties agree
they should be included. These can include:
 A union among security clause.
 A management rights clause.
 Seniority.
 Fringe benefits.
 Layoff and reduction in work language.
 ‗Floating‘ procedure.
 Insurance.
 Retirement issues.
 Professional issues.
The contract is considered to be in effect when both management of the
organization and employees agree on its content. The final agreement is subject to a ratification
vote by the affected employees. Passage of the contract, or ratification, is obtained by a simple
majority of eligible members who vote.
Contract administration:
The role of administrating the contract then falls to an individual designated as the
union representative. The individual may be an employee of the union or a member of the
nursing staff. It is the duty of the union representative to provide fair and equal representation to
all members of the unit. The role of the union representative is explain the provisions of the
contract to the union membership and be available to help in the grievance process.
The nurse manager‟s role:
The nurse manager in a health care organization where nurses are organized into a
collective bargaining unit participates in resolving grievances, using the agreed upon grievance
procedure.

CLASSIFICATION OF GRIEVANCE:
Grievance can usually be classified as
o Those caused by misunderstanding.
o Those caused by intentional contract violations.
o Those caused by symptomatic problems outside the scope of the labour agreement.
Grievance caused by a misunderstanding usually stem from circumstances surrounding the
grievance, a lack of familiarity with the contract or an inadequate labour agreement.
Intentional violation of a contract is usually an effort to capitalize on ambiguous contract
language or past practices.
Symptomatic grievances are simply a means for the employee to show dissatisfaction or
frustration and stem from the human element in management / labour relationship.
THE GRIEVANCE PROCESS: an example;
The following steps comprise the typical grievance process:
Step 1:- the employee talks informally with her or his direct supervisor, usually as soon
as possible after the incident has occurred. A representative of bargaining agent is allowed to be
present. A written request for the next step is given to the immediate supervisor within ten work
days. The employee, supervisor, and agent will be present for any discussion.
Step 2:- if the response to step 1 is not satisfactory, a written appeal may be submitted
within 10 work days to the director of nursing. The employee, agent, grievance chairperson and
the top nursing administrator or designs can be provided in 5 work days subsequent to these
meetings.
Step 3:- the employee, agent, grievance chairperson, nursing administrator and director
of human resources meet for discussion. The 10 and 5 day time limits for appeal and answer are
again observed.
Step 4:- the final step is arbitration, which is invoked when no solution suggested is
acceptable. An arbitrator who is a neutral third party is selected and is present at these meetings.
The submission of grievance may be required within 15 days after step 3 is completed.
SUGGESTIONS HELPFUL IN HANDLING GRIEVANCE:
 The objective of the grievance process is not to achieve conquest. You have to
work with one another after resolution of the grievance, so treat each other with
courtesy and respect.
 Do not, whatever your position, allow disagreements or disputes among members
of your team to be public.

 Expedience is a must; delaying tactics serve only to heighten emotions. However
allow time to consider the facts.
 Stay objective: emotionalism usually leads to further problems.
 Implementing decisions or filing grievances requires planning. Get all the facts
and information‘s, evaluated and anticipates the other party‘s response. Seek
guidance from those higher in administrative positions.
 Never refuse to meet with the grievant representatives.
 The bargaining unit representative, though in a unique position, is not immune
from reprimand or discipline.
 Integral to bargaining are solutions that may also accommodate future changes
and needs.
 Be prepared to give or take acceptable compromises and alternate solutions
within the framework of the contract, no matter which party suggests them.
 Pat formulas do not settle grievance or solve problems.
 Observe the time limits. If you do not, the bargaining unit may lose the right to
continue the grievance to the next level.
 In adjusting a grievance, knowledge is very important.
 Gloating over a ‗nursing‘ is human but remember that you may ‗lose‘ the next
one; don‘t become overconfident.
THE GRIEVANCE HEARING
In the grievance hearing, remember this key behaviour:
 Put the grievant at ease. Do not interrupt or disagree.
 Listen openly and carefully.
 Discuss the problem calmly and with an open mind.
 Get the story straight. Get all the facts ask logical questions.
 Consider the grievant view points
 Avoid snap judgements. Do not jump to conclusions
 Make an equitable decision, and then give it to the grievant promptly.
Decertification:
Occasionally, members of a particular may decide that the union they want or that
no union at all is needed. In such a case, the members of the bargaining unit have the right to
either change their union affiliation or remove the union by using a process known as
decertification. This process is essentially the same as that following by the NLRB for a
representation election.

TYPES OF STRIKES:
Jurisdictional Recognition
Strikes strikes
Economic TYPES OF Sympathy
Strikes STRIKES strikes
Illegal Unfair
Strikes labor strikes
Economic strikes:
Employee‘s attempt to get their employer to meet their demands by their services. An
employ cannot be fired for participating in an economic strike but can be replaced.
Unfair labour strikes:
Result from an unfair labour practice by an employer or a union.
Sympathy strikes:
Employees of one employer strike in support of another. Workers can refuse to cross to
picket lines.
Jurisdictional strike:
In jurisdictional strike there is a work stoppage over the assignment of work to two or
more unions. Employees may strike because the employer assigned a particular job to another
union.
Recognition strikes:
It is a work stoppage to force an employer to bargain with a particular organisation.
Illegal strikes:
The category of illegal strike comprises violent strikes, boycott or secondary strikes and
wildcat or surprise strikes that are not authorised by the union.

BARGAINING FORM AND TACTICS
A collective bargaining process generally consists of four types of activities- distributive
bargaining, integrative bargaining, attitudinal restructuring and intra-organizational bargaining.
Distributive bargaining:
It involves haggling over the distribution of surplus. Under it, the economic issues like
wages, salaries and bonus are discussed. In distributive bargaining, one 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. Also known as conjuctive bargaining
Integrativebargaining:
This involves negotiation of an issue on which both the parties may gain, or at least neither
party loses. For example, representatives of employer and employee sides may bargain over
the better training programme or a better job evaluation method. Here, both the parties are
trying to make more of something. In general, it tends to be more cooperative than
distributive bargaining. This type of bargaining is also known as cooperative bargaining.
Attitudinalrestructuring:
This involves shaping and reshaping some attitudes like trust or distrust, friendliness or
hostility between labor and management. When there is a backlog of bitterness between both
the parties, attitudinal restructuring is required to maintain smooth and harmonious industrial
relations. It develops a bargaining environment and creates trust and cooperation among the
parties.
Intra-organizationalbargaining:
It generally aims at resolving internal conflicts. This is a type of maneuvering to achieve
consensus with the workers and management. Even within the union, there may be
differences between groups. For example, skilled workers may feel that they are neglected or
women workers may feel that their interests are not looked after properly.
LEVELS OF COLLECTIVE BARGAINING
As 3 levels
1. National level
2. Sectoral/ industrial level
3. Company/ enterprise level

Economy-wide (national) bargaining is a bipartite or tripartite form of
negotiation between union confederations, central employer associations and
government agencies. It aims at providing a floor for lower-level bargaining on
the terms of employment, often taking into account macroeconomic goals.
Sectoral bargaining, which aims at the standardization of the terms of
employment in one industry, includes a range of bargaining patterns. Bargaining
may be either broadly or narrowly defined in terms of the industrial activities
covered and may be either split up according to territorial subunits or conducted
nationally
.
The third bargaining level involves the company and/or establishment. As a
supplementary type of bargaining, it emphasizes the point that bargaining levels need
not be mutually exclusive.

IMPORTANCE OF COLLECTIVE BARGAINING
Collective bargaining includes not only negotiations between the employers and unions but
also includes the process of resolving labor-management conflicts. Thus, collective
bargaining is, essentially, a recognized way of creating a system of industrial jurisprudence.
It acts as a method of introducing civil rights in the industry, that is, the management should
be conducted by rules rather than arbitrary decision making. It establishes rules which define
and restrict the traditional authority exercised by the management.
Importance to employees
o It increases the strength of the workforce, thereby, increasing their bargaining
capacity as a group.
o Collective bargaining increases the morale and productivity of employees.
o It restricts management‘s freedom for arbitrary action against the employees.
Moreover, unilateral actions by the employer are also discouraged.
o Effective collective bargaining machinery strengthens the trade unions
movement.
o The workers feel motivated as they can approach the management on various
matters and bargain for higher benefits.
o It helps in securing a prompt and fair settlement of grievances. It provides a
flexible means for the adjustment of wages and employment conditions to
economic and technological changes in the industry, as a result of which the
chances for conflicts are reduced.
o Collective bargaining develops a sense of self respect and responsibility
among the employees.
Importance to employers
1. It becomes easier for the management to resolve issues at the bargaining level rather
than taking up complaints of individual workers.
2. Collective bargaining tends to promote a sense of job security among employees and
thereby tends to reduce the cost of labor turnover to management.
3. Collective bargaining opens up the channel of communication between the workers
and the management and increases worker participation in decision making.
4. Collective bargaining plays a vital role in settling and preventing industrial disputes.
Importance to society
1. Collective bargaining leads to industrial peace in the country

2. It results in establishment of a harmonious industrial climate which supports which
helps the pace of a 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.
It provides a method or the regulation of the conditions of employment of those who are
directly concerned about them.
ADVANTAGES AND DISADVANTAGES OF COLLECTIVE BARGAINING:
Advantages:
o Equalization of power
o Viable grievance procedure
o Equitable distribution of work
o Professionalism promoted
o Nurses control practice
Disadvantages:
o Adversary relationship
o Strikes may not be prevented
o Leadership may be difficult to obtain
o Unprofessional behaviour
o Interference with management
NURSES UNIONS AND ASSOCIATIONS
Since its inception, the ANA has had an active interest in the economics security of nurses.
 The original purposes of ANA was ―to promote the usefull and honor, the financial and
other interest of the nursing profession‖- Flannigan-1976. Although this statement was
useful in helping to shape the role of the profession in supporting collective bargaining
for nurses, the ANA did not officially adopt an economic security program that included
collective bargaining for nurses through the Economics and General welfare program,
which currently is called the Department of labor Relations and work place advocacy.
 The ANA is a registered labor organization, but it does not engage in direct collective
bargaining. The actual certification of units, negotiation of contracts, and administration
of contracts is conducted by the SNA.
 The SNA have the freedom to independently decide their own level of participation
regarding collective bargaining.

 In 1983, the nursing leaders established their first orgsnisation, the American Society of
Superintendents of Training Schools for Nurses, one of whose purpose was a
commitment to promote the general welfare of nurses.
 In early 1900s, working conditions and salaries for nurses were extremely poor.
 In 1929, some nurses began to recognize that protest and collective action were necessary
if the conditions of the nurse were to improve.
 In 1945, Shirley Titus, then the executive director of the California nurses association,
chaired a committee to study the employment conditions of nurses; as a result of the
findings of this committee, ANA adopted what was called the economic security
program.
 In 1974, the health care amendments referred to earlier made it possible for nurses to use
legal sanctions if necessary to ensure bargaining related to conditions of employment.
Since the passage of these amendments, many state nurses associations (SNAs) have
qualified as a legal bargaining agents for nurses.
 In 1982 ANA changed structure to become a federation of state association. This change
has rendered the state associations more direct representation of their member nurses.
OCCUPATIONAL HEALTH AND SAFETY
INTRODUCTION:
All occupational fields have their own hazards. There are variety of hazards to which
workers may be exposed and which may cause various diseases. By following the proper
guidelines and precautions, all occupational hazards can be minimized.
OCCUPATIONAL ENVIRONMENT:
By ―occupational environment‖ is meant the sum of external conditions and influences
which prevail at the place of the work and which have a bearing on the health of the working
population. Basically there are three types of interaction in the working environment:
a. Man and physical, chemical and biological agents.
b. Man and machine.
c. Man and man.
Man and physical, chemical and biological agents:
Physical agent- the physical factors in the working environment which may be adverse to
health are heat, cold, humidity, air movement, heat radiation, light, noise, vibrations and ionizing
radiation. The factors act in different ways on the health and efficiency of the workers, singly or
in different combinations. The amount of work and the breathing place, toilet, washing and
bathing facilities are also important factor in occupational environment.

Chemical agents- these comprises a large number of chemicals, toxic dust and gases
which are the potential hazards to the health of the workers. Some chemical agents cause
disabling respiratory illnesses, some causes injury to health and deleterious effect on the blood
and other organs of the body.
Biological agents- the workers may be exposed to viral, rickettsial, bacterial and
parasitic agents which may result from close contact with animals or their products,
contaminated water, soil or food.
Man and machine:
An industry or factory implies the use of machines driven by power with emphasis on
mass production. The unguarded machines, protruding and moving parts, poor installation of the
plant, lack of safety measures are the cause of accidents which is the major problem in industries.
Man and man:
There are numerous psychological factors that operates in the place of work. These are
human relationships amongst workers themselves on the one hand, and those in authority over
them on the other hand. Examples of psychosocial factors include the type and rhythm of work,
work stability, service conditions, job satisfaction, leadership style, security, workers
participation, communication, system of payment, welfare conditions, degree of responsibility,
trade union activities, incentives and a host of similar other factors, all entering the field of
human relationships. In modern occupational health, the emphasis is upon the people, the
conditions in which they live and work, their hopes and fears and their attitudes towards their
job, their fellow-workers and employers.
OCCUPATIONAL HAZARDS:
An industrial worker may be exposed to five types of hazards, depending upon his
occupation:
1) Physical hazards.
2) Chemical hazards.
3) Biological hazards.
4) Mechanical hazards.
5) Psychosocial hazards.
Physical hazards:
 Heat and cold: the common physical hazard in most industries is heat. The direct effects
of heat exposure are burns, heat exhaustion, heat stroke and heat cramps; the indirect
effects are decreased efficiency, increased fatigue and enhanced accident rates. Important
hazards associated with cold work are chilbans, erthrocynosis, immersion foot, and
frostbite as a result of cutaneous vasoconstriction. General hypothermia is not unusual.
 Light:.The acute effects of poor illumination are eye strain, headache, eye pain,
lachrymation, congestion around the cornea and fatigue. The chronic effects on health

include ―miner‘s nystagmus‖. Exposure to excessive brightness or ―glare‖ is associated
with discomfort and annoyance and visual fatigue.
 Noise: The effects of noise are of two types : auditory effects which consist of temporary
or permanent hearing loss and non auditory effects which consist of nervousness, fatigue,
interference with communication by speech, decreased efficiency and annoyance.
 Vibration: Vibration usually affects the hands and arms. After some months or years of
exposure, the fine blood vessels of the fine fingers may become increasingly sensitive to
spasm (white fingers). Exposure to vibration may also produce injuries of the joints of the
hands, elbows and shoulders.
 Ultraviolet radiation: occupational exposure to ultraviolet radiation occurs mainly in arc
welding. Such radiation mainly affects the eyes, causing intense conjunctivitis and
keratitis (Welder‘s flash). Symptoms are redness of the eyes pain, these usually disappear
in a few days with no permanent effect on vision or on the deeper structures of the eyes.
 Ionizing radiation: ionizing radiation is finding increasing application in medicine and
industry, eg: X- ray and radioactive isotopes. Important radio-isotopes are cobalt 60 and
phosphorus 32. Certain tissues such as bone marrow are more sensitive than others and
from genetic standpoint, there are special hazards when the gonads are exposed. The
radiation hazard comprises genetic changes, malformation, cancer leukaemia, depilation,
ulceration, sterility and in extreme cases death. The international commission of
radiological protection has set the maximum permissible level of occupational exposure
at 5 rem per year to the whole body.
Chemical hazards:
There is hardly any industry which does not make use of chemicals. The chemical hazards
are on the increase with the introduction of newer and complex chemicals. Chemical agent acts
in three ways: local action, inhalation and ingestion. The ill-effects produced depend upon the
duration of exposure, the quantum of exposure and individual susceptibility.
 Local action: some chemicals cause dermatitis, eczema, ulcers and even cancer by primary
irritant action; some causes dermatitis by an allergic action.
 Inhalation: Dusts are produced in a number of industries- mines, foundry, quarry, pottery,
textile, wood or stone working industries. The most common dust disease in this country are
silicosis and anthracosis.
Gases: Gases are sometimes classified as simple gases(eg; oxygen, hydrogen), asphyxiating
gases (e.g. carbon monoxide, cyanide gas, sulphur dioxide, chlorine) and anesthetic gases
(eg; chloroform, ether, trichloroethylene) carbon monoxide hazards is frequently reported in
the coal-gas manufacturing plants and steel industries.

Metals and their compounds: a large number of metals and compounds are used throughout
industry. The chief mode of entry of some of them is by inhalation as dust or fumes. Metals
may be of antimony, arsenic, beryllium, cadmium, cobalt, manganese, mercury, phosphorus,
chromium, zinc and others.
 Biological hazards: workers may be exposed to infective and parasitic agent of the place of
work. The occupational disease in this category are brucellosis, leptospirosis, anthrax,
hydatidosis, psittacosis, tetanus, encephalitis, fungal infections, schistosomiasis and a host of
others. Persons working among animal products(eg; hair, wool, hides) and agricultural
workers are specially exposed to biological hazards.
 Mechanical hazards: the mechanical hazards in industry centre round machinery,
protruding and moving parts and the like. About 10% of accidents in industry are said to be
due to mechanical causes.
 Psychosocial hazards: the psychosocial hazards arises from the worker‘s failure to adapt to
the alien psychosocial environment. Frustration, lack of job satisfaction, insecurity, poor
human relationship, emotional tension are some of the psychological factors which may
undermine both physical and mental health of the workers.
The health effects can be classified in two main categories: psychological and behavioral
changes- including hostility, aggressiveness, anxiety , depression, tardiness, alcoholism, drug
abuse, sickness, absenteeism. Psychosomatic illhealth: including fatigue, headache, pain in the
shoulders, neck and back; propensity to peptic ulcer, hypertension, heart disease and rapid
ageing.
OCCUPATIONAL DISEASE:
Occupational diseases are usually defined as diseases arising out of or in the course of
employment.
Disease due to physical agent:
1. Heat- heat hyperpyrexia, heat exhaustion, heat syncope, heat cramps, bruns and
local effects such as prickly heat.
2. Cold- trench foot, frost bite, chilblains
3. Light- occupational cataract, miner‘s nystagmus
4. Pressure- caisson disease, air embolism, blast(explosion)
5. Noise- occupational deafness
6. Radiation- cancer, leukaemia, aplastic anemia, pancytopenia
7. Mechanical factors- injuries, accidents
8. Electricity- burns

Disease due to chemical agents:
1. Gases: Co2, Co, HCN, CS, NH3, N2, H2S, HCL, SO2
-
these causes gas poisoning.
2. Dusts (pneumoconiosis)
 Inorganic gases: coal dust-anthracosis; silica-silicosis; asbestos-asbestosis, cancer;
iron-siderosis.
 Organic(vegetable) dusts: cane fibre-bagassossis; cotton dust-byssinosis; tobacco-
tobacossis; hay or grain dust-framers lung.
3. Metals and their compounds: toxic hazards from lead, mercury, cadmium, manganese,
beryllium, arsenic, chromium etc.
4. Chemicals: acids, alkalies, pesticides
5. Solvents: carbon bisulphide, benzene, trichloroethylene, chloroform, etc.
Disease due to biological agents:
Brucellosis, leptospirosis, anthrax, actinomycosis, hydatidosis, psittacosis, tetanus,
encephalitis, fungal infections, etc.
Occupational cancer:
Cancer of the skin, lungs, bladder.
Occupational dermatosis:
Dermatitis, eczema
Disease of psychological origin:
Industrial neurosis, hypertension, peptic ulcer, etc.
Pneumoconiosis: Dust within the size of 0.5 to 3 micro is a health hazard producing, after a
variable period of exposure, a lung disease known as pneumoconiosis, which may gradually
cripple a man by reducing his working capacity due to lung fibrosis and other complications. The
hazardous effects of dusts on the lungs depend upon a number of factors such as:
a) Chemical composition
b) Fineness
c) Concentration of the dust in the air
d) Period of exposure
e) Health status of the person exposed.
Silicosis: among the occupational disease, silicosis is the major cause of permanent disability
and mortality. It is caused by inhalation of dust containing free silica or silicon dioxide.
Pathologically, silicosis is characterized by a dense ―nodular‖ fibrosis, the nodules ranging from
3 to 4mm in diameter. Some of the early manifestations are irritant cough, dyspnoea on exertion
and pain in the chest.
Anthracosis: Anthracosis exhibits two general phases in coal miners pneumoconiosis: the first
phase is labeled as simple pneumoconiosis which is associated with little ventilator impairment.
This phase may require 12 years of work exposure for its development. The second phase is
characterized by progressive massive fibrosis; this causes severe respiratory disability and
frequently results in premature death.

Byssinosis: it is due to inhalation of cotton fibre dust over long periods of time. The symptoms
are chronic cough and progressive dyspnoea, ending in chronic bronchitis and emphysema.
Bagassosis: is the name given to an occupational disease of the lung caused by inhalation of
bagasse or sugar-cane dust. It was first reported in India by Ganguli and Pal in 1955 in a
cardboard manufacturing firm near Kolkata. The sugarcane fiber which until recently went to
waste is now utilized in the manufacture of paper, cardboard and rayon. The symptoms consists
of breathlessness, cough
Asbestosis:
Asbestos are silicates of varying composition(magnesium, iron, calcium, sodium,
aluminium). Asbestos is of 2 types – serpentine (hydrated magnesium silicate) and amphibole
type (contain magnesium). Asbestos is used in the manufacture of asbestos cement, fire proof
textiles, roof tiling, brake lining, etc.
Asbestos enters the body by inhalation, and fine dust may be deposited in the alveoli. The
disease is characterized by dyspnoea, clubbing of fingers, cardiac distress and cyanosis. Chest x-
ray shows a ground-glass appearance in the lower two third of the lungs. It causes pulmonary
fibrosis leading to respiratory insufficiency and death, carcinoma of the bronchus and gastro
intestinal tract.
Preventive measures:
1. Use of safer types of asbestos(chrysolite and amosite)
2. Substitution of other insulants – glass fiber, mineral wood, calcium silicate, plastic foams.
3. Dust control and biological monitoring(x-ray, lung function)
4. Periodic examination of workers and continuing research.
FARMER‟S LUNG:
It is due to the inhalation of mouldy hay or grain dust which contains micropolyspora
faeni , the main cause of farmer‘s lung. Its growth is encouraged by moist hay or grain dust. The
disease is characterized by respiratory symptoms and finally leads to pulmonary fibrosis and
pulmonary damage.
OCCUPATIONAL CANCER
The characteristics of occupational cancer are:
 They appear after prolonged exposure
 The period between exposure and development of disease may be 10 to 25 years.
 The disease may develop even after cessation of exposure.
 The localization of tumors is remarkably constant in any one occupation.
1. SKIN CANCER:- Skin cancer is a main occupational hazard among gas workers, oven
workers, tar distillers, oil refiners, dye-stuff makers, road makers and in industries associated
with the use of mineral oil, tar and related compounds.
2. LUNG CANCER:- It is an occupational hazard in gas industry, asbestos industry, nickel and
chromium work and in mining of radio-active substances. The main carcinogens in these areas
are nickel, chromates, asbestos, coal tar, etc.

3. BLADDER CANCER:- The industries associated with bladder cancer are the dye-stuffs and
dyeing industry, rubber, gas, and the electric cable industries. The major bladder carcinogens are
benzidine, auramine, beta-naphthylamines, etc.
4. LEUKAEMIA:- Exposure to benzol, roentgen rays and radio-active substances give rise to
leukaemia. Benzol is a dangerous chemical and is used as a solvent in many industries.
CONTROL OF INDUSTRIAL CANCER:
 Elimination or control of industrial carcinogens – well-designed building or machinery,
closed system of production.
 Medical examinations and Inspection of factories.
 Notification and licensing of establishments
 Personal hygiene measures
 Education of workers and management and research.
OCCUPATIONAL DERMATITIS:
Occupational dermatitis is a big problem in many industries. The causes may be
 Physical- heat, cold, moisture, friction, pressure, x-rays
 Chemical- acid, alkalies, dyes, solvents, grease, tar, chlorinated phenols
 Biological- living agents such as bacteria, virus, fungi, parasites.
 Plant products- leaves, vegetables and its dust , flowers and pollen grains.
The dermatitis producing agents are further classified into:
 Primary irritants – acids, alkalies, dyes
 Sensitizing substances – allergic dermatitis.
PREVENTION:
 Pre-selection - the workers should be medically examined before employment.
 Protection – protecting clothing, long leather gloves, aprons, boots, barrier creams.
 Personal hygiene – supply of warm water and adequate washing facility, soap, towels.
 Periodic inspection – medical checkup and early detection, transfer from risky area,
proper education of workers to identify skin irritation.
RADIATION HAZARDS:
A number of industries use radium and other radio-active substances. X-rays are used both in
medicine and industry. Exposure to ultraviolet rays occurs in arc and other electric welding
processes. Infrared rays are produced in welding and glass blowing. The main effects of radiation
are acute burns, dermatitis malignancies, genetic effects etc.
 Shielding of workers in x-ray field, so that direct contact to skin can be avoided.
 The employees should be monitored at intervals not exceeding 6 months.
 Suitable protective clothing
 Adequate ventilation in work place to prevent inhalation of harmful gases and dust.
 Replacement and periodic examination of workers in every 2 months.

 Pregnant women should not be allowed to work in risky areas.
LEAD POISONING:
Lead is used in variety of industries such as manufacture of storage batteries, glass
manufacture, ship building, printing and potteries, rubber industry etc. Thousands of tons of lead
every year is exhausted from automobiles. All lead components are toxic – lead oxide, lead
carbonate, lead arsenate, etc. Lead has an effect on membrane permeability. Mode of absorption
is of 3 ways – inhalation, ingestion and absorption through skin. Normal adult ingest about 0.2 to
0.3 mg of lead per day from food and beverages. Confirmation of lead poisoning shows a blood
count more than 70 mue gm./100 ml and urine lead more than 5mg/lt.
The toxic effect of inorganic lead exposure are abdominal colic, constipation, loss of
appetite, blue-line on the gums, anaemia, wrist drop and foot drop. The toxic effects of organic
lead compounds are mostly on the CNS- insomnia, headache, mental confusion, delirium, etc.
 Substitution of lead with less toxic materials.
 Isolation of all processes which gives rise to lead dust and fumes.
 Local exhaust ventilation.
 Personal protection, personal hygiene and good housekeeping
 Periodic examination of workers and health education.
 Medical management- saline stomach wash if ingested, d-penicillamine.
HEALTH PROBLEMS DUE TO INDUSTRIALIZATION:
 Environmental sanitation problems – housing, water pollution, air pollution, sewage
disposal.
 Communicable diseases
 Food sanitation
 Mental health.
 Accidents and Social problems.
 Morbidity and mortality.
MEASURES FOR HEALTH PROMOTION OF WORKERS:
The aim of occupational health is ― the promotion and maintenance of the highest
degree of physical, mental and social well-being of workers in all occupations‖. The measure for
the general health protection of workers was the subject of discussion by an ILO/WHO
Committee on Occupational Health in 1953. The committee recommended the following:
1. NUTRITION:
In many developing countries malnutrition is an important factor contributing to poor
health among workers and low work productivity. Malnutrition may also affect the metabolism
of toxic agents and also the tolerance mechanisms. Under the Indian Factories Act, every
industry should provide a canteen when the numbers of employees exceed 250. The aim is to
provide balanced diets and snacks at reasonable cost under sanitary control. It is important to
combine this action with the education of the workers on the value of a balanced diet.

2. COMMUNICABLE DISEASE CONTROL:
The industry provides an excellent for early diagnosis, treatment, prevention and
rehabilitation. There should be an adequate immunization program against preventable
communicable diseases. The communicable diseases of special importance in India are
tuberculosis, typhoid fever, viral hepatitis, amoebiasis, intestinal parasites, malaria and venereal
diseases.
3. ENVIRONMENTAL SANITATION:
Within the industrial establishment , the following needs attention for the prevention of
spread of communicable diseases;
 Water supply
 Food
 Toilet
 General plant cleanliness
 Sufficient space
 Lighting , ventilation , temperature
 Protection against hazards
 Housing
4. MENTAL HEALTH:
Industrial workers are susceptible to the effects of love, recognition, rejection, job
satisfaction, rewards and discipline. The goals of mental health in industry are;
 To promote the health and happiness of the workers
 To detect the signs of emotional stress and strain and to secure relief
 The treatment of employees suffering from mental illness
 Rehabilitation of those who become ill
5. MEASURES FOR WOMEN AND CHILDREN:
 Expectant mothers are given maternity leave for 12 weeks, of which 6 weeks precede the
expected date of confinement they are allowed maternity benefit with cash payment.( ESI
act, 1948)
 Provision of free antenatal, natal and postnatal services.
 Night work between 7 pm to 6 am is prohibited.(Factories Act)
 Provide crèches in factories where more than 30 women workers are employed.
 The Indian Mines Act 1923, prohibits work under ground.
 No child below the age of 14 shall be employed to work in any factory or mine or
engaged in any other hazardous employment.
6. HEALTH EDUCATION:
It is an important health promotional measure. It should be given in all levels –
management, supervisory staff, workers, trade union leaders and community.

7. FAMILY PLANNING:
Family planning is now become a decisive factor for the quality of life, and this applies to
industrial workers also. The workers must adopt the small family norm.
PREVENTION OF OCCUPATIONAL DISEASES:
The various measures for the prevention of occupational diseases may be grouped
under 3 headlines:
 Medical measures
 Engineering measures
 Legislative or statutory measures
1. MEDICAL MEASURES:
 Pre-placement examination
 Periodical examination
 Medical and health care services
 Notification
 Supervision of working environment
 Maintenance and analysis of records
 Health education and counseling
2. ENGINEERING MEASURES:
> Design of building > Dust – enclosure and isolation
> Good housekeeping > Local exhaust ventilation
> General ventilation > Protective devices
> Mechanization > Environmental monitoring
> Substitution > Statistical monitoring and research
3. LEGISLATION:
The most important factory laws in India today are ;
 The Factory Act , 1948
 The Employees State Insurance Act , 1948
Some of other specialized acts adapted to the particular circumstances of the industry are –
The Mines Act, The Plantation Act, The Minimum Wages Act, The Maternity Benefit Act, etc.
OHSMS:
In the changed industrial scenario, an emphatic world wide Endeavour is visible in improving
quality in all functions of an organization. Recognizing that the workplace safety and health is a
decisive factor in an organizational effectiveness, several management frameworks have been
proposed to implement cost-effective occupational health safety(OHS) in preventing work place
aliments and promoting health and welfare of workers resolving around the international
standards organization families of management standards(eg:ISO 9000 and 14000).
Broadly, an ideal OHS management system (OHSMS) should provide a structured process to
minimize potentials of work-related injuries and illness, increase productivity by reducing the
direct and indirect cost associated with accidents, and increase the quality of manufactured

products for rendered services. It must provide a direction to OHS activities, in accordance with
organizational policies, regulatory requirements, industry practices and standards, including
negotiated labour arguments. Therefore, conforming to an OHSMS may be significant value to
an organization. This approach has drawn significant attention among the standard organizations,
the accreditation and certification bodies and the national agencies in formalizing, implementing
and evaluating OHSMS.
The framework for certification of OHSMS, namely occupational health and safety assessment
series (OHSAS) specification (OHSAS 18001;1999) has been developed by an association of
national standards and certification bodies, and specialist consultants. It has been developed to be
compatible with the ISO 9000 (quality) and ISO 14000 (environment) standards in order to align
and integrate quality, environment and OHS, management systems in organizations.
The organization which has established, implemented and maintained OHSMS meeting the
specification, is eligible to apply for certification. The scheme is established with the aim that
upon receiving the certification, the organization will become more aware and self regulating in
promoting health and safety at their work places. The certification offers independent
verification and auditing that an organization has taken reasonable measures to minimize
workplace risks and injuries.
In order to implement OHSMS, 18001 specification, an organization, requires to establish OHS
policy.
Management review
Audit Feedbackfrom measuring performance
Planning
Top management establishes OHS policy, standing health and safety objectives and commitment
to continual improvement of health and safety performance and comply with OHS legislation
and requirements.
policy
Audit feed back from measuring
Implementation and operation
Plan and integration concepts of hazards prevention, meet statutory, regulatory and policy
requirements, develop OHS goals and objectives, and establish OHS management program.
Planning
Feedback from measuring performance
Audit
Checking and corrective action
Implement the OHSMS, prioritizing the OHS resources, defining the structure and responsibility
of personnel, establishing documentation of the care system elements and interaction, including
procedure for controlling documents and data.
Implementation and operation
Policy
Planning
Implementation
and operation
Checking and
corrective action

Audit Feedback from measuring performance
Management review
Evaluate, monitor and control OHS hazards through corrective and preventive actions.
Checking and corrective action
Internal factors external factors
OHS policy
Undertake management review to monitor progress of OHSMS implementation.
IMPORTANCE OF OCCUPATIONAL HEALTH IN HOSPITALS
Hospitals are large, organizationally complex, system driven institutions employing large
numbers of workers from different professional streams. They are also potentially hazardous
workplaces and expose their workers to a wide range of physical, chemical, biological,
ergonomical and psychological hazards. Thus Occupational Health and Safety issues relating to
the personal safety and protection of its workers is a very important Environmental Health
concern for hospitals.
Personal (Staff) Protection – Physical Hazards
Radiation Exposure
There is a wide range of radiation hazards related to medical imaging (x rays, nuclear
scans utilizing radioactive isotopes) and radiation oncology which utilizes ionizing radiation
from a variety of sources to treat a range of malignant tumors. These sources include (i) sealed
sources containing radioactive material such as isotopes of radium, cobalt and strontium, and (ii)
linear accelerators emitting short wave length gamma waves.
Licensing users of this technology is strictly controlled (i) appropriate training, certification and
credentialing of users (ii) demonstrated implementation of safety precautions related to storage,
use and shielding of non target personnel (iii) regular inspection, maintenance and certification
of equipment by the Department of Physics within Queensland Health, and (iv) ongoing
monitoring of radiation exposure of staff using the equipment.
Back Injury
Hospital staff and particularly nurses are prone to back injury from the need to lift and
roll immobilized or disabled patients for toilet, washing, dressing and pressure care. Hospitals
are now required to give training on back care to all new staff. This training, combined with the
use of wards persons to assist nurses and the use of hydraulic lifting devices, has decreased the
risk of back injury considerably
.
Checking and
corrective action

Burns due to Steam Sterilizing
Larger hospitals now have Central Sterilizing Departments utilizing appropriately trained,
dedicated staff, that are familiar with and follow set policy and procedure. This type of
specialized set up minimizes risk of physical injury from hot equipment. However, smaller
peripheral steam sterilizers are still required in some departments such as the Operating Theatres.
Where possible many smaller satellite hospitals now use the Central Sterilizing Department of
their larger referral Base Hospital for their sterilization needs.
Laser Burns
Lasers are now frequently used in Operating Theatres and appropriate protective
equipment must be used, especially eye protection to prevent retinal burns. The use of this
equipment is covered by set protocols.
Electrical Defibrillators
Use of this equipment is restricted to those staff who have undergone competency based
training and certification.
Personal Violence
Risk of injury from personal violence is an important hazard in Emergency Departments
who at times deal with mad, bad or intoxicated patients. Similarly, Psychiatric Units who have to
look after the psychotically disturbed are also at risk. Again, staff education and set policy and
procedure needs to be in place for dealing with aggressive patients. Personal security alarms, a
system for rapidly mobilizing ancillary staff, and a set approach to safely restraining,
immobilizing and sedating violent patients are all important components.
Personal (Staff) Protection – Chemical Hazards
Toxic chemicals in use in hospitals include:-
 Industrial cleaners used by contracted cleaning staff.
 Chemical sterilizers, in particular gluteraldehyde used for the sterilization of endoscopes
and other equipment that cannot be steam sterilized.
 Tissue preservatives such as formaldehyde used to store and preserve body tissue prior to
histopathology.
 Chemical reagents used in the hospital Pathology Laboratory.
 Cytotoxic drugs requiring preparation prior to parenteral administration to cancer
patients.
 Processing chemicals for X-ray film development.
 Anesthetic gases in the Operating Theatre.
The hierarchy of principles for controlling chemical hazards are well documented and utilized
within hospitals:-
 Elimination (use an alternative process or strategy eg. disposables).
 Substitution (use the least toxic chemical that will do the job).
 Isolation (keep the relevant chemical in one isolated area if possible).
 Enclosure (e.g. gluteraldehyde fume cupboard, preparation enclosure for cytotoxics,
closed circuit anesthetic machines with scavenging of exhaust gases).
 Ventilation (X-ray processors).
 Personal protection (gloves, goggles, plastic gowns etc. where appropriate).

 Personal hygiene (hand washing after use).
 General cleanliness (clean up spills, appropriate storage, etc.).
Again, relevant staff must have appropriate training and education in the use of any of these
chemicals, and must be informed of any dangers including those of low risk.
Personal (Staff) Protection – Biological Hazards
Management of biological hazards should be comprehensively covered in the hospital‘s
Infection Control Manual, with the policies and procedures developed and monitored by an
Infection Control Committee chaired by an Infection Control Nurse. There are 3 important
modes of disease transmission from patients to staff:
1. Airborne and droplet aerosol exposure - includes viral upper respiratory tract infections,
measles and TB. Preventative measures include (i) keeping distance (>1m) from frontal
coughing as much as possible (ii) wash hands after every patient contact and especially
avoid rubbing eyes before washing (iii) high filtration face masks (where applicable -
generally not practical in the outpatient setting) (iv) isolate inpatients in a negative air
pressure room.
2. Skin contact exposure - includes Staphylococcus aureus and Varicella. Prevention
requires protective gown and gloves.
3. Exposure to infectious fluids via broken skin, eyes, mucous membranes, and parenteral
exposure - includes hepatitis B, hepatitis C, and HIV from all body fluids except sweat,
as well as gastroenteritis and hepatitis A from fecal fluid. Preventative measures include
universal precautions (gloves, gown, goggles and mask), and appropriate management of
sharps, spills, and contaminated waste.
If acute exposure to a biological hazard does occur, staff members need to be aware of relevant
policies and procedures for appropriate management of the exposure. This will include:
 Appropriate washing for mouth, eyes or skin exposure
 First aid for penetrating sharps injury
 Prophylaxis for high risk exposure
 Testing of the source if possible
 Testing and follow up of exposed staff
 Incident reporting.
Personal (Staff) Protection – Psychological Hazards
Hospitals are stressful places for sick and injured patients and their families. However they
can also be stressful for staff due to such factors as:
 Shift work, on call duty, fatigue and ―burn out‖.
 High workload and demand.
 High or unrealistic patient expectations.
 Verbal abuse or threats from disgruntled or intoxicated patients.
 High or unrealistic expectations from supervisors and management.
 Problematic interpersonal work relationships.
 Frustrations due to limited resources, especially staffing levels.
 Poor organizational climate with low staff morale.
Hospitals are part of a high demand, high expectation service industry and are heavily reliant on
staff for the friendly, safe, effective and efficient delivery of services. To optimize productivity

and attitude of staff, senior management must be committed to ensuring a conducive
organizational climate with high staff morale. Clear priorities and direction, realistic
performance goals and workloads, commitment to continuing education and quality assurance,
reception to staff feedback, and support with counseling services for stressed staff are all
important components.
Patient Protection
Nosocomial Infection Control
Minimizing adverse outcomes of health care for inpatients is of prime importance to
hospitals and a major focus of Quality Assurance activities. A very significant indicator of
quality care is the nosocomial infection rate.
The 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 need to be familiar
with its contents. Regular feedback on surveillance of nosocomial infection rates will help
motivate staff to remain vigilant.
Patient Safety
Injury prevention for patients may require some of the following interventions when
appropriate:-
 Diligence in keeping bed rails up particularly for those patients with an altered conscious
state from medication or illness.
 Bathroom / toilet aids particularly for the elderly or disabled.
 Nurse and physiotherapy assisted mobilization during recovery.
 Walking aids for the disabled, and during recovery.
 Occupational therapy home assessment for home aids.
 Community nurse visits for bathing etc. following discharge.
Evacuation Plans for Internal Emergencies
Various internal emergencies including fire, explosion and bomb threat may require
evacuation of all or parts of the hospital. Well-documented and rehearsed evacuation plans are
required to ensure the safe evacuation of disabled, immobilized or otherwise helpless patients. In
critical care areas this will include manual back up for life support systems.
Food Safety
Hospital kitchens prepare meals for inpatients and in many cases prepare meals for the
staff canteen. It is obviously imperative that food storage, handling and preparation is done to the
highest standards and poses no risk to already sick or compromised patients.
ROLE OF OCCUPATION HEALTH NURSE:
Occupational health nurses, as the largest single group of health care
professionals involved in delivering health care at the workplace, have responded to these new
challenges. They have raised the standards of their professional education and training,
modernized and expanded their role at the workplace, and in many situations have emerged as

the central key figure involved in delivering high quality occupational health services to the
working populations. Occupational health nurses, working independently or as part of a larger
multi professional team, are at the frontline in helping to protect and promote the health of
working populations.
DEFINITION:- OCCUPATIONAL HEALTH NURSE
Occupational Health Nurses (OHN)s are registered nurses who independently
observe and assess the worker's health status and to respect them from job tasks and hazards.
Using their specialized experience and education, these registered nurses recognize and prevent
health effects from hazards exposure.
SCOPE
Educationally prepared to recognize adverse health effects of occupational exposure and
address methods for hazard abatement and control, OHNs bring their nursing expertise to all
industries such as meat packing, manufacturing, construction as well as the health care industry.
 OHNs:
o Have special knowledge of workplace hazards and the relationship to the
employee health status.
o Understand industrial hygiene principles of engineering controls, administrative
controls, and personal protective equipment.
o Have knowledge of toxicology and epidemiology as related to the employee and
the work site.
Typical OHN Activities:
 Observation and assessment of both the worker and the work environment.
 Interpretation and evaluation of the worker's medical and occupational history, subjective
complaints, and physical examination, along with any laboratory values or other
diagnostic screening tests, industrial hygiene and personal exposure monitoring values.
 Interpretation of medical diagnosis to workers and their employers.
 Appraisal of the work environment for potential exposures.
 Identification of abnormalities.
 Description of the worker's response to the exposures.
 Management of occupational and non-occupational illness and injury.
 Documentation of the injury or illness.
Role of the Occupational Health Nurse in Workplace Health Management
The occupational health nurse may fulfill several, often inter related and complimentary,
roles in workplace health management, including:
 __Clinician
 __Specialist
 __Manager
 __Co-ordinator
 __Adviser
 __Health educator
 __Counsellor
 __Researcher

1. CLINICIAN:
 Primary prevention - The occupational health nurse is skilled in primary prevention of
injury or disease. The nurse may identify the need for, assess and plan interventions to,
for example modify working environments, systems of work or change working practices
in order to reduce the risk of hazardous exposure.
 Emergency care - The occupational health nurse is a Registered Nurse with a great deal
of clinical experience and expertise in dealing with sick or injured people. The nurse
should provide initial emergency care of workers injured at work, transfer of the injured
worker to hospital and emergency services. Occupational health nurses employed in
mines, on oil rigs, in the desert regions are more responsible for this work.
 Treatment services - In some countries occupational health services provide curative
and treatment services to the working population, in other countries such activities are
restricted.
 Nursing diagnosis - Occupational health nurses are skilled in assessing client‘s health
care needs, establish a nursing diagnosis and formulating appropriate nursing care plans,
in conjunction with the patient or client groups, to meet those needs. Nurses can then
implement and evaluate nursing interventions designed to achieve the care objectives.
The nurse has a prominent role in assessing the needs of individuals and groups, and has
the ability to analyse, interpret, plan and implement strategies to achieve specific goals.
 Individual and group care plan - The nurse can act on the individual, group, enterprise
or community level.
 General Health advice and health assessment - The occupational health nurse will be
able to give advice on a wide range of health issues, and particularly on their relationship
to working ability, health and safety at work or where modifications to the job or working
environment can be made to take account of the changing health status of employees.
2. SPECIALIST:
 Occupational health policy, and practice development, implementation and
evaluation- The specialist occupational health nurse may be involved, with senior
management in the enterprise, in developing the workplace health policy and strategy
including aspects of occupational health, workplace health promotion and environmental
health management.
 Occupational health assessment - Occupational health nurses can play an essential role
in health assessment for fitness to work, pre employment or pre placement examinations,
periodic health examinations and individual health assessments for lifestyle risk factors.
 Health surveillance - Where workers are exposed to a degree of residual risk of
exposure and health surveillance is required by law the occupational health nurse will be
involved in undertaking routine health surveillance procedures, periodic health
assessment and in evaluating the results from such screening processes. The nurse will
need a high degree of clinical skill when undertaking health surveillance and maintain a
high degree of alertness to any abnormal findings.
 Sickness absence management - Occupational health nurses can contribute by helping
managers to manage sickness absence more effectively. The nurse may be involved in
helping to train line managers and supervisors in how to best use the occupational health
services.

 Rehabilitation - Planned rehabilitation strategies, can help to ensure safe return to work
for employees who have been absent from work due to ill health or injury. The
occupational health nurse is often the key person in the rehabilitation programme who
will, with the manager and individual employee, complete a risk assessment, devise the
rehabilitation programme, monitor progress and communicate with the individual, the
occupational health physician and the line manager.
 Maintenance of work ability - The occupational health nurse may develop pro-active
strategies to help the workforce maintain or restore their work ability.
 Health and safety
 Hazard identification - The occupational health nurse often has close contact with the
workers and is aware of changes to the working environment. Because of the nurses
expertise in health and in the effects of work on health they are in a good position to be
involved in hazard identification.
 Risk assessment - Legislation is increasingly being driven by a risk management
approach. Occupational health nurses are trained in risk assessment and risk management
strategies depending upon their level of expertise.
3. MANAGER:
 Management - In some cases the occupational health nurse may act as the manager of
the multidisciplinary occupational health team, directing and co-ordinating the work of
other occupational health professionals. The OH nurse manager may have management
responsibility for the whole of the occupational health team, or the nursing staff or
management responsibility for specific programmes.
 Administration - The occupational health nurse can have a role in administration.
Maintaining medical and nursing records, monitoring expenditure, staffing levels and
skill mix within the department, and may have responsibility for managing staff involved
in administration.
 Budget planning - Where the senior occupational health nurse is the budget holder for
the occupational health department they will be involved in securing resources and
managing the financial assets of the department. The budget holder will also be
responsible for monitoring and reporting within the organization on the use of resourses.
 Marketing
 Quality assurance
 Professional audit
 Continuing professional development
4. CO-ORDINATOR:
 Occupational health team - The occupational health nurse, acting as a coordinator, can
draw together all of the professionals involved in the occupational health team. In many
instances the nurse will be the only member of the team who is permanently employed by
the institution.
 Worker education and training - The occupational health nurse has a role in worker
education. This may be within existing training programmes or those programmes that
are developed specifically by occupational health nurses to, for example, inform, educate

and train workers in how to protect themselves from occupational hazards, workplace
preventable diseases or to raise awareness of the importance of healthy practices.
 Environmental health management - The occupational health nurse can advise the
enterprise on simple measures to reduce the use of natural resources, minimise the
production of waste, promote re-cycling and ensure environmental health.
5. ADVISER:
 To management and staff on issues related to workplace health management -
Occupational health nurses act as advisers to management and staff on the development
of workplace health policies and practices, and can fulfil an advisory role by participating
in, for example, health and safety committee meetings, health promotion meetings, and
may be called upon to provide independent advice to managers or workers who have
specific concerns over health related risks.
 As a conduit to other external health or social agencies - Occupational health nurses
act in an advisory role when seeing individuals who may have problems that, whilst not
directly related to work may affect future work attendance or performance.
6. HEALTH EDUCATOR:
 Workplace Health promotion - Health education as one of the key prerequisites of
workplace health promotion is integral aspect of the occupational health nurses‘ role. In
some countries the nurse is required to support activities aimed at adoption of healthy
lifestyles within on-going health promotion process, as well as participate in health and
safety activities. Occupational health nurses can carry out a needs assessment for health
promotion.
7. COUNSELLOR:
 Counselling and reflective listening skills - Where the nurse has been trained in using
counselling or reflective listening skills they may utilise these skills in delivering care to
individuals or groups.
 Problem solving skills - Due to the close working relationship which occupational health
nurses have with the working population, and because of the nurses‘ position of trust,
occupational health nurses are often approached for advice on personal problems.

8. RESEARCHER:
 Research skills - Nurses are becoming increasingly familiar with both quantitative and
qualitative research methodologies, and can apply these in occupational health nursing
practice. In the main, occupational health nurses working at the enterprise level, are more
likely to use simple survey techniques, or semi-structured interviews, and to use
descriptive statistical techniques in their presentation of the data.
 Evidence based practice - Occupational health nurses are skilled in searching the
literature, reviewing the evidence available, which may be in the form of practice

guidelines or protocols, and applying these guidance documents in a practical situation.
Occupational health nurses should be well skilled in presenting the evidence, identifying
gaps in current knowledge.
 Epidemiology - The most widely used and accepted form of investigation into
occupational related ill health and disease is based on large-scale epidemiological studies.
ETHICS IN OCCUPATIONAL NURSING
The International Commission on Occupational Health (ICOH) has published
useful guidance on ethics for occupational health professionals. This guidance is
summarized in the following three paragraphs;
1. Occupational Health Practice must be performed according to the highest professional
standards and ethical principles. Occupational health professionals must serve the health
and social wellbeing of the workers, individually and collectively. They also contribute to
environmental and community health.
2. The obligations of occupational health professionals include protecting the life and the
health of the worker, respecting human dignity and promoting the highest ethical
principles in occupational health polices and programs. Integrity in professional conduct,
impartiality and the protection of confidentiality of health data and the privacy of workers
are part of these obligations.
3. Occupational health professionals are experts who must enjoy full professional
independence in the execution of their functions. They must acquire and maintain the
competence necessary for their duties and require conditions which allow them to carry
out their tasks according to good practice and professional ethics.
CONCLUSION:
Occupational diseases should not be neglected and should give proper attention at
time. It is the main role of a nurse to work as an educator and protector in the field of
occupation. Early detection and timely management can control occupational diseases.

Unit VII
MATERIAL
MANAGEMENT
 Concepts, principles and procedures
 Planning and procurement procedures :
Specifications
 ABC analysis,
 VED (very important and essential daily use)
analysis
 Planning equipments and supplies for nursing
care: unit and
 hospital
 Inventory control
 Condemnation

MATERIAL MANAGEMENT
CONCEPTS
Material management is concerned with providing the drugs, supplies and equipment needed by
health personnel to deliver health services. The right drugs, supplies and equipment must be at
the right place, at the right time and in the right quantity in order that health personnel deliver
health services. Without proper material, health personnel cannot work effectively, they feel
frustrated and the community lacks confidence in the health services and unless appropriate
materials are provided in proper time and is required quantity, productivity of personnel will not
be upto expectation.
Definition
Planning and control of the functions supporting the complete cycle (flow) of materials, and the
associated flow of information. These functions include (1) identification, (2) cataloging, (3)
standardization, (4) need determination, (5) scheduling, (6) procurement, (7) inspection,(8)
quality control, (9) packaging, (10) storage, (11) inventory control, (12)distribution, and (13)
disposal. Also called as materials planning.
Objectives of material management
 To reduce cost of material
 Ensure a good support with suppliers(vendors)
 Effective and efficient handling of materials at all stages and in all sections.
In other hand objectives of material management
 Low purchase price
 Maintaining continuous supply
 Maintaining quality
 Cordial relationship with supplier
 Low pay roll cost
 Development of vendose
 Good record
 Low storage cost
 Favourable reciprocal relation
 New material & products
 Standardization

 Product improvement
 Interdepartmental harmony
 Economic forecasting.
Aim of Material Management
To get
1. The right quality
2. Right quantity of supplies
3. At the right time
4. At the right place
5. For the right cost.
Purpose of Material Management
 To gain economy in purchasing
 To satisfy the demand during period of replenishment
 To carry reserve stock to avoid stock out.
 To stabilize fluctuations in consumption
 To provide reasonable level of client services
 Increase efficiency of health care systems.
 Develop knowledge and skills of health care
 Provide materials in required quantity and quality as when required.
Basic Principles of material Management
 Effective management and supervision; it deals on material functions of; planning,
organizing, staffing, controlling, report and budgeting.
 Sound purchasing method
 Skillful and hard poised negotiation
 Effective purchase system
 Should be simple
 Simple inventory control program.
Functions of Material Management
 Material planning & budgeting
 Purchasing
 Inventor control
 Cost reduction

 Value analysis
 Receiving & inspection
 Stocking & distribution
 Disposal.
Elements of Material Management
 Material planning
 Purchasing
 Receiving & warehousing
 Store keeping
 Inventory control
 Value analysis
 Standardization
 Production control
 Transportation
 Material handling
 Disposal scarp
PROCEDURE
Good material managers adopt the following procedures:
 Taking inventory regularly and systematically
 Requisitioning at indenting according to actual needs
 Receiving and inspecting incoming items
 Storing and protecting items
 Issuing items for use
 Proper use of items.

Some more procedures
 Identification of need
 Establishment of standards and specification, character, quality with full description
 Preparation of requisition or indents in the predesigned
 Selection of the right source that is supplier
 Determine right price, availability and delivery time
 Placement of purchase order
 Follow up
 Arranging of receipt, inspection, rejection replacement for defective pieces.
 Verification of invoices
 Payment of bills
 Maintenance of record.
PLANNING AND PROCUREMENT PROCEDURES IN MATERIAL
MANAGEMENT
Material management is a scientific technique, concerned with planning, organizing and
controlling the flow of materials from their initial purchase through internal operations to the
service point through distribution. The material management in the health care system is
concerned with providing the drugs, supplies and equipment needed by health personnel to
deliver health services. About 40 percent of the funds in the health care system are used up for
providing materials. It is of great importance that materials of right quality are supplied to the
consumers. Material management integrates all material functions;
 Planning for materials
 Demand estimation
 Purchasing
 Inventory management
 Inbound traffic
 Warehousing and stores
 Incoming quality control

MATERIAL PLANNING
"Material planning is the scientific way of determining the requirements that goes into
meeting production needs within the economic investment policies‖.
- Gopalakrishnan & Sunderasan
It is done at all stages and all levels of management. Material planning is based on certain
feedback information and reviews.
Aim of material management planning
To get:
 The Right quality
 Right quantity of supplies
 At the Right time
 At the Right place
 For the Right cost
Purpose of material management planning
 To gain economy in purchasing
 To satisfy the demand during period of replenishment
 To carry reserve stock to avoid stock out
 To stabilize fluctuations in consumption
 To provide reasonable level of client services
Objectives of material management planning
Primary objectives
 Right price
 High turnover
 Low procurement and storage cost
 Continuity of supply
 Consistency in quality
 Good supplier relations
Secondary objectives:
 Development of personnel
 Good information system
 Forecasting

 Inter-departmental harmony
 Product improvement
 Standardization
 Make or buy decision
 New materials and products
 Favorable reciprocal relationships
Basic principles of material management Planning
Effective management and supervision depends on managerial functions of:
 Planning
 Organizing
 Staffing
 Directing
 Controlling
 Reporting
 Budgeting
 Sound purchasing methods
 Skillful and hard poised negotiations
 Effective purchase system
 Should be simple
 Must not increase other costs
 Simple inventory control programme
Techniques of Material Planning
 Bill of Material technique:
 BOM is the simplest technique of materials planning.
 Explosion of bill of materials refers to splitting the requirements for the product to
be manufactures in to its basic components. E.g. in health care is drugs
manufactured in the pharmacy
 This technique is ideally suited to engineering industries.
 The technique is based on demand forecasts.
 Requirement for various materials are listed with their complete specifications
 Past Consumption Analysis Technique
 In this technique future projection is made on the basis of the past consumption
data, which is analyzed taken in to consideration the past and future plans.
 Statistical tools like mean, median, mode and standard deviation are used in
analyzing the past consumption.

Elements of Material Management Planning
 Demand estimation
A large number of items are used in the hospital. The advisory committee for
development of surgical instruments, equipment and appliances (1963) identified 3200
items of instruments, equipments and appliances being used in the hospital.
 Identify the needed items
 Need for variety reduction-less number of materials, less will be the problems of
planning
 Lying down proper specification based on ISI or other standards
 Calculate from the trends in Consumption
 Review past the consumption in the past
 Review with resource constraints
 Availability of funds
 Procurement process planning
Problems affecting material planning
 Corporate/ Government objectives and plans
 Technology available
 Market demand
 Lead time and rejection rates
 Working capital available
 Nature of inventory required
 Capacity and its utilization of the organization
 Seasonal variations
 Information and data available
 Overall material policy
PROCUREMENT
Most organizations have a detailed set of rules and regulations regarding the procedure
for ordering for materials. In the Government systems DGHS play a crucial role in purchasing
materials of heavy cost.
Objectives of procurement system

 Acquire needed supplies as inexpensively as possible
 Obtain high quality supplies
 Assure prompt and dependable delivery
 Distribute the procurement workload to avoid period of idleness and overwork
 Optimize inventory management through scientific procurement procedures
Procurement cycle
 Review selection
 Determine needed quantities
 Reconcile needs and funds
 Choose procurement method
 Select suppliers
 Specify contract terms
 Monitor order status
 Receipt and inspection
Methods in Procurement Process and Negotiation Strategies
 Open tender
 Public bidding, resulting in low prices
 Published in newspapers
 Quotations must be sent in the specific forms that are sold, before the time and date
mentioned in the tender form
 Technical bid
 Financial bid
 Restricted or limited tender
 From limited suppliers (about 10)
 Lead-time is reduced
 Better quality
 Negotiated procurement
 Buyer approaches selected potential Suppliers and bargain directly
 Fix at a rate acceptable to both parties
 Used in long time supply contracts
 Direct procurement
 Purchased from single supplier, at his quoted price

 Prices may be high
 Reserved for proprietary materials, or low priced, small quantity and emergency
purchases
 Rate contract
 Firms are asked to supply stores at specified Rates during the period covered by the
Contract
 Spot purchase
 It is done by a committee, which includes an officer from stores, accounts and
purchasing departments
 Risk purchase
 If supplier fails, the item is purchased from other agencies and the difference in cost
is recovered from the first supplier
 Many Suppliers Strategy
 Many sources per item
 Adversarial relationship
 Short-term
 Little openness
 Negotiated, sporadic PO‘s
 High prices
 Infrequent, large lots
 Delivery to receiving dock
 Few Suppliers Strategy
 1 or few sources per item
 Partnership (JIT)
 Long-term, stable
 On-site audits and visits
 Exclusive contracts
 Low prices (large orders)
 Frequent, small lots
 Delivery to point of use
 Contractual services by Directorate General of Supplies and Disposals for Government
Institutions

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

Issue and use
Can be centralized or decentralized
Inventory control
It means stocking adequate number and kind of stores, so that the materials are available
whenever required and wherever required. Scientific inventory control results in optimal balance
Functions of inventory control
 To provide maximum supply service, consistent with maximum efficiency and optimum
investment.
 To provide cushion between forecasted and actual demand for a material
ABC ANALYSIS
DEFINITION
ABC analysis helps us in segregating the items from one another and tells us how much valued
the items is and controlling it to what extent is in the best interest of the organization.
 It is the analysis of stores items on cost criteria. It has been seen that a large number of
items consume only a small percentage of resources and vice versa.
 A items- Represents high cost centre
 B items- intermediate cost centre
 C items- low cost centre.
 ―It is the process of classifying items by using values as measure‖.
OBJECTIVE
The main objective is to frame policy guidelines regarding control of items. First of all
the items are classified into three classes viz A items, B items and C items. Expensive items are
to be branded as A items, which constitute 10% of overall items but whose percentage in terms

of value is around 70%. The least expensive items are to be branded as C items, whose number
items will be 70% of total number of items but its value will be around 10% of the total items of
inventory. The in-between are to be branded as B items whose number of items will be
THE ABC METHOD OF INVENTORY CONTROL
Also called as Pareto analysis. In ABC analysis, the entire lot of inventory is classified into three
groups based on their annual value and not on their individual cost given as:
 Class A: High value items, which accounts for major share of annual inventory value.
Stricter control must obviously be applied on these items right from the initial stages of
estimating requirement, fixing the minimum stocks, lead time.
A items:
1. Rigorous value analysis
2. Rigid estimates
3. Strict and close watch
4. Management of items should be done at top management level
5. Centralized purchasing and storage
 Class B: Medium value items, which do not belong to either of the classes and not so
strict control procedures, need be followed in regard to the items in this group.
B items
1. Moderate controls
2.Purchase based on rigid requirement
3.Reasonably strict watch and control
4. Management be done at middle level

 Class C: Low values items, but are required in large quantities and consists of various
types and varieties like clips, washers. It needs only a simple and inexpensive system of
control in which some of the routine may be relaxed.
C items
1. Ordinarily control measures
2. Purchased based on usage estimates
3. Controls exercises by store keeper
4. Management be done at lower levels.
5.Decentralized (delegated) purchasing
Another recommended breakdown of ABC classes:
1. "A" approximately 10% of items or 66.6% of value
2. "B" approximately 20% of items or 23.3% of value
3. "C" approximately 70% of items or 10.1% of value
ABC CLASSIFICATION LEVELS
Items Class A Class B Class C
Number of items as a % of total number 10 20 70
Annual usage value as a % on total usage
value
70 20 10
Annual value (a) is defined as: A= VQ,
where, Q= annual consumption on quantity terms
V= value (cost) per item

ABC analysis tells us that 5-10 percent of all items(called A category) accounts for 70% of
annual consumption costs, another 10-20% of items (B category) account for 20-30% of the
costs, while the balance 70% of items(C category) account for about 5-10% of costs.
PROCEDURE OF ABC CLASSIFICATION
When carrying out an ABC analysis, inventory items are valued (item cost multiplied by quantity
issued/consumed in period) with the results then ranked. The results are then grouped typically
into three band. These bands are called ABC codes.
 Step 1:
List down item-wise annual consumption of inventory with its unit price and determine the
annual consumption of each item.
 Step 2:
Rewrite the above list in descending order of money value with additional column to enter
‗cumulative % value‘.
 Step 3:
a. From the list prepared, mark the serial number of items against which the
cumulative % value of annual consumption reaches a figure of 70%
approximately. These are called class A items and compute the number of class A
items as a percent of total items.
b. Continue this process down the list and note the serial number of items against
which the cumulative % value reads approx. 90%. These additional items
constitute class B.
c. The remaining items in the list form class C items and determines quantity in
percent of total number of items.
 Step 4:
Plot a curve with cumulative percentage of annual usage on quantity terms on X-axis and money
value on Y-axis.
CONTROL
 Class A items are controlled and purchased only on as-required basis to minimize
carrying cost. Higher level control is exercised, these being high value items.

 Class C items can be purchased in bulk for the requirement of the entire year,
being of low value. The control is exercised at lower level.
 Class B items come in between A and C on degree of control.
ADVANTAGES
Provides a mechanism for identifying items that will have a significant impact on overall
inventory cost
It helps in economizing ones effort to achieve greater results.
It helps to segregating those items which ought to be given priority to maximize results.
The usefulness of this management tool is that, by focusing on the ‗A‘ category items,
70% results can be achieved with just 5% effort.
Once A category items are identified, it is possible to devote more attention to these
items to minimize purchase costs and exercise control over consumption in a more
effective manner.
Proper use of valuable time of store personnel.
Simple no confusing formulas are involved
LIMITATION
 When number of items runs into several thousands, it is not convenient to compute and
carry out this analysis.
 More chances of deterioration in storage exist since class c items are purchased in bulk
and inventory on these piles up.
 Loose control on C may result in shortages.
 ABC focuses on money value and not on functional importance of such items,
resulting in shortages of critical items.
 ABC does not take into account variation of prices of items as time goes.
 ABC ignores market conditions, market availability, competitions, seasonal variations
etc.

VED ANALYSIS
In VED Method (vital, essential and desirable) , each stock item is classified on either
vital, essential or desirable based on how critical the item is for providing health services. The
vital items are stocked in abundance, essential items are stocked in medium amounts and
desirable items we stocked in small amounts. Vital and essential items are always in stock which
means a minimum disruption in the services offered to the people.
THE VED METHOD OF INVENTORY CONTROL
In VED analysis, the inventory is classified as per the functional importance under the following
three categories:
 Vital (V)
 Essential (E)
 Desirable (D)
 Vital:
Items without which treatment comes to standstill: i.e. non- availability cannot be tolerated. The
vital items are stocked in abundance, essential items and very strict control.
 Essential:
Items whose non availability can be tolerated for 2-3 days, because similar or alternative items
are available. Essential items are stocked in medium amounts, purchase is based on rigid
requirements and reasonably strict watch.
 Desirable:
Items whose non availability can be tolerated for a long period. Desirable items are stocked in
small amounts and purchase is based on usage estimate.
Although the proportion of vital, essential and desirable items varies from hospital to hospital
depending on the type and quantity of workload, on an average vital items are 10%, essential
items are 40% and desirable items make 50% of total items available.

PURPOSES
 In a manufacturing organization, there are number of items which are very vital or critical
in production.
 Their availability must be ensured at all times for smooth production, so need to be
strictly controlled.
 Essential items follow vital items in their hierarchy of importance.
 Desirable items are least importance in terms of functional considerations, which are
loosely controlled at the lower level.
MATRIX OF ABC/ VED ANALYSIS
There can be combination of these two categories like a matrix combining ABC and VED
categories. This matrix is more relevant in the hospitals. The AV category becomes the most
important for inventory control because the items are very much cost consuming being a
category and also vital for uses. These items can be controlled by the top-level management. The
CD category items are not very costly and at same time of desirable category. These items can be
controlled at the lower level.
V E D
A AV AE AD
B BV BE BD
C CV CE CD

CONTROL OF VED ITEMS
a. Category I items: these items are the most important ones and require control by the
administrator himself.
b. Category II items: these items are of intermediate importance and should be under control
of the officer in charge of the stores.
c. Category III items: these items are of least importance which can be left under the control
of the store keeper.
d. The grouping will essentially depend upon the strategy of management and the
environment of functioning. However these simple techniques can be effective in
material management system.
e. Items with high criticality (V), but required in small quantity (A) should receive highest
priority. Items with low criticality (D) and which are required in big quantity should
receive least priority.
PLANNING EQUIPMENTS AND SUPPLIES FOR NURSING CARE: UNIT AND
HOSPITAL
Material Management Cycle
Demand estimation
Receiving & inspection
Stocking
Inventory control
Distribution
Hospital Supplies and Equipments
Hospital supplies and equipments are dealt with under material management. Supplies are those
items that are used up or consumed ; hence the term consumable is used for supplies. The

supplies in hospital include drugs, surgical goods (disposables, g;lass wares), chemicals,
antiseptics, food materials, stationeries, the linen supply etc. The term equipment is used for
more permanent type of article and may be classified as fixed and movables. Fixed equipment is
not a structure of the building, but it is attached to the walls or floors.(sterilizer) Movable
equipment includes furniture , instruments etc.
Materials used in hospitals
Hospital material medical side
 Perfusion material
 Surgical disposables
 Instruments
 Drugs, medicine, oxygen, linen
 Biomedical equipment
 Disinfecting items
 Computers, telephone and fax
 Food and beverage materials
 Anesthetic equipment
 Electro medical equipment
 Glass ware, dental machines
 Surgical dressing utensils
 Artificial limbs,bandages, cots for
patient, furniture
 Engineering items and many others
Hospital material management side
 Computer, fax, telephone, stationery
items
 Public address items overhead
projector
 Audiovisual systems
Purchase of supplies and equipment
The purchase of equipments and supplies in a hospital is carried out through:
1. General store
2. Dietary department and
3. Pharmacy department

When planning for the purchase of articles, budgeting is done not only for the actual price of
articles but also for the additional costs that are involved such as :
 Transport charges (local delivery reduce the transport charge)
 Incidental costs
 Cost of chemicals and other consuable to be used with the equipment(eg; ECG paper for
an ECG machine)
 Operating costs(hiring a technician)
 Cost of maintenance service; 10-20% of hospital equipment may remain idle if serving is
not done periodically.
 Cost of technology obsolesces: When a better quality appears in market there is tendency
to discard the old model.
 Replacement cost of equipment
Selection of article:
While buying articles it has to meet the standards. Indian Standards Institution is the
national agency set up to bring standardization of articles in India. Articles that meet the criteria
specified by the Indian Standard Institution will be marked by ISI markings. The articles bought
should safety to the patient and personnel. Faulty instruments and equipments cause not only
inconvenience in the patient care, but also it may cause the loss of life.
Purchasing article:
 The material used for any equipment should be durable, non-corroding, non- toxic and
safe for use.
 Should have standard shapes and dimensions to fit into various situations
 Reparability and spare part availability of the article
 Interchangability of the article
 All surgical instruments used in a hospital should be sterilisable and they should stand
the tests for leakage, hydraulic pressure tests for bursting etc
 Should have accuracy in measurements
 Should have ease of operation

The central supply service
Most hospital have a central department where equipments and supplies are stored and from
which they are distributed to the units. The type of materials that is kept in the central supply
room varies from hospital to hospital . OIn some hospital the central soppy room deals only the
sterile supplies and ward trays. In other hospitals all types of equipment such as oxygen, suction,
ward trays, catheters, syringes etc are stored here.
Linen supply:
Methods of handling linen supply include:
a) Departmentalised system
b) Centralised linen supply
General utility services in the hospital
1. Electric supply and installations
2. Water supply
3. Disposal of waste –liquids and solids
4. Refrigeration , air conditioning, ventilation and environment control
5. Trasport
6. Supply of medical gases, compressed air, hot water, vacuum suction and gas plants
7. Laundry
8. Fire –hazard
9. Communication
10. Repairs workshop.
Essential equipments for a 50 bedded district hospital(WHO)
1) Scope of services
 Essential clinical services- medicine, surgery, pediatrics, OBG, and acute
psychiatry( when necessary)
 Optional clinical services – Oral surgery, orthopedic surgery, otolaryngology,
neurology and psychiatry

 Essential clinical support- anesthesia, radiology and clinical laboratory
 Optional clinical support services- pathology and rehabilitation including
physiotherapy.
2) Essential medical equipment
 Diagnostic imaging equipment –It includes x-ray and ultrasound equipment. X-
ray equipment can be stationery in one room or mobile.
 Laboratory equipment-
o Microscope
o Blood counter
o Analytical balance
o Calorimeter
o Centrifuge
o Water bath
o Incubator/oven
 Refrigerator
 Instillation and purification apparatus
3) Electrical medical equipment
 Portable electrocardiograph
 Defibrillator(external)
 Portable anesthetic unit
 Respirator- it should be applicable for prolonged administration during post
operative care.
 Dental chair unit- a complete unit should be available to carry out standard dental
operations.
 Suction pump- one portable and one other suction pump are required.
 Operating theatre lamp- one main lamp with at least 8 shadows lamp and an
auxillary of 4 lamp units.
 Delivery table-it should be standard and mainly operated.
 Diathermy unit- a standard coagulating unit which is operated by hand or foot
switch, with variable poor control.

4) Other equipment
 Autoclave – for general sterilization
 Small sterilizers- for specific services.eg. Stabiliser
 Cold chain and other preventive medical equipment
 Ambulance
5) Small, inexpensive equipment and instruments
 Equipment and instruments, such as BPapparatus, oxygen manifolds, stethoscope,
diagnostic sets and spotlights.
PLANNING SUPPLIES AND EQUIPMENTS DURING EMERGENCIES AND
DISASTER
Introduction
Emergency preparedness planning requires a wide variety of supplies, equipment and
resources, including personal protective equipment (PPE), decontamination equipment, and
training. Planning should include collaborating with local emergency planning committees,
local/state public health departments, and area hospitals to determine the supplies, equipment,
and resources each healthcare facility needs to handle a disaster.
Products and contracted suppliers
Many products generally available and routinely used in healthcare facilities may also be
used in emergency preparedness/safety planning. Other specialized items – for example, Level C
equipment like powered respirators – are used primarily in emergency preparedness. The Safety
Institute's emergency preparedness products file, lists products and equipment that may be
considered when developing an emergency preparedness supply inventory. This file is intended
to serve only as an example and may not include all items and contracted suppliers that should be
considered.
Products and equipment for emergency preparedness
Healthcare facilities purchase many of the supplies and materials needed for safety and
emergency preparedness on a regular basis from a variety of companies. Some of these routine

supplies may also be designated for a disaster supply inventory. In addition, emergency
preparedness requires specialized equipment and supplies. Many companies with comprehensive
emergency-preparedness, safety-related equipment offers catalogs, some of which are available
online.
Product categories
The following table provides some sample categories and subcategories of search terms that may
be useful in locating specific healthcare products, equipment, and training services for
emergency preparedness.
Safety catalog search terms by categories and subcategories
Category Subcategories
Apparel – Personal or
protective clothing
Eye, face, head, foot, hearing protection;
respiratory protection
Personal protective
equipment (PPE)
PPE response kits
(A, B, C, D)
Example: first responder level C kit
Clinical diagnostics Clinical diagnostics; sample collection/transportation; swabs, wipes
Decontamination Spill control
Detection; monitoring Detection instruments; personal alarm kits; gas detection instruments
Fire equipment Extinguishers
First aid Blankets, kits
Mail handling products Powder-free gloves, bags
Monitoring

Operations; traffic
safety
Crowd control, flashlights, signs, barricades
Safety First aid, personal protection
Surge capacity Temporary negative pressure units
Training resources Health & training services; respiratory protection training, hearing and
biological screening
General Considerations in material management during disaster:
a. Supplies and Equipment:
1. Extra supplies will be obtained from purchasing personnel through runners.
2. Outside supplies will be ordered by the Purchasing Director and brought into the hospital
via the loading dock.
3. Be responsible for setting up extra beds in hospital if needed, as well as transporting
storeroom supplies and bringing in extra supplies from other areas.
4. Be willing to help with movement of victims from ambulance to Triage.
b. Materials Management - Purchasing
1. Department Head or designee will call in their own personnel as needed after reporting to
Command Center.
2. Be prepared to supply all departments with needed supplies.
3. Director will designate assistant to supply runners or volunteers to deliver supplies.
4. Have an up-to-date list of suppliers who can quickly supply extra materials.
5. Have Kardex in Storeroom up-to-date.
c. Valuables and Clothing:
1. Large paper or plastic bags are available in the treatment Areas and the storeroom for
patient's clothing and valuables.
d. Housekeeping and Laundry
1. Department head or designee will call in their own personnel as needed after reporting to
Command Center.
2. Be sure all hallways or traffic areas are clear of cleaning carts, equipment and etc.

e. Operating Room, CSR, PAR, Anesthesia, & OP
1. Check area for supplies and equipment.
2. Keep minimum list of supplies on hand and be prepared to process additional sterile
supplies quickly.
3. Notify anesthetists who will maintain adequate anesthesia and drug supplies.
f. Hospital Unit - Supervisor will:
1. Prepare for expansion by notifying maintenance of number of extra beds needed and
where to set them up.
2. Send for extra supplies needed from Purchasing, CSR, Laundry, and Dietary.
3. Will make wheelchairs available.
g. Laboratory
1. Have arrangements made to obtain additional blood, equipment and supplies from area
agencies.
i. Pharmacy
1. Report to Command Center, and then remain in department.
2. Have list of drug suppliers that can provide emergency supplies quickly
3. Keep minimum supply of emergency drugs on hand at all times.
4. Pharmacy should remain open and have a runner to deliver needed meds to areas.
j. Respiratory Therapy
1. Keep adequate supply of bubblers, cannulas, masks and flow meters available in
Respiratory Therapy Department.
2. Be prepared to obtain additional respirators and equipment as needed.
3. Keep resuscitation equipment in good operating condition and well marked.
INVENTORY CONTROL, CONDEMNATION AND DISPOSAL.
Definition Of inventory control:
Inventory: inventory is the list of moveable items which are required to manufacture a product
or to maintain equipment. Inventory is a unique item having identification number, nomenclature
and specification.
Following are the types of inventory:
 Raw materials
 Components
 Work in progress
 Finished goods

The inventory is basically of two types:
Official inventory: the materials lying in the main store s and being accounted for but have not
been issued to the user units.
a. Medical and surgical items
b. Dressings
c. Linens
d. X-ray supplies
e. Laboratory supplies
f. Housekeeping items
g. All processed sterile items
Unofficial inventory: the materials have been issued to the user units like the dispensary, CSSD,
laundry, wards, OPD, cast rooms etc. In case of forecasting or demand estimation, these items
are not taken into consideration by the hospital administration, so it is called as un-official
inventory for hospitals.
Functions of inventory control:
 To carry adequate stock to avoid stock-outs
 To order sufficient quantity per order to reduce order cost
 To stock just sufficient quantity to minimize inventory carrying cost
 To make judicial selection of limiting the quantity of perishable items and costly
materials
 To take advantage of seasonal cyclic variation on availability of materials to order the
right quantity at the right time.
 To provide safety stock to take care of fluctuation in demand/ consumption during lead
time.
 To ensure optimum level of inventory holding to minimize the total inventory cost.
Concepts relevant in controlling inventory costs:
The following concepts are relevant in controlling the inventory costs:
Periodic/ cyclic system: this system involves review of stock status at periodic/ fixed
intervals and placement of orders depending on the stock on hand and rate of
consumption. The ordering interval is thus fixed but the quantity to be ordered varies
each time.
Two bin system: it is a system where the stock of each item is held in two bins, one
large bin containing sufficient stock to meet the demands during interval between
arrival of an order quantity and placing of next order, and the other bin containing
stocks large enough to satisfy probable demands during the period of replenishment.
When the first bin is empty, an order for replenishment is placed, and the stock in the
second bin is utilized until the ordered material is received.

Lead time: this is the period required to obtain the supply once the need is
determined. It is therefore the average number of days between placing an indent and
receiving the material. Lead time is composed of two elements: administrative or
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 )
Costs:
a. Ordering costs: this is the cost of getting an item into the store. The process of ordering
starts with raising requisition, placing an order, follow up, transportation receipt and
inspection, acceptance and placing in stores.
b. Carrying costs: this is the cost of holding an item in the store till it is issued out or sold.
Following are the elements:-
 Interest on capital cost incurred.
 Cost of obsolescence, wastages, damages.
 Rent, insurance, depreciation and taxes
 Maintenance costs of inventory like special treatment, stock taking etc.
 Operating costs of store like direct labor and overheads like electricity, dust
proofing etc.
c. Shortage costs: these are the costs incurred both directly and indirectly due to shortages
like intangible costs due to loss of goodwill, opportunity loss or production hold costs.
d. Total inventory cost: A total inventory cost consists of carrying costs and ordering costs.
e. Lead time: this is the time which has elapsed between placing an order till the same items
are received, stocked and ready to use.

Average inventory:
Average inventory is defined in two cases:
Average inventory at constant usage rate:
Average inventory = opening stock+ closing stock
2
Average inventory at variable usage rate:
 Simple average method:
Average inventory = opening stock+ closing stock
2
 Six monthly average method:
Average inventory= opening stock+ stock after 6 months+ closing stock
2
 Quarterly average method:
Average inventory = sum of 4_- quarterly stock + closing stock
5
 Monthly average method:
Average inventory = sum of 12_- quarterly stock + closing stock
13
Selective inventory control:
Definition: selective inventory control means grouping the inventory and classifying for the
purpose of applying the right type of control based on their costs and functional importance.
Objective: the primary objective of inventory control is to minimize total cost of inventory. It
requires the following
 Supervision on planning and control of inventory functions like forecast of requirements
 Purchase quantity fixation
 Storage and supply
Need for selective inventory control:
Inventory consists of many items, in which some are costly whereas some may be not.
Some inventories are required in large quantities whereas some are required in limited
quantities, thus each item require different type of control, some tight and some loose.

Methods of selective inventory control:
Following are the popular methods of selective inventory control:
a. ABC analysis
b. VED analysis
CONDEMNATION & DISPOSAL
The materials which could not be used within its shelf life, deteriorated and declared unfit for
use, became obsolete or banned due to legal provisions are considered for condemnation or
disposal.
Criteria for condemnation:
The equipment has become:
1. Non-functional & beyond economical repair
2. Non-functional & obsolete
3. Functional, but obsolete
4. Functional, but hazardous
5. Functional, but no longer required
PROCEDURE FOR CONDEMNATION
Following procedure is generally carried out in case of the materials particularly drugs and non-
drug items:
 A condemnation committee comprising of three or more members is constituted by the
competent authority, the terms of reference of the committee are:
i. To go in details of the reasons as to why this situation has occurred.
ii. The people who are responsible for the lapses on the aspects from acquisition to
storage and distribution of materials.
iii. To suggest measures to be taken for disposal of the items.
 The committee members go into details through inventory records right from the point of
demand estimation to the distribution level of materials, and will find out reasons for
being an item surplus and remained unused.
 The committee will declare the items condemned and make recommendation for further
disposal of items.
 The condemned items are to be destroyed, so it is to be taken out from the inventory
registers, a write off sanction of the competent authority is obtained before final disposal.
 The items particularly medicines which are toxic and cannot be disposed of by burial or
as per the relevant laid down rules under the subject of waste disposal.

The effective measures are taken for disposal of surplus items before it becomes unfit for use is:
A list of surplus material is circulated among the hospital staff/user units requesting them
to pay special attention for mobilizing such items and giving priority to this category of
items.
The surplus materials are transferred to other hospitals where these may be required.
The surplus materials are offered to the manufacturer/ suppliers for buy back.
In case of materials other than drugs like equipments, instruments any such articles are
treated as salvage or scrap, whatever the case may be, action is taken accordingly:
 The materials may be sold by inviting tender.
 Open auctions of items through authorized auctioneers.

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

QUALITY ASSURANCE- CONTINUOUS QUALITY IMPROVEMENT
Introduction
Quality management (QM) and quality improvement (QI) are the basic concepts
derived from the philosophy of total quality management (TQM). Now it is preferred to use
the term Continuous Quality Improvement (CQI) since TQM can never be achieved. And the
method of monitoring of healthcare for CQI is done with Quality Assurance (QA).
Definition
―Quality assurance is a judgment concerning the process of care based on the extent to
which that care contributes to valued outcomes.‖ -Donabedian 1982
―Quality assurance is the measurement of provision against expectations with declared
intention and ability to correct any demonstrated weakness.‖ -Shaw
―Quality assurance is a management system designed to give maximum guarantee and
ensure confidence that the service provided is up to the given accepted level of quality, the
standards prescribed for that service which is being achieved with a minimum of total
expenditure.‖ -British Standards Institute
―CQI is an ongoing quality improvement measure using management and scientific
methods of quality assurance involving data collection, its analysis, and formulating ways to
improve performance outcome according to proposed standards.‖
Quality assurance vs. Continuous quality improvement (Koch, 1993)
Quality improvement is not necessarily a replacement for existing quality assurance activities,
but rather an approach that broadens the perspectives on quality.
Quality assurance (QA) Quality Improvement (QI)
 Inspection oriented (detection)
 Reaction
 Correction of special causes
 Responsibility of few people
 Narrow focus
 Leadership may not be vested
 Problem solving by authority
 Planning oriented (prevention)
 Proactive
 Correction of common causes
 Responsibility of all people involved
with the work
 Cross- functional
 Leadership actively leading
 Problem solving by employees at all
levels

Objectives
 To successfully achieve sustained improvement in health care, clinics need to design
processes to meet the needs of patients.
 To design processes well and systematically monitor, analyze, and improve their
performance to improve patient outcomes.
 A designed system should include standardized, predictable processes based on best
practices.
 Set Incremental goals as needed.
NASA Ames Research Center Health Unit
 Public accountability- It provides evidence that the funds are being spend both
effectively resulting in optimum utilization of the resource resulting in operational
efficiency and efficiency of services provided.
 Management improvement- This is to provide quality assurance programme as a tool
for managerial problem solving. It includes identification of the problem in areas of
technical quality, efficiency, risk and patient satisfaction to assess its nature, causes and
taking effective actions to reduce or eliminate the identified problems.
 Facilitation of adoption of innovations- It includes evaluation of performance of
individuals professionals, preparation of appropriate criteria for assessment of processes
and outcome, exchange of information within and outside the organization, and
introduction of innovations with assessment of their impact on patient care outcome, risk
and satisfaction by using the patient as a unit for analysis.
Quality assurance whether in health or education had two main objectives:
 To provide technical assistance in designing and implementing effective strategies for
monitoring quality and correcting systemic deficiencies and
 To refine existing methods for ensuring optimal quality health care through an applied
research programme
(Decker, 1985 and Schroeder, 1984).
Purposes/ Need
 Rising expectations of consumer of services.
 Increasing pressure from national, international, government and other professional
bodies to demonstrate that the allocation of funds produces satisfactory results in terms of
patient care.

 The increasing complexity of health care organizations.
 Improvement of job satisfaction.
 Highly informed consumer
 To prevent rising medical errors
 Rise in health insurance industry
 Accreditation bodies
 Reducing global boundaries.
Principles
 QM operates most effectively within a flat, democratic and organizational structure.
 Managers and workers must be committed to quality improvement.
 The goal of QM is to improve systems and processes and not to assign blame.
 Customers define quality.
 Quality improvement focuses on outcome.
 Decisions must be based on data.
According to W Edward Deming; (Deming‘s 14 points)
 Crete consistency of purpose for improvement of product and service.
 Adopt the new philosophy
 Cease dependence on inspection to achieve quality.
 End the practice of awarding business on the basis of price tag.
 Improve constantly and forever the systems of production and service.
 Institute training on the job.
 Institute leadership.
 Drive out fear.
 Break down barriers between departments.
 Eliminate slogans, exhortations, and target for the workforce.
 Eliminate numerous quotas for the workforce and numerical goals of management.
 Remove barriers that rob people of pride and workmanship.
 Institute a vigorous programme of education and self-improvement for everyone.
 Put everyone in the company to work to accomplish the transformation.
Approaches
 General approach
 Specific approach
General approach: - It involves large governing or official bodies evaluating a person or
agencies‘ ability to meet established criteria or standard during a given time.

a) Credentialing- It is the formal recognition of professional or technical competence
and attainment of minimum standards by a person and agency. Credentialing
process has 4 functional components
 To produce a quality product
 To confirm a unique identity
 To protect the provider and public
 To control the profession
b) Licensure- It is a contract between the profession and the state in which the
profession is granted control over entry into an exit from the profession and over
quality of professional practice.
c) Accreditation- It is a process in which certification of competency, authority, or
credibility is presented to an organization with necessary standards.
d) Certification
e) Charter- It is a mechanism by which a state government agency under state law
grants corporate state to institutions with or without right to award degrees.
f) Recognition- It is defined as a process whereby one agency accepts the
credentialing states of and the credential confined by another.
g) Academic degree
Specific approach: - These are methods used to evaluate identified instances of provider and
client interactions.
a) Audit- It is an independent review conducted to compare some aspect of quality
performance, with a standard for that performance.
b) Direct observation- Structured or unstructured based on presence of set criteria.
c) Appropriateness evaluation- The extent to which the managed care organization provides
timely, necessary care at right levels of service.
d) Peer review- Comparison of individual provider‘s practice either with practice by the
provider‘s peer or with an acceptable standard of care.
e) Bench marking- A process used in performance improvement to compare oneself with
best practice.
f) Supervisory evaluation
g) Self-evaluation

h) Client satisfaction
i) Control committees
j) Services- Evaluates care delivered by an institution rather than by an individual provider.
k) Trajectory- It begins with the cohort of a person who shares distinguishing
characteristics and then follows the group going through the healthcare system noting
what outcomes are achieved by the end of a particular period
l) Staging- It is the measurement of adverse outcomes and the investigation of its
antecedence.
m) Sentinel- It involves maintaining of factors that may result in disease, disability or
complications such as;
 Review of accident reports
 Risk management
 Utilization review
Elements/ components
 According to Donabedian;
 Structure Element- The physical, financial and organizational resources provided
for health care.
 Process Element- The activities of a health system or healthcare personnel in the
provision of care.
 Outcome Element- A change in the patient‘s current or future health that results
from nursing interventions.
 According to Manwell, Shaw, and Beurri, there are 3A‘s and 3E‘s;
 Access to healthcare
 Acceptability
 Appropriateness and relevance to need
 Effectiveness
 Efficiency
 Equity
STANDARDS
Standards are written formal statements to describe how an organization or professional
should deliver health service and are guidelines against which services can be assessed. Kirk and
Hoesing (1991) stated that standards are needed to;

 Provide direction
 Reach agreement on expectations
 Monitor and evaluate results
 Guide organizations, people and patients to obtain optimal results.
Standards are directed at structure, process, and outcome issues and guide the review of systems
function, staff performance, and client care. The organizations providing quality indexes are;
•AHRQ –Agency for Healthcare Research and Quality
•IHI –Institute for Healthcare Improvement
•JCAHO –Joint Commission on Accreditation of Healthcare Organizations
•NAHQ –National Association for Healthcare Quality
•IOM –Institute of Medicine
•NCQA –National Committee for Quality Assurance
Areas of QA
The assurance in various key areas are;
 Outpatient department- The points to be remembered are;
 Courteous behavior must be extended by all, trained or untrained personnel.
 Reduction of waiting time in the OPD and for lab investigations by creating more
service outlets.
 Provide basic amenities like toilets, telephone, and drinking water etc.
 Provision of polyclinic concept to give all specialty services under one roof.
 Providing ambulatory services or running day care centers.
 Emergency medical services
Services must be provided by well trained and dedicated staff, and they should
have access to the most sophisticated life- saving equipment and materials, and
also have the facility of rendering pre- hospital emergency medical aid through a
quick reaction trauma care team provided with a trauma care emergency van.
 In- patient services
Provide a pleasant hospital stay to the patient through provision of a safe, homely
atmosphere, a listening ear, humane approach and well behaved, courteous staff.
 Specialty services
A high tech hospital with all types of specialty and super- specialty services will
increase the image of the hospital.
 Training
A continuous training programme should be present consisting of ‗on the job
training‘, skill training workshops, seminars, conferences, and case presentations.

MODELS
1. Donabedian Model (1985): It is a model proposed for the structure, process and outcome of
quality. This linear model has been widely accepted as the fundamental structure to develop
many other models in QA.
2. ANA Model: This first proposed and accepted model of quality assurance was given by Long
& Black in 1975. This helps in the self- determination of patient and family, nursing health
orientation, patient‘s right to quality care and nursing contributions.
Identify
structure ,
standard and
criteria
Apply the process,
standards and
criteria
Evaluate
outcome of
standards
and criteria

3. Quality Health Outcome Model: The uniqueness of this model proposed by Mitchell & Co is
the point that there are dynamic relationships with indicators that not only act upon, but also
reciprocally affect the various components.
System
(Individual,
Group/ organization)
Intervention Outcome
Client
(Individual, Family & Community)
4. Plan, Do, Study, Act cycle: It is an improvement model advocated by Dr. Deming which is
still practiced widely that contains a distinct improvement phase.
Use of PDSA model assumes that a problem has been identified and analyzed for its most
likely causes and that changes have been recommended for eliminating the likely causes. Once
the initial problem analysis is completed, a Plan is developed to test one of the improvement
changes. During the Do phase, the change is made, and data are collected to evaluate the results.
Study involves analysis of the data collected in the previous step. Data are evaluated for
evidence that an improvement has been made. The Act step involves taking actions that will
‗hardwire‘ the change so that the gains made by the improvement are sustained over time.
5. Six Sigma: It refers to six standard deviations from the mean and is generally used in quality
improvement to define the number of acceptable defects or errors produced by a process.
It consists of 5 steps: define, measure, analyze, improve and control (DMAIC).
 Define: Questions are asked about key customer requirements and key processes to
support those requirements.
 Measure: Key processes are identified and data are collected.
 Analyze: Data are converted to information; Causes of process variation are identified.
 Improve: This stage generates solutions and make and measures process changes.
 Control: Processes that are performing in a predictable way at a desirable level are in
control.

Quality tools
 Chart audits
It is the most common method of collecting quality data using charts as quality
assessment tool.
 Failure mode and effect analysis: prospective view
It is a tool that takes leaders through evaluation of design weaknesses within their
process, enable them to prioritize weaknesses that might be more likely to result
in failure (errors) and, based on priorities decide where to focus on process
redesign aimed at improving patient safety.
 Root- cause analysis: retrospective view
It is sometimes called a fishbone diagram, used to retrospectively analyze
potential causes of a problem or sources of variation of a process. Possible causes
are generally grouped under 4 categories: people, materials, policies and
procedures, and equipment.
 Flow charts
These are diagrams that represent the steps in a process.
 Pareto diagrams
It is used to illustrate 80/ 20 rule, which states that 80% of all process variation is
produced by 20% of items.
 Histograms
It uses a graph rather than a table of numbers to illustrate the frequency of
different categories of errors.
 Run charts
These are graphical displays of data over time. The vertical axis depicts the key
quality characteristic, or process variable. The horizontal axis represents time.
Run charts should also contain a center line called median.
 Control charts
These are graphical representations of all work as processes, knowing that all
work exhibit variation; and recognizing, appropriately responding to, and taking
steps to reduce unnecessary variation.
Indicators of quality assurance
 Waiting time for different services in the hospital
 Medical errors in judgment, diagnosis, laboratory reporting, medical treatment or surgical
procedures, etc.
 Hospital infections including hospital- acquired infections, cross infections.
 Quality of services in key areas like blood bank, laboratories, X- ray department, central
sterilization services, pharmacy and nursing.

Quality improvement process- Steps
QI process steps include;
 Identify needs most important to the consumer of health care services.
 Assemble a multidisciplinary team to review the identified consumer needs and services.
 Collect data to measure the current status of these services.
 Establish measurable outcomes and quality indicators.
 Select and implement a plan to meet the outcomes.
 Collect data to evaluate the implementation of the plan and achievement of outcomes.
Quality assurance cycle:
In practice, QA is a cyclical, iterative process that must be applied flexibly to meet the needs of a
specific program. The process may begin with a comprehensive effort to define standards and
norms as described in Steps 1-3, or it may start with small-scale quality improvement activities
(Steps 5-10). Alternatively, the process may begin with monitoring (Step 4). The ten steps in the
QA process are discussed.
1. Planning for Quality Assurance
This first step prepares an organization to carry out QA activities. Planning begins with a review
of the organizations scope of care to determine which services should be addressed.
2. Setting Standards and Specifications
To provide consistently high-quality services, an organization must translate its programmatic
goals and objectives into operational procedures. In its widest sense, a standard is a statement of
the quality that is expected. Under the broad rubric of standards there are practice guidelines or
clinical protocols, administrative procedures or standard operating procedures, product
specifications, and performance standards.

3. Communicating Guidelines and Standards
Once practice guidelines, standard operating procedures, and performance standards have been
defined, it is essential that staff members communicate and promote their use. This will ensure
that each health worker, supervisor, manager, and support person understands what is expected
of him or her. This is particularly important if ongoing training and supervision have been weak
or if guidelines and procedures have recently changed. Assessing quality before communicating
expectations can lead to erroneously blaming individuals for poor performance when fault
actually lies with systemic deficiencies.
4. Monitoring Quality
Monitoring is the routine collection and review of data that helps to assess whether program
norms are being followed or whether outcomes are improved. By monitoring key indicators,
managers and supervisors can determine whether the services delivered follow the prescribed
practices and achieve the desired results.
5. Identifying Problems and Selecting Opportunities for Improvement
Program managers can identify quality improvement opportunities by monitoring and evaluating
activities. Other means include soliciting suggestions from health workers, performing system
process analyses, reviewing patient feedback or complaints, and generating ideas through
brainstorming or other group techniques. Once a health facility team has identified several
problems, it should set quality improvement priorities by choosing one or two problem areas on
which to focus. Selection criteria will vary from program to program.
6. Defining the Problem
Having selected a problem, the team must define it operationally-as a gap between actual
performance and performance as prescribed by guidelines and standards. The problem statement
should identify the problem and how it manifests itself. It should clearly state where the problem
begins and ends, and how to recognize when the problem is solved.
7. Choosing a Team
Once a health facility staff has employed a participatory approach to selecting and defining a
problem, it should assign a small team to address the specific problem. The team will analyze the
problem, develop a quality improvement plan, and implement and evaluate the quality
improvement effort. The team should comprise those who are involved with, contribute inputs or
resources to, and/or benefit from the activity or activities in which the problem occurs.
8. Analyzing and Studying the Problem to Identify the Root Cause
Achieving a meaningful and sustainable quality improvement effort depends on understanding
the problem and its root causes. Given the complexity of health service delivery, clearly
identifying root causes requires systematic, in-depth analysis. Analytical tools such as system
modeling, flow charting, and cause-and-effect diagrams can be used to analyze a process or
problem. Such studies can be based on clinical record reviews, health center register data, staff or
patient interviews, service delivery observations.
9. Developing Solutions and Actions for Quality Improvement

The problem-solving team should now be ready to develop and evaluate potential solutions.
Unless the procedure in question is the sole responsibility of an individual, developing solutions
should be a team effort. It may be necessary to involve personnel responsible for processes
related to the root cause.
10. Implementing and Evaluating Quality Improvement Efforts
The team must determine the necessary resources and time frame and decide who will be
responsible for implementation. It must also decide whether implementation should begin with a
pilot test in a limited area or should be launched on a larger scale. The team should select
indicators to evaluate whether the solution was implemented correctly and whether it resolved
the problem it was designed to address. In-depth monitoring should begin when the quality
improvement plan is implemented. It should continue until either the solution is proven effective
and sustainable, or the solution is proven ineffective and is abandoned or modified. When a
solution is effective, the teams should continue limited monitoring.
JCAHO quality assurance guidelines/steps:
1. Assign responsibility:
According to the Joint Commission, ―The nurse administrator is ultimately responsible for the
implementation of a quality assurance program. Completing step one of the Joint Commission‘s
ten step process require writing a statement that described who is responsible for making certain
that QA activities are carried out in the facility. Assigning responsibility should not be confused
with assuming responsibility.
2. Delineate scope of care and services:
Scope of care refers to the range of services provided to patients by a unit or department. To
delineate the scope of care for a given department personnel should ask themselves,‘ what is
done in the department?‘
3. Identify important aspects of care and services:
Important aspects of nursing care can best be described as some of the fundamental contribution
made by nurses while caring for patients. They are the most significant or essential categories of
care practiced in a given setting. There is no prescribed list of important aspects of care that
every organization must monitor.
4. Identify indicators of outcome (no less than two; no more than four):
A clinical indicator is a quantitative measure that can be used as a guide to monitor and evaluate
the quality of important patient care and support service activities. Indicators are currently
considered as being of two general types i.e. sentinel events and rate-based. Indicators also differ
according to the type of event they usually measures (structure, process or outcome).
5. Establish thresholds for evaluation:
Thresholds are accepted levels of compliance with any indicators being measured. Thresholds
for evaluation are the level of or point at which intensive evaluation is triggered. A threshold can
be viewed as a stimulus for action.

6. Collect data:
Once indicators have been identified, a method of collecting data about the indicators must be
selected. Among the many methods of data collection is interviewing patient/family, distributing
questionnaires, reviewing charts, making direct observation etc.
7. Evaluate data:
When data gathering is completed in the process of planning patients care, nurses make
assessments based on the findings. In the QA process as a whole, when data collection has been
completed and summarized, a group of nurses makes an assessment of the quality of care.
8. Take action:
Nurses are action-oriented professionals. For many nurses, the greater portion of every day is
spent on patient‘s intervention. These actions and interventions conducted by nurses promote
health and wellness for patients. Converting nursing energy into the QA process requires
formulating an action plan to address identified problems.
9. Assess action taken:
Continuous and sustained improvement in care requires constant surveillance by nurses of the
intervention initiated to improve care.
10. Communicate:
Written and verbal messages about the results of QA activities must be shared with other
disciplines throughout the facility.
NURSING AUDIT
Audit in nursing management is the professional evaluation of the quality of the patient care, by
analysing through all the facilities , services rendered, measures involved in diagnosis, treatment
and other conditions and activities that affect the patients.
Definition
―Nursing audit refers to the assessment of the quality of clinical nursing.‖ - Elison
―Nursing audit is the means by which nurses themselves can define standards from their
point of view and describe the actual practice of nursing.‖ - Goster Walfer
Characteristics
 It improve the quality of nursing care
 It compares actual practice with agreed standards of practice.
 It is formal and systemic.
 It involves peer review.
 It requires the identification of variations between practice and standards followed by the
analysis of causes of such variations.

 It provides feedback for those whose records are audited.
 It includes follow- up or repeating an audit sometimes later to find out if the practice is
fulfilling the agreed standards.
Objectives
 To evaluate the quality of nursing care given.
 To achieve the desired and feasible quality of care.
 To provide a way for better records.
 To focus on care provided and care provider.
 To provide rationalized care thereby maintaining uniform standards worldwide.
 To contribute to research.
Methods of Audit
There are mainly two methods;
 Retrospective view- It refers to the detail quality care assessment after the patient has
been discharged. The records can be reviewed for completeness of records, diagnosis,
treatment, lab investigations, consultations, nursing care plan, complications, and end
results.
 Concurrent view- It is achieved by reviewing patient care during the time of hospital stay
by the patient. It includes assessing the patient at the bedside in relation to
predetermined criteria like errors, omissions, deficiencies, as well as efficiencies and also
excess in the care of patients under them. It involves direct and indirect observation,
interviewing the staff responsible for care, and reviewing the patients‘ records and care
plan.
It can be also done to identify the job satisfaction of staff nurses in accordance with their
work performance.
Audit cycle
According to Payne, the steps in audit or utilization review include;
 Criteria development
 Selection of cases
 Work sheet preparation
 Case evaluation
 Tabulation of evaluation
 Presentation of reports
The basic audit cycle can be depicted as;

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

PERFORMANCE APPRAISAL
INTRODUCTION
A continual and troublesome question facing nurse managers today is why some employees
perform better than others. Making decisions about who performs what tasks in a particular
manner without first considering individual behaviour can lead to irreversible long term
problems. Each employee is different in many respects. A manager needs to ask how such
differences influence the behaviour and performance of the job requirements. Ideally, the
manager performs this assessment when the new employee is hired. In reality, however, many
employees are placed in positions without the managers having adequate knowledge of their
abilities and / or interests. This often results in problems with employee performance, as well as
conflict between employees and managers.
MEANING
Performance appraisal means the systematic evaluation of the performance of an expert or his
immediate superior.
Performance appraisal is a method of evaluating the behavior of employees in the work
spot, normally including both the quantitative and qualitative aspects of job performance.
Performance here refers to the degree of accomplishment of the tasks that make up an
individual's job. It indicates how well an individual is fulfilling the job demands. Often the term
is confused with effort, but performance is always measured in terms of results and not efforts.
The performance appraisal process includes day-to-day manager-employee interactions
(coaching, counseling, dealing with policy/procedure violations, and disciplining); written
documentation (making notes about an employee's behavior, completing the performance
appraisal form); the formal appraisal interview; and follow-up sessions that may involve coach-
ing and/or discipline when needed.
DEFINITION
Edwin b flippo, ―performance appraisal is a systematic, periodic and so far as humanly possible,
an impartial rating of an employee‘s excellence in matters excellence in matters pertaining to his
present job and to his potentialities for a better job‖

The performance of an employee is compared with the job standards. The job standards are
already fixed by the management for an effective appraisal.
According to scott, clothier and spriegal, ―performance appraisal is a record of progress for
apprentices and regular employees, as a guide in making promotions, transfer or demotions, as a
guide in making lists for bonus distribution, for seniority consideration and for rates of pay, as an
instrument for discovering hidden genius, and as a source of information that makes conferences
with employees helpful‖.
OBJECTIVES OF APPRAISAL.
1. To determine the effectiveness of employees on their present jobs so as to decide their
benefits.
2. To identify the shortcomings of employees so as to overcome them through systematic
guidance and training.
3. To find out their potential for promotion and advancement.
PURPOSES AND BENIFITS
Performance appraisal can serve many purposes and has several benefits. Among them are:
1. To provide backup data for management decisions concerning salary standards, merit
increases, selection of qualified individuals for hiring, promotion or transfer, and
demotion or termination of unsatisfactory employees.
2. To serve as a check on hiring and recruiting practices and as validation of employment
tests.
3. To motivate employees by providing feedback about their work.
4. To discover the aspirations of employees and to reconcile them with the goals of the
organisation,
5. To provide employees with recognition for accomplishments,
6. To improve communication between supervisor and employee, and to reach an
understanding on the objectives of the job,

7. To help supervisors observe their subordinates more closely, to so a better coaching job,
and to give supervisors a stronger part to play in personnel management and employee
development,
8. To establish standards of job performance.
9. To improve organisational development by identifying training and development needs to
employees and designing objectives for training programmes based on those needs,
10. To earmark candidates for supervisory and management developments and
11. To help the organisation determine if it is meeting its goals.
IMPORTANCE
Now a day, the management uses performance appraisal as a tool. The scope of performance
appraisal is not limited to pay fixation and is enlarged to include many decisions.
1. Performance appraisal helps the management to take decision about the salary increase of
an employee.
2. The continuous evaluation of an employee helps in improving the quality of an employee
in job performance.
3. The Performance appraisal brings out the facilities available to an employee, when the
management is prepared to provide adequate facilities for effective performance.
4. It minimises the communication gap between the employer and employee.
5. Promotion is given to an employee on the basis of performance appraisal.
6. The training needs of an employee can be identified through performance
appraisal.
7. The decision for discharging an employee from the job is also taken on the basis
of performance appraisal.
8. Performance appraisal is used to transfer a person who is misfit for a job to the
right placement.
9. The grievances of an employee are eliminated through performance appraisal.

10.The job satisfaction of an employee increases morale. This job satisfaction is
achieved through performance appraisal.
11.It helps to improve the employer and employee relationship.
CONCEPT OF PERFORMANCE APPRAISAL
1. The appraisal should be in writing and carried at least once a year.
2. The performance appraisal information should be shared with the employee.
3. The employee should have the opportunity to respond in writing to the appraisal.
4. Employees should have a mechanism to appeal the results of the performance
appraisal.
5. The manager should have adequate opportunity to observe the employees job
performance during the course of the evaluation period.
6. Anecdotal notes on the employee‘s performance should be kept during the entire
evaluation period.
7. Evaluator should be trained to carry out the performance appraisal process.
8. As for as possible, the performance appraisal should focus on employee behaviour
and results rather than on personal traits or characteristics.
CHARECTERISTICS AND OBSTACLES
The following characteristics are essential elements of effective performance appraisal:
1. The philosophy, purpose, and objectives of the organisation are clearly stated so that
performance appraisal tools can be designed to reflect these.
2. The purposes of performance appraisal are identified, communicated, and understood.
3. Job descriptions are written in such a manner that standards of job performance can be
identified for each job.
4. The appraisal tool used is suited to the purposes for which it will be utilised and is
accompanied by clear instructions for its use.

5. Evaluators are trained in the use of the tool.
6. The performance appraisal procedure is delineated, communicated, and understood.
7. Plans for policing the appraisal procedure and evaluation appraisal tools are developed
and implemented.
8. Performance appraisal has the full support of top management.
9. Performance appraisal is considered to be fair and productive by all who participate in it.
The principal obstacles to effective performance appraisal are:
1. Lack of support from top management.
2. Resistance on the part of evaluators because:
a. Performance appraisal demands too much of supervisors efforts in terms of time,
paperwork, and periodic observation of subordinates performance.
b. Supervisors are reluctant to play god by judging others.
c. Supervisors do not fully understood the purpose and procedures of performance
appraisal.
d. Supervisors lack skills in appraisal techniques.
e. Performance appraisal is not perceived as being productive.
3. Evaluation biases and rating errors, which result in unreliable and invalid ratings.
4. Lack of clear, objective standards of performance.
5. Failure to communicate purposes and results of performance appraisal to employees.
6. Lack of a suitable appraisal tool.
7. Failure to police the appraisal procedure effectively.

PRINCIPLES OF PERFORMANCE APPRAISAL
1. Single employee is rated by two ratters. Then, the comparison is made to get accurate
rating.
2. Continuous and personal observation of an employee is essential to make effective
performance appraisal.
3. The rating should be done by an immediate superior of any subordinate in an
organization.
4. A separate department may be created for effective performance appraisal.
5. The rating is conveyed to the concerned employee. It helps in several ways. The
employee can understand the position where he stands and where he should go.
6. The plus points of an employee should be recognised. At the same time, the minus points
should not be highlighted too much, but they may be hinted to him.
7. The management should create confidence in the minds of employees.
8. The standard for each job should be determined by the management.
9. Separate printed forms should be used for performance appraisal to each job according to
the nature of the job.
KINDS OF PERFORMANCE APPRAISAL
There are many kinds of performance appraisal available. But the management wants to
adopt only one of the types of performance appraisal. The appraisal is done adopting any one
of the two approaches. These two approaches are traits and results. The traits approach refers
to appraising the employee on the basis of his attitudes. The result approach refers to
appraising the employee on the basis of results of his accomplishments of a job.
1. Ranking method
This method is very old and simple form of performance appraisal. An employee is
ranked one against the other in the working group under this method.
Example: if there are ten workers in the working group, the most efficient worker is
ranked as number one and the least efficient worker is ranked as number ten.

Advantages
a. Each employee or worker can be compared with the other person.
b. A small organization can get maximum benefits through the ranking method.
Disadvantages
a. A big organization is not able to get sizable benefits from the ranking method.
b. Ranking method does not evaluate the individuality of an employee.
c. It lags objectivity in the assessment of employees.
2. Paired Comparison Method
This method is a part of ranking method. Paired comparison method has been developed
to be used in a big organization. Each employee is compared with other employees taking
only one at a time. The evaluator compares two employees and puts a tick mark against
an employee whom he considers a better employee. In the same way, an individual is
compared with all other existing employees. Finally an employee who gets maximum
ticks for being a better employee is consider the best employee.
Advantages
a. This method is suitable for big organizations.
b. Individual traits are evaluated under this method.
Disadvantages
a. The understanding of this method is difficult one.
b. It involves considerable time.
3. Forced distribution method
A method which forces the rater to distribute the ratings of the overall performance of an
employee is known as forced distribution method. Group wise rating is done under this
method. This method is suitable to large organisations, but the individual traits could not
be appraised under this method.
Example: a group of workers doing the same job would fall into the same group as
superior, at and above average, below average and poor. The rator rates 15% of the

workers as superior, 35% of the workers as at and above average, 35% of workers as
below average and 15% of workers as poor.
4. Grading
Certain categories of abilities or performance of employees are defined well in advance
to fall in certain grades under this method. Such grades are very good, good, average,
poor and very poor. Here the individual traits and characteristics are identified.
5. Checklist
The appraisal of the ability of an employee through getting answers for a number of
questions is called the method of check list. These questions are related to the behaviour
of an employee. The evaluation is done by a separate department, but the duty of
collection of checklist answers is given to a person who is designated as a rator. The rator
indicates the answers of an employee against each question by putting a tick mark. There
are two columns provided to each question as yes or no.
A model check list is given below.
A. Is the employee satisfied with the job? Yes No
B. Does he finish the job accurately? Yes No
C. Does he respect the superiors? Yes No
D. Is he ready to accept responsibilities? Yes No
E. Does he obey the orders? Yes No
6. Forced choice method
A series of groups of statements are prepared positively or negatively under this method,
both these statements describe the characteristics of an employee, but the rator is forced
to tick any one of the statements either out of positive statements or out of negative
statements. The degree of description of the characteristics of an employee varies from
one statement to another.
The following are the positive statements;
a. The employee completes the job in time usually.
b. The employee has the ability to complete the job and complete the job as and when
there is a need.

The negative statements are also prepared. The final rating is done on the basis of all such
statements. But the ratter does not know the statements which are for final rating.
7. Critical Incident method
The performance appraisal of an employee is done on the basis of the incidents occurred
really to the concerned employee. Some incidents occurred due to the inability of the
employee, but the rating is done on all the events occurred in a particular period.
Some of the events or incidents are given below.
a. Refused to co-operate with other employees
b. Unwilling to attend further training
c. Got angry over work or with subordinates
d. Suggested a change in the method of production
e. Suggested a procedure to improve the quality of goods
f. Suggestion of a method to avoid or minimize wastage, spoilage and scrap.
g. Refused to obey orders
h. Refused to follow clear cut instructions
8. Field review method
An employee‘s performance is appraised through an interview between the rator and the
immediate superior or superior of a concerned employee. The rator asks the superiors
questions about the performance of an employee, the personnel department prepares a
detail report on the basis of this collected information. A copy of this report is placed in
the personnel file of the concerned employee after getting approval from the superior.
The success of this type of appraisal method is based on the competence of the
interviewer.
9. Essay evaluation
With easy evaluation technique the nurse manager is required to describe the employee‘s
performance over the entire evaluation period by writing a narrative detailing the strength
and weaknesses of the appraise. If done correctly this approach can provide a good deal
of valuable data for discussion in the appraisal interview.

COMPONENTS TO BE EVALUATED
Nurse engages in a variety of job related activities to reflect the multi dimensional nature
of the job. The performance appraisal form usually acquires a nurse manager to rate several
different performance dimension.
The components are
a. Use of nursing process
b. Professionalism
c. Maintaining safety
d. Continuing education
e. Initiative character.
STEPS FOR PEER REVIEW
1. The employee selects peers to conduct the evaluation. Usually two to four peers are
identified through a pre determined process.
2. The employee submits self evaluation port folio. The port folio might describe how he or
she met objectives and/or pre determined standards during the past evaluation cycle.
Supporting materials are included.
3. The peer evaluates the employee. This may be done individually or in a group. The
individuals are group then submit a written evaluation to the manager.
4. Manager and employee meet to discuss the evaluation. The manager‘s evaluation is
included and objectives for the coming evaluation cycle are finalized.
APPRAISAL INTERVIEW
Once the manager completes an accurate evaluation of performance, he/she should arrange
an appraisal interview. The appraisal interview is the first step in employee development.
1. They provide feedback to an employee which enables him to improve his performance in
future.
2. They help management to ascertain and assess the training needs of individual
employees.

3. They enable management to know the problems and difficulties experienced by
subordinates in discharging their responsibilities and also their suggestions for removing
these difficulties.
Types of appraisal interview
1. Tell and sell interview
It is based on the assumption that employees have some deficiencies but they need to
be convinced about these deficiencies. The purpose of this interview is
a. To let the employee to know how well he is doing.
b. To draw up a plan of improvement for him.
c. To gain the employees acceptance of the evaluation.
2. Tell and listen interview.
The objective of this interview is to communicate the evaluation to the employee and
then listen sympathetically to his reactions. It consists of two parts
The first part covers the strong and week points of the employee‘s performance.
The second part is used to explore thoroughly the employee‘s feelings about the
evaluation.
3. Problem solving interview.
In this interview the aim is not appraisal but development of an employee. Therefore,
the interviewer takes himself out of his usual role as a judge and puts himself in the
role of a helper. He does not communicate the evaluation to the employee. He does
not communicate the evaluation to the employee. He does not point out the areas of
improvement; rather he stimulates the employee into thinking about improving his
own performance. He does not supply remedies or solutions but considers all ideas on
job improvement suggested by the employee. This he does by skilful questions
Example. Can you plan to deal with emergencies?

Key behaviours for an appraisal interview
1. Put the employee at ease
2. Clearly state the purpose of the appraisal interview
3. Go through the ratings one by one with the employee.
4. Draw out the employee reactions to the ratings.
5. Decide on specific ways in which performance areas can be strengthened.
6. Set a follow up date.
7. Express confidence in the employee.
METHODS OF APPRAISIGN PERFORMANCE
There is no one performance appraisal system, which will work equally well in all work patterns,
a number of techniques are available to managers and occasionally more than one method is
used. An organisation must decide whether it wants to measure in terms of performance and
what method of measurement works best. It can then experiment with that method.
Several common methods of performance appraisal including their advantages and disadvantages
are described next.
When using the easy technique the evaluator writes a paragraph or more regarding a particular
employee‘s strengths and potential. Essay content should reflect the employee‘s performance in
relation to his job description. It may also include information about personal characteristics
which are pertinent to the employees job, such as the ability to work well with others or
motivation for professional growth. Well done essays have the advantage of providing an in-
depth analysis of performance. Essays are also especially suitable for identifying training and
development needs and problem areas.
1. The disadvantages of essays are
2. They are time consuming
3. They tend to vary greatly in length and content
4. They are difficult to combine or compare since different essays cover different aspects of
performance.

The graphic rating scale requires the rater to assign a numerical value or letter grade to each
dimensions of performance to indicate judgements ranging from superior to unsatisfactory. The
advantages of the graphic rating scale are that it is generally more consistence and reliable than
the essay, it is usually acceptable to raters, and it is easy to construct. The graphic rating scales
primary disadvantages are that it does not yield the depth of information attained in the essay
approach, and its validity can be challenged unless the factors to be rayed are chosen carefully
and comprehensively.
The critical incidence technique operated by supervisors collecting and recording instances of
their subordinates are performing in ways that are of critical importance to the success or failure
of the job. These critical incidents are reviewed with the employees during a scheduled feedback
interview. The advantage of the critical incident technique is that the evaluator rates performance
rather than personality traits. In addition, this method is useful in helping supervisors do a better
coaching job and communicate performance appraisal information to subordinates. The
disadvantage of the critical incident technique is that if requires the supervisors to write down
incidents daily, or at least weekly which can be very time consuming and sometimes difficult to
accomplish.
LIMITATIONS OF PERFORMANCE APPRAISAL
The following are the limitations of performance appraisal:
1. The performance appraisal methods are unreliable.
2. If an employee is well known to an employer, the performance appraisal may not be
correct.
3. The inability of supervision to appraise an employee does not bring out the accurate
performance appraisal.
4. Some qualities of an employee can not be easily appraised through any performance
appraisal method.
5. A supervisor may appraise an employee to be good to avoid incurring his displeasure.
6. Uniform standards are not followed by the supervisors in the performance appraisal.

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

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

1.Individual conference
2.Group conference
3.Training sessions
4.Review of records
5.Evaluation sessions
6.Direct observation
COMMON SUPERVISORY METHODS
PRINCIPLES APPLIED TO NURSING:
 Supervision should be focused on the attainment of one goal, the giving of a high quality
of nursing care.
 Strives to make the ward a good learning situation.
 Supervision is well planned.
 It should posters the ability to think and act herself.
 Helps her to attain objectives stimulates interest and effort.
 Encourages and challenges her to greater endeavour through adequate approval
commendation and by recognition of work well done.
 To make pattern for analysis and to analyze continuously her success in reaching the
objectives.
WHO IS SUPERVISOR?
• A supervisor is a person who is primarily incharge of a section & is responsible for both
quality & quantity of production, for the efficient performance of the equipment, & for
the employees in his charge & their efficiency, training & morale
• A supervisor drives authority from the departmental head for getting work done from the
workers by using the resources of the enterprises.
• He issues instructions to the workers, directs their activities & reports to the department
head on the performance of his section.

QUALITIES OF A GOOD SUPERVISOR:
• Trained person
• Understand the training background and ability of the supervised.
• Good knowledge, the local practice
• Good in health, skills in T.G & PR/t have pleasing manner.
• Good listener.
• Supervisor should have leads examplenory life
• Creative enthusiasm
• Just impartial human, tolerant and tactful
• Helpful
• Good power of judgment.
SUPERVISION CONSIST OF
FUNCTIONS OF SUPERVISION:
Leadership
Motivation
Communication
Evaluation
A. Administrative
B. Educative
C. Communicative D. Evaluative

A. Administrative:
• Assignment of the work loads of individual and groups according to the level of physical
and mental competence (or) preparing the duty roaster.
• Identify the needs for supplies and equipment and providing materials and supplies to
facilitate the staff performance.
• Identify the problem and helps to solve.
B. Educative:
• Orientation
• Teaching subordinates
• Plan and conduct in service education program
• Ensuring staff developments
C. Communicative
• The supervision act as a communicator between the staff and authorities and other health
team members.
• She facilitates communication
• She should encourage free communication among persons between worker and
community representatives and members of health team.
D. Evaluative:
 Supervisor is supposed to carryout performance appraisal of all the staff this include
identify the cause of difficulty.
 Providing C E and guidance.
OTHER FUNCTIONS ARE:
• Co-ordinates there of subordinates and agents and promote team worker.
• Promote social contact with in the team to bring staff together and increases group
cohesiveness.
• Develops mutual confidence
• Raises level of motivation
• Develops good IPR
• Maintains R & R
• Establish control over the subordinates

AS A MANAGER SUPERVISOR HAS TO PERFORM THE FOLLOWING
FUNCTIONS
 Planning the work
 Issuing orders
 Providing guidance & leadership
 Motivation
 Preserving records
 Controlling output – performance of the worker
 Liaison between management & workers
 Grievance handling
 Industrial safety
STEPS IN SUPERVISION:
When supervision is needed the supr has to make plan for supervision by using certain
steps to follow.
1. Defining of the job to be done
2. Selection and organization of supervisor activities based on available resources.
3. Anticipation of difficulties
4. Establishment of criterion for evaluation determining what extent the programme has met
problem / objectives acc to plan.
Types of supervision:
(1) Direct supervision – Face to face talk with worker
 Points to be considered:
- Do not loose temper
- Use democratic approach and avoid autographic
- Give workers chance to reply
- Do not talk too much and too fast
- Be human in behavior
- Do not give instructions – haphazard way.

(2) Indirect supervision: With the help of record and reports of the worker and through
written instructions.
This includes:
- Ensuring – carrying out allotted work
- Analysis of monthly progress – input efforts and achievement
- Analyzing amount of work allotted
- Support and guidance.
Methods of supervision:
(1) Technical vs. creative supervision
(2) Co-operative vs. authoritarian
(3) Scientific vs. institutive
(4) Task oriented vs. employee oriented
I. Technical – These are basic supervisory skills and which need to be trained – group
discussion and conference
For example: techniques of service study, record construction, time study etc.
Creative – provides maximum adaptation to the situ
Ex. Instead of orientation period of two week for each new staff member, a variable plan in
both contents and time according to the needs of each individual should formulated.
II. Cooperative – full participation of each member of the group in planning, action and
decision.
Authorization: supervision responsibility centers entirely on the supervisor, with the staff
following his / her orders.
• Both are needed all to situation.
III. Scientific supervision – Relies on objective study and measurement than personal
judgment / opinion.
Intitutive supervision :It needs to maintain IPR

IV. Task oriented supervision emphasize the task more than performer.
Employee oriented: Supervisors are more concerned about worker staff their needs and
welfare than assigned tasks.
TOOLS FOR SUPERVISION
 Checklist
 Rating scales
 Nurses reports
 Nursing rounds
 Job descriptions
 Personnel policies
 Staff educations
 Problem solving approach
TECHNIQUES OF SUPERVISION
 A technique is a way of doing something. Techniques vary with the personality and
ability of the individuals who are being supervised, the activities that are being performed
under supervision and the immediate circumstances.
 Any technique used for supervision must be based on sound democratic psychological
principles which takes account the nurse‘s individuality.
THE PROCESS OF SUPERVISION:
Stage 1: Preparation for supervision
1. A supervisor should focus on specific issue.
- Efficacy of service provided to the
- Relevant problems
- Efficacy problem utilization management of limited resources.
2. Study of document

3. Identification of priorities
4. Preparation of a supervision schedule
Stage 2: supervision
Use tools: - Job description
- Task description
- Weekly time table
- Check list / rating for each work
• As a supervisor the following duties has to be performed.
• Establish contact
• Review the objectives, targets and norms
• Review job descriptions
• Note actual / potential conflict
• Observe the actual performance.
• Observe the individual nursing staff carries out his/her tasks.
• Identify the gaps & needs for follow up action based on feed back data attained through
the observation.
Stage 3: Follow up of supervision
Unless actions to follow-up the gaps and needs identified during stage are taken, supervision
remains incomplete. Each supervisor must prepare a report on the observations made during
supervision. The follow-up action may include:
• Organizing in-service training programmes/continuing education programmes for the
nursing personnel.
• Reorganization of time table / work plan/ duty roaster.
• Initiating changes in logistic support or supply system.
• Initiating actions for organizing staff welfare activities.
• Counseling and guidance regarding career development and professional growth.

THE EFFECTIVENESS OF SUPERVISION DEPENDS ON:
1. Human relations skill
2. Technical and Managerial knowledge
3. Leadership position
4. Improved upward relations
5. Relief from non-supervisory duties
6. General and lose supervision
1. Human relations skill:
Supervision is mainly concerned with instructing, guiding and inspiring human
beings towards greater performance. For purpose of direction, the supervisor has to
rely on leadership, counseling, communication and other determinants of human
relations
2. Technical and Managerial knowledge:
Guidance implies a complete understanding of all work problems, for which
supervisor should have good knowledge about technical aspect of job and also the
managerial aspect
3. Leadership position
The authority of supervisor must be made commensurate with their duty so as to
make the job of supervision a satisfying, rewarding and challenging one
4. Improved upward relations
To ensure god quality of supervisors, the supervisor‘s should be regularly allowed to
present their views and suggestions to top executive in regard to the personnel and
their works performance.
5. Relief from non-supervisory duties
To make the supervisory duties purposeful, the supervisors are to be relieved of many
routine activities that divert their attention from the real job.
6. General and lose supervision
According to some experience, the general and loose supervision is more productive
than close supervision. Here the leader must allow freedom and initiative to his
followers for pursuing a common course of action.

PROBLEMS OF SUPERVISION
PROBLEMS IN NURSING SERVICE:
There are no perfect nursing service programs/situations without any problems
1. Shortage of nursing personnel.
2. Individual differences among personnel in interests, capacities and abilities.
3. Lack of information, insight and understanding of changes and developments in the
interest of the continuance and improvement of nursing.
4. Lack of clearly defined assignments, multiple responsibility and lack of planning on the
part of those to whom personnel is responsible
5. Outdated policies, procedures and guides to workmanship which cause them to be
disregarded and unused.
6. Inadequate, unsafe, and defective equipment.
7. . Ill health in the part of personnel
8. Undesirable personnel characteristics with special attention to attitudes.
COMMON PROBLEMS IN COMMUNITY HEALTH NURSING SUPERVISION:
1. Problems inherent to budgeting, planning and timing.
2. Personnel problems including problems of poor performance.
3. Grievances
4. Lack of financial resources.
5. Lack administrative support
6. Staff members who are inflexible and resist any type of change
7. Assignment to projects other than those committed to perform
8. Lack of political support
9. . Staff members who do not accept or support the program goals.
10. Conflict within the nursing unit itself.

11. Inability to proceed (for many reasons) because the timing is wrong
12. Inability to hire qualified personnel.
13. .Changes in program priorities.
14. Other issues can include anything from car rental, uniform allowance, security of the
staff within the community, need for supplies and equipment, duplication of services
provided by another organization.
DISCIPLINE
INTRODUCTION
One method by which a nurse manger can control subordinates behaviour is to invoke
official disciplinary procedure. Discipline can be self-control by which an employee brings his or
her behaviour into agreement with the agency‘s official behaviour code, or it can be a managerial
action to enforce employee compliance with agency rules and regulations.
DEFINITION
Discipline is defined as a training or moulding of the mind and character to bring about
desired behaviours.
Discipline refers to working in accordance with certain recognized rules, regulations and
customs, whether they are written or implicit in character.
AIMS AND OBJECTIVES OF DISCIPLINE
The aims and objectives of discipline are:
1. To obtain a willing acceptance of the rules, regulations and procedures of an organization
so that organizational goals can be achieved.
2. To impart an element of certainty despite several differences in informal behavior
patterns and other related changes in an organization
3. To develop among the employees a spirit of tolerance and a desire to make adjustments
4. To give and seek direction and responsibility
5. To create an atmosphere of respect for the human personality and human relations
6. To increase the working efficiency and morale of the employees so that their productivity
is stepped up, the cost of production brought down and the quality of production
improved.

PRINCIPLES OF DISCIPLINARY ACTION
1. Have a positive attitude:
The manager‘s attitude is very important in preventing or correcting undesirable behavior.
People tend to do what is expected of them. Therefore the manager must maintain a positive
attitude by expecting the best from the staff.
2. Investigate carefully:
The ramifications of a disciplinary action are serious. If a staff nurse is disciplined unfairly or
unnecessarily, the effects on the entire staff nurse may be severe. Therefore managers must
proceed with caution. They should collect facts, check allegations, and even ask the accused
employees for their side of the story.
3. Be prompt:
If the disciplinary action is delayed, the relationship between the punishment and the offense
becomes less clear.
4. Protect privacy:
Disciplinary actions affect the ego of the staff nurse. Discussing the situation in private,
causes less resentment and greater chance for future co-operation. However, a public
reprimand may be necessary for the nurse who does not take private criticism seriously.
5. Focus on the act:
When disciplining a staff nurse, the manager should emphasize that it was the act that was
unacceptable, not the employee.
6. Enforce rules consistently:
Consistency reduces the possibility of favoritism, promotes predictability, and fosters
acceptance of penalties.
7. Be flexible:
Individuals and circumstances are never the same. A penalty should be determined only after
the entire record is reviewed.
8. Advise the employee:
The employees must be informed that their conduct is not acceptable. Anecdoctal notes can be
of little value if the staff nurse is not informed of the contents promptly.
9. Take corrective, consistent action:
The manager should be sure that the staff nurse understands that the behavior was contrary to
the organizations requirements.
10. Follow up:
The manager should quietly investigate to determine whether the staff nurse behavior has
changed. If not, the manager should determine the reason for the nurse‘s attitude.
COMPONENTS OF A DISCIPLINARY ACTION PROGRAM
1. CODES OF CONDUCT: The employees must be informed of codes of conduct. Agency
handbooks, policy manuals, and orientation programs may be used. Eg. Employee code of
conduct.
2. AUTHORISED PENALTIES: The 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.
EMPLOYEE CODE OF CONDUCT
The basic pre-requisite for effective discipline is employee awareness of agency rules and
regulations governing employee behaviour. Behaviour rules should be written in clear and
concise language, incorporated in a hand-book and given to new employees during induction,
posted in each work unit and discussed with employees by manager of each unit. The
significance of code of conduct is that each employee should behave and perform in a way that
preserves the company values and commitments.
PENALTIES
 Oral reprimands: For minor violations that may have occurred for the first time, managers
may opt give an oral warning in private. When oral warning is given, the nurse manager is
advised to make an anecdoctal record of time, place, occasion and gist of the reprimand.
 Written reprimand: If the offense is more severe or repeated, the reprimand may be written.
The written notice should include the name of the employee, name of manager, nature of the
problem, the plan for correction, and consequences of future repetition. The employee has to
sign it, to indicate that the employee has read it. A copy should be given to the employee and
one retained for the personnel file. If again the terms are not met, other penalties will probably
be necessary.
 Other penalties:
 Fines may be charged for offences such as tardiness.
 Loss of privileges might include transfer to a less desirable shift and loss of preference
for assignments.
 Demotion is a questionable solution. It creates hard feelings which may be contagious
and more likely places offenders in a position for which they are overqualified.
 Suspension: for a period of time
 Withholding increment
 Termination(dismissal): permanent termination of services.
APPROACHES OF DISCIPLINE
1. TRADITIONAL APPROACH
It emphasizes punishment for undesirable behaviour. The purposes of traditional discipline
are punishment for sin, enforce conformity to custom, and strengthen authority of the old over
the young. Here discipline is always applied by superiors to subordinates, the severity of
punishments is designed to be proportional to the severity of the offense, and when no single
individual admits to the violation, the whole group is punished to motivate group members to
identify the violator or punish him or her themselves
2. DEVELOPMENTAL APPROACH
It emphasizes discipline as a shaper of desirable behavior. The purpose of developmental
discipline is to shape behaviour by providing favourable consequences for the right behaviour

and unfavourable consequences for the wrong behavior; and avoidance of physical
punishment, protection of the rights of the accused and replacement of arbitrary individual
judgements of guilt.
3. POSITIVE DISCIPLINE APPROACH
 It is based on the assumption that an employee with self-respect, respect for authority, and
interest in the job will adhere to high quality work standards; and when an interested,
respectful and self-respecting worker temporarily strays from his/ her usually highs standards,
a friendly reminder is enough to redirect their efforts in the desired direction
 Organisations that have employed a positive discipline have noted a subsequent decrease in
absences, dissmisals, disciplinary actions, grievances and arbitration, along with improvement
of employee morale.
4. SELF CONTROLLED DISCIPLINE APPROACH
The employees bring his or her behaviour into agreement with the organisations
behavioural official code i.e. the employees regulate their own activities for the common good
of the organisation. As a result human beings are reduced to work for a peak performance
under self controlled discipline.
5. ENFORCED DISCIPLINE APPROACH
A managerial action enforces compliance with organisations‘ rules and regulations ie. It is
a common discipline imposed from the top. Here the manager exercises his authority to
compel the employees to behave in a particular way.
SELF DISCIPLINE
It refers to one‘s effort at self-control for the purpose of adjusting oneself to certain needs and
demands. This form of discipline is based on two psychological principles. First, punishment
seldom produces the desired results. Often, it produces undesirable results. Second, a self-
respecting person tends to be a better worker than one who is not.
CONSTRUCTIVE VS DESTRUCTIVE DISCIPLINE
Constructive discipline (positive discipline) uses discipline as a means of helping the employees
grow, not as a punitive measure. The primary emphasis here is assisting employees to behave in
a manner that allows them to be self-directive in meeting organizational goals.
Destructive discipline (also called enforced or negative discipline): If employees are forced to
follow the rules and regulations of the organization by inducing fear in them, then it is termed as
negative discipline
DEALING WITH DISCIPLINARY PROBLEMS
Disciplinary action may be ineffective because of methodological weakness or of procedural
omissions by the manager. Methodological problems result from improper documentation of
disciplinary interview and procedural problems from failure to apply discipline in a timely
fashion and to follow due process.

1. DISCIPLINARY CONFERENCE
It is a group discussion using both directive and non-directive interview techniques. It is
damaging to employee‘s self-esteem to receive criticism from an authoritative figure. Thus a
disciplinary conference is anxiety provoking situation for both employee and the manager.
2. DISCIPLINARY LETTER
It is a letter send to the nurse/employee immediately after the conference, documenting the
interview content from the managers viewpoint. It is needed as sometimes employee‘s anxiety
may block perception of the painful feedback offered by the manager.
3. MODEL STANDING ORDERS
It specifies the terms and conditions which govern day to day employer-employee relationship,
infringement of which could result in a charge of misconduct
4. ERRORS IN DISCIPLINIG EMPLOYEES
The frequent errors encountered while disciplining the employees are:
Delay in administering discipline
Ignoring rule violation in hope that it is an isolated event
Accumulations of rule violations, causing irritated manager to ―blow up‖
Administering sweetened discipline
Failure to administer progressively severe sanctions
Failure to document disciplinary actions accurately
Imposing discipline disproportionate to the seriousness of the offense
Disciplining inconsistently
DISCIPLINARY PROCEEDINGS ENQUIRY IN MANAGEMENT
CCSR(CENTRAL CIVIL SERVICES RULES) AND KCSR(KARNATAKA CIVIL SERVICES
RULES)
General Civil Services Rules
The essence of Government service is the sense of discipline to which all Government
employees are subject and it is related to the employees code of conduct and discipline.
Article 311 of the constitution enumerates two fundamental principles upon which the whole
procedural law concerning departmental punishments on civil servants rests.
The first clause of the article contains the guarantee that no civil servant shall be dismissed
or removed by an authority surbordinate to that by which he was appointed.
The second clause guarantees to him a reasonable opportunity of defence on the charges
against him, supplemented by a second opportunity of showing cause why such a punishment
should not be imposed on him, if after enquiry it is proposed to dismiss or to remove or to
reduce him in rank.
Only the appointing authority can impose major punishment (dismissal, removal or reduction
in rank). The power of punishment can never be delegated.

Enquiry officer is a officer subordinate to the appointing authority; who conducts formal
enquiry about the charges on the charged official. The enquiry report contains findings of the
charges, but there should be no recommendations about the punishment.
CAUSES OF DISCIPLINARY PROCEEDINGS
A. Acts
1. Acts amounting to crimes
Eg. Bribery, corruption
2. Acts amounting to misdemeanor
Eg. Misbehavior, insurbordination, disobedience
3. Acts amounting to misconduct
Eg. Violation of conduct rules or standing orders
B. Omissions
Eg. Habitual late attendance, irresponsibility, negligence.
STAGES OF DISCIPLINARY PROCEEDING ENQUIRY
1. Preliminary enquiry
2. Decision to start formal departmental enquiry
3. Suspension
4. Charge sheet and its service
5. Appointment of enquiry officer
6. Written statement of defence
7. Recording of evidence by the enquiry officer
8. Personal hearing of charged official
9. Report of enquiry officer
10. Show cause notice by the disciplinary authority
11. Reply to show-cause notice and decision thereon
12. Review of punishment order
13. Appeal or revision
14. Reinstatement and restitution
15. Show-cause notice against withholding of emoluments for suspension period in the case
of a reinstated.
EVALUATION
INTRODUCTION
The realisation of goals and objectives is based on the accuracy of the judgements and
inferences made by decision-makers at every stage. To arrive at a good decision the test,
measurements and evaluation are being used in all situations. Thus evaluation has become a part
and parcel of every system to determine the achievement of goals in a given period.

MEANING AND DEFINITION
The term evaluation is derived from the word ‗valoir‘ which means ‗to be worth‘. Thus
evaluation is the process of judging the value or worth of an individuals achievements or
characteristics.
―It is an act or process that involves the assignment of a numerical index to whatever is being
assessed‖
―Evaluation is an act or process that allows one to make a judgement about the desirability or
value of a measure‖
SELF EVALUATION
DEFINITION
Self evaluation is defined as judging the quality of one‘s work, based on evidence and explicit
criteria, for the purpose of doing better work in the future.
PURPOSES OF SELF EVALUATION
1. To encourage continuing self-evaluation and reflection and to promote an ongoing, innovative
approach.
2. To encourage individual professional growth in areas of interest to the employee
3. To improve morale and motivation by treating the employee as a professional in charge of his
or her own professional growth.
4. To encourage collegiality and discussion about practices among peers in an organisation
5. To support employees as they experiment with approaches that will move them to higher
levels of performance
BENEFITS OF SELF EVALUATION
1. Increased confidence in their own learning, in trying out new ideas, in changing their practice
and in their power to make a difference.
2. Enthusiasm for collaborative working, despite initial anxieties about being observed and
receiving feedback
3. Improved team-work and greater flexibility in their use of their skills
4. Increased awareness of new techniques and greater insight into thinking
5. Enhanced planning skills to ensure more effective task management.
TOOLS FOR SELF EVALUATION
Staff annual professional review procedures
Peer support
o Coaching
o Joint preparation of materials
o Planning
o Team building

Observation can involve experts, can be informal or formal procedures. Feedback from such
observation is very valuable, but must be handled sensitively
Audit checklist
PEER EVALUATION
INTRODUCTION
In response to the public‘s clamor for improved care quality, some nursing organizations
instituted peer review as one method for increasing nurses‘ accountability for effective decision-
making and interventions. It is a mechanism for developing faculty leaders who can meet the
challenges posed by public demands for accountability in healthcare management.
DEFINITION
Peer review is a process by which employees of the same rank, profession, and setting evaluate
one another‘s job performance against accepted standards.
- O‘ Loughlin and Kaulbach
THE SUCCESS OF PEER EVALUATION DEPENDS ON
 Short but objective method
 Trained observers
 Constructive feedback for faulty development
 Open communication and trust
METHODS OF PEER EVALUATION
Direct observation
Videotaping
Evaluation of course materials
Analysis of portfolios
PROCESS OF PEER REVIEW
I. Establish a policy requiring peer reviews
II. Establish criteria for peer evaluations
III. Procedure for conducting peer evaluations
a. Faculty chosen to conduct peer evaluations shall be tenured and hold on academic
rank higher than that of the faculty member being evaluated
b. A written report, addressing the criteria, shall be prepared and signed by the
evaluator
c. The department shall archive the written evaluations for use in future evaluations
d. One copy of the peer evaluation shall be placed in the permanent personnel file of the
person being evaluated
e. All reports of peer evaluations shall be included in the tenure file, and are to be
carefully reviewed at the department.

PATIENT SATISFACTION
INTRODUCTION
Consumers of health care services demand quality care. Patient satisfaction has been used as an
indicator of quality services provided by health care personnel. The most important predictor of
patients overall satisfaction with hospital care is particularly related to their satisfaction with
nursing care. In recent years, the focus on consumerism in a highly competitive environment has
led to increased interest in measuring patient satisfaction with health care.
DEFINITION
―Patient satisfaction is defined as a health care recipients reaction to salient aspects of the
context, process, and result of their service experience.‖ -
Pascoe (1983)
―Patient satisfaction is deﬁned as the extent of the resemblance between the expected quality
of care and the actual received care.‖
- Scarding (1994)
NEED FOR EVALUATING PATIENT SATISFACTION
 Data about patient satisfaction equips nurses with useful information about the structure,
process and outcome of nursing care
 It is a requirement for therapeutic treatment and is equivalent to self therapy. Satisﬁed patients
help themselves get healed faster because they are more willing to comply with treatment and
adhere to instructions of health care providers, and thus have a shorter recovery time.
METHODS OF MONITORING PATIENT SATISFACTION
Medical audit
Quality assurance committee reviews
Indices of nursing performances
Judgemental method
COMPONENTS OF EVALUATION OF PATIENT SATISFACTION
1. Evaluation of the programs and activities of various departments including outpatient care,
inpatient care, overall health education activities of the hospital
2. Evaluation of the various resources available in the hospital for effective health care
3. Evaluation of effectiveness of hospital personnel including medical, paramedical, nursing as
well as non-medical employees of the hospital.
4. Services are relevant to the needs of the population it serves.
Patient satisfaction with nursing care is important for any health care agency because nurses
comprise the majority of health care providers and they provide care for patients 24 hours a day.

ULITILISATION REVIEW
The utilisation review program includes determining appropriate hospital length of stay and
necessary treatments for various illnesses and conditions and reviewing patient medical records
on admission and at intervals during hospitalisation to ensure that the patient receives
appropriate care.
AIMS AND OBJECTIVES:
1. The main aim is to curb the exploding health care costs with conservative use of
hospitalisation and expensive diagnostic and treatment procedures.
2. They work in liason with a business organisation to provide healthcare services to the
organisation‘s employees at discounted rates.
3. Cost containment to limit each patient‘s diagnostic and treatment measures to the fewest,
least expensive procedures that will relieve patient symptoms, avert costly complications,
and return the patient to fullest possible function in the shortest time possible.
UTILISATION REVIEW NURSE
 A utilization review nurse is a registered nurse who reviews individual medical cases to
confirm that they are getting the most appropriate care.
 They can work for insurance companies, determining whether or not care should be approved
in specific situations, and they can also work in hospitals.
 Members of this profession do need to possess compassion, but they also need to be able to
review situations dispassionately to make decisions which are fair, even if they may be
uncomfortable.
 At a hospital, a utilization review nurse examines patient cases if the hospital feels that a
patient may not be receiving the appropriate treatment.
 In an insurance company, the utilization review nurse inspects claims to determine whether
or not they should be paid.
 The nurse weighs the patient's situation against the policy held by the patient, the standards
of the insurance company, and the costs which may be involved in treatment.
 To work in this field, it is usually necessary to hold a current nursing license, and to have
experience in the field.

Unit IX
FISCAL PLANNING  Steps
 Plan and non-plan, zero budgeting, mid-term
appraisal, capital and
 revenue
 Budget estimate, revised estimate, performance
budget
 Audit
 Cost effectiveness
 Cost accounting
 Critical pathways
 Health care reforms
 Health economics
 Health insurance
 Budgeting for various units and levels

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

Purposes of budget
1. To provide definite targets for income and expenditure of the department
2. To co-ordinate the activities of the different functional heads in the working of these
departmental budget
3. To enable a cash flow statement prepared month by month
4. To aid management in formulating future policy decision to promote the growth and
welfare of the organizations
5. To provide useful tool for the control of costs
6. To provide a tool for communication and co ordination within the organization.
7. To improve financial planning and decision making.
8. To identify controllable and uncontrollable cost area.
Importance of budget
Budget is a numerical description of expected income and planned expenditure for an
organization for a specified period of time. It is a concrete, picture of the total operation of an
enterprise/ organization/ institution in monetary term, i.e., finance
The following point serves the importance of budget:
 Budget is needed for planning for future course of action and to have a control over all
activities in the organization
 Budget facilities co coordinating operation of various departments and sections for
realizing organizational objectives.
 Budget serves as a guide for action in the organization
 Budget helps one to weigh the values and to make decision when necessary on whether
one is of a greater value in the programme than the other
Principles of Budget
Budget is an operational plan for a definite period, usually a year, expressed in financial
terms and based on expected income and expenditure.
1. Budget should provide sound financial management by focusing on requirement of the
organization
2. Budget should focus on objectives and policies of the organization. It must flow from
objectives and give realistic expression to the way of realizing such objectives.
3. Budget should ensure the most effective use of scarce financial and non financial resources.
4. Budget requires that programme activities planned in advance
5. Budgetary process requires consistent delegation for which fixed duties and responsibilities
are required to be allocated to managers at different level for framing and executing budget.

6. Budgeting should include coordinating efforts of various departments establishing frame of
reference for managerial decisions, and providing a criterion for evaluating managerial
performance.
7. Setting budget target requires an adequate checks and balance against the adoption of too
high or too low estimate. Utmost care is a must for fixing targets.
8. Budget period must be appropriate to the nature of business or service and to the type of
budget.
9. Budget is prepared under the direction and supervision of the administrator or finance officer.
10. Budget is to be prepared and interpreted consistently throughout the organization in the
communication of planning process.
11. Budget necessitates a review of the performance of the previous year and an evaluation of its
adequacy both in quantity and quality.
12. While developing a budget, the provision should be made for its flexibility.
STEPS IN BUDGETING
COLLECTION OF PAST DATA
ASSESS SUCCESS AND FAILURES OF PAST
SETTING OBJECTIVES FOR FORECAST YEAR
OBJECTIVES ARRANGED IN TERMS OF INDICATED UNITS
PREPARATION OF REPORTS ON EXPENSES
PREPARATION OF BUDGET REPORT
REVIEW OF BUDGET REPORT
EVALUATION FOR MODIFICATION OR CHANGRS
FINAL PRESENATION BEFORE BOARD OF TRUSTEES FOR DECISION

GENRAL BUDGET: How to make your self
Step 1 : Determine your monthly income
Take into consideration your payroll deductions (health insurance or other group benefits,
income taxes, union dues, pension) and other sources of income.
– Add together all income, less deductions. On a piece of paper record the resulting
figure as VALUE A.
Step 2: List your “fixed” and “variable” monthly expenses
Such as housing, utilities, food and transportation. Remember to allocate funds for
clothing, medical care, child care, personal expenses, recreation and emergencies/repairs.
– Add all of your expenses–this is VALUE B.
Step 3: Find your “discretionary income”
– By subtracting your total expenses (B) from your total net income (A).
– Write this number down on a piece of paper as VALUE C.
Step 4: List all unsecured debts
• The monthly payments and the balances. If you don‘t know your exact debt amount, now
is the time to determine it.
– Write this number down on a piece of paper as VALUE C.
Step 5: Determine if you have any remaining discretionary income
• After making these installment payments by subtracting your total monthly
payments to creditors (D) from your discretionary income (C).
• If this figure is a negative number, you are not ready for Step 6 – setting goals.
Consult a personal financial counsellor and work on getting this figure into the
positive numbers
Step 6 to establish short- and long-term goals
• Make a list of these goals
 Long-Term – Real Estate Purchases, Future Education, Retirement
 Short-Term – Home Improvements, New Car, Travel
 Other Desired Investments – Stocks, Bonds, CDs, Mutual Funds
• Determine how much you need to save monthly

Steps in effective budgeting process
• Determine the requirements: inputs from all levels of hierarchy must be obtained
• Develop plan: Budget for 12months is set. Zero-Based budget
• Analyze and control the operation: continuous monitoring is essential
• Review the plan: Periodic revision and modification
Steps in budgeting for college of nursing
• Request for the needs of various departments
• Review the budget appropriation and actual expenditure for the current year
• Contemplated changes
• Salary fixation
• Requirement estimation
• Summary of new needs
The steps of planning budget for nursing unit
• Assistance of his/her subordinates
• Review of budget
• Ascertain changes
• Preparing requirements
• Summary of new needs
• Submitting to institutional administrator
Roles and Responsibilities of the Nurse Administrator/Principal in Budgeting
– Participation in planning budget
– Consult an take assistance of his/her subordinates
– Request sufficient finds
– Submit budget request
– Support the budget when it is allotted.
– Cover the routine budget control

NURSING AUDIT
Audit in nursing management is the professional evaluation of the quality of the patient
care, by analysing through all the facilities , services rendered, measures involved in diagnosis,
treatment and other conditions and activities that affect the patients.
Definition
 ―Nursing audit refers to the assessment of the quality of clinical nursing.‖- Elison
 ―Nursing audit is the means by which nurses themselves can define standards from their
point of view and describe the actual practice of nursing.‖Goster Walfer
Characteristics
 It improve the quality of nursing care
 It compares actual practice with agreed standards of practice.
 It is formal and systemic.
 It involves peer review.
 It requires the identification of variations between practice and standards followed by the
analysis of causes of such variations.
 It provides feedback for those whose records are audited.
 It includes follow- up or repeating an audit sometimes later to find out if the practice is
fulfilling the agreed standards.
Objectives
 To evaluate the quality of nursing care given.
 To achieve the desired and feasible quality of care.
 To provide a way for better records.
 To focus on care provided and care provider.
 To provide rationalized care thereby maintaining uniform standards worldwide.
 To contribute to research.
Methods of Audit
There are mainly two methods;
 Retrospective view- It refers to the detail quality care assessment after the patient has
been discharged. The records can be reviewed for completeness of records, diagnosis,
treatment, lab investigations, consultations, nursing care plan, complications, and end
results.
 Concurrent view- It is achieved by reviewing patient care during the time of hospital
stay by the patient. It includes assessing the patient at the bedside in relation to
predetermined criteria like errors, omissions, deficiencies, as well as efficiencies and also
excess in the care of patients under them. It involves direct and indirect observation,

interviewing the staff responsible for care, and reviewing the patients‘ records and care
plan.
It can be also done to identify the job satisfaction of staff nurses in accordance with their
work performance.
Audit cycle
According to Payne, the steps in audit or utilization review include;
 Criteria development
 Selection of cases
 Work sheet preparation
 Case evaluation
 Tabulation of evaluation
 Presentation of reports
The basic audit cycle can be depicted as;
In general, the stages of audit cycle are;
 Identify the need for change
 Setting criteria and standards
 Collecting data on performance
 Assess criteria against criteria and standards
 Identify need for change (re- evaluation)
Advantages
 Patient is assured of good service.
 Better planning of quality improvement can be done.
 It develops openness to change.
 It provides assurance, by meeting evidence based practice.
 It increases understanding of client‘s expectations.
 It minimizes error or harm to patients.
 It reduces complaints or claims.
1. set
standards
2. observe
practice
changes
3. compare
with standards
4. implement
change

Disadvantages
 It may be considered as a punishment to professional group.
 Medico- legal importance- They feel that they will be used in court of law as any
document can be called for in a court law.
 Many components may make analysis difficult.
 It is time consuming
 It requires a team of trained auditors.
COST ACCOUNTING AND COST ANALYSIS
Introduction
Cost effectiveness and cost accounting are important aspects in the managerial level. If
these factors are not being monitored properly the profit of the organization may be drastically
affected. So each administrator should be aware of this. Thus it forms an important aspect in the
part of administration.
Origin of cost accounting
Cost accounting has long been used to help managers understand the costs of running a
business. Modern cost accounting originated during the industrial revolution, when the
complexities of running a large scale business led to the development of systems for recording
and tracking costs to help business owners and managers make decisions.
In the early industrial age, most of the costs incurred by a business were what modern
accountants call "variable costs" because they varied directly with the amount of production.
Money was spent on labor, raw materials, power to run a factory, etc. in direct proportion to
production. Managers could simply total the variable costs for a product and use this as a rough
guide for decision-making processes.
Some costs tend to remain the same even during busy periods, unlike variable costs,
which rise and fall with volume of work. Over time, the importance of these "fixed costs" has
become more important to managers. Examples of fixed costs include the depreciation of plant
and equipment, and the cost of departments such as maintenance, tooling, production control,

purchasing, quality control, storage and handling, plant supervision and engineering. In the early
twentieth century, these costs were of little importance to most businesses. However, in the
twenty-first century, these costs are often more important than the variable cost of a product, and
allocating them to a broad range of products can lead to bad decision making. Managers must
understand fixed costs in order to make decisions about products and pricing.
Definition
Cost accounting
Cost accounting is the process that supports the budget reporting system and the agency
efforts for cost containment.
Cost accounting is a set of techniques for associating costs with the purpose for which
obtained.
Classical cost elements are:
1. Raw materials
2. Labor
3. Indirect expenses/overhead
Elements of cost
1. Material (Material is a very important part of business)
A. Direct material
2. Labor
A. Direct labor
3. Overhead
A. Indirect material
B. Indirect labor
Standard cost accounting
In modern cost accounting, the concept of recording historical costs was taken further, by
allocating the company's fixed costs over a given period of time to the items produced during
that period, and recording the result as the total cost of production. This allowed the full cost of
products that were not sold in the period they were produced to be recorded in inventory using a

variety of complex accounting methods, which was consistent with the principles of GAAP
(Generally Accepted Accounting Principles). It also essentially enabled managers to ignore the
fixed costs, and look at the results of each period in relation to the "standard cost" for any given
product.
An important part of standard cost accounting is a variance analysis,, which breaks down
the variation between actual cost and standard costs into various components (volume variation,
material cost variation, labor cost variation, etc.) so managers can understand why costs were
different from what was planned and take appropriate action to correct the situation.
Classification of costs
Classification of cost means, the grouping of costs according to their common characteristics.
The important ways of classification of costs are:
 By nature or element: materials, labor, expenses
 By functions: production, selling, distribution, administration, R&D, development,
 As direct and indirect
 By variability: fixed, variable, semi-variable
 By controllability: controllable, uncontrollable
 By normality: normal, abnormal
There are various managerial accounting approaches:
 Standardized or standard cost accounting
 Lean accounting
 Activity-based costing
 Resource consumption accounting
 Throughput accounting
 Marginal costing/cost-volume-profit analysis

Activity-based costing
Activity-based costing (ABC) is a system for assigning costs to products based on the
activities they require. In this case, activities are those regular actions performed inside a
company. "Talking with customer regarding invoice questions" is an example of an activity
inside most companies.
Accountants assign 100% of each employee's time to the different activities performed
inside a company (many will use surveys to have the workers themselves assign their time to the
different activities). The accountant then can determine the total cost spent on each activity by
summing up the percentage of each worker's salary spent on that activity.
A company can use the resulting activity cost data to determine where to focus their
operational improvements. For example, a job-based manufacturer may find that a high
percentage of its workers are spending their time trying to figure out a hastily written customer
order. Via ABC, the accountants now have a currency amount pegged to the activity of
"Researching Customer Work Order Specifications". Senior management can now decide how
much focus or money to budget for resolving this process deficiency. Activity-based
management includes (but is not restricted to) the use of activity-based costing to manage a
business.
While ABC may be able to pinpoint the cost of each activity and resources into the
ultimate product, the process could be tedious, costly and subject to errors.
As it is a tool for a more accurate way of allocating fixed costs into product, these fixed
costs do not vary according to each month's production volume. For example, an elimination of
one product would not eliminate the overhead or even direct labor cost assigned to it. ABC better
identifies product costing in the long run, but may not be too helpful in day-to-day decision-
making.

Lean accounting
Lean accounting has developed in recent years to provide the accounting, control, and
measurement methods supporting lean manufacturing and other applications of lean thinking
such as healthcare, construction, insurance, banking, education, government, and other
industries.
There are two main thrusts for Lean Accounting. The first is the application of lean methods
to the company's accounting, control, and measurement processes. This is not different from
applying lean methods to any other processes. The objective is to eliminate waste, free up
capacity, speed up the process, eliminate errors & defects, and make the process clear and
understandable. The second (and more important) thrust of Lean Accounting is to fundamentally
change the accounting, control, and measurement processes so they motivate lean change &
improvement, provide information that is suitable for control and decision-making, provide an
understanding of customer value, correctly assess the financial impact of lean improvement, and
are themselves simple, visual, and low-waste. Lean Accounting does not require the traditional
management accounting methods like standard costing, activity-based costing, variance
reporting, cost-plus pricing, complex transactional control systems, and untimely & confusing
financial reports. These are replaced by:
 lean-focused performance measurements
 simple summary direct costing of the value streams
 decision-making and reporting using a box score
 financial reports that are timely and presented in "plain English" that everyone can
understand
 radical simplification and elimination of transactional control systems by eliminating the
need for them
 driving lean changes from a deep understanding of the value created for the customers
 eliminating traditional budgeting through monthly sales, operations, and financial
planning processes (SOFP)
 value-based pricing
 correct understanding of the financial impact of lean change

As an organization becomes more mature with lean thinking and methods, they recognize that
the combined methods of lean accounting in fact creates a lean management system (LMS)
designed to provide the planning, the operational and financial reporting, and the motivation for
change required to prosper the company's on-going lean transformation.
Marginal costing
This method is used particularly for short-term decision-making. Its principal tenets are:
 Revenue (per product) − variable costs (per product) = contribution (per product)
 Total contribution − total fixed costs = (total profit or total loss)
Thus, it does not attempt to allocate fixed costs in an arbitrary manner to different products. The
short-term objective is to maximize contribution per unit. If constraints exist on resources, then
Managerial Accounting dictates that marginal cost analysis be employed to maximize
contribution per unit of the constrained resource
Throughput Accounting
Throughput Accounting (TA) is a dynamic, integrated, principle-based, and
comprehensive management accounting approach that provides managers with decision support
information for enterprise optimization.
Advantages
The accumulated data enable a head nurse to assess the cost
It enables a nurse manager to identify the interaction between different expenditure.
It enables a manager to identify popular services.
Disadvantages
It is difficult to associate some costs with particular programme
It is the fact that it is difficult for a manager to justify the cost of a nursing care programme.
Cost effectiveness
Cost-effectiveness analysis

Cost-effectiveness analysis is a form of economic analysis that compares the relative
costs and outcomes (effects) of two or more courses of action. Cost-effectiveness analysis is
distinct from cost-benefit analysis, which assigns a monetary value to the measure of effect.
Cost-effectiveness analysis is often used in the field of health services, where it may be
inappropriate to monetize health effect. Typically the CEA is expressed in terms of a ratio where
the denominator is a gain in health from a measure (years of life, premature births averted, sight-
years gained) and the numerator is the cost associated with the health gain.[
Cost benefit analysis
It is a tool with great potential for the decision maker so long as he or she recognises the
difficulty in determining the true costs and benefits of various alternatives. This tool can be
especially useful when trying to decide between alternative expenditure of money.
A cost benefit ratio (z) is defined as the ratio of the value of benefits of an alternative to
the value of alternative cost.
Z= Present value of economic benefits/ present value of economic costs
Cost benefit analysis is designed to consider the social costs and benefit attributable to
the project. The benefits are expressed in monetary terms to determine whether a given
programme is economically sound and to select the best out of several programmes.
CRITICAL PATHWAY
Clinical Pathways: multidisciplinary plans of best clinical practice. Many synonyms exist
for the term Clinical Pathways including: Integrated Care Pathways, Multidisciplinary pathways
of care, Pathways of Care, Care Maps, and Collaborative Care Pathways.
Clinical Pathways were introduced in the early 1990s in the UK and the USA, and are
being increasingly used throughout the developed world. Clinical Pathways are structured,
multidisplinary plans of care designed to support the implementation of clinical guidelines and
protocols. They are designed to support clinical management, clinical and non-clinical resource
management, clinical audit and also financial management. They provide detailed guidance for
each stage in the management of a patient (treatments, interventions etc.) with a specific
condition over a given time period, and include progress and outcomes details.

Clinical Pathways have four main components (Hill, 1994, Hill 1998):
1. A timeline
2. The categories of care or activities and their interventions
3. Inter-mediate and long term outcome criteria
4. The variance record (to allow deviations to be documented and analysed).
Critical Pathway Development
 Select a Topic .
Topic selection in general should concentrate on high-volume, high-cost diagnoses and
procedures. Critical pathway development has focused on several cardiovascular diseases and
procedures because of volume and costs. These include bypass surgery, diagnostic
catheterization, coronary angioplasty, acute myocardial infarction, and unstable angina. These
diagnoses and procedures tend to be more suitable for critical pathway development because of
the predictable course of events that occur during the hospitalization. In addition, marked
variation in care has been observed in these conditions, which makes the goal of decreased
variation and reduction in resource utilization possible. Furthermore, there has been evidence of
noncompliance with guideline recommendations. In this case, the pathways might improve
guideline compliance and potentially improve quality of care.
 Select a Team .
It is important to develop a multidisciplinary team for critical pathway development.
Historically, critical pathway development has been a nursing initiative. Although this has been a
successful model in some institutions, one fault of this process is lack of physician commitment
to the pathway. Active physician participation and leadership is crucial to the development and
implementation of the pathway. In addition, it is important to include representatives from all
groups that would be affected by the pathway, for example, house staff, physical therapy
personnel, and dietary personnel. The lack of involvement of physicians has been cited as a
reason for failure of a pathway.
 Evaluate the Current Process of Care .
In this step, data, rather than anecdotal reports, are key to understanding current variation.
For systems with electronic medical records, this process may be more automated. For other
systems, a careful review of medical records is necessary to identify the critical intermediate
outcomes, rate-limiting steps, and high-cost areas on which to focus.

 Evaluate Medical Evidence and External Practices .
After key rate-limiting steps have been identified, the critical pathway team must
evaluate the literature to identify evidence of best practices. For most rate-limiting steps, there
are few data available to define optimal processes of care. The critical pathway development
team will often lack answers to specific questions such as appropriate observation period or
length of stay. In the absence of evidence, comparison with other institutions, or
"benchmarking," is the most reasonable method to use.
 Determine the Critical Pathway Format .
The format of the pathway may vary widely. Important features include a task-time
matrix in which specific tasks are specified along a timeline. There is a spectrum of pathways
that range from a form that takes the place of the medical record to a simple checklist. A
reduction in charting that may occur with more complicated pathways is a benefit. However, if
the pathway format is too difficult to follow, it will not be used. Critical pathways have become
widely available in electronic format, where electronic charting and pathway compliance are
obtained simultaneously. One disadvantage to this method is the absence of a standard medical
record. This may result in duplication of efforts and possible noncompliance with the pathway.
This is particularly true among physicians who are likely to be resistant to novel charting
methods. For some systems, a simple checklist at the front of the paper chart may be an optimal
method for implementing the pathway. These checklists would have areas to be filled in by
different staff members active in patient care.
 Document and Analyze Variance .
Variances are patient outcomes or staff actions that do not meet the expectation of the
pathway. In general, variance in clinical pathways is a result of the omission of an action or the
performance of an action at an inappropriate (often, a late) time period. Because the critical
pathway is a series of time-associated actions, this analysis of variance can be overwhelmed by
multiple data points. Computer-assisted pathway analysis can help with this issue. Another
approach is for the pathway team to concentrate on a few critical items in the pathway that have
been identified in advance, such as extubation time after cardiac surgery or length of stay in the
intensive care unit. These are critical intermediate outcomes that may have a substantial number
of important contributory factors. Arguably, the selection of areas to analyze and the analysis of
variance are among the most important processes in the critical pathway. Identification of factors
that contribute to variance and interventions to improve those factors are the key features in
process improvement.
Critical Path Analysis and PERT Charts

Critical Path Analysis and PERT are powerful tools that help you to schedule and manage
complex projects. They were developed in the 1950s to control large defense projects, and have
been used routinely since then.
As with Gantt Charts, Critical Path Analysis (CPA) or the Critical Path Method (CPM)
helps you to plan all tasks that must be completed as part of a project. They act as the basis both
for preparation of a schedule, and of resource planning. During management of a project, they
allow you to monitor achievement of project goals. They help you to see where remedial action
needs to be taken to get a project back on course.
Within a project it is likely that you will display your final project plan as a Gantt Chart
(using Microsoft Project or other software for projects of medium complexity or an excel
spreadsheet for projects of low complexity).The benefit of using CPA within the planning
process is to help you develop and test your plan to ensure that it is robust. Critical Path Analysis
formally identifies tasks which must be completed on time for the whole project to be completed
on time. It also identifies which tasks can be delayed if resource needs to be reallocated to catch
up on missed or overrunning tasks. The disadvantage of CPA, if you use it as the technique by
which your project plans are communicated and managed against, is that the relation of tasks to
time is not as immediately obvious as with Gantt Charts. This can make them more difficult to
understand.
A further benefit of Critical Path Analysis is that it helps you to identify the minimum
length of time needed to complete a project. Where you need to run an accelerated project, it
helps you to identify which project steps you should accelerate to complete the project within the
available time. .
PERT (Program Evaluation and Review Technique)
PERT is a variation on Critical Path Analysis that takes a slightly more skeptical view of
time estimates made for each project stage. To use it, estimate the shortest possible time each
activity will take, the most likely length of time, and the longest time that might be taken if the
activity takes longer than expected.
Use the formula below to calculate the time to use for each project stage:
Shortest time + 4 x likely time + longest time
-----------------------------------------------------------
6

Importance
Critical Path Analysis is an effective and powerful method of assessing:
• What tasks must be carried out.
• Where parallel activity can be performed.
• The shortest time in which you can complete a project.
• Resources needed to execute a project.
• The sequence of activities, scheduling and timings involved.
• Task priorities.
• The most efficient way of shortening time on urgent projects.
CPM - Critical Path Method
In 1957, DuPont developed a project management method designed to address the challenge of
shutting down chemical plants for maintenance and then restarting the plants once the
maintenance had been completed. Given the complexity of the process, they developed the
Critical Path Method (CPM) for managing such projects.
CPM provides the following benefits:
 Provides a graphical view of the project.
 Predicts the time required to complete the project.
 Shows which activities are critical to maintaining the schedule and which are not.
CPM models the activities and events of a project as a network. Activities are depicted as nodes
on the network and events that signify the beginning or ending of activities are depicted as arcs
or lines between the nodes. The following is an example of a CPM network diagram:

CPM Diagram
Steps in CPM Project Planning
1. Specify the individual activities.
2. Determine the sequence of those activities.
3. Draw a network diagram.
4. Estimate the completion time for each activity.
5. Identify the critical path (longest path through the network)
6. Update the CPM diagram as the project progresses.
1. Specify the Individual Activities
From the work breakdown structure, a listing can be made of all the activities in the project. This
listing can be used as the basis for adding sequence and duration information in later steps.
2. Determine the Sequence of the Activities
Some activities are dependent on the completion of others. A listing of the immediate
predecessors of each activity is useful for constructing the CPM network diagram.
3. Draw the Network Diagram
Once the activities and their sequencing have been defined, the CPM diagram can be drawn.
CPM originally was developed as an activity on node (AON) network, but some project planners
prefer to specify the activities on the arcs.
4. Estimate Activity Completion Time
The time required to complete each activity can be estimated using past experience or the
estimates of knowledgeable persons. CPM is a deterministic model that does not take into

account variation in the completion time, so only one number is used for an activity's time
estimate.
5. Identify the Critical Path
The critical path is the longest-duration path through the network. The significance of the critical
path is that the activities that lie on it cannot be delayed without delaying the project. Because of
its impact on the entire project, critical path analysis is an important aspect of project planning.
The critical path can be identified by determining the following four parameters for each
activity:
• ES - earliest start time: the earliest time at which the activity can start given that its
precedent activities must be completed first.
• EF - earliest finish time, equal to the earliest start time for the activity plus the time
required to complete the activity.
• LF - latest finish time: the latest time at which the activity can be completed without
delaying the project.
• LS - latest start time, equal to the latest finish time minus the time required to complete
the activity.
The slack time for an activity is the time between its earliest and latest start time, or
between its earliest and latest finish time. Slack is the amount of time that an activity can be
delayed past its earliest start or earliest finish without delaying the project.
The critical path is the path through the project network in which none of the activities
have slack, that is, the path for which ES=LS and EF=LF for all activities in the path. A delay in
the critical path delays the project. Similarly, to accelerate the project it is necessary to reduce
the total time required for the activities in the critical path.
6. Update CPM Diagram
As the project progresses, the actual task completion times will be known and the
network diagram can be updated to include this information. A new critical path may emerge,
and structural changes may be made in the network if project requirements change.
CPM Limitations
CPM was developed for complex but fairly routine projects with minimal uncertainty in
the project completion times. For less routine projects there is more uncertainty in the
completion times, and this uncertainty limits the usefulness of the deterministic CPM model. An

alternative to CPM is the PERT project planning model, which allows a range of durations to be
specified for each activity.
Benefits
 Support the introduction of evidence-based medicine and use of clinical guidelines
 Support clinical effectiveness, risk management and clinical audit
 Improve multidisciplinary communication, teamwork and care planning
 Can support continuity and co-ordination of care across different clinical disciplines and
sectors;
 Provide explicit and well-defined standards for care;
 Help reduce variations in patient care (by promoting standardisation);
 Help improve clinical outcomes;
 Help improve and even reduce patient documentation
 Support training;
 Optimise the management of resources;
 Can help ensure quality of care and provide a means of continuous quality improvement;
 Support the implementation of continuous clinical audit in clinical practice
 Support the use of guidelines in clinical practice;
 Help empower patients;
 Help manage clinical risk;
 Help improve communications between different care sectors;
 Disseminate accepted standards of care;
 Provide a baseline for future initiatives;
 Not prescriptive: don't override clinical judgement;
 Expected to help reduce risk;
 Expected to help reduce costs by shortening hospital stays
Issues with Critical Pathways
There are many issues in critical pathway development and implementation that are of concern to
practitioners who care for patients with cardiovascular disease.
 The first issue is that critical pathways address processes in the "ideal" patient and in
some cases do not address issues in the majority of patients who enter the path.
Identification of appropriate patients to enter the pathway is an important issue in
implementation. In general, critical pathways are more applicable to patients with
uncomplicated illnesses who are undergoing procedures or surgery. For patients treated
with medical conditions such as acute coronary syndromes, it is difficult to define
"appropriate" treatment for the majority of patients. Therefore, critical pathways will tend
to identify a great deal of variance in the care of these patients that may or may not be

wasteful or potentially harmful. The goal of placing most patients within pathways may
not benefit the individual patient.
 A second issue is how to evaluate critical pathways as an effective tool in improving
patient care. As we have mentioned, little controlled research has been performed on the
effectiveness of pathways. One reason for this is that at any one medical center,
"pathway" care cannot be easily differentiated from "usual" care because of
contamination from the pathway intervention. Randomized trials with the unit of
randomization at the medical center would be the optimal evaluation method.
 The real impact of critical pathways and appropriateness protocols is their use as tools for
collection of information. Pathways can serve as a screening test for inefficient care. The
danger is that a pathway with too many critical areas under review will be too sensitive,
resulting in the review of a large number of marginally appropriate cases.Review of
critical pathway data should be focused on the highest-impact areas in terms of either
cost, quality of care, or, preferably, both.
Issues - potential problems and barriers to the introduction of CPs
 May appear to discourage personalised care
 Risk increasing litigation
 Don't respond well to unexpected changes in a patient's condition
 Suit standard conditions better than unusual or unpredictable ones
 Require commitment from staff and establishement of an adequate organisational
structure
 Problems of introduction of new technology
 May take time to be accepted in the workplace
 Need to ensure variance and outcomes are properly recorded.
HEALTH CARE REFORM
Health care reform is a general rubric used for discussing major health policy creation or
changes—for the most part, governmental policy that affects health care delivery in a given
place. Health care reform typically attempts to:
 Broaden the population that receives health care coverage through either public sector
insurance programs or private sector insurance companies
 Expand the array of health care providers consumers may choose among
 Improve the access to health care specialists
 Improve the quality of health care
 Give more care to citizens
 Decrease the cost of health care
 We need a different approach to healthcare reforms in India

Goal
The goal of healthcare reform is to make healthcare more accessible and available to all
citizens. Currently, millions remain uninsured due to job loss, or because healthcare premiums
would simply be too costly. Ideally, healthcare reform would enable more, to become insured,
and also decrease the cost of healthcare. However, this is a goal that is not so easily obtained,
due to the complexities of the healthcare system , and the quality of care provided here.
The primary objectives of health care reform include:
 Provide healthcare coverage for all.
 Decrease the costs of health care services and coverage
Health care reforms in India
The Ministry of Health and Family Welfare is the Indian government ministry charged
with health policy in India. It is also responsible for all government programs relating to family
planning in India.
The Minister of Health and Family Welfare holds cabinet rank as a member of the
Council of Ministers. The current minister is Shri. Ghulam Nabi Azad, who is assisted by a
Minister of States for Health and Family Welfare, Shri. Dinesh Trivedi & Shri. S. Gandhiselvan.
The ministry is composed of three departments:
1 Department of Health
2 Department of Family Welfare
3 Department of AYUSH
1. Department of Health
The Department of Health deals with health care, including awareness campaigns, immunization
campaigns, preventive medicine, and public health. Bodies under the administrative control of
this department are:
1) National AIDS Control Programme (AIDS)
2) National Cancer Control Programme (cancer)
3) National Filaria Control Programme (filariasis)
4) National Iodine Deficiency Disorders Control Programme (iodine deficiency)
5) National Leprosy Eradication Programme (leprosy)

6) National Mental Health Programme (mental health)
7) National Programme for Control of Blindness (blindness)
8) National Programme for Prevention and Control of Deafness (deafness)
9) National Tobacco Control Programme (tobacco control)
10) National Vector Borne Disease Control Programme (NVBDCP) (vector-born disease)
11) Pilot Programme on Prevention and Control of Diabetes, CVD and Stroke (diabetes,
cardiovascular disease, stroke)
12) Revised National TB Control Programme (tuberculosis)
13) Universal Immunization Programme
14) Medical Council of India
15) Dental Council of India
16) Pharmacy Council of India
17) Indian Nursing Council
18) All India Institute of Speech and Hearing (AIISH), Mysore
19) All India Institute of Physical Medicine and Rehabilitation (AIIPMR), Mumbai
20) Hospital Services Consultancy Corporation Limited (HSCC)
2. Department of Family Welfare
The Department of Family Welfare (FW) is responsible for aspects relating to family welfare,
especially in reproductive health, maternal health, pediatrics, information, education and
communications; cooperation with NGOs and international aid groups; and rural health services.
The Department of Family Welfare is responsible for:
• 18 Population Research Centres (PRCs) at six universities and six other institutions
across 17 states
• National Institute of Health and Family Welfare (NIHFW), South Delhi
• International Institute for Population Sciences (IIPS), Mumbai
• Central Drug Research Institute (CDRI), Lucknow

• Indian Council of Medical Research (ICMR), New Delhi - founded in 1991, it is one of
the oldest medical research bodies in the world
3. Department of AYUSH
The Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy
(AYUSH) deals with ayurveda (Indian traditional medicine), and other yoga, naturopathy, unani,
siddha, and homoeopathy, and other alternative medicine systems.
The department was established in March 1995 as the Department of Indian Systems of
Medicines and Homoeopathy (ISM&H).The department is charged with upholding educational
standards in the Indian Systems of Medicines and Homoeopathy colleges, strengthening
research, promoting the cultivation of medicinal plants used, and working on Pharmacopoeia
standards. Bodies under the control of the Department of AYUSH are:
Various research councils
1) Central Council for Research in Ayurveda and Siddha (CCRAS)
2) Central Council for Research in Unani Medicine (CCRUM)
3) Central Council for Research in Homoeopathy (CCRH)
4) Central Council for Research in Yoga and Naturopathy (CCRYN)
5) Several educational institutions:
6) National Institute of Ayurveda, Jaipur (NIA)
7) National Institute of Siddha, Chennai (NIS)
8) National Institute of Homoeopathy, Kolkata (NIH)
9) National Institute of Naturopathy, Pune (NIN)
10) National Institute of Unani Medicine, Bangalore (NIUM)
11) Institute of Post Graduate Teaching and Research in Ayurveda, Jamnagar,Gujarat
(IPGTR)
12) Rashtriya Ayurveda Vidyapeeth, New Delhi (RAV)
13) Morarji Desai National Institute of Yoga, New Delhi (MDNIY)
14) Indian Medicine Pharmaceutical Corporation Limited (IMPCL), Mohan, Uttaranchal (a
public sector undertaking)

15) Professional councils
16) Central Council of Homoeopathy (CCH)
17) Central Council of Indian Medicine (CCIM)
Healthcare in India
India has a universal health care system run by the local (state or territorial) governments.
Government hospitals, some of which are among the best hospitals in India, provide treatment at
taxpayer expense. Most essential drugs are offered free of charge in these hospitals. However,
the fact that the government sector is understaffed, underfinanced and that these hospitals
maintain very poor standards of hygiene forces many people to visit private medical
practitioners.
The charges for basic in-hospital treatment and investigations are much less compared to
the private sector. The cost for these subsidies comes from annual allocations from the central
and state governments. For example, an outpatient card at AIIMS (one of the best hospitals in
India) costs a one-time fee of 10 rupees (around 20 cents U.S.) and thereafter outpatient medical
advice is free. In-hospital treatment costs depend on financial condition of the patient and
facilities utilized, but are usually much less than the private sector. For instance, a patient is
waived treatment costs if their income is below the poverty line. Another patient may seek an
air-conditioned room for an additional fee.
Primary health care is provided by city and district hospitals and rural primary health
centres (PHCs). These hospitals provide treatment free of cost. Primary care is focused on
immunization, prevention of malnutrition, pregnancy, child birth, postnatal care, and treatment of
common illnesses.[citation needed] Patients who receive specialized care or have complicated
illnesses are referred to secondary (often located in district and taluk headquarters) and tertiary
care hospitals (located in district and state headquarters or those that are teaching hospitals).
Now organizations like Hindustan Latex Family Planning Promotional Trust and other
private organizations have started creating hospitals and clinics in India, which also provide free
or subsidized health care and subsidized insurance plans.
Indian healthcare reforms
In India, reforms can develop on sound principles on the basis of the learning of all available
systems, our strengths and needs. To make the common man healthy in the Indian scenario, we
need a different approach.
 37 percent of Indian population is undernourished. They have difficulty in meeting even
basic needs. 55 percent of the population have a diet which is calorie sufficient but
nutrient deficient whereas eight percent of the population is over-nourished. Hence, there

is a total imbalance of nutrition which leads to anaemia, TB and many other diseases
which increases the disease burden of India.
 Statistics tells us that arthritis, hypertension, diabetes, CVD, cancer patients and elderly
patients are major part of our disease burden. Besides acute diseases, almost all of them
trace their origin to (a lack of) nutrition.
 As Indian population is getting increasingly health conscious, almost 64 percent of out-
of-pocket expenditure in India constitutes healthcare expenditure as compared to 18
percent globally. This population can be called as 'Healthy Boomers'. They need to be
properly directed towards maintaining their health, in the same way as they have career
and financial plans.
 All nations have a significant role of Health Insurance in healthcare. In India, both the
patient and the payer is almost same. Here, a sharing model between Health Insurance
and patient can be adopted. 70 to 75 percent of the burden can be still borne by patient or
medical consumer, depending on the nature of disease. Therefore, I am of the opinion
that this sharing ratio should even be reversed as the severity of the disease increases, for
example in the case of cancer, where the institution should bear 70 percent of the
expenses otherwise the patient will die of the cost before the disease kills him.
 65 percent of Indian population lives in rural areas while only two percent qualified
medical doctors are available in these areas. Indian healthcare today is urban centric. It
needs to be reformed through medical infrastructure inclusive of doctors, nurses,
paramedicos, etc.
 Indian healthcare system should start from preventive care through nutrition. Reforms
must provide impetus to lift the population which is at the bottom of the pyramid.
 'Health is Wealth' is an old paradigm of India, as people were in 'scarcity thinking' mode,
as they were completely dependent on their livelihood to provide for their family's health
and well being. Resources were earlier scarce and people were driven to planning. This
mentality has given way to the 'abundant mentality' as today's generation has not seen
these scaricity of resources. Demographics are changing as well, and today 60 percent of
population does not have the responsibilities of a family to look after. For them this
paradigm needs to be inculcated through education. This new paradigm should originate
from nutrition to exercises to preventive healthcare to healthcare. It should be proactive
rather than reactive in terms of its reforms.
 As quickly as possible, health must become a priority issue for the Government of India.
Though the Department of Pharmaceuticals today comes under the Ministry of Chemicals
and Fertilizers Food, it deals with issues concerning our health like Food Safety &
Standards (FSS), Ayush and related bodies. Therefore, it should be appropriately part of
Ministry of Health and Family Welfare or in any other suitable ministry. Government has
taken up health issues like HIV, TB and tobacco through massive government programs.

 Overall, India needs to reform its healthcare system through policies, medical
infrastructure, education and realization of right nutrition to lifestyle management. Acute
diseases over time will be at reactive end of the reforms
HEALTH CARE ECONOMICS
Funding models
Universal health care in most countries has been achieved by a mixed model of funding.
General taxation revenue is the primary source of funding, but in many countries it is
supplemented by specific levies (which may be charged to the individual and/or an employer) or
with the option of private payments (either direct or via optional insurance) for services beyond
that covered by the public system.
Almost all European systems are financed through a mix of public and private
contributions. The majority of universal health care systems are funded primarily by tax revenue
(e.g. Portugal, Spain, Denmark and Sweden). Some nations, such as Germany, France and Japan
employ a multi-payer system in which health care is funded by private and public contributions.
However, much of the non-government funding is by defined contributions by employers and
employees to regulated non-profit sickness funds. These contributions are compulsory and vary
according to a person's salary, and are effectively a form of hypothecated taxation.
A distinction is also made between municipal and national healthcare funding. For
example, one model is that the bulk of the healthcare is funded by the municipality, speciality
healthcare is provided and possibly funded by a larger entity, such as a municipal co-operation
board or the state, and the medications are paid by a state agency.
Universal health care systems are modestly redistributive. Progressivity of health care
financing has limited implications for overall income inequality.
Single payer
The term single-payer health care is used in the United States to describe a funding
mechanism meeting the costs of medical care from a single fund. Although the fund holder is
usually the government, some forms of single-payer employ a public-private system.
Public
Some countries (notably the United Kingdom, Italy, Spain and the Nordic countries)
choose to fund health care directly from taxation alone. Other countries with insurance-based
systems effectively meet the cost of insuring those unable to insure themselves via social security
arrangements funded from taxation, either by directly paying their medical bills or by paying for
insurance premiums for those affected.

Compulsory insurance
This is usually enforced via legislation requiring residents to purchase insurance, though
sometimes, in effect, the government provides the insurance. Sometimes there may be a choice
of multiple public and private funds providing a standard service (e.g. as in Germany) or
sometimes just a single public fund (as in Canada). The U.S. Patient Protection and Affordable
Care Act is a law based on compulsory insurance.
Private insurance
In some countries with universal coverage, private insurance often excludes many health
conditions which are expensive and which the state health care system can provide. For example
in the UK, one of the largest private health care providers is BUPA which has a long list of
general exclusions even in its highest coverage policy. In the USA (which tried to transition
towards universal health care, but is being challenged through the court systems as
unconstitutional, because of the mandatory purchasing requirement) dialysis treatment for end
stage renal failure is generally paid for by government and not by the insurance industry. Persons
with privatized Medicare (Medicare Advantage) are the exception and must get their dialysis
paid through their insurance company, but persons with end stage renal failure generally cannot
buy Medicare Advantage plans.
HEALTH INSURANCE
Health insurance is insurance against the risk of incurring medical expenses. By
estimating the overall risk of health care expenses, an insurer can develop a routine finance
structure, such as a monthly premium or payroll tax, to ensure that money is available to pay for
the health care benefits specified in the insurance agreement. The benefit is administered by a
central organization such as a government agency, private business, or not-for-profit entity.
History and evolution
The concept of health insurance was proposed in 1694 by Hugh the Elder Chamberlen
from the Peter Chamberlen family. In the late 19th century, "accident insurance" began to be
available, which operated much like modern disability insurance.This payment model continued
until the start of the 20th century in some jurisdictions (like California), where all laws regulating
health insurance actually referred to disability insurance.
Accident insurance was first offered in the United States by the Franklin Health
Assurance Company of Massachusetts. This firm, founded in 1850, offered insurance against
injuries arising from railroad and steamboat accidents. Sixty organizations were offering accident
insurance in the U.S. by 1866, but the industry consolidated rapidly soon thereafter. While there
were earlier experiments, the origins of sickness coverage in the U.S. effectively date from 1890.
The first employer-sponsored group disability policy was issued in 1911.

Before the development of medical expense insurance, patients were expected to pay
health care costs out of their own pockets, under what is known as the fee-for-service business
model. During the middle to late 20th century, traditional disability insurance evolved into
modern health insurance programs. Today, most comprehensive private health insurance
programs cover the cost of routine, preventive, and emergency health care procedures, and most
prescription drugs, but this is not always the case.
Hospital and medical expense policies were introduced during the first half of the 20th
century. During the 1920s, individual hospitals began offering services to individuals on a pre-
paid basis, eventually leading to the development of Blue Cross organizations.[5]
The
predecessors of today's Health Maintenance Organizations (HMOs) originated beginning in
1929, through the 1930s and on during World War II
How it works
A health insurance policy is a contract between an insurance company and an individual
or his sponsor (e.g. an employer). The contract can be renewable annually, monthly or be
lifelong. The type and amount of health care costs that will be covered by the health insurance
company are specified in advance, in a member contract or "Evidence of Coverage" booklet. The
individual insured person's obligations may take several forms:[8]
 Premium: The amount the policy-holder or his sponsor (e.g. an employer) pays to the
health plan to purchase health coverage.
 Deductible: The amount that the insured must pay out-of-pocket before the health insurer
pays its share. For example, policy-holders might have to pay a $500 deductible per year,
before any of their health care is covered by the health insurer. It may take several
doctor's visits or prescription refills before the insured person reaches the deductible and
the insurance company starts to pay for care.
 Co-payment: The amount that the insured person must pay out of pocket before the
health insurer pays for a particular visit or service. For example, an insured person might
pay a $45 co-payment for a doctor's visit, or to obtain a prescription. A co-payment must
be paid each time a particular service is obtained.
 Coinsurance: Instead of, or in addition to, paying a fixed amount up front (a co-payment),
the co-insurance is a percentage of the total cost that insured person may also pay. For
example, the member might have to pay 20% of the cost of a surgery over and above a
co-payment, while the insurance company pays the other 80%. If there is an upper limit
on coinsurance, the policy-holder could end up owing very little, or a great deal,
depending on the actual costs of the services they obtain.
 Exclusions: Not all services are covered. The insured are generally expected to pay the
full cost of non-covered services out of their own pockets.
 Coverage limits: Some health insurance policies only pay for health care up to a certain
dollar amount. The insured person may be expected to pay any charges in excess of the
health plan's maximum payment for a specific service. In addition, some insurance
company schemes have annual or lifetime coverage maximums. In these cases, the health
plan will stop payment when they reach the benefit maximum, and the policy-holder must
pay all remaining costs.

 Out-of-pocket maximums: Similar to coverage limits, except that in this case, the insured
person's payment obligation ends when they reach the out-of-pocket maximum, and
health insurance pays all further covered costs. Out-of-pocket maximums can be limited
to a specific benefit category (such as prescription drugs) or can apply to all coverage
provided during a specific benefit year.
 Capitation: An amount paid by an insurer to a health care provider, for which the
provider agrees to treat all members of the insurer.
 In-Network Provider: (U.S. term) A health care provider on a list of providers preselected
by the insurer. The insurer will offer discounted coinsurance or co-payments, or
additional benefits, to a plan member to see an in-network provider. Generally, providers
in network are providers who have a contract with the insurer to accept rates further
discounted from the "usual and customary" charges the insurer pays to out-of-network
providers.
 Prior Authorization: A certification or authorization that an insurer provides prior to
medical service occurring. Obtaining an authorization means that the insurer is obligated
to pay for the service, assuming it matches what was authorized. Many smaller, routine
services do not require authorization.
 Explanation of Benefits: A document that may be sent by an insurer to a patient
explaining what was covered for a medical service, and how payment amount and patient
responsibility amount were determined.
BUDGETING FOR VARIOUS UNITS.
How to Make a Hospital Budget
Making a hospital budget is only second to medical delivery systems in for a hospital. In
fact, if a budget is not properly written, the hospital may be unable to deliver medical services at
all. So many expenses and sources of revenue must be taken into consideration, so the budget
process takes an expert to get through it successfully. Let's find out how to start.
Difficulty: Challenging
Instructions
1. Determine hospital revenue.
 Revenue can come from patient payments, tax dollars, donations, insurance credits.
 Be sure to deduct a percentage of the patient bills that will remain uncollected, the
charity work expected by the hospital and the pro bono work it does.
2. Figure out expenses.
 Start with the physical facility.
 How much does it cost to keep up the building or buildings.

 What is the maintenance cost of each department, engineering, air-conditioning,
heat, water, other utilities.
 Know what equipment costs, how much must be replaced per patient day, and if
any can be recycled.
 Include the non-medical cost of each bed in the hospital. Include advertising.
3. Know the cost of
 Personnel, all employees and ancillary staff, including consultants, outsourced
contracts, perhaps laundry or nurse staffing services.
 For all employees of the hospital, from janitorial to hospitalists, figure the fringe
benefits the hospital must pay for each.
4. Add all medical equipment costs, ongoing and expected expansion or replacement of new
diagnostic equipment.
5. Know the medical costs of each bed.
 How many staff hours are spent on each bed, occupied or not.
 Use this figure as an average to get a cost per patient year.
 Add to that the non medical costs per bed.
 Include every possible cost that keeps that bed in the hospital.
 Don't forget replacement costs per annum for any and all patient needs.
6. What about expansion?
 Are you planning a new wing, or the renovation of an old one?
 Are you expanding into a new specialty that could bring in extra revenue?
 Estimate that revenue when planning your budget.
7. Don't forget parking garages, lots, landscaping, groundskeeping or window washing.
8. Include all insurance for the facility and personnel.
9. Write in an emergency expense fund. Disasters occur and the hospital must be prepared
for them when they arrive.
10. To do the budget, use a spreadsheet

BUDGET FOR EDUCATIONAL INSTITUTION.
School should have a separate budget, i.e. principal in charge of the school of nursing
should be the drawing and disbursing officer and empowered to plan for operating the funds
in all different heads (as per government rules and regulations and as seemed necessary for
running an educational institutions).
Both the school/college and hospital should have separate budget. The budget for the
school or college is annually planned by the nursing director, principal and general manager
and approved by the managing director.
The budget is classified into 3 heads as
1. Revenue 2. Expenditure 3. Capital
1. Revenue: It includes assets, fixed deposits, investments, loan, advances and income.
2. Expenditure: It includes capital, recurring annual mandatory and non recurring.
The recurring annual mandatory expenditure includes:
- University Administration Fees – Rs. 50,000/
- Affliation Fees – Rs.3,00,000/ - and every year
Rs 50,000/- per course
- Inspection Fees Rs 25,000/-
- State council – Rs 7000/ every year for recognition.
- INC recognition fees Rs 50,000/ per course.
- INC inspection or affliation fees is 7,500/
- Reinspection fees 7000/
- Affliation fees to other institution.
The recurring monthly expenditure also include
- Rent
- Salary
- Stationary items
- Contingency
- Guest relation
- House keeping indent
- Pharmacy indent
- AV aids
- Journals
- Books
- Maintenance: Repair, Replacement, Electricity, Phone, Drinking Water, Sewage
Disposal.

Non recurring expenditure includes:
- DME endowment
Endowment Fund (property or income left to someone like insurance) Rs 20,00,000/-
in two installments (before one year 10,00,000/ and second year Rs.10,00,000/) which is
paid to the DME office.
- Security fixed deposit Rs.10,00,000/ with the joint account of registrar of the university
and trustees.
- Solvency certificate(state of having more money than one owes) for Rs. 30,00,000/ from
nationalized bank for a period of 5 years.
- University endowment
Approximately the Revenue is Rs. 21,24,000/ and where as the Expenditure is Rs. 20,52,859/
Annual auditing is done to plan for the next year budget and to evaluate the current year
budget.

Unit X
NURSING
INFORMATICS
 Trends
 General purpose
 Use of computers in hospital and community
 Patient record system
 Nursing records and reports
 Management information and evaluation
system (MIES)
 E- nursing, Telemedicine, telenursing
 Electronic medical records

NURSING INFORMATICS – CONCEPT AND TRENDS
Definitions:
Informatics (informatics comes from the French word informatique which means
computer science). Informatics is defined as computer science + information science. Used in
conjunction with the name of a discipline, it denotes an application of computer science and
information science to the management and processing of data, information, and knowledge in
the named discipline. Thus we have, medical informatics, nursing informatics, pharmacy
informatics and so on.
Hebda (1998 p. 3), defines nursing informatics as "the use of computers technology to support
nursing, including clinical practice, administration, education, and research."
American Nurses Association (ANA) (1994) has defined nursing informatics as "the
development and evaluation of applications, tools, processes, and structures which assist nurses
with the management of data in taking care of patients or supporting the practice of nursing."
Graves, J. R., & Corcoran, S. (1989). The Study of Nursing Informatics. Image: Journal of
Nursing Scholarship, 27, 227-231. Define nursing informatics as "a combination of computer
science, information science and nursing science designed to assist in the management and
processing of nursing data, information and knowledge to support the practice of nursing and the
delivery of nursing care."
Framework of nursing informatics:
The framework for nursing informatics relies on the central concepts of data, information and
knowledge:
 Data is defined as discrete entities that are described objectively without interpretation
 Information as data that is interpreted, organized or structured
 Knowledge as information that has been synthesized so that interrelationships are
identified and formalized.
Resulting in decisions that guide practice
The management and processing components may be considered the functional components of
informatics.
Management & Processing
Data Information Knowledge

Example:
Data: 140 systolic
Information: 50 year-old male, day 3 of hospitalization, BP 140/70
Knowledge: Pt. demographics, record of BP readings, circulation system: anatomy &
physiology, pharmacokinetics of ordered medication
Decisions: That guide practice.
Nursing Process
Enables the professional nurse to be the “Coordinator” of each patient’s care
– Communicate & coordinates care with ALL other clinical disciplines
– Coordinate discharge planning, education & teaching, transition of care
– Manages ALL information related to the nursing process and patient
Because information management is integrated into the Nursing Process and Practice, some
Nursing Communities identify a 5th step in Nursing Process DOCUMENTATION
Well-documented information provides:
• What care has been provided and what is outstanding
• Outcomes of care provided and responses to the plan of care
• Current patient status & assessments
• Support decisions based on assessments to drive new plans of care.
Automation of Documentation
Up-to-date, accurate information of each step of the Nursing Process is the Power behind safe,
high quality patient-centered care!
Successful Automation
• Successful implementation of information Systems requires
�well designed systems that support Nursing Process within the culture of
an organization and/or specific care providers
�Acceptance & integration of information systems into the regular workflow
of nursing process & patient care
�Resources that can support the above
• Support nursing work processes using technology
– Design systems to match clinical workflows
�Telehealth

�Home health
�Ambulatory care
�Long-term care
�Acute care – all specialties
�Outpatient settings
�Software development
�Redesign work flows
The Value of Nursing Informatics
• Increase the accuracy and completeness of nursing documentation
• Improve the nurse‘s workflow
– Eliminate redundant documentation
• Automate the collection and reuse of nursing data
• Facilitate analysis of clinical data
•Nursing Informatics promotes and facilitate. Access to resources and references for nurses and
the entire interdisciplinary team in both clinical and administrative settings
• Benefits for nurses and the interdisciplinary team:
 Support for their mission to deliver high quality, evidence-based care
 Support for better service by facilitating true interdisciplinary care
 Promotes improvement in key relationships with physicians, peers
 Interdisciplinary care team members, patients & families
• Benefits in the administrative setting
– Support for cost savings and productivity goals
– Facilitate change management
The goal of Nursing Informatics is to improve the health of populations, communities,
families, and individuals by optimizing information management and communication. This
includes the use of technology in the direct provision of care, in establishing effective
administrative systems, in managing and delivering education experiences, in supporting life-
long learning, and in supporting nursing research.
Scope of Standards of Nursing Informatics Practice - American Nurses Association 2001
Clinical Work
Information
and
Communication
technologies
Organisation of
medicine and
health care (system)
Three Domains Needing an “Effective Fit”

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

• Assesses and understands what and for what reasons things happen
• Assesses and understands the context and identifies consequences for clinical work and
imperatives for change
• Selects and prioritises opportunities, problems, imperatives and requirements for change
• Knows of appropriate technological developments and relates them to information
requirements; knows of opportunities and imperatives for change
• Creates an information and technology and strategy plan
• Involves, informs, persuades, prepares for these technologies and other changes
• Plans and introduces new technologies and other changes
• Evaluates, reviews and assesses the impact and values it
• select the appropriate information and communication technologies,
• involve perceived beneficiaries,
• identify the prospective benefits,
• successfully plan, implement and evaluate the impact of change
General purpose of Nursing Informatics
The main point of nursing informatics is to use technology to enhance patient care and nursing
practice. Nursing informatics is a narrower, specialized field inside of the wider medical
informatics. Nursing informatics represents the way that nurses utilize technology in their daily
duties. This includes using the latest developments to help make nursing more modern and
efficient — while still providing excellent personalized patient care. Indeed, with nursing
informatics, it is often easier to give the proper individualized patient care because the vital
statistics that nurses need are often right at their fingertips.
 Nursing informatics is a way of keeping patient information properly organized.
 Technologies, including tablet computers and mobile devices, can help nurses keep up
with what they need.
 Integrated systems allow nurses to make notes that everyone can access, meaning that
each change of shift runs smoothly, and time isn‘t taken up with trying to convey
information.
 . Nursing informatics can also help with dosing instructions, staff assignments, and lab
results. The idea is that technology and information should be easily accessible to nurses
so that they can do a better job of caring for their patients
 Another function of nursing informatics is to help create care plans.
 Nursing informatics makes use of the information coordinated by technology to help
nurses make better decisions.

Nursing skill need related to informatics and technology:
• Use information and communication technology to document and evaluate patient care,
advance patient education & enhance the accessibility of care.
• Use appropriate technology to assess and monitor patients.
• Work on an interdisciplinary team to make ethical decisions regarding the application of
technologies and the acquisition of data.
• Adapt the use of technologies to meet patient needs.
• Teach patients about health care technologies
• Protect the safety and privacy of patients in relation to the use of health care and
information technologies.
• Use information technologies to enhance one‘s own knowledge base.
Challenges of Managing Health related informatics and technology
• Confidentiality of client health information
• Ethics related to new therapies
• Evaluating the quality of information
• Information security
• Potential health and personal problems from too much technology.
Our future
• Technological advances are advantageous only if nurses find them useful and learn how
to use them
• Nurses may tend to focus on machinery rather than persons
• Information overload
APPLICATION OF NURSING INFORMATICS IN NURSING PRACTICE,
EDUCATION & RESEARCH
Definition: In 2008, the American Nurses Association (ANA) defined this growing field in
its Scope and Standards for Nursing Informatics Practice as ―a specialty that integrates nursing
science, computer science, and information science to manage and communicate data,
information, knowledge and wisdom in nursing practice.‖
Goal: The goal of Nursing Informatics is to improve the health of populations,
communities, families, and individuals by optimizing information management and
communication. This includes the use of technology in the direct provision of care, in
establishing effective administrative systems, in managing and delivering education

experiences, in supporting life-long learning, and in supporting nursing research. (ANA,
2001)
History: Early hospital computer systems developed from business computing systems in
the late 1950s and early 1960s, and were used for accounting, billing, inventory and similar
business-related functions. Others were developed during the 1960s primarily for storing
patient information to be used by medical staff. Nurses have worked in informatics roles for
over twenty-five years, but the phrase ―nursing informatics‖ was not seen in the literature
until 1984. Since 1984, nursing informatics has established itself as a specialty in the nursing
field. Nurses identified as informatics specialists numbered 15 in 1981; there were over
5,000 by 1991 (Saba& McCormick1996). In 1992, the American Nurses Association‘s
Congress of Nursing Practice supported the recommendation of the Council on Computer
Applications in Nursing to officially recognize NI as a nursing specialty.
A. APPLICATION OF NURSING INFORMATICS IN CLINICAL PRACTICE:
 NURSING INFORMATICS AND NURSING PROCESS
The nursing process is the core of patient care delivery. In the
nursing process continuum, nurses are constantly faced with data and
information. Data and information are integrated in each step of the
nursing process:
 Assessment
 Diagnosis
 Planning
 Implementation and
 Evaluation
Nursing documentation, which is often identified as the sixth
step in the nursing process, is vital in information management.
Hence, it is necessary for nurses to document accurately and
precisely to determine the desired outcome.
 Practical application (Point-of-Care Systems and Clinical
Information Systems)
 Work lists to remind staff of planned nursing interventions
 Computer generated client documentation
 Electronic Medical Record (EMR) and Computer-Based Patient
Record (CPR)
 Monitoring devices that record vital signs and other
measurements directly into the client record (electronic medical
record)
 Computer - generated nursing care plans and critical pathways, automatic billing
for supplies or procedures with nursing documentation

Monitoring System: Comprehensive patient monitoring systems that can be configured to
measure and display various patient parameters.
Pulse Oximeter: Measure the arterial haemoglobin oxygen saturation of the patient's blood.
Intracranial Pressure Monitors: are connected to sensors inserted into the brain through a
cannula or bur hole.
Apnoea Monitors: Use electrodes or sensors placed to detect cessation of breathing, display
respiration parameters, and trigger an alarm.
Ventilators: Consist of a flexible breathing circuit, gas supply, heating/humidification
mechanism, monitors, and alarms.
Infusion Pumps: Employ automatic, programmable pumping mechanisms to supply the patient
with fluids intravenously or epidurally through a catheter.
Crash Carts: Also called resuscitation carts or code carts, are strategically located in the ICU for
immediate availability when a patient experiences cardio-respiratory failure.
Intra-Aortic Balloon Pump: Use a balloon placed in the patient's aorta to help the heart pump.
Clinical Information System: Consists of information technology that is Applied at the point of
clinic

A_Text_book_on_Nursing_Management_Accord.pdf

A_Text_book_on_Nursing_Management_Accord.pdf

More Related Content

What's hot

Similar to A_Text_book_on_Nursing_Management_Accord.pdf

More from nagamani42

Recently uploaded

A_Text_book_on_Nursing_Management_Accord.pdf