Hospital ward– is a block (or area) forming a division of a hospital (or a suite of rooms) shared by patients who need a similar kind of care.
It might be a large room, or combining couples of rooms, or assimilation of some coups under single management.
In-charge– is s/he, who shoulders these responsibilities of a ward. An In- charge is responsible for managing ward under her/his custody as a whole.
Goal of Ward Management
· To provide highest quality nursing care for patient.
· To provide a clean, well ventilated environment for patient and protect her/him from infection, accidents and hazards.
· To help the staff in achieving highest degree of job satisfaction.
· To provide facilities to meet the needs of patient and their attendants.
Components of Ward Managements
· Patient care;
· Personnel Management;
· Ensure supply and equipment;
· Environment Cleanliness;
· Follow of policies and procedures
Actions for ward management
· Evaluate nursing needs of patient and skill of person.
· Prepare monthly, weekly and daily time table for staff nurses.
· Give teaching and guidance to juniors.
· Develop good human relations.
· Evaluate personnel.
· Maintain inventories, requesting for supplies and services.
· .... Assign tasks to nurses.
· Coordinate with other departments for effective patient care.
· Gain co-operation from subordinates and supervisors.
· Delegate responsibility for patient care.
Role of In-Charge Nurse
In the health care delivery systems where the health status of the client is considered stable, implementation of the plan of care may be carried out by the in-charge nurse.
Monitoring
An in-charge is always a supervisor. Monitoring is her/his prime duty allover the time as defined by the Board/Council. Supervisors are first leader-level nurses, who are appropriately qualified and experienced and have received some preparation for the role. Supervisors can also be other, except in-charge nurse, who have sufficient training and experience in supervisory skills. They also to be supervised
Documentation and Record Keeping
Accurate record keeping and careful documentation is an essential part of nursing practice. The Nursing Council state that good record keeping helps to protect the welfare of patients and institution’ – which of course is a fundamental aim for nurses everywhere.
The concept and ideology of record keeping are-
Better information maintain
· Automatic form and report creation
· Avoid drudgery of repetitive typing
· Eliminate Writing and problems of poor handwriting
More Efficiency
· Eliminates paperwork and the need for getting a range of letterheads and stationery
· Speedy analysis of data.
Quality record keeping helps providing skilled and safe care wherever you are working. Registered nurses have a legal and professional duty of care according to the nursing and midwifery council guidelines, so your record keeping and documentation should demonstrate:
A full description of your assessment and the care planned and given.
Relevant information about your patient or client at any given time and what you did in response to their needs.
You have understood and fulfilled your duty of care, which you have taken all reasonable steps to care for the patient.
Documentation
You will see lots of different charts, forms and documentation. Every hospital, care home and community nursing service will have the same basic ones, but with small variations that work best locally.
The common documents that you will use include some of the following.
§ To act as a working document for day-to-day recording of patient care
§ To store a chronological account of the patient’s life, illnesses, its context and who did what and to what effect
§ To enable the clinician to communicate with him or herself
§ To aid communication between team members
§ To allow continuity of approach in a continuing illness,
§ To record any special factors that appear to affect the patient or the patient’s response to treatment
§ To record any factors that might render the patient more vulnerable to an adverse reaction to management treatment
§ To record risk assessments to protect the patient
§ To record the information received from others, includingcareers
§ To store a record to which the patient may have access
§ To inform medico-legal investigations
§ To inform clinical audit, governance and accreditation
§ To inform bodies handling complaints and inquiries
§ To inform research
§ To inform analyses of clinical activity.
§ To allow contributions to national datasets.
Nursing Assessment Sheet
The nursing assessment sheet contains the patient’s biographical details (e.g. name, age etc.), the reason for admission, the nursing needs and problems identified for the care plan, medication, allergies and medical history.
· Specific
· Measurable
· Achievable
· Realistic
· Urine flow
· Weight
· Bowel
· Fluid-intake
· Output
Hospital
Hospital word has been derived from the latin word ‘HOSPES’ as we know, which means ‘a host or guest’ or ‘hotel’, hostel.
Some also believe that the origin of the hospital from the word ‘HOSPITUM’ a rest house for travelers or night shelter showing ‘hospitality’ to the guests.
Hospital is a social organisation and logical combination of the activities of a number of persons with different level of knowledge and skills for achieving a common goal of patient care through a hierarchy of authority and responsibility
Organising is a process of grouping the activities in workable units and connected by authority, communication and control.
HOSPITAL
HOSPITALITY
Organization
DIFFINITION
Organization is the anatomy and Management is the physiology of the process.
Organization is the systemic bringing together of interdependent parts to form a unified whole through which authority, control and coordination may be exercised to achieve a given purpose.
Organisational structure represented by a basic organisational chart forming the skeleton of the organisation.
ORGANISATION STRUCTURE
CENTRALISATION
It implies standardisation, uniformity, and central authority. From one side it ensures better decision making, co-ordination.
Better authority of control and cost-effective due to less skilled administrators. But it blocks the carrier structure and requires strong administrative skills and leader ship.
DECENTRALISATION
It reduces burden on central authority. It brings decision making closer to people in local context.
Greater potential for multi sectoral approach Increases efficiency of staff due to their participation in decision making.
Decentralisation is exciting but may ruin the organisation if attention is not paid to:-
· Degree of decentralisation
· Skill and experience of local manager
· His leadership qualities and team sprit.
MIXED (MATRIX)
Decentralisation should not be totally free from control of central authority. The degree and extent of de centralisation should match organisation function and objective.
Decentralisation should be within the policy frame work of each organisation and at where needed.
It is a diagrammatic representation of the administrative set up which easily shows the line of command, control and responsibility ,staff relation,job grouping and communication.
The structure of the organogram is like a pyramid, broader at base taper at appex. Hospital has got a Matrix type of Organogram.
Matrix organisation is a mix of product and function where people with similar skills are grouped together to execute activities to achieve organisational objective.
2. In a hospital some part of the organisation has scalar type of function while others are informally structured.
3. The hospital provides patient care with a multi functional team comprising of people with different level of knowledge and skill.
4. There are therefore dual reporting system at various levels.
5. It is structured in such a way that facilitates horizontal flow of authority in addition to its vertical control.
6. The matrix structure gets its name for its resemblance to a table which has both rows and columns .
7. The functional manager in the matrix work with the project manager to assess the resource requirement.
8. And their timely utilisation by the functional manager.
9. The general manager is at the top and outside the basic matrix net work
10. Information sharing is mandatory in such an organization
11. The basis for hospital to have a matrix organisational structure to create a synergism through shared responsibility between the administrative and functional departments in the hospital system.
Advantage of organogram
· It helps to identify in consistencies and complexities in the organisation structure.
· Helps to identify major line of decision making authority.
· It indicates the employees there position, status and role in the organisation.
· It is to identify the services (functional units), span of control, and crossed line authority.
· Chart needs to be modified with change of role and authority.
SUPERVISION AND AUTHORITY
a. Hierarchy
Hierarchy shows the tire of Superior- Sub-ordinate relation ship.
Extent to which it should be tall or short depends on the type and function of the organisation.
b. Span of control
It expresses the number of persons that a manager can directly control or supervise
This depends on type of sctivity,knowledge,skill leadership quality of supervisor.
c. Unity of command
The basic principle of span of control is unity of command.
The sub-ordinate should take direction from one authority only.
There by increases efficiency and effectiveness of the organization
Therefore grouping in the organisation is essential.
d. Grouping
Grouping depends on task and function. Hospital employs people with different skills and functions. More centrally it is associated with planning, decision making, and administration Peripheral implementation, monitoring and supervision. Hence functional grouping is ideal.
· Integration
Integration is the linking of line function to staff (group) function to make it a unified whole.
But the problem in the hospital is because of functional groups with different skills and job responsibility like doctors, nurses, technical and un-skilled group ‘D’ staff.
· Formalisation
Formalisation of the organisation is necessary to increase the efficiency and effectiveness by fitting into the organisational structure.
I. Participation
Participation provides a feeling of ownership leading to increase commitment, morale, and motivation. But participation should be restricted only to issues directly concerning the individual or group like carrier development, personal welfare, and their task and activities. If the suggestion is relevant should be accepted. The participant must have adequate knowledge of the subject in which participating.
II. Delegation
It is the most difficult part of formalization or job designing.
Delegating authority must choose the level of delegation, extent of power and authority to be given.
Superior to chose sub-ordinate for delegation.
Territory of authority to be clearly defined.
There has to be mutual trust between delegator and delegant. Delegator must have full control over end result and give regular feedback to delegant.
III. Job enrichment
Enrichment depends on nature of job.
It is formalised to match the rules , job description and procedure manual.
High skilled persons like doctors, nurses, technical staff requires low job description while low skilled and un skilled staff need high job definition.
Job enrichment is required to make it interesting, attractive, interlocking and inter dependable.
Introduction
“an institution of community health/ a specialized complex organization, that makes use of physicians, surgeons & team of technical staff, in order to provide facilities for diagnosis, therapy, rehabilitation, prevention, education & research.
Classification is mainly based on :
· Clinical grounds
· Non-clinical grounds
· Size
· Cost
· System of medicine
Classification of hospitals based on clinical grounds: Medicine-based
· Pediatrics
· Psychiatric and other nervous diseases
· General medicine
Classification of hospitals based on Surgery
· Orthopedics
· Gynecology & obstetrics
· Maternity: - short-term - long-term
Classification of hospitals based on non-clinical grounds:
· Governmental hospitals:
· Army hospital - city hospital - navy hospital - civil hospital b.
· Non-governmental hospitals
· Private hospitals(for profit)
· Non-profit hospitals ( church hospital, community hospital, hospital, charitable hospital)
Classification of hospitals based on size:
· large hospitals: beds : 1000 and above b.
· medium hospitals: beds : 500-1000 c.
· small hospitals: beds : 100-500 d.
· very small hospitals: beds : less than 100
Classification of hospitals based on cost:
a. Elite hospitals
Consist of high technology & medical science advancements - comprise deluxe rooms, with t.v, telephones & refrigerator also known as “5-star hospitals”
example : apollo hospital .
b. Budget hospitals
Meant for moderate-low budget people (example: charitable & civil hospitals )
Classification of hospitals based on system of medicine:
· Allopathic hospitals
· Ayurvedic hospitals
· Homeopathic hospitals
· Unani hospitals
organization is defined as
“a dynamic process, in which various managerial activities bring on organization of hospitals & bind people together, for the achievement of common goals & consists of various eminent personalities in the field of :
· Medical education
· Administration
· Research
· Politics (optional)
Function of governing body is to frame all major policies, plans objectives”
Most important body of a hospital is the governing body/ board of directors/ board of trustees.
Governing body & programmes of hospital appoints a hospital administrator to get various functions performed like clinical services, nursing, pharmacy services, etc
Governing body have to give personal attention to patients - nurses are trained for prenatal care, observation, patient comfort during labour, etc. - nursing director is the in-charge of nursing services,assigned specific number of beds.
Services performed by hospital organization: include:
· Nursing services: - largest part of a hospital - functions all 24 hours - nurses
make a hospital an ideal community institution - hospital is duty-bound to provide diagnostic, preventive
· Out-patient services: - focus on comfort for out-patients, as the approach for major/minor illnesses - these services & curative measures to the out-patient.
· Assisted by various technicians - services include utilization of equipments like: a. Sonography b. X-ray c. Ecg d. Ct-scan, etc.
· Radiological services: - performed under direction of a competent radiologist - chief radiologist
· Central supply services: - refers to medical & surgical supply services - meant for diagnosis, treatment, prevention, education & research - involves their collection, processing, storage & issuance against proper indent form - qualified & skilled staff personnel are responsible for its maintenance.
· Hospital pharmacy services: - controls pharmacy operation in any hospital - fills prescription & no. Of necessities from wards - functions begin from drug procurement to distribution to i.p and o.p - responsible for :
a. Proper drug delivery
b. Manufacture
c. Information system
d. Sterilization
e. Drug storage
f. Advicing patient on drug use
· Medical record services: - valuable materials, as they help medical & para-medical staff for evaluation - also used for education, research & training - consists of :
a. Patient history
b. Physical examination details
c. Lab- test reports
d. Physican’s advice, etc. - it is mandatory to store medical records properly to facilitate easy access on requirement.
· Store services: - receive, store & issue materials against requisition forms of various departments & wards - hospital consists of:
a. Medical store
b. Store for general items
c. Surgical stores, etc - maintain a buffer stock of certain materials, including life-saving drugs.
· Miscellaneous services: - aimed at overall benefit & patient care - include:
a. Dietary services
b. Ambulatory services
c. Laundry services
d. Transport services
e. Mortuary services
f. Library
DEFINITION OF TERMS
ü Common law: accumulation of law as a result of judicial court decisions.
ü Civil law (private law): law that derives from legislative codes and deals with relations between private parties.
ü Public law: concerns relationships between an individual and the state. The thrust of public law is to attain what are deemed valid public goals, such as reporting child abuse.
ü Criminal law: concerns actions against the safety and welfare of the public, such as robbery. It is part of the public law.
Informed consent: implies that significant benefits and risks of any procedure, as well as alternative methods of treatment, have been explained; person has had time to ask questions and have these answered; person has agreed to the treatment voluntarily and is legally competent to give consent; and communication is in a language known to the client. Reasonably prudent nurse: nurse must react as a reasonably prudent nurse trained in that specialty area would react. For example, if a nurse works with fetal monitors, she must know how to use the monitors, know how to read the strips, and know what actions to take based on the findings.
NURSING LICENSURE
ü Mandatory licensure required in order to practice nursing.
ü Nurse Practice Act: each state has one to protect nurses’ professional capacity, to set educational requirements, to distinguish between nursing and medical practice, to define scope of nursing practice, to legally control nursing through licensing, and to define standards of professional nursing.
ü American Nurses Association: “The practice of nursing means the performance for compensation of professional services requiring substantial specialized knowledge of the biological, physical, behavioral, psychological, and sociological sciences and of nursing theory as the basis for assessment, diagnosis, planning, intervention, and evaluation in the promotion and maintenance of health; the case finding and management of illness, injury, or infirmity; the restoration of optimum function; or the achievement of a dignified death.
ü Nursing practice includes but is not limited to: administration, teaching, counseling, supervision, delegation, and evaluation of practice and execution of the medical regimen, including the administration of medications and treatments prescribed by any person authorized by state law to prescribe. Each registered nurse is directly accountable and responsible to the consumer for the quality of nursing care rendered.”
ü Revoking a license: Board of Examiners in each state in the United States and each province in Canada has the power to revoke licenses for just cause, such as incompetence in nursing practice, conviction of crime, drug addiction, obtaining license through fraud, or hiding criminal history.
CRIMES AND TORT
ü Crime: an act committed in violation of societal law and punishable by fine or imprisonment. A crime does not have to be intended (as in giving a client an accidental overdose that proves to be lethal).
ü Felonies: crimes of a serious nature (e.g., murder) punishable by imprisonment of longer than 6 months.
ü Misdemeanors: crimes of a less serious nature (e.g., shoplifting), usually punishable by fines or short prison term or both.
ü Tort: a wrong committed by one individual against another or another’s property.
ü Fraud, negligence, and malpractice are torts (e.g., losing a client’s hearing aid, or bathing the client in water that causes burns).
ü Fraud: misrepresentation of fact with intentions for it to be acted on by another person (e.g., falsifying college transcripts when applying for a graduate nursing program).
ü Negligence: “Omission to do something that a reasonable person, guided by those ordinary considerations which ordinarily regulate human affairs would do; or doing something which a reasonable and prudent person would not do”
Types of negligent acts related to:
ü Sponge counts: incorrect counts or failure to count.
ü Burns: heating pads, solutions, steam vaporizers.
ü Falls: side rails left down, infant left unattended.
ü Failure to observe and take appropriate action—forgetting to take vital signs and check dressing in a client who is newly postoperative.
ü Wrong medicine, wrong dose and concentration, wrong route, wrong client.
ü Mistaken identity—wrong client for surgery.
ü Failure to communicate—ignore, forget, fail to monitor, report, or document client’s status or to report complaints of client or family.
ü Loss of or damage to client’s property— dentures, jewelry, money.
ü Inappropriate use of equipment (e.g., excessive IV fluids via pump).
ü Malpractice: part of the law of negligence as applied to the professional person; any professional misconduct, unreasonable lack of skill, or lack of fidelity in professional duties, such as accidentally giving wrong medication or forgetting to give correct medication or instilling wrong strength of eye drops into the client’s eyes. Proof of intent to do harm is not required in acts of commission or omission.
INVASION OF PRIVACY
ü Compromising a person’s right to withhold self and own life from public scrutiny.
ü Implications for nursing—avoid unnecessary discussion of client’s medical condition; client has a right to refuse to participate in clinical teaching; obtain consent before teaching conference.
LIBEL AND SLANDER
ü wrongful action of communication that damages person’s reputation by print, writing, or pictures (libel), or by spoken word using false words (slander).
ü Implications for nursing—make comments about client only to another health team member caring for that client.
PRIVILEGED COMMUNICATIONS
ü Information relating to condition and treatment of client requires confidentiality and protection against invasion of privacy.
ü This applies only to court proceedings. Selected person does not have to reveal in court a client’s communication to him or her. The purpose of privileged communication is to encourage the client to communicate honestly with the treating practitioner. It is the client’s privilege at any time to permit the professional to release information.
ü Therefore, if the client asks the nurse to testify, the nurse must truthfully give all information. However, if the nurse is a witness against the client, without the client’s permission to release information, the nurse must keep the information confidential by invoking the privileged communication rule
if the state law recognizes it and if it applies to the nurse.
ASSAULT AND BATTERY
ü Violating a person’s right to refuse physical contact with another.
ü Definitions
ü Assault—the attempt to touch another or the threat to do so and person fears and believes harm will result.
ü Battery—physical harm through willful touching of person or clothing, without consent.
ü Implications for nursing—need to obtain consent to treat, with special provisions when clients are underage, unconscious, or mentally ill.
VIII. GOOD SAMARITAN ACT
Protects health practitioners against malpractice claims resulting from assistance provided at scene of an emergency (unless there was willful wrongdoing) as long as the level of care provided is the same as any other reasonably prudent person would give under similar circumstances.
NURSES’ RESPONSIBILITIES TO THE LAW
A nurse is liable for nursing acts, even if directed to do something by a physician. B. A nurse is not responsible for the negligence of the employer (hospital). C. A nurse is responsible for refusing to carry out an order for an activity believed to be injurious to the client. D. A nurse cannot legally diagnose illness or prescribe treatment for a client. (This is the physician’s responsibility.) E. A nurse is legally responsible when participating in a criminal act (such as assisting with criminal abortions or taking medications from client’s supply for own use). F. A nurse should reveal client’s confidential information only to appropriate health-care team members. G. A nurse is responsible for explaining nursing activities but not for commenting on medical activities in a way that may distress the client or the physician. H. A nurse is responsible for recognizing and protecting the rights of clients to refuse treatment or medication, and for reporting their concerns and refusals to the physician or appropriate agency people. I. A nurse must respect the dignity of each client and family.
ORGAN DONATION
ü Legal aspects to protect potential donors and to expedite acquisition
ü Prohibits selling of organs (National Organ Transplant Act).
ü Guidelines regarding who can donate, how donations are to be made, and who can receive donated organs (Uniform Anatomical Gift Act).
ü Legal definition of brain death (Uniform Determination of Death Act)—absence of: breathing movement, cranial nerve reflex, response to any level of painful stimuli, and cerebral blood flow; and flat EEG.
ü Donor criteria
ü Contraindications for being organ donator: HIV-positive status and metastatic cancer.
ü Prospective donors of both organs and tissues: those with no neurological functions, but have cardiopulmonary functions.
ü Prospective donors of only tissues: those with no cardiopulmonary function (e.g., can donate corneas, eyes, saphenous veins, cartilage, bones, skin, heart valves).
ü Management of donor
ü Maintain body temperature at greater than 96.8°F with room temperature at 70° to 80°F, warming blankets, warmer for intravenous fluids.
ü Maintain greater than 100% PaO2 and suction/turn and use positive end-expiratory pressure (PEEP) to prevent hypoxemia caused by airway obstruction, pulmonary edema.
ü Maintain central venous pressure at 8 to 10 mm Hg and systolic blood pressure at greater than 90 mm Hg to prevent hypotension caused by complete dilation of systemic vasculature due to destruction of brain’s vasomotor center, cessation of antidiuretic hormone production, and decreased cardiac output. Give fluid bolus and vasopressors, and monitor sodium levels.
ü Maintain fluid and electrolyte balance due to volume depletion. Monitor for hyponatremia, hyperkalemia, and hypokalemia, and intake and output.
ü Prevent infections due to invasive procedures (e.g., tubes, catheters) by using aseptic technique.
ü [social-locker]
Legal Aspects of Nursing: Questions Most Frequently Asked by Nurses About Nursing and the Law
TAKING ORDERS
ü A.Should I accept verbal phone orders from a physician? Generally, no. Specifically, follow your hospital’s bylaws, regulations, and policies regarding this.
Failure to follow the hospital’s rules could be considered negligence.
ü B. Should I follow a physician’s orders if
I know it is wrong, or (b) I disagree with his or her judgment? Regarding
(a)—no, if you think a reasonable, prudent nurse would not follow it; but first inform the physician and record your decision. Report it to your supervisor. Regarding
(b)—yes, because the law does not allow you to substitute your nursing judgment for a doctor’s medical judgment. Do record that you questioned the order and that the doctor confirmed it before you carried it out. C. What can I do if the physician delegates a task to me for which I am not prepared? Inform the physician of your lack of education and experience in performing the task. Refuse to do it. If you inform the physician and still carry out the task, both you and the physician could be considered negligent if the client is harmed by it. If you do not tell the physician and carry out the task, you are solely liable.
OBTAINING CLIENT’S CONSENT FOR MEDICAL AND SURGICAL PROCEDURES:
ü Is a nurse responsible for getting a consent for medical-surgical treatment? Obtaining consent requires explaining the procedure and risks involved, which is the physician’s responsibility. A nurse may accept responsibility for witnessing a consent. This carries with it little legal liability other than obtaining the correct signature and describing the client’s condition at time of signing.
CLIENT’S RECORDS (DOCUMENTATION)
ü What should be written in the nurse’s notes? All facts and information regarding a person’s condition, treatment, care, progress, and response to illness and treatment. Document consent or refusal of treatment. Purpose of record: factual documentation of care given to meet legal standards; used to refute unwarranted claims of negligence or malpractice.
How should data be recorded? Entries should:
ü State date and time given.
ü Be written, signed, and titled by caregiver or supervisor who observed action.
ü Follow chronological sequence.
ü Be accurate, factual, objective, complete, precise, and clear.
ü Be legible; use black pen.
ü Use universal abbreviations.
ü Have all spaces filled in on documentation forms; leave no blank spaces.
CONFIDENTIAL INFORMATION
ü If called on the witness stand in court, do I have to reveal confidential information? It depends on your state, because each state has its own laws pertaining to this. Consult a lawyer. Inform the judge and ask for specific directions before relating in court information that was given to you within a confidential, professional relationship.
ü Am I justified in refusing (on the basis of “invasion of privacy”) to give information about the client to another health agency to which a client is being transferred?
No. You are responsible for providing continuity of care when the client is moved from one facility to another. Necessary and adequate information should be transferred between professional health-care workers. The client’s consent for this exchange of information should be obtained.
Circumstances under which confidential information can be released include:
ü By authorization and consent of the client.
ü By order of the court.
ü By statutory mandate, as in reporting cases of communicable diseases or child, elder, or dependent adult abuse.
Prevent Legal Problems
ü Practice in a safe setting
ü Employs appropriate number and skill mix of personnel.
ü Has P&P that promotes quality improvement. (Risk management and JC)
ü Keeps equipment in good working order.
ü Provides orientation and continuing education.
ü Communicate with providers, patient, family.
ü Document accurately, in timely manner, and concisely, If not documented, not done
ü Rapport with patient & family can be protection from lawsuits
ü Meet the standard of care in facility, trends in area of practice, ANA Nursing: Scope & Standards of Practice; Stay within own limits of education, expertise & state’s Nurse Practice Act
Legal Tips Administer meds properly
ü Monitor for & report deterioration
ü Communicate effectively
ü Delegate responsibly
ü Document accurately & timely
ü Know & follow facility policies & procedures
ü Use equipment properly
Morals: rules of conduct in regard to decisions of right or wrong values: attitudes, ideals, or beliefs that one holds & uses to guide behavior ethics: reflects what actions one should take; habits or customs bioethics: application of ethical theories and principles to moral issues or problems in health care.
ü Ethical dilemma caused by advances in technology that allow us to keep patients alive.
ü Moral distress: pain/anguish affecting mind, body, relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action; however, as a result of real or perceived constraints, participates in perceived moral wrongdoing
Nursing Code of Ethics-
ü Code of ethics is a hallmark of a profession—guidelines of professional self-regulation Provision 2 describes the nurse’s primary commitment to the patient.
ü Provision 5 describes the responsibility of nurses to maintain their own integrity.
ü A wise nurse who is aware of deep personal values and moral standards will make decisions regarding practice setting so the nurse’s own personal integrity remains intact, while putting patients and their needs first Moral Reflection = critical analysis of one’s morals beliefs and actions
Kohlberg’s Levels of Moral Development:
; research on men & boys; justice focused
ü Pre-conventional: perspective is self-centered; decisions based on wants/needs, not right/wrong; children < 9 yo, adolescents, adult criminals; respond to punishment
ü Conventional: moral decisions conform to expectations of family/society; what pleases others; most adolescents & adults function at this level; respond to prospect of personal reward
ü Post-conventional: individual develops own moral values; ignore self-interest and group norms in making moral choices; may sacrifice themselves on behalf of the group; create own morality; minority of adults achieve this level
Gilligan’s levels of moral development
ü Individual survival
ü Goodness,
ü self-sacrifice
Morality of caring & responsible to others and self
ü A moral person responds to need & demonstrates a considerations of care & responsibility in relationships
Understanding Ethical Dilemmas in Nursing-
ü From personal value systems & beliefs Involving peers’ & other’s behaviors.
ü Regarding patient rights: right to privacy, informed consent, to die, confidentiality, respectful care, care without discrimination, information concerning medical condition & treatment, right to refuse to participate in research studies; partnership regarding treatment plan.
ü Patient self-determination act (1991) gives patients legal right to determine how they wish to be treated in life-or-death situations.
ü Ethical issues related to immigration and migration
ü Dilemmas created by institutional issues
ü Dilemmas created by patient data access issues
Federal and state statutes and regulations
ü In addition to nursing malpractice, there are multiple federal and state laws and regulations that impact the practice of nursing and may impose liability.
The following discussion presents a brief overview of some of these:
ü The Privacy Act (1974) regulates the collection, use, maintenance, and distribution of personally identifiable information about individuals that is kept in the record systems of federal agencies. This act impacts all health care providers and health care plans that transmit health care information in electronic form. It has been described as a consumer protection act.
ü The Health Insurance Portability and Accountability Act-Congress enacted the Health Insurance Portability and Accountability Act (HIPAA, 1996) to limit the ability of an employer to deny health insurance coverage to employees with preexisting medical conditions.
ü The law also directed the US Department of Health and Human Services (USDHHS) to develop privacy rules, including, but not limited to, the use of electronic medical records.
ü In recent years, this has expanded to include other considerations for electronic transmission of health care information.
ü Among other things, HIPAA gives individuals the right to obtain their own medical records and request amendments to their medical records (USDHHS, n.d.-a) and allows the individual to learn where the records have been disclosed.
ü HIPAA provides that individuals must be provided with medical records within 30 days of a request. It also prohibits release of personal health information without permission.
ü Generally, a HIPAA-compliant, signed authorization must be presented in order to obtain medical records.
ü Social networking can have a significant impact on health care practice. Society has become adept at using computers, cell phones, Facebook, and Twitter for exchange of information. However, the ease of exchange of information does not exempt the health care provider from obtaining a HIPAA-compliant consent form. There have been cases of practitioners sharing an interesting case or sharing health care information over social networking sites. Without the patient's consent, it is not appropriate to share information, especially when the information is not shared on a secured network and is out there for the world to see. This can result in civil and criminal penalties. Therefore, it is important to be aware that a HIPAA-compliant authorization must be obtained for any exchange of health care information.
ü The Health Care Quality Improvement Act (1986) encourages hospitals, state licensing boards, and professional societies to identify and take corrective action for health care workers who may be found by peer review to be engaged in negligent or unprofessional conduct.
ü This act encourages peer review, and, if performed correctly, it might provide immunity from civil liability. Many states encourage “peer review” and internal investigations of incidents that have resulted in harm to patients and provide statutory protection of peer review activities within an organization. In addition, hospitals/facilities and personnel have a strong interest in providing quality care and preventing future harm to their patients through such review activities.
ü Patient Self-Determination Act (PSDA, 1990) mandates that individuals receiving medical care must be given written information about their rights under state law to make decisions about medical care, including the right to accept or refuse medical or surgical treatment (Crego, 1999).
ü The PSDA defines the rights of competent patients to make binding, legally enforceable decisions about their health care preferences that are to be followed should they later become unable to express their wishes.
ü This includes assigning a patient care advocate for medical decision making and endorsing a witnessed and notarized living will for end-of-life decisions. Many state legislatures have added additional legal steps and actions that need to be taken for end-of-life decisions that may vary greatly from state to state.
ü Elder abuse and neglect-Elder abuse has become a growing problem. Various states have mandatory requirements for reporting elder abuse and neglect. To encourage reporting, many states have enacted immunity provisions protecting individuals who report abuse and/or neglect from civil liabilities. Also, some states, in addition to having mandatory reporting requirements, include penalties for individuals who fail to comply. Nurses are often observers of abuse or neglect and should be aware of reporting requirements.
ü The National Center on Elder Abuse (NCEA), directed by the US Administration on Aging, is committed to helping national, state, and local partners to be fully prepared to ensure that older Americans live with dignity, integrity, and independence and without abuse, neglect, and exploitation.
ü The NCEA is a resource for policy makers, social services, health care practitioners, the justice system, researchers, advocates, and families.
ü Reporting child abuse-WOC nurses are in a unique position to identify and report suspected child abuse. Children who are chronically ill or require wound care and/or ostomy care are at risk for abuse. Since the early 1970s, federal and state legislation has been enacted to protect children from abuse. Those who report abuse are generally protected from liability.
ü Professional practice acts and licensure-For each group of health care professionals, licensed by the state, laws and regulations are in place that define the scope of practice and outline the oversight authority vested in their professional regulatory boards.. The scope of practice of an individual practitioner is an important consideration because practicing outside of the scope of nursing can open the individual to civil liability and censorship by the board of nursing.
ü The scope of practice of nursescan also be further defined by hospital policies and procedures. The policies and procedures of individual organizations should show evidence of compliance with licensing board requirements and legislative requirements, as well as with guidelines established by such agencies as The Joint Commission. National and state nurse associations are other resources that provide guidelines for the practice of nursing.
MANAGEMENT OF HOSPITAL SUPPLIES & EQUIPMENTS
• Supplies are items that are used up or consumed – Eg: drugs, surgical goods (disposables, glass wares), chemicals, antiseptics, food materials, stationeries, the linen supply etc.
• Equipment is used for more permanent type of article – Fixed equipment is items attached to the walls or floors (eg; sterilizer,) – Movable equipment includes furniture,
Purchase of supplies & equipments
Done through – General store – Dietary department and – Pharmacy department
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.
• About 40 percent of the funds in the health care system are used up for providing materials.
AIM :
· Right material,
· In right quantities
· At right time,
· At right price,
· From right sources
· At a least cost.
Elements
· Planning for materials
· Demand estimation
· Purchasing
· Inventory management
· Inbound traffic
· Warehousing and stores
· Incoming quality control
Factors for Budgeting a purchase –
· Transport charges (local delivery reduces the transport charge)
· Incidental costs
· Cost of chemicals and other consumable to be used with the equipment (eg; ECG paper for an ECG machines)
· Operating cost (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
When purchasing an article;
· It 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 articles
· Inter-changeability of the article (Exchange facility)
· All surgical instruments used in a hospital should be sterilizable 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
The central supply varies hospitals to hospital
• Some hospital the central soppy room deals with only the sterile supplies and ward trays.
• Some hospitals all types of equipment such as oxygen, suction, ward trays, catheters, syringes etc supplied centrally
Factors in Material Purchase
1. Type of service provided by the hospital
2. Age of patients: children need different type and amount of equipments than adults.
3. Sex- men and women sometime require different type of equipment.
4. Degree and type of illness- neurologic patients sometimes require more bedsides, rubber mattress and linen than patients with other type of illness.
5. Cost of items- cost of items will limit the purchase of number of equipment.
General Utility Services in the Hospital
Ø Electric supply and installations
Ø Water supply
Ø Disposal of waste
Ø Ventilation and environment control
Ø Transport
Ø Supply of medical gases , compressed air,hot water, vacuum suction and gas plants
Ø Laundry
Ø Fire hazard
Ø Communication
• Essential clinical services- medicine, surgery, paediatrics., OBG, and acute psychiatry(when necessary)
• Optional clinical services – oral surgery, orthopedic surgery, otolaryngology, neurology and psychiatry.
• Essential clinical support- anaesthesia, radiology and clinical laboratory
• Optional clinical support services- pathology and rehabilitation including physiotherapy. Essential medical equipment
• Diagnostic imaging equipment –it include x-ray and ultrasound equipment. X-ray equipment can be stationary in one room or mobile
• Laboratory equipments
• Refrigerator – an ordinary household refrigerator with a freezer unit, for storing preparations, vaccines, blood etc.
• Instillation and purification apparatus - it should be made of metal that resists acid, and alkali and should be free standing.
Electrical medical equipment
• Portable electrocardiograph
• Defibrillator( external)
• Portable anaesthetic unit
• Respirator
• Suction pump
• Operating theatre
• Delivery table
• Diathermy unit
Other equipments
• Autoclave
• Small sterilizers
• Cold chain
• Ambulance
Small, inexpensive equipment and instruments
• BP apparatus, oxygen manifolds, stethoscope, diagnostic sets and spotlights.
Introduction
Material planning is the scientific way of determining the requirements that goes into meeting production needs within the economic investment policies.
It is done at all stages and all levels of management. Material planning is based on certain feedback information and reviews.
. Aim
• 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
Basic Principles
Sound purchasing methods Skillful and hard poised negotiations
Effective purchase system
Should be simple
Must not increase other costs
Simple inventory control programme
Elements of material planning
. Procurement
. 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
Methods of Procurement
1. Open tender
2. Restricted or limited tender
3. Negotiate d procurement
4. Direct procurement
5. Rate contract
6. Spot purchase
. Points to Remember Proper specification Invite quotations from reputed firms Comparison of offers based on basic price, freight and insurance, taxes and levies Quantity and payment discounts Payment terms Delivery period, guarantee.
Procurement of Equipments
• 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
• Store must be of adequate space
• Appropriate method of store
• 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
Inventory control is a scientific system which indicates as to what to order, when to order, and how much to order, and how much to stock so that purchasing costs and storing costs are kept as low as possible.
• To keep the investment on inventories to stock outs and shortages.
• To avoid carrying cost.
• To improve quality of care with lesser inventory
. • To avoid obsolescence of inventor
Techniques
ABC Analysis (Always Better Control)
VED Analysis (Vital, Essential, Desirable)
HML Analysis (High, Medium, Low)
FSN Analysis (Fast, Slow moving and Non- moving)
SDE Analysis (Scarce, Difficult, Easy)
ABC Analysis
This is based on cost criteria
It divides inventory into 3 categories A, B & C based on their annual consumption value. Also known as Selective Inventory Control Method (SIM)
ABC analysis has universal application for fields requiring selective control.
VED Analysis
This is based on critical value and shortage cost of an item.
Vital items – Its shortage may cause havoc & stop the work in organization. – Are stored adequately to ensure smooth operation.
Essential items – Here, reasonable risk can be taken. – They should be sufficiently stocked to ensure regular flow of work.
Desirable items – Its non availability does not stop the work because they can be easily purchased from the market as & when needed. – They may be stocked very low or not stocked
HML Analysis
This is based on cost per unit.
Highest- high price items
Medium- medium price items
Low- low price items
This is used to keep control over consumption at departmental level for deciding the frequency of physical verification.
. FSN Analysis
This is based on utilization.
Fast moving, Slow moving & Non moving
Classification is based on the pattern of issues from stores & is useful in controlling obsolescence. Date of receipt or last date of issue, whichever is later, is taken to determine the no. of months which have lapsed since the last transaction.
The items are usually grouped in periods of 12 months. It helps to avoid investments in non moving or slow items. It is also useful in facilitating.
SDE Analysis
This is based on availability of items.
Scarce- managed by top level management. Maintain big safety stocks.
Difficult – maintain sufficient safety stocks.
Easily availability- maintains minimum safety stocks.
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