NURSING MANAGEMENT FUNCTION CONTROLLING Controlling or evaluating is an on-going function of management which occurs during planning, organizing, and directing activities. It includes assessing and regulating performance in accordance with the plans that have been adopted, the instructions issued, and the principles established. The controlling process opens opportunities for improvement and comparing performance against set standards. Reasons for conducting evaluation 1. Evaluation ensures that quality nursing care is provided 2. It allows for the setting of sensible objectives and ensures compliance with them. 3. It provides standards for establishing comparisons. 4. It promotes visibility and a means for employees to monitor their own performance.
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NURSING MANAGEMENT FUNCTION
CONTROLLING
Controlling or evaluating is an on-going function of management which occurs during
planning, organizing, and directing activities. It includes assessing and regulating performance in
accordance with the plans that have been adopted, the instructions issued, and the principles
established.
The controlling process opens opportunities for improvement and comparing
performance against set standards.
Reasons for conducting evaluation
1. Evaluation ensures that quality nursing care is provided
2. It allows for the setting of sensible objectives and ensures compliance with them.
3. It provides standards for establishing comparisons.
4. It promotes visibility and a means for employees to monitor their own performance.
5. It highlights problems related to quality care and determines the areas that require priority
attention.
6. It provides an indication of the costs of poor quality.
7. It justifies the use of resources.
8. It provides feedback for improvement.
Evaluation Principles
1. The evaluation must be based on the behavioral standards of performance which the
position requires. The goals and objectives are clearly presented to the employee and
performance evaluation is based on these.
2. In evaluating performance, there should be enough time to observe employee’s behavior.
Usual and consistent behavior should be evaluated rather than those isolated or typical
actuations.
3. The employee should be given a copy of the job description, performance standards and
evaluation form before the scheduled evaluation conference. This way, the rater and the
employee to be rated can discuss issues from the same frame of reference.
4. The employee’s performance appraisal should include both satisfactory and
unsatisfactory results with specific behavioral instances to exemplify these evaluative
comments.
5. Areas needing improvement must be prioritized to help the worker upgrade his/her
performance.
6. The evaluation conference should be scheduled and conducted at a convenient time for
the rater and the employee under evaluation, in a pleasant surrounding and with ample
time for discussion.
7. The evaluation report and conference should be structured in such a way that it is
perceived and accepted positively as a means of improving job performance
Characteristics of an Evaluation Tool
The evaluation tool should be objective, reliable and sensitive. Objectivity means that the
evaluation tool is free from bias. Reliability refers to the accuracy or precision of the tool such
that it will produce the same results if administered twice. Validity refers to the relevancy of the
measurement to the performance of the employee while sensitivity means that the instrument can
measure fine lines of differences among the criteria being measured.
Basic Components of the Control Process
1. Establishment of standards, objectives, and methods for measuring performance
2. Measurement of actual performance
3. Comparison of results of performance with standards and objectives and identifying
strengths and areas for correction and/or improvement
4. Action to reinforce strengths or successes
5. Implementation of corrective action as necessary.
HEALTH CARE CONSUMERISM
The term "consumerism" was first used in 1915 to refer to "advocacy of the rights and interests
of consumers" (Oxford English Dictionary).
In economics, consumerism refers to economic policies placing emphasis on consumption. In an
abstract sense, it is the belief that the free choice of consumers should dictate the economic
structure of a society (cf. Producerism, especially in the British sense of the term).
Health consumerism is a movement which advocates patients’ involvement in their own health
care decisions. It is a movement from the “doctor says/patient does” model to a partnership
model. Health consumerism tries to encourage health information empowerment and the transfer
of knowledge so that patients can be informed and thus more involved in the decision-making
process. It also attempts to promote public understanding of basic organ function, the processes
of chronic disease, and the beginnings of how to best prevent these diseases.
Health Care Consumerism is a trend that encourages individuals to get the care they need, and
helps make employees more engaged in health care consumers.
Examples of health care consumerism
A subset of healthcare consumerism has a similar name, Consumer Driven Healthcare
(CDH.) CDH usually describes the insurance aspects of healthcare only, including the
various types of insurance plans, supplements and subsets available such as Health
Savings Accounts.
Patients can choose their insurance coverage. Most Americans get their insurance through
their employers. Each year, usually during November and December, employers offer an
"open enrollment" period during which employees may review their choice of insuror for
the next year. By comparing their medical service needs, with the providers made
available through that insuror, with the costs of premiums, deductibles and co-pays,
patients have some control over their ultimate healthcare costs.
Patients can choose their providers. While some insurance plans limit choices, the ability
to make a choice is still available to most. Patients may learn about a provider's
credentials, licensing, even marks against the provider's reputation and use that
information to choose which providers they prefer to see for their care.
Patients can review their medical records and correct errors and misinformation. Errors
occur in patient's records for a variety of reasons. Sometimes medical staffs are in a hurry
and information is omitted. Sometimes transcriptions are incorrect. Other times,
derogatory information that does not belong in a patient's record needs to be removed.
The Medical Information Bureau may have a file on a patient's credit and medical
history. Smart healthcare consumers are aware of this reporting agency, and know how to
contact them to make sure their records are fair and correct.
Complementary and alternative medical (CAM) options, such as herbal remedies,
acupuncture or yoga, have expanded in recent years. Patients, frustrated with their
allopathic (mainstream medical) options, are choosing CAM treatments more frequently.
This shift in attitude on the part of patient-consumers is making integrative medicine, a
combination of allopathic and CAM, more popular.
Consumerism is a meaningful trend, not an interesting fad. As consumers assume more personal
responsibility for improving their health and covering their health care costs, and gain increased
awareness of treatment options, provider quality levels and price differences, they will want to
take even greater control of their health care decisions. Industry leaders who understand the
implications, challenges and opportunities of consumerism will be better positioned for future
impact and success.
The journey to a consumer-centric health care system will not be easy, and the specific and
practical implications of consumerism may vary widely among health plans. Shifting from a
complex, volume-driven, patient-oriented system will take time, action and investment.
Likewise, consumers must continue to take on a new level of responsibility and accountability
for their health, health care and health financing. Fortunately, the desire for change is there, and
Deloitte’s 2009 Survey of Health Care Consumers provides a starting point for action.
Forward-thinking organizations already recognize the untapped opportunities that exist in a
consumer-centric health care market and are responding by offering new approaches to care and
financing, modifying incentives, and developing the products, information, online services and
other tools needed to shift behaviors and attitudes. But a large gap remains between what is
available and what consumers say they would use. The opportunity to fill this gap with new,
innovative products and services is open to all. (According to Deloitte's 2009 Survey of Health
Care Consumers - conducted by the Deloitte Center for Health Solutions under the direction of
Dr. Paul H. Keckley.)
How consumerism impacts nurses
The role that nurses play in consumerism and health care is still being defined. As health care
costs escalate, a greater portion of patient care has fallen to nurses. Chronic disease management
has become a nursing specialty, and the demand for nurse practitioners is ever increasing. Nurse
practitioners, of course, can handle nearly 90% of all routine health care needs at a fraction of the
cost to insurance companies and individuals, and they can also offer patients (or "consumers")
longer appointments and provide more in-depth information—meaning more "bang for the
buck." HMOs and other insurance plans are encouraging patients to choose nurse practitioners as
their primary care givers whenever possible. Additionally, nurse midwives are being used more
frequently instead of obstricians, particularly as internet-educated pregnant women want to go
into their labor and delivery with more "natural" options.
Even in traditional physician-driven health care, nurses are often asked to spend a great deal of
time answering patients questions and helping those patients sort internet-provided fact from
fiction about their diagnosis. Hospitalized patients often spend more time with their nurses than
they do their doctors, so nurses need to be highly educated—and willing to talk—to their
increasingly knowledgeable patients.
There is no doubt that the consumerism trend is impacting health care, and nurses will find that
their role continues to evolve and change as the rest of the health care field attempts to combat
the current health care economic crisis. Once again, nurses find themselves on the cutting edge
of care, and will surely find themselves up to the challenge.
QUALITY ASSURANCE
Introduction
Quality refers to excellence of a product or a service, including its attractiveness, lack of
defects, reliability, and long-term durability
Quality assurance provides the mechanisms to effectively monitor patient care provided
by health care professionals using cost-effective resources.
Nursing programs of quality assurance are concerned with the quantitative assessment of
nursing care as measured by proven standards of nursing practice.
Quality assurance system motivates nurses to strive for excellence in delivering quality
care and to be more open and flexible in experimenting with innovative ways to change
outmoded systems.
Florence Nightingale introduced the concept of quality in nursing care in 1855 while
attending the soldiers in the hospital during the Crimean war.
Concepts of quality health care
Quality is defined as the extent of resemblance between the purpose of healthcare and the
truly granted care (Donabedian 1986).
Quality assurance originated in manufacturing industry “to ensure that the product
consistently achieved customer satisfaction”.
Quality assurance is a dynamic process through which nurses assume accountability for
quality of care they provide.
It is a guarantee to the society that services provided by nurses are being regulated by
members of profession.
“Quality assurance is a judgment concerning the process of care, based on the extent to
which that cares contributes to valued outcomes”. (Donabedian 1982).
“Quality assurance as the monitoring of the activities of client care to determine the
degree of excellence attained to the implementation of the activities”. (Bull, 1985)
Quality assurance is the defining of nursing practice through well written nursing
standards and the use of those standards as a basis for evaluation on improvement of
client care (Maker 1998).
Approaches for a quality assurance program
Two major categories of approaches exist in quality assurance they are
1. General
2. Specific
A. General Approach
It involves large governing of official body’s evaluation of a persons or agency’s ability
to meet established criteria or standards at a given time.
1) Credentialing
formal recognition of professional or technical competence and attainment of minimum
standards by a person or agency
Credentialing process has four functional components
a) To produce a quality product
b) To confer a unique identity
c) To protect provider and public
d) To control the profession.
2) Licensure
Individual licensure is a contract between the profession and the state, in which the
profession is granted control over entry into and exists from the profession and over
quality of professional practice.
The licensing process requires that regulations be written to define the scopes and limits
of the professional’s practice.
Licensure of nurses has been mandated throuhout the world by laws and regulations..
3) Accreditation
ISO
JCI
NABH
NAAC
4) Certification
Certification is usually a voluntary process with in the profession.
A person’s educational achievements, experience and performance on examination are
used to determine the person’s qualifications for functioning in an identified specialty
area.
B. Specific approaches
1) Peer review
Peer review is divided in to two types.
1. The recipients of health services by means of auditing the quality of services
rendered.
2. The health professional evaluating the quality of individual performance.
2) Standard as a device for quality assurance
Standard is a pre-determined baseline condition or level of excellence that comprises a model to
be followed and practiced. The ANA standard for practice include:
Standard 1: The collection of data about health status of the patient is systematic and
continuous. The data are accessible, communicative, and recorded.
Standard 2: Nursing diagnosis are derived from health status data.
Standard 3: The plan of nursing care includes goals derived from the nursing diagnoses.
Standard 4: The plan of nursing care includes priorities and the prescribed nursing
approaches or measures to achieve the goals derived from the nursing diagnoses.
Standard 5: Nursing actions provide for patient participation in health promotion,
maintenance, and restoration.
Standard 6: Nursing actions assist the patient to maximize his health capabilities.
Standard 7: The patient’s progress or lack of progress towards goal achievement is
determined by the patient and the nurse.
Standard 8: The patient’s progress or lack of progress towards goal achievement directs
re-assessment, re-ordering of priorities, new goal setting, and a revision of the plan of
nursing care.
3) Audit as a tool for quality assurance
Nursing audit may be defined as a detailed review and evaluation of selected clinical
records in order to evaluate the quality of nursing care and performance by comparing it
with accepted standards.
Models of quality assurance
1. System Model
Tasks are broken down into manageable components based on defined objectives.
The basic components of the system are:
1. Input
2. Throughput
3. Output
4. Feedback
The input can be compared to the present state of systems, the throughput to the developmental
process and output to the finished product. The feedback is the essential component of the
system because it maintains and nourishes the growth.
2) ANA Quality Assurance Model
The basic components of the ANA model are:
1. Identify values
2. Identify structure, process and outcome standards and criteria
3. Select measurement
4. Make interpretation
5. Identify course of action
6. Choose action
7. Take action
8. Reevaluate
1) Identify Value
In the ANA value identification looks as such issue as patient/client, philosophy, needs and
rights from an economic, social, psychology and spiritual perspective and values, philosophy of
the health care organization and the providres of nursing services.
2) Identify structure, process and outcome standards and criteria:
Identification of standards and criteria for quality assurance begins with writing of
philosophy and objective of organization.
The philosophy and objectives of an agency serves to define the structural standards of
the agency.
Standards of structure are defined by licensing or accrediting agency.
Evaluation of the standards of structure is done by a group internal or external to the
agency.
The evaluation of process standards is a more specific appraisal of the quality of care
being given by agency care providers.
3) Select measurement needed to determine degree of attainment of criteria and standards
Measurements are those tools used to gather information or data, determined by the
selections of standards and criteria.
The approaches and techniques used to evaluate structural standards and criteria are,
nursing audit, utilization’s reviews, review of agency documents, self studies and review
of physicals facilities.
The approaches and techniques for the evaluation of process standards and criteria are
peer review, client satisfactions surveys, direct observations, questionnaires, interviews,
written audits and videotapes.
The evaluation approaches for outcome standards and criteria include research studies,
client satisfaction surveys, client classification, admission, readmission, discharge data
and morbidity data.
4) Make interpretations
The degree to which the predetermined criteria are met is the basis for interpretation
about the strengths and weaknesses of the program.
The rate of compliance is compared against the expected level of criteria
accomplishment.
5) Identify Course of Action
If the compliance level is above the normal or the expected level, there is great value in
conveying positive feedback and reinforcement
. If the compliance level is below the expected level, it is essential to improve the
situations.
It is necessary to identify the cause of deficiency. Then, it is important to identify various
solutions to the problems.
6) Choose action
Usually various alternative course of action are available to remedy a deficiency.
Thus it is vital to weigh the pros and cons of each alternative while considering the
environmental context and the availability of resources.
7) Take Action
It is important to firmly establish accountability for the action to be taken.
This step then concludes with the actual implementation of the proposed courses of
action.
8) Reevaluate
The final step of QA process involves an evaluation of the results of the action.
The reassessment is accomplished in the same way as the original assessment and begins
the QA cycle again.
Careful interpretation is essential to determine whether the course of action has improves
the deficiency, positive reinforcement is offered to those who participated and the
decision is made about when to again evaluate that aspect of care.
Quality assurance process
1. Establishment of standards or criteria
2. Identify the information relevant to criteria
3. Determine ways to collect information
4. Collect and analyze the information
5. Compare collected information with established criteria
6. Make a judgment about quality
7. Provide information and if necessary, take corrective action regarding findings of
appropriate sources
8. Determine ways to collect the information
Factors affecting quality assurance in nursing care
1) Lack of Resources
Insufficient resources, infrastructures, equipment, consumables, money for recurring
expenses and staff make it possible for output of a certain quality to be turned out under
the prevailing circumstances.
2) Personnel problems
Lack of trained, skilled and motivated employees, staff indiscipline affects the quality of
care.
3) Improper maintenance
Buildings and equipments require proper maintenance for efficient use. If not maintained
properly the equipments cannot be used in giving nursing care.
To minimize equipment down time it is necessary to ensure adequate after sale service
and service manuals.
4) Unreasonable Patients and Attendants
Illness, anxiety, absence of immediate response to treatment, unreasonable and unco-
operative attitude that in turn affects the quality of care in nursing.
5) Absence of well informed population
To improve quality of nursing care, it is necessary that the people become knowledgeable
and assert their rights to quality care.
This can be achieved through continuous educational program.
6) Absence of accreditation laws
There is no organization empowered by legislation to lay down standards in nursing and medical
care so as to regulate the quality of care. It requires a legislation that provides for setting of a
stationary accreditation / vigilance authority to:
a) Inspect hospitals and ensures that basic requirements are met.
b) Enquire into major incidence of negligence
c) Take actions against health professionals involved in malpractice
7) Lack of incident review procedures
During a patients hospitalizations reveal incidents may occur which have a bearing on the
treatment and the patients final recovery. These critical incidents may be:
a) Delayed attendance by nurses, surgeon, physician
b) Incorrect medication
c) Burns arising out of faulty procedures
d) Death in a corridor with no nurse / physician accompanying the patient etc.
8) Lack of good and hospital information system
A good management information system is essential for the appraisal of quality of care.
a) Workload, admissions, procedures and length of stay
b) Activity audit and scheduling of procedures.
9) Absence of patient satisfaction surveys
Ascertainment of patient satisfaction at fixed points on an ongoing basis. Such surveys carried
out through questionnaires, interviews to by social worker, consultant groups, and help to
document patient satisfaction with respect to variables that are
a) Delay in attendance by nurses and doctors.
b) Incidents of incorrect treatment
10) Lack of nursing care records
Nursing care records are perhaps the most useful source of information on quality of care
rendered. The records.
a) Detail the patient condition
b) Document all significant interaction between patient and the nursing personnel.
c) Contain information regarding response to treatment
d) Have the dates in an easily accessible form.
11) Miscellaneous factors
a. Lack of good supervision
b. Absence of knowledge about philosophy of nursing care
c. Lack of policy and administrative manuals.
d. Substandard education and training
e. Lack of evaluation technique
f. Lack of written job description and job specifications
g. Lack of in-service and continuing educational program
Framework for quality assurance:
1. Maxwell (1984)
Maxwell recognized that, in a society where resources are limited, self assessment by health care
professionals is not satisfactory in demonstrating the efficiency or effectiveness of a service. The
dimensions of quality he proposed are:
Access to service
Relevance to need
Effectiveness
Equity
Social acceptance
Efficiency and economy
2. Wilson (1987)
Wilson considers there to be four essential components to a QA programme. These are:
Setting objectives
Quality promotion
Activity monitoring
Performance assessment
3. Lang (1976)
This framework has subsequently been adopted and developed by the ANA. The stages includes;
Identify and agree values
Review literature, Known QAP
Analyze available programs
Determine most appropriate QAP
Establish structure, plans, outcome criteria and standards
Ratify standards and criteria
Evaluate current levels of nursing practice against ratified structures
Identify and analyze factors contributing to results
Select appropriate actions to maintain or improve care
Implement selected actions
Evaluate QAO
Stages of development of international standards
An International Standard is the result of an agreement between the member bodies of ISO. It
may be used as such, or may be implemented through incorporation in national standards of
different countries.
International Standards are developed by ISO technical committees (TC) and subcommittees
(SC) by a six-step process:
Stage 1: Proposal stage
Stage 2: Preparatory stage
Stage 3: Committee stage
Stage 4: Enquiry stage
Stage 5: Approval stage
Stage 6: Publication stage
The six stages:
Stage 1: Proposal stage
The first step in the development of an International Standard is to confirm that a particular
International Standard is needed. A new work item proposal (NP) is submitted for vote by the
members of the relevant TC or SC to determine the inclusion of the work item in the programme
of work.
The proposal is accepted if a majority of the P-members of the TC/SC votes in favour and if at
least five P-members declare their commitment to participate actively in the project. At this stage
a project leader responsible for the work item is normally appointed.
Stage 2: Preparatory stage
Usually, a working group of experts, the chairman (convener) of which is the project leader, is
set up by the TC/SC for the preparation of a working draft. Successive working drafts may be
considered until the working group is satisfied that it has developed the best technical solution to
the problem being addressed. At this stage, the draft is forwarded to the working group's parent
committee for the consensus-building phase.
Stage 3: Committee stage
As soon as a first committee draft is available, it is registered by the ISO Central Secretariat. It is
distributed for comment and, if required, voting, by the P-members of the TC/SC. Successive
committee drafts may be considered until consensus is reached on the technical content. Once
consensus has been attained, the text is finalized for submission as a draft International Standard
(DIS).
Stage 4: Enquiry stage
The draft International Standard (DIS) is circulated to all ISO member bodies by the ISO Central
Secretariat for voting and comment within a period of five months. It is approved for submission
as a final draft International Standard (FDIS) if a two-thirds majority of the P-members of the
TC/SC are in favour and not more than one-quarter of the total number of votes cast are negative.
If the approval criteria are not met, the text is returned to the originating TC/SC for further study
and a revised document will again be circulated for voting and comment as a draft International
Standard.
Stage 5: Approval stage
The final draft International Standard (FDIS) is circulated to all ISO member bodies by the ISO
Central Secretariat for a final Yes/No vote within a period of two months. If technical comments
are received during this period, they are no longer considered at this stage, but registered for
consideration during a future revision of the International Standard. The text is approved as an
International Standard if a two-thirds majority of the P-members of the TC/SC is in favour and
not more than one-quarter of the total number of votes cast are negative. If these approval criteria
are not met, the standard is referred back to the originating TC/SC for reconsideration in light of
the technical reasons submitted in support of the negative votes received.
Stage 6: Publication stage
Once a final draft International Standard has been approved, only minor editorial changes, if and
where necessary, are introduced into the final text. The final text is sent to the ISO Central
Secretariat which publishes the International Standard.
Impact of ISO in a LOCAL HOSPITALS:
Positive impacts:
1. Nurses are accountable for their actions and, professionally, we have responsibility to
evaluate the effectiveness of our care
2. Nurses can deliver a high standard of care, and being empowered to identify and resolve
problems can add to personal satisfaction with work
3. Documents state clearly how the health service should perform and what the patient can
expect
4. Guaranteeing standards of care to the public must be a duty of all those who work within
the health service
5. Nurses are actively involve in audit, service reviews, standard-setting and customer
relations
6. Improves the overall quality of nursing care
7. Improves all types of documentation and communication
8. Helps in professional growth
Negative impacts:
1. Lack of adequate resources
2. Lack of trained, skilled and motivated employees, staff indiscipline affects the quality of
care.
3. ISO activities may overburden the nursing personnel
4. Nurses will not get adequate time to spent with the patient, most of the time may be
spending for recording and reporting
5. The hospital will be restricted only to ISO standards
6. Hospital has to provide special training for all the staffs those who are involved in ISO
inspection
7. All types of services will be under the control of ISO
Impact of ISO in local NURSING EDUCATIONAL INSTITUTIONS:
Positive impacts:
1. Improves the quality of nursing education
2. improves the quality of nursing practice
3. Helps to maintain international standard
4. Helps to compare the standard with another institution
5. Helps in personnel development of teachers
6. Helps to maintain all the records in time
7. Avoids malpractice and bias
8. Encourages extra-curricular activities also
9. Act as a control for all the activities
10. Improves professional growth
Negative impacts:
1. Gives more importance to documentation
2. Over-burden for the teachers
3. Teachers need to take special training in maintaining the standards
4. Not observing the actual practice
5. Organizational philosophy and policies has to be modified according to the ISO standards
Critical analysis:
Strengths: ISO helps to improve and maintain the quality of educational institutions and
hospitals
Weakness : Standards are set by the institution itself, it may be biased
Opportunities: Helps in professional growth
Threats: Organizational philosophy and policies may not be considered
Conclusion
To ensure quality nursing care within the contemporary health care system, mechanisms for
monitoring and evaluating care are under scrutiny. As the level of knowledge increases for a
profession, the demand for accountability for its services likewise increases. Individuals within
the profession must assume responsibility for their professional actions and be answerable to the
recipients for their care. As profession become more interdependent, it appears that the power
base will become more balanced, allowing individual practitioners to demonstrate their
competence and expertise. Quality assurance programme will helps to improve the quality of
nursing care and professional development.
RECORDS AND REPORT SYSTEM
Standards of Nursing Practice require that documentation be pertinent, concise and
reflective of the patient’s status. This includes the patient’s needs, problems, capabilities and
limitations. Nursing interventions and patient’s responses must be documented.
Guidelines for good Reporting and Documentation
1. Factual- Information about the patients and their care must be based on facts that are
descriptive and objective.
2. Accurate- A client’s record must be accurate and reliable. Measurements should be
accurate. Care should be observed in the use of abbreviations.
3. Confidential- The information given by patients and their families are privileged. Such is
given in good faith and in confidence. Information gathered by examination, observation,
conversation or treatment should be shared only with members of the health team
participating in the patient’s care; to the police if it is a medico-legal case; to the nearest
public health agency if the disease is communicable and there exists a need for public
health action such as immunization of residents within the community where the patient
resides; or when the patient himself/herself has permitted the release of information such
as in claims for sick leave, insurance or disability pay privileges.
4. Complete- Charting should be complete and concise giving only essential information. It
should describe nursing care rendered and the client’s response to that care. Unnecessary
and lengthy words or irrelevant details should be avoided.
5. Current- Recording and reporting should be up-to-date. These include vital signs,
administered medicines and treatments, preparations for diagnostic examinations,
changes in the client’s condition and the action taken. Admissions, discharges, transfers
or death should be documented.
6. Organized- The information should be communicated in a logical format or sequence.
The nurse describes her assessment and intervention and the physician’s orders if any, in
their logical order of occurrence. Disorganized data may lead to confusion and errors.
7. Ethical- negative or retaliatory remarks about a patient or a member of the health team
should be avoided as these breed ill-feeling and poor relationships. Words such as
“incooperative,non-compliant” should be avoided. Instead, describe what the patient did
that was interpreted as being uncooperative.
Precaution to observe in documentation
1. Only the nurse who performs the nursing intervention makes the entry and signs it.
Accountability belongs to him/her as well.
2. Charting made by nursing students should be countersigned by their clinical instructors,
indicating that the students have been actually supervised.
3. Chart all important information before going on a break or when leaving the unit.
Another nurse may possibly duplicate the giving of medications if this was not
documented or properly endorsed.
4. Do not make erasures. It might indicate that something is being covered up, modified or
hidden.
Reports
Reports are either oral, taped or written exchanges of information between nurses and/or
members of the health team. These include change-of-shift reports, telephone orders and reports
and transfer reports.
1. Change-of-shift reports
Is a system of communication aimed at transferring essential information and
holistic care for patients. Its purpose is to provide continuity of patient care for 24 hours.
a. Oral report
b. Audio tape report
c. Nursing Rounds
2. Telephone Reports and Orders
3. Transfer Reports
Patients may be transferred from one unit to another as their condition or case
warrants it. The receiving unit is usually notified in advance about the transfer so that the
unit or bed which the patient will occupy, including special equipment if needed, will be
prepared.
Before a patient is transferred to another agency, proper coordination must first be
made to ensure that the agency has the poor services and facilities needed by the patient.
A transfer report accompanies the patient. The patient’s medical record (chart) is left at
the original agency.
Documentation
Documentation is anything printed or written that can be used as record or proof for
authorization. A medical record is a comprehensive description of the client’s health status and
needs as well as evidence of each health care member’s accountability in giving that care.
Purposes of records
1. Communication - the patient’s record facilitates communication among members of the
health team on various shifts. It keeps track of the patient’s progress and condition and
the measures taken to maintain continuity of care. It serves as a reference point for further
assessment.
2. Legal evidence of care - the record serves as a description of what happened to the
patient. Under the law, any nursing care given, if not documented, is care not rendered no
matter how excellent it is. Agency protocol must be observed in releasing information.
3. Education - A client’s record is used by students of medicine, nursing and other
paramedical students for educational purposes. It contains medical and nursing diagnosis,
signs and symptoms of diseases, successful and unsuccessful therapies, diagnostic
findings and client behaviors. Student learns various health problems and types of
treatment and care from a client’s record.
4. Financial Billing - Hospitalization bills of pay patients or those financed by Medicare or
Health Maintenance Organizations and Insurance companies are based on the patient’s
chart. Payment or reimbursement will be based on what is reflected in the patient’s chart.
This includes physician’s orders which have been carried out adequately and correctly,
services rendered medicines, treatments, and diagnostic and laboratory services. A review
of the patient’s record determines the payment or reimbursement that a client will pay or
receive.
5. Evaluation of quality of care rendered - this is done to determine the degree to which
quality assurances or quality improvement standards are being met.
6. Research and Statistical information - Clinical records are used to supply statistical
data related to frequency of disorders, complications, use of specific medical and nursing
therapies, deaths and recoveries. It is also used to describe characteristics of client
population in a health care agency.
Forms of nursing documentation
Forms vary according to the institution’s needs. They are used to make documentation easy,
quick and comprehensive. They present special types of information that eliminates repeated
data in the nursing notes.
- Nursing health history and assessment worksheet
- Graphic flowsheets
- Medicine and treatment record
- Kardex
- Discharge summary
- Nursing progress notes/Soapie charting
Discipline
In the past, discipline meant rigid obedience to rules and regulations, the violation of
which resulted in punitive actions.
Today, discipline is regarded as a constructive and effective means by which employees
take personal responsibility for there own performance and behavior.
Some factors that influence self discipline are;
1. A strong commitment to the vision, philosophy, goals and objectives of the institution.
Strong commitment results in cohesion and teamwork which in turn encourage greater
conformity to expected norms of conduct with in the organization.
2. Laws that govern the practice of all professionals and their respective Codes of Conduct.
For all government employees, the Civil Service Rules and Regulations as provided for in
P.D. 807 and the Code of Conduct for Public Officials, R.A. 6713 are also to be complied
with
3. Understanding the rules and regulations of the agency. All employees are oriented on the
rules, regulations and policies of the agency. Some organizations give their employees a
handbook containing these and the possible sanctions for their infractions.
4. An atmosphere of mutual trust and confidence. Self-discipline thrives best in an
atmosphere of trust and confidence between superiors and subordinates. The latter can
consult their superiors about their problems without fear. The superiors trust their
workers will do their best in performing their jobs without being “snoopervised”. The
subordinates trust that their superiors will be fair and just in decisions concerning their
welfare.
5. Pressure from peers and organization demand that workers perform their jobs to the best
of their abilities.
Disciplinary approaches
This should includes set of disciplinary policies and procedures, a uniform application of
discipline rules, a disciplinary committee, and an orientation program for all new employees
where expectations of appropriate performance and behavior are emphasized. There must be
continuous communication to all employees regarding changes in personnel and discipline
policies. Changes must be communicated before these are affected.
Successful implementation of disciplinary action is characterized by promptness,
fairness, impartiality, nonpunitiveness, advance warning, and follow-through.
Problem solving
Effective supervision aids supervisors in analyzing the work problems of their
subordinates. Counseling becomes part of an oral warning session before resorting to a
disciplinary action.
Disciplinary action
Any employee charged for breach of the rules and regulations, policies, norms of conduct
shall be given due process. There must be existing rules of conduct governing his behavior and a
documentation of actual violation of such rule must support charges. The employee charged must
be notified in writing about the violation and given the right to counsel.
Disciplinary action should be progressive in nature such as counseling and oral warning,
written warning, suspension and dismissal.
Counseling and oral warning
Counseling and oral warning are best given in private and in an informal atmosphere. The
employee is given a fair chance to air his side. The relevant facts are analyzed and evaluated
against his performance. The employee is then counseled regarding expectations of improved
behavior/performance, ways of correcting the problem and a warning that a repetition of the
same offense may warrant further disciplinary action. The employee must commit to correct the
behavior. He should be informed of any follow-up action that may be taken.
Written warning
Written warning is the second step in disciplinary action. It is preceded by an interview
similar to the oral warning. The employee must be told after the interview that he will be given a
written warning. This includes the statement of the problem, identification of the rule which was
violated, consequences of continued deviant behavior, the employee’s commitment to take
corrective action, and any follow-up action to be taken.
Suspension
Suspension over minor violation is given after an evidence of oral and written warnings.
Although a violation is a major infraction, suspension, rather than dismissal is applied when
management feels that the employee can still be rehabilitated. Accurate documentation of oral
and written warnings including suspension, if done, are necessary evidences of due process.
Dismissal
Dismissal is invoked only when all other disciplinary efforts have failed. The
Disciplinary Committee should be very sure that the cause for dismissal conforms to the criteria
of a major discipline violation as contained in the policy manual, and for government employees,
those contained in the Civil service Rules and regulations and the codes of conduct. A review is
usually done by higher management. In the case of government employees this is further
reviewed by their respective departments and final affirmation is done by the Civil Service
Commission.
Reference:
1. Margaret MM. Professionalization of nursing; current issues and trends. JB Lippincott
company; Philadelphia: 1992
2. Karen P, Corrigan P. Quality improvement in nursing and health care. Chapman& Hall;
Newyork: 1995
3. Patrica&Cerrell. Nursing leadership and management; A practical guide. Thomson
Delmar; Canada: 2005
4. Roger E. Professional competence and quality assurance in the caring professions.
Chapman& Hall; USA: 1993
5. Basavanthappa BT. Nursing administration. Jaypee brothers; New Delhi: 2000
6. Srinivasan AV. Managing a modern hospital. Sage publishers; New Delhi: 2000
7. Barbara C. Contemporary nursing issues trends and management, Mosby publication; St
