ADVANCED NURSING PRACTICE

AN ASSIGNMENT

ON

NURSING AS A PROFESSION

SUBMITTED TO; MISS HARLEEN KAUR LECTURER DEPTT OF OBG DATE;24th JAN, 2012.

SUBMITTED BY; NAVPREET KAUR M.Sc NURSING 1ST YEAR DEPTT OF MEDICAL SURGICAL NURSING

INDEX

S.NO. 1 2 3 4 5 6 7 8

TOPIC HISTORY OF DEVELOPMENTOF NSG.PROFFESION CHARACTERISTICS CRITERIA PERSPECTIVE OF NSG. PROFFESION CODE OF ETHICS ROLE OF REGULATORY BODIES ROLE OF RESEARCH, LEADERSHIP, MANAGEMENT IN NURSING. QUALITY ASSURANCE

PAGE NO. 3 6 8 9 16 32 68 88

HISTORY OF DEVELOPMENT OF NURSING PROFESSION INTRODUCTION: Knowledge of the professions history increases the nurses awareness and promotes an understanding of the social and intellectual origins of the discipline. From its earliest history nursing was a form of community service to protect and preserve the family. Historically men and women held the role of nurse. In Prehistoric Period, women were responsible for gathering herbs, roots and plants that were used to heal the sick. HISTORY OF NURSING: CHRISTIANITY: The entry of women into nursing can be traced to approximately 300 AD. Christians taught that men and women are equal before God and appealed to carry on His work in the behalf of all who were in distress. The founding of Benedictine Order in sixth century increased the number of men in nursing. MIDDLE AGES: During the middle Ages (1100-1200 AD) charitable institutions were started to care for the aged, sick and poor. Nurses delivered custodial care and depended on physicians or priests for direction. Nurse Midwifery flourished during middle ages. FIFTEENTH TO NINETEENTH CENTURY: The Crusades expanded health care by establishing hospital and nursing orders for men. Christianity greatly influenced the development of nursing. One of the earlist records of Christian nursing was the formation of the order of Deaconesses, a group of public health or visting nurses. Deaconesses appointments by the bishops were highly valued and given only to women of hgih social standing. The need for nurses and increasing nursing responsibilities were due to the economic growth of eighteenth century, the smallpox epidemics and the Revolutionary War. The Sisters of Charity, founded in 1633 by St. Vincet de Paul, cared for people in hospitals, asylums and poor houses. The sisters became widely known as visiting nurses because they cared for sick people in their homes. The first Supervisor of the Sisters of Charity was Louise de Gras and was later known as Sr. Louise de Marillac. She established perhaps the first educational program to be associated with a nursing order. In 1809 the Sisters of Charity was introduced in America by Mother Elizabeth Senton, later their name was changed to Daughters of Charity. In the eighteenth century the further growth of cities brought an increase in the number of hospitals and expanded role of nurses. Smallpox epidemics in the French Colonies and during the Revolutionary war the English colonies increased the need of nursing services. Because there was little formal nursing education, nursing knowledge and skills were generally passed by experienced nurses. During the nineteenth century Protestant churches revived the Deaconess Order. The Deaconess Institute at Kaiserwerth, Germany was established in 1836 by Pastor Theodore Flieder. FLORENCE NIGHTINGALE: The founder of modern nursing, Florence Nightingale, established the first nursing philosophy based on health maintenance and restoration in Notes of Nursing: What it is and What it is not. Her views on nursing were derived from a spiritual philosophy, developed in her adolescence and adulthood and reflecting the changing needs of society.

In 1853 Nightingale went to Paris to study with the Sisters of Charity and was appointed superintendent of The English General Hospitals in Turkey. During this Crimean War period she brought about major reforms in hygiene, sanitation and nursing practice and reduced the mortality rate at the Barracks Hospital, Turkey. THE CIVIL WAR: The civil war stimulated the growth of nursing in United States .Clara Barton, founder of American Red Cross, tended soldiers on the battle field, cleansing the wounds, meeting their basic needs and comforting them in death. Dorothea Leynde Dix, Mary Ann Ball and Harriet Tubman also influenced nursing during Civil War. After the Civil War, nursing schools in the United States and Canada began to pattern their curricula after the Nightingale School. St. Catherines in Ontario, was founded in 1874.The first African-American professional nurse was Mary Mahoney. Isabel Hampton Robb, a graduate of St. Catherines in Ontario was the first superintendent of Johns Hopkins training school in Baltimore, Maryland in 1894.Nursing in hospitals expanded in the late nineteenth century. However, nursing in the community did not increase significantly until 1893, when Lillian Wald and Mary Brewster opened the Henry Street Settlement which focused on the health needs of poor people who lived in the tent aments in New York City. Wald described her activities with the Henry Settlement in the textbooks The House on Henry Street and Windows on Henry Street. TWENTIETH CENTURY: In the early twentieth century, a movement toward a scientific, research-based defined body of nursing knowledge and practice was seen. Nurses began to assume expanded and advance practice roles. Mary Adelaide Nutting, a member of the first graduating class at Johns Hopkins Hospital and successor to Isabel Hampton Robb as superintendent of the Johns Hopkins Training School, was instrumental in the affiliation of nurses education with university. She became the first professor of nursing at Columbia University Teachers College in 1907. In 1923 the Rockfeller foundation funded a survey of nursing education, The Goldmark Report. The report concluded that the nursing education needed increased financial support and suggested that the money be given to university schools of nursing. As education developed, nursing practice also expanded. In 1901 the Army Nurse Corps was established. By the year 1908 Navy Corps established. By the year 1920s nursing specialization was developing. Graduate nurse midwifery programs were initiated and beginning in 1950s specialty nursing organizations such as Association of Operating Room Nurses (1949), American Association of Critical Care Nurses and Oncology Nursing Society were formed. Today, the profession is faced with multiple challenges. Nurses and Nurse Educators are revising nursing practice and curricula to meeting the ever changing needs of society. CHARACTERISTICS OF PROFESSION: Although nursing has been called a profession for many years, an assessment of characteristics of a profession indicates that it should more accurately be considered as emerging profession. Characteristics of a profession have been defined as: Authority to control its own work. Exclusive body of specialized knowledge. Extensive period of formal training. Specialized competence. Control over work performance.

Service to society. Self-regulation. Credentialing system to certify competence. Legal reinforcement of professional standards. Ethical practice. Creation of a collegial subculture. Intrinsic rewards. Public acceptance.

Apart from this the characteristics of a profession can be categorized as following: Intellectual: This character is reflecting commitment to serve society. This category has three components: a) Body of knowledge: professional practice is based on body of knowledge derived from experience (leading to expertise) and research (leading to theoretical foundation for knowledge).This knowledge base contributes to judgement and rationale for modifying actions according to specific situation. However, the education has often emphasized proven methods for responding to particular kinds of situations e.g. clients may be discharged without self care teaching because the doctor did not write an order. b) Specialized education: Nursing transmits knowledge through specialized education. However, there are five levels of basic education for registered nurses, all of which prepare for one licensure examination. Three of five levels (diploma, associate degree and baccalaureate degree) accept high school graduation where as other two (masters degree and doctoral degree) accept college with liberal arts majors. c) Critical and Creative Thinking: A logical and critical thinking process is one essential component of professional practice. The nursing process is a problem solving approach. It includes: Collect and organize information derived from multiple sources. Decide what is needed, based on that information. Select and implement one approach from among many possible approaches. Evaluate the Personal: This category emphasizes on autonomy. Autonomy means the practitioners have control over their own functions in a work setting. Autonomy involves independence, a willingness to take risks and responsibility and accountability for ones own actions as well as self-determination and self-regulation. The autonomous practitioners are also obligated to collaborate with others for the benefit of the patient. Interpersonal: Nursing is a significant therapeutic interpersonal process. It functions cooperatively with other human processes that make health possible for individuals in the communities. The nurse collaborates with the patient, significant results of the process.

Ethical practice. Creation of a collegial subculture. Intrinsic rewards. Public acceptance.

Apart from this the characteristics of a profession can be categorized as following: Intellectual: This character is reflecting commitment to serve society. This category has three components: d) Body of knowledge: professional practice is based on body of knowledge derived from experience (leading to expertise) and research (leading to theoretical foundation for knowledge).This knowledge base contributes to judgement and rationale for modifying actions according to specific situation. However, the education has often emphasized proven methods for responding to particular kinds of situations e.g. clients may be discharged without self care teaching because the doctor did not write an order. e) Specialized education: Nursing transmits knowledge through specialized education. However, there are five levels of basic education for registered nurses, all of which prepare for one licensure examination. Three of five levels (diploma, associate degree and baccalaureate degree) accept high school graduation where as other two (masters degree and doctoral degree) accept college with liberal arts majors. f) Critical and Creative Thinking: A logical and critical thinking process is one essential component of professional practice. The nursing process is a problem solving approach. It includes: Collect and organize information derived from multiple sources. Decide what is needed, based on that information. Select and implement one approach from among many possible approaches. Evaluate the results of the process. Personal: This category emphasizes on autonomy. Autonomy means the practitioners have control over their own functions in a work setting. Autonomy involves independence, a willingness to take risks and responsibility and accountability for ones own actions as well as self-determination and self-regulation. The autonomous practitioners are also obligated to collaborate with others for the benefit of the patient. Interpersonal: Nursing is a significant therapeutic interpersonal process. It functions cooperatively with other human processes that make health possible for individuals in the communities. The nurse collaborates with the patient, significant others and health care providers in the formulation of overall goals and plan of care and in the decisions related to care and deliver of services. CRITERIA OF PROFESSION: Bixler and Bixler Criteria for Profession: Genevieve and Roy Bixler who were against the status of Nursing as a Profession 1945, appraised nursing according to their original seven criteria as follows: A profession utilizes in its practice a well defined and well organized body of knowledge, which is on the intellectual level of the higher training. 1. A profession constantly enlarges the body of knowledge its uses and improves its techniques of education and service by the use of the scientific method. 2. A profession entrusts the education of its practitioners to institutions of higher education. 3. A profession applies its body of knowledge in practical service, which is vital to human beings and social welfare. 4. A profession functions autonomously in the formulation of professional policy and in control of professional activities there by.

5. 6.

A profession attracts individuals of intellectual and personal qualities who exalt service above personal gain and who can recognize their chosen profession as life long. A profession strives to compensate its practitioners by providing freedom of action, opportunity for continuous professional growth and economic security. After examining all the criteria of profession and other related concepts and aspects world health organization has already recognized Nursing as a Profession.

PRESPECTIVE OF NURSING PROFESSION: At National Level: During the Post Independence period there has been enormous change and development in the field of medicine, medical technology, health care and nursing. Some vital recommendations to the Bohre Committee relevant to nursing profession are given below: 1. Stipends to the nursing students: In order to prevent economic barriers in the way of suitable persons entering the nursing profession, the committee suggested the provision of Rs.60 per month for pupil nurses. 2. Nurses, Midwives and Dais: The committee suggested that by 1971, the number of trained nurses available in country should be raised to 7,40,000. As essential step towards the achievement of this objective was the removal of the existing unsatisfactory conditions of training and service. The committee made proposals to improve the situations. 3. Training of Nurses and Midwives: In view of the extreme shortage of nursing personnel the committee recommended that the first group of 100 training centers, each taking 50 pupils ,should be started two years before the Health Organization began to be established, that another set of 100 training centres should be created during the first two years of the schemes and that a third group of the same number of training centres should be established before the third year of the second quinquennium. 4. Male Nurses: Male nurses should be trained and employed in large numbers in the Male wards and Male Out Patient Departments of Public hospitals, thus releasing women workers for other work. 5. Public Health Nurses: The committee also made specific proposals with regard to the training of Public Health Nurses. These should be fully qualified nurses with training in midwifery as well. 6. Midwives: The number of midwives actually available for midwifery duties in the country was probably 5000.The committee laid down certain fundamental requirements which should be met before an institution could be organized as a training centre for Midwives. 7. Dais: The continued employment of women as dais was inevitable. The committee advocated the training of dais as an in trim measure until an adequate number of midwives would become available. 8. Nursing Staff: The report recommended to produce another category of Nursing Health Personnel called 9. Auxiliary Personnel. Auxiliary Nurse Midwife training was started to meet the health needs of the country. of Indian Nursing Council: As a result of Bohre Committee recommendations, Indian Nursing Council was established in 1947 to regulate the standards of Nursing Education. Nursing Council made three important decisions: a) There should be only two standards of training of General Nursing and Midwifery: i. The full course of General nursing to be for three years followed by a minimum of nine months of midwifery. ii. A course of Auxiliary Nurse Midwife for two years. b) The minimum entrance requirement of General Nursing Course to be Matriculation and for Auxiliary Nurse Midwife to be 7th or 8th standard of education. c) The Auxiliary Nurse Midwife Course to replace various courses like Junior Grade Nursing Certificate and courses other than for nurses.

DEVELOPMENT OF NURSING EDUCATION IN INDIA: The Auxiliary Nurse Midwife/ General Nurse Midwife Programme: a) The Indian Nursing Council at its meeting in 1950 came out with some important decisions relating to future patterns of Nursing Training in India. One of the important decision was that there should be two standards of training of Nursing and Midwifery: A full course of 3 yrs in Nursing and minimum of 6 months of Midwifery. A course of Auxiliary Nurse Midwives of 2 yrs which would replace various courses for Junior Grade Certificate. The first course of A.N.M was started at St.Marys Hospital Taran Taran, Punjab in 1951.Initially a very few training centres undertook to give this course but the financial aid was given by Govt. Of India under the scheme for preparing personnel for Primary Health Centres gave a great impetus to the training program. The entrance qualification was raised from 7th class passed to matriculation. UNIVERSITY LEVEL PROGRAMMES: Basic B.Sc Nursing: The need for providing basic training in nursing at University Level was felt by the members of TNAI from 1940 onwards. B.Sc Nursing (Hons.) was started at Delhi in July 1946 in School Of Hospital Administration which was started in 1943.This school was renamed as College Of Nursing which is now called Rajkumari Amrit Kaur College OF Nursing in1972.This college is located at Lajpat Nagar, New Delhi. A similar course in B.Sc Nursing was started at CMC Vellore, Madras University, Tamil Nadu in 1946 by the Joint Church Society of England, U.S.A and Canada. Post Basic/ Post Certificate B.Sc Nursing: The need for higher training for certificate nurses was also stressed by the Mudaliar Committee in 1962.For up gradation of professional standard, two year Post Basic Certificate B.Sc Degree Programme for nurses with Diploma in General Nursing and Midwifery was started in Dec.1962 by the School of Nursing, University of Thiruvananthpuram. POST-GRADUATION EDUCATION: M.Sc Nursing Education: Two year course in Master of Nursing was started at Rajkumari Amrit Kaur College of Nursing, New Delhi in 1959.In 1969, M.SC Nursing was started at CMC, Vellore affiliated to Madras University. The M.Sc Nursing Curriculum was prepared and prescribed by Indian Nursing Council in 1986 which is implemented by all the colleges. M.Sc in Psychiatric Nursing was also started in Sept. 1983 at NIMHANS, Bangalore. This college is affiliated to Bangalore University. M.Phil Programme: The inspection committee constituted by INC under statute 30(4) for the inspection of the college, visited RAK College of Nursing, New Delhi on September 13, 1977 and advised the principal to form an M.Phil committee to assess all the requirements for the said Programme. But due o some administrative reasons the M.Phil Programme could be started only on Oct.15, 1986 after due approval of the M.Phil Committee members. The Programme is of 1 yr for regular candidates and 2 yr for part time candidates. Ph.D Programme: Ph.D Programme was started in few colleges of nursing like College of Nursing PGI, Co llege Of Nursing CMC Vellore, College Of Nursing Affiliated to Mangalore University and at RAK College of Nursing, Delhi University etc. from 1990 onwards. Ph.D Programme in Psychiatric Nursing is also there in NIMHANS, Bangalore, for their own faculty. AT GLOBAL LEVEL: Introduction: There are various educational routes for becoming a Professional Registered Nurse. Initially hospital Schools of nursing were developed to educate nurses to work within those institutions.

Associate Degree Education: The associate degree program in the United States is a 2 yr program that is usually offered by a University or Junior College. This program focuses on the basic sciences, theoretical and clinical courses related to the practice of nursing. Diploma Education: The diploma program in the United States is a 2-3 yr hospital based program. Diploma programs focus on the basic sciences and on theoretical and clinical courses related to nursing practice, usually with a substantial clinical component. In U.S, diploma programs are declining in numbers. In Canada, diploma programs are offered in community colleges or hospitals and are 2 yr programs. Baccalaureate Education: The baccalaureate degree program usually encompasses 4 yr of study in a college or university. The program focuses on basic sciences and on theoretical and clinical courses, as well as courses in social sciences, arts and humanities to support nursing theory. In Canada, the degree of Bachelor of sciences in Nursing (B.Sc nursing) or Bachelor in Nursing (BN) is equivalent to the degree of Bachelor of Sciences un Nursing (BSN) in the United States. RN completion programs are available at many colleges and universities. These programs are designed to assist the practicing RN in obtaining a baccalaureate degree in Nursing. Accreditation: To be accredited, nursing programs must meet certain criteria established by the National League for Nursing Accrediting (NLNAC).This voluntary accreditation is available for basic nursing education programs and masters degree programs in nursing. Licensure: In the U.S, RN candidates must pass the National Council Licensure Examination For Registered Nurses (NCLEX-RN), which is administered by the individual State Board Of Nursing. Regardless of educational preparation, the examination for RN licensure is exactly the same in every state in United States. Certification: Beyond the NELEX-RN, National Nursing Organizations such as ANA, have many types of certification that the nurse can work toward. After passing the initial examination, the nurse maintains certification by ongoing continuing education and clinical or administrative practice. Masters Degree Preparation: A person completing a graduate program can receive the degree of Masters in Arts (MA) in Nursing or Masters in Science in Nursing. This provides the advanced clinician with strong skills in nursing sciences and research based clinical practice. A Masters degree in nursing can be valuable for nurses seeking roles of nursing educator, clinical nurse specialist, nurse administrator or nurse practitioners. Doctoral Preparation: The first nursing doctorate program was opened in 1953 at University of Pittsburgh. Other programs emphasized on basic research and theory and award the degree of Doctor Of philosophy (Ph.D). Continuing and In-service Education: Continuing education involves formal, organized and educational programs preferred by state Nurses Associations and Educational and Health Care Institutions. Other goals include helping nurses become specialized in a particular area of practice and teaching nurses new skills and techniques. Licensed Practical Nurse Education: A licensed practical or vocational nurse is trained in basic nursing techniques and direct client care. The Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) practices under the supervision of a Registered Nurse (RN) in a hospital or community health practice settings. ETHICS Introduction Ethics includes personal behaviors and issues of character e.g. kindness, tolerance and generosity. Ethic is derived from the word ETHOS ethos as defined by Bernad Harding compromises distinction attitudes, which characterize the cultural outlook of professional group.

Ethics are the distinction between right and wrong based on a body of knowledge, not just based on opinions. Ethics in nursing is set of moral codes of professional behaviors towards holistic care. The ethical code is a set of guidelines formulated by the members of profession with the help of specialists in the field of nursing leaders, advocate\lawyers at times members from the society. Purposes of code of ethics in nursing Standards for the behaviors of nurse and provide general guidelines for nursing action in ethical dilemmas. The code helps to distinguish between right and wrong at a given time especially when alternatives appear just as satisfactory. The code enables a correct decision and a uniform decision with in the groups. Helps to protect rights of individuals, families and community and also the right of the nurse.

Uses of code of ethics Acknowledge the rightful place of individual in health care delivery system. Constitutes towards empowerment of individual to become responsible for their health and wellbeing. Contributes to quality care. Identifies obligations in practice, research and relationships. Inform the individual, families, community and other professionals about expectation of nurse. Ethical principles 1. Ethical principles of respect and autonomy : Respect for a person involves:- level of understand of another person or empathy and reducing exploitation. Autonomy: - persons independence, self determining action allow the patient to make decision 2. Principle of beneficence:Activity seeking benefits, promotion of good. The duty to do balance between benefits and harms, Paternalism is an undesirable outcome of beneficence, in which the he alth care provider decides what is best for the client and attempt to encourage the clients to act against his or her own choices. 3. Principle of justice and families:Basic principle is that each person has equal right to the liberty available to everyone. 4. Principle of veracity:- The obligation to tell the truth. 5. Principle of fidelity:- The duty to do what one has promised. Ethical dilemma An ethical dilemma occurs when there is conflict between two or more ethical principles. No correct decision exists. The nurse must make a choice between two alternatives that are equally unsatisfactory. Such dilemmas may occur a result of differences in cultural or religious beliefs. Ethical reasoning is the process of thinking through what one ought to do in an orderly and systematic manner to provide justification for actions based on principles.

CODE OF ETHICS FOR NURSES IN INDIA 1. The nurse respects the uniqueness of individual in provision of care. Nurse: Provides care for individual without consideration of caste, creed, religion, culture, ethnicity, gender, socioeconomic and political status, personal attributes, or any other grounds. Individualize the care considering the beliefs, values and cultural sensitivity. Appreciates the place of individualize in the family and community and facilities participation of significant others in the care. Develop and promotes trustful relationship with individuals. Recognizes uniqueness to response of individuals to interventions and adapts accordingly. 2. 3. 4. 5. The nurse respects the rights of individuals as partners in care and help in making informed choices. Nurse:Appreciates individuals right to make decisions about their care and therefore gives adequate and accurate information for enabling them to make informed choices. Respects the decisions made by individuals regarding their care. Protects the public from misinformation and misinterpretations. Advocates special provisions to protect vulnerable individuals/groups. The nurse respects individuals right to privacy maintains confidentiality and shares information judiciously. Nurse:Respects the individuals right to privacy of their personal information. Maintains confidentiality of privileged information except in life threatening situations an uses discretions in sharing information. Takes informed consent and maintains anonymity when information is required for quality assurance/academic/legal reasons. Limits the access computerized to authorize persons only. Nursing maintains competence in order to render quality nursing care. Nursing care must be provided only by registered nurse. Nurse strives to maintain quality nursing care and upholds the standard of care. Nurse values containing education initiates and utilize all opportunities for self development. Nurse values research adhering to ethical principles. The nurse is obliged to practice within framework of ethical professional legal boundaries. Nurse:Adheres to code of ethics an code of professional conduct for nurses in India developed by Indian nursing council. Familiarizes with relevant laws and practices in accordance with the law of the state.

6. Nurse obliged to work harmoniously with members of the health team. Appreciates the team efforts in rendering care. Cooperates, coordinates and collaborates with members of the health team to meet the needs of people.

7. Nurse combines to reciprocate the trust invested in nursing profession by society. Nurse: Demonstrate personal etiquettes in all dealings. Demonstrate professional attributed in all dealings. CODES OF PROFESSIONAL CONDUCT FOR NURSES 1 . Professional responsibility and accountability Nurse: Appreciates sense of self worth and nurtures it. Maintains standards of personal conduct reflecting credit upon the profession. Carries out responsibilities within the framework of the professional boundaries. Is accountable for maintaining practice standards set by Indian Nursing Council. Is accountable for own decisions and actions. Is compassionate Is responsible for continuous improvement of current practices. Provides adequate information to individuals that allow then informed choices. Practices healthful behaviors. 2. Nursing practice Nurse: Provides care in accordance with set standards of practice. Respect individuals and families in the context of traditional and cultural practices promoting healthy practices and discouraging harmful practices. Treat all individuals and families with human dignity in providing physical, psychological, emotional, social and spiritual aspects of care. Promotes participation of individuals and significant others in the care Ensures safe practice Consult, coordinates, collaborates and follows up appropriately when individuals care needs exceed the nurses competence. 3 . Communication and interpersonal relationship Nurse: Establish and maintains effective interpersonal relationships with individuals, families and communities. Upholds the dignity of team members and maintains effective interpersonal relationship with them. Appreciates and nurtures professional role of team members. Cooperates with other health professionals to meet the needs of the individuals, families and communities. 4. Valuing human being Nurse: Takes appropriate action to protect individuals from harmful unethical practice. Consider relevant facts while taking conscience decisions in the best interest of individuals Encourages and supports individuals in their right to speak for themselves on issues affecting their health and welfare. Respects and supports choices made by individuals. 5 . Management Nurse: Ensures appropriate allocation and utilization of available resources.

Participates in supervision and education of students and other formal care providers Uses judgment in relation to individual competence while accepting and delegating responsibility. Facilitates conductive work culture in order to achieve institutional objective. Communicates effectively following appropriate channels of communication. Participates in evaluation of nursing services. Participates in policy decisions, following the principle of equity and accessibility of services. Participates in performance appraisal. Works with individuals to identify their needs and sensitizes policy makes and funding agencies for resources allocation. . Professional advancement. Nurse:Ensures the protection of the human rights while pursuing the advancement of knowledge. Contributes to the development of nursing practice. Participates in determining for upholding own knowledge an competencies Contributes to care professional knowledge by conducting and participating in research.

AUTONOMY Introduction Autonomy means that individuals are able to act for themselves to the level of their capacity. It is the right of individuals, governing their actions according to their own purpose and reason. Professional nurse autonomy is defined as belief in the centrality of the client when making responsible discretionary decisions, both independently and interdependently, that reflect advocacy for the client. Critical attributes include caring, affiliative relationships with clients, responsible discretionary decision making, collegial interdependence, and proactive advocacy for clients. Antecedents include educational and personal qualities that promote professional nurse autonomy. Accountability is the primary consequence of professional nurse autonomy. Associated feelings of empowerment link work autonomy and professional autonomy and lead to job satisfaction, commitment to the profession, and the professionalization of nursing. A student-centered, process-orientated curricular design provides an environment for learning professional nurse autonomy. To support the development of professional nurse autonomy, the curriculum must emphasize knowledge development, understanding, and clinical decision making. Respect for autonomy requires that a person honors anothers right to govern himself or herself. The legal doctrine of informed consent for treatment and for participation in research. The following are required for a patient to give informed consent: Disclosure adequate presentation of relevant information about the proposed treatment or study. Understanding adequate comprehension of the disclosed information. Voluntary agreement free assent, uninfluenced by external controlling factors. Competence adequate decision-making capacity. The principle of autonomy may be difficult to apply in patient care when there is strong conviction on the part of the nurse or other members of health care team that respecting self-determined choice is not really in the best interest of the patient. In this type of situation, the nurse may need to consider limits of individual patient autonomy and the criteria for justified paternalism on the part of the nurse. Paternalism is defined as the overriding of patient choices or intentional actions in order to benefits to the patient. Although paternalism is seldom justified in the care of patients, there is reason to believe that some situations warrant overriding patient autonomy.

When the benefits to be realized are great and the harms that will be avoided are significant (childress, 1982). ACCOUNTABILITY Introduction Accountability is the process that mandates that individuals are answerable for their actions and have an obligation to act. Accountability involves assuming only the responsibility that are within ones scope of practice and not assuming responsibility for activities in which competences has not been achieved. Accountability involves admitting mistakes rather than blaming others and evaluating the outcomes of ones own actions. Accountability includes a responsibility to the client to be competent to render nursing services in accordance with standards of nursing practice and to adhere to the professional ethics code. The concepts of Accountability have two major attributes: - answerability and responsibility. Accountability can be defined in terms of either of these attributes but answerability for how one has promoted, protected and met the health needs of the client. It means to justify or to give an account according to accepted moral standards or norms for choices and actions that the nurse has made and carried out. It involves a relationship between the nurse and other parties and its contractual. The terms of legal accountability are contained in licensing procedures and state nurses practice acts. The terms moral accountability are contained in the ANA code for nurse and other standards of nursing practice in the form of norms set by members of the profession. It is noted that accountability means providing an explanation or rationale for what has been done in nursing role. Accountability of nursing personnel Nursing personnel are accountable for: Providing safe and therapeutic environment for the patients. Delivering component and personalized care. Maintaining adequate supplies of material and equipment for smooth functioning of the ward/unit. Maintaining accurate and upto date records and reports. Maintaining good interpersonal relationships. Protecting clients legal rights and privacy. Working within ethical and legal boundaries. Keeping pace with changing health needs and developing technology. Delivering care as per standards laid down by profession, statutory body and institution. Delegating responsibility appropriately. Contributing to development of the profession.

ASSERTIVENESS Introduction Assertiveness is a tool for expressing ourselves confidently and a way of saying yes and no in an appropriate way. It is considered as health behavior for all people against personal powerlessness and results in personal empowerment. Nursing has determined that assertive behavior among its practioners is an invaluable component for successful professional practice.

Assertiveness is a style of behavior to interact with people while standing up for your rights. Assertive manner certainly means that well feel more empowered and more in control of circumstances. However, it is definitely not a strategy to get our own way more frequently. Assertiveness offers many benefits: We create health, meaningful relationship. There is less friction and conflicts. There is increased self respect as well as respect from others. Our self esteem is enhanced and we always feel in control. Our productivity at work and the home increases. Theres less stress at work and overall sense of well being. In expressing ourselves appropriately, we neednt hold grudges, or store pent up emotions. Our emotional and physical health improves. As nurse work in different situations they have to be assertive in order to meet the challenges and to win the cooperation from others. LEGAL ASPECTS IN NURSING Introduction A knowledge of legal aspects in nursing is absolutely essential for each nurse to safeguard self and clients from legal complications. Consumers are each becoming increasingly aware of their legal rights in the health care. It is essential; therefore, a nurse should know her legal rights and professional boundaries, and their consequences of nonconformity. Members of public may become victim of violence unintentionally even by the gentle hands of nurse or by the tender touch of a surgeon or a physician. As a nurse it has become an important necessity to be aware of the legal aspects associated with caring and helping people in the health industry today. Nursing legislation The first nursing law created was that of nursing registration in 1903 and they have only evolved and expanded over the years to create a thick book which must be studied today by aspiring nurses. Laws and regulations as they affect nurse in India are controlled by state legislation, as state registration acts and a central act, the Indian nursing council act, which was enacted in 1947; and amended in 1957 The legal aspects of nursing are taught and expected to be kept up on throughout every nurse's career. Employment as a nurse does not only require a nursing degree but knowledge of the medical laws that will apply to you should there is a misunderstanding or challenge by a patient or their family. A nursing job is something many young people aspire to but without the legal knowledge behind them, many hospitals will not hire them now that legal issues are becoming more and more problematic. Legal implications are as follows: Torts Assault Battery Negligence Malpractice Fraud False imprisonment Invasion of privacy Legal documents Informed consent Torts: torts are when others interfere in individuals privacy, mobility, property or personal interests.

Assault: Assault occurs when a person puts another person in fear of a harmful or offensive contact. The victim fears and believes that harm will result as a result of the threat. Battery: it is an intentional touching of anothers body without the others consent. Negligence: it is conduct that falls below the standard of care that a reasonable person ordinarily would use in a similar circumstances or it is described as lack of proper care and attention carelessness. Malpractice: failure to meet the standards of acceptable care which results in harm to another person, Fraud: it results from a deliberate deception intended to produce unlawful gains. False imprisonment: it occurs when a client is not allowed to leave a health care facility when there is no legal justification to detain the client or when restraining devices are used without an appropriate clinical need. Invasion of privacy: it includes violating confidentiality intruding on private client or family matters, and sharing client information with unauthorized persons. Legal documents: it comprised: a) Advance directive: written document recognized by law that provides directions concerning the provision of care when a person is unable to make his or her own treatment choices. b) Do not resuscitate orders: written order by a physician when a client has indicated a desire to be allowed to die if the client stops breathing or the clients heart stops beating. Informed consent: it is clients approval [or that of the clients legal representative] to have his or her body touched by a specific individual. NURSING LIABILITIES AND PREVENT MEASURES In order to protect you from malpractice suits, nurses must take as many precautions as they can during their daily shifts. Recording, documenting and reporting your daily routines and decisions is one of the most common ways to make sure you are on track with your patience and in the right. All nursing observations should be noted carefully, describing accurately not only any typical or erratic changes in the patients conditions, but also any lack of cooperation, or any other behavioral problems. Patients complains should be recorded as accurately and specifically as time and space on the chart would permit some complaints often provide a clue to the cause of an accident that might otherwise would have been difficult to explain. Nurse must report through proper channels, any activity or lack of it, by any subordinates which indicates that they are not properly trained to carry out the assigned functions and duties, Authorities must be informed regarding any kind of equipment, materials or supplies, which for any reasons less than safe for use in the patients care. An alert nurse will always be aware of the fact that accidents can and will inevitably occur. Insurance protection: there is a moral and practical necessity for a nurse to purchase good liability coverage. Legal responsibility Legal responsibility in nursing means to practice nursing within the guidelines laid down by the law of centre/state, statutory bodies and institutional polices. The main responsibility of nurses is to provide care based on nursing diagnosis, prioritizing the needs; planning, implementation and evaluating the nursing care. Nurse provides care to the patient based on needs, respect, dignity, and right without considering race, nationality, caste, creed, color or socio economic status. There are certain determinants of legal framework for nursing practice in India: -

INDIAN NURSING COUNCIL ACT Norms Code of ethics and professional conduct STATE NURSING COUNCIL ACT

Central/state government acts Norms Standing orders

Legal framework for nursing practice

Institutional policies, rules, regulations, standing orders

Precedents

1.

Registration Licensing is a mandatory procedure for practice of nursing. Registration aims at protecting patients by providing qualified nurses. The nurse is responsible to obtain registration in the respective State Nursing Registration Council. Employers should recruit only as per the State Nursing Home Act. 2. Legal Liability/Act Of Negligence License of a nurse can be suspended or cancelled for any act of negligence or mal practice, following a specified procedure.

Legal liability/ act of negligence

Criminal (IPC)

Civil

Under section 304 of Indian penal code (IPC) E.g. wrong medication leading to death of patient

Tort in civil court (Negligence e.g. not giving railing bed to conscious patient causing fall of patient)

3.

1. 2. 3. 4. 5. 6. 7. 8.

Medico Legal case (M.L.C.): A medical legal case is a patient who is admitted to the hospital with some unnatural pathology and has to be taken care of in concurrence with the police and/or court. Types of clients which are categorized as MLC in a hospital are: Road traffic accidents Injuries inflicted during brawls/fights, shooting, bomb blasts etc. Suicide Burns Poisoning Rape victim Assault Nurses role in a medico-legal case Obtain complete history from patient or significant other(s) Inform the police officer/constable on duty in the hospital and the CMO. When it is made a MLC. Then record it on the patients case sheet with red ink at right hand top corner. Do not give any statement about patients condition to police, magistrate or media. Only a doctor has to give information. When a patient has to be discharged, inform the CMO. After clearance from them, then only he/she can be discharged. If a MLC patient absconds inform the CMO immediately and the treating doctor. No patient can leave against medical advice. Documentation the care given to patients timely, accurately and duly sign the nurses notes. Records and all the documents pertaining to patient should be handled with care, during the stay in the hospital. They must be kept safely and should be handed over to the authorized person as designated by the hospital authority.

9. 10.

4.

Incase death of a MLC, the body is not to be handed over to the relatives. It needs to be accurately labeled and sent to the mortuary CMO and/ or police officer should be informed simultaneously. Appropriately authority must be informed. Correct identity A nurse/midwife is responsible to make sure that all babies born in hospital are correctly labeled at birth and handed over to right parent. Unknown/unconscious patients must be labeled as soon as their identity is known. Patients who have to undergo surgery should be appropriately identified and labeled Site of operation to be correctly marked particularly where symmetrical sides or organs there. Operation theatre (O.T.): scrub nurse has to see all the instruments/ swabs are returned. She has to say OKAY before closure by the surgeon.

5.

Left Against Medical Advice (L.A.M.A.) Inform medical officer incharge. Signatures of both patients and witness to be taken as per institutional policy. 6. Patients Property Inform patient on admission that hospital does not take responsibility of his belonging. If patient is unconscious/ or otherwise required then a list of items must be made, counter checked by two staff nurses and kept under safe custody. 7. Dying Declaration: Doctor or nurse should not involve themselves in dying declaration, in case where police records the dying declaration. Dying declaration is to be recorded by the magistrate. But if condition of patient becomes serious then medical officer can record it along with two nurses as witness. Dying Declaration can be recorded by the nursing staff with two nurses as witness when medical officer is not present. Then the declaration to be sent immediately under sealed cover to the magistrate. 8. Wills: For this doctor has to be present for he can recode if requested. 9. Examination of rape case: Female attendant/female nurse must be present during the examination. 10. Artificial human insemination:

11.

Written consent should be obtained from both donor and recipient. Donor and recipient must have the same blood group. Donors and recipients identity should be kept confidential. All related documents should be kept confidential and safe. Poison case: Do not give either verbal or written opinion. Do not allow to take photos unless special permission is granted by appropriate authority. Do not give any information to public or press. Preserve all evidence of poisoning. Collect and preserve all excreta, vomitus and aspirates, seal them immediately and send to forensic laboratory at the earliest

Consumer Protection Act(1986) Consumer protection act was passed by parliament in 1986 to provide for better protection of the interest of consumers and focuses on consumer justice through the establishment of consumers councils and authorities for the settlement of consumers disputes and matters connected therewith. The scope of the Act is wide enough to include a vast variety of services. Rights of a consumer/ patient are:

Right of consumer education. Nurses role to prevent complications 1. Review nursing practice periodically. Update knowledge and improve skill by attending short term courses, in-service education and continuing education programmes. 2. Should have complete knowledge of all rules and regulations of hospital and know their descriptions (duties and responsibilities). 3. Follow nursing practice standards/protocols. 4. Be a keen observer. 5. Written instructions must have rules and code of practice laid down to ensure the safety and well being of patients and nurses. 6. All hospitals must have rules an code of practice laid down ensure the safety and well being of patients and nurses. 7. Maintain records and reports of the unit properly. 8. Follow 6 Rs right patient, right drug, right time and right route with right technique. 9. Check the treatment order and use professional judgment before implementing. 10. Do not exceed the limits of nursing procedure laid down by statutory bodies. Conclusion: Every nurse should act as per the legal guidelines for nursing practice while caring for patients since negligence may cause a great distress to nurse, the patient and others, as well as to reputation of the institution. Every individual is ordinarily liable for their own negligence. Therefore nurse have a responsibility of seeing that no harm comes to their patients and also to themselves. ROLE OF REGULATORY BODIES AND PROFESSIONAL ORGANISATIONS ORGANIZATION According to L. White, "Organization is the arrangement of personnel for facilitating the accomplishment of some agreed purpose though alloca tion of functions and responsibilities."

Right to safety. Right be informed. Right to choose. Right to be heard. Right to seek redressal.

PROFESSIONAL ORGANISATION Professional organization provides a mean through which your own professional development can be channeled with authorit y because of their representative character. It provides you an opportunit y to express your viewpoints, develop your leadership qualities and abilities and keep you well informed of professional trends and news. All qualified nurses must participate in their professional state and national organisations to keep themselves informed of new developments and for upgrading the profession. Some of the organisation discussed below are recognized at national and international level and have a great role in uplifting the nursing profession. INDIAN NURSING COUNCIL INC The Indian Nursing Council is a statutory body constituted under the Indian Nursing Council Act, 1947. It was established in 1949. The council is responsible for regulation and Maintenance of a uniform standard of training for nurses, Midwives, Auxiliary Nurses Midwives and Health visitors. Indian Nursing Council Act, 1947 Indian Nursing Council Act, 1947, provides for constitution and composition of the Council consisting of the following: 1. 2. a. b. 3. 4. 5. 6. 7. One nurse enrolled in a state register elected by each State Council; Two members elected from among themselves by the heads of institutions recognised by the Council for the purpose of this clause in which training is given: For obtaining a University degree in Nursing; or In respect of a post-certificate course in teaching of nursing and in nursing administration; One member elected from among themselves by the heads of institutions in which health visitors are trained; One member elected by the Medical Council of India. One member elected by the Central Council of the Indian Medical Association. One member elected by the Council of the Trained Nurses Association of India. One midwife or auxiliary nurse -midwife enrolled in a State Register, elected by each of the State Councils in t he four groups of State mentioned below, each group of States being taken in rotation in the following order namel y: Kerala, Madhya Pradesh, Uttar Pradesh and Haryana. Andhra Pradesh, Bihar, Maharashtra and Rajasthan. Karnataka, Punjab and West Bengal. Assam, Gujarat, Tamil Nadu and Orissa The Director General of Health Services, ex -officio; The Chief Principal Matron, Medical Directorate, Arm y Headquarters. The Chief Nursing Superintendent, Office of the Director General of Health Services. The Directo r of Maternit y and Child Welfare, Indian Red Cross Societ y. The Chief Administrative Medical Officer (by whatever name called) of each State other than a Union Territory.
22

a. b. c. d. 8. 9. 10. 11. 12.

13. Four members nominated by the Central Government, of whom at least two shall be nurses, midwives or health visitors enrolled in a State register and one shall be an experienced educationalist. AMENDMENTS IN I.N.C. ACT 1947 The Act was amended in November 1957 to provide for the following things: 1. Foreign Qualification a) A citizen of India holding a qualification which entitles him or her to be registered with any registering body may, by the approval of the council, be enrolled in any state register. A person not being citizen of India, who is employed as a Nurse, Midwif e, ANM, Teacher or Administrator in any hospital or institution in any state, by the approval of President of Council, be enrolled temporaril y in state register. In such cases foreign qualifications are recognized temporaril y for a period of 5 years. If on e continues to practice in India, an extension of recognition should be sort from INC. Indian Nurses Register The council shall cause to be maintained in the prescribed manner a Register of Nurses, midwives, ANM & Health visitors to be known as the Indi an Nurses Register, which shall contain the names of all persons who are for the time being enrolled on any state register. Such register shall be deemed to be a public document within the meaning of the Indian Evidence Act, 1872.

b)

2. a)

b)

ORGANISATION CHART

COMMITTEES 1. Executive Committee of the Council to deliberate on the issues related to maintenance of standards of nursing programs
23

2.

3.

4.

The Nursing Education Committee - The committee is constituted to deliberate on the issues concerned mainl y with nursing education and policy matters concerning the nursing education. Equivalence Committee to deliberate on the issues of recognition of f oreign qualifications which is essential for the purpose of registration of the Indian Nursing Council Act, 1947, as amended. Finance Committee - This is another important Sub -Committee of the Council which decides upon the matters pertaining to finance of the Council in terms of budget, expenditure, implementation of Central Govt. orders with respect to service conditions etc.

FUNCTIONS To establish and monitor a uniform standard of nursing education for nurses, midwives, auxiliary nurse Midwives and heal th visitors by doing inspections of the institutions. To recognize the qualifications for the purpose of registration and employment in India and abroad. To give approval for registration of Indian and Foreign nurses possessing foreign qualification. To proscribe the syllabus and regulation for nursing programme. Power to withdraw the recognition of qualification standards, that an institution recognized by a state council for the training of nurses, midwives, auxiliary nurse midwives or health visitors does not satisfy the requirements of council. To advise the state Nursing Councils, examination board, state government and central government in various important items regarding nursing education in country. Guidelines for establishment of new nursing School/College in India Approved by INC 1. Any organization und er the central Government, State Government, Local body or a Private or Public Trust, Mission, Voluntaril y registered under societ y Registration Act wishes to open a school of nursing should obtain the no objection /Essentialit y certificate from the state Government. 2. The Indian Nursing Council on receipt of the proposal from the institution to start nursing programme, will undertake the first inspection to assess suitabilit y with regard to Physical Infrastructure, clinical facilit y and teaching facult y in order to give permission to start the programme. 3. After the receipt of the permission to start the Nursing programme from INC, the institution shall obtain that approval from the State Nursing Council and examination Board. 4. Institution will admit the stud ents onl y after taking approval of state nursing council and examination board. 5. The INC will conduct inspection every year till the first batch completes the programme. Permission will be given year by year till the first batch completes.

24

TYPE OF INSPE CTION 1. First Inspection: The first inspection is conducted on receipt of the proposal received from the institute to start any Nursing programme prescribed by INC. 2. Re-Inspection: Re-inspections are conducted for those institutions, which are found unsuitable by INC. The institution and the government are informed about the deficiencies and advised to improve upon them. Once the institution takes necessary steps to rectify the deficiencies, institution should submit the compliance report with documentary proof of the deficiencies pointed out and re -inspection fees. On receipt of the compliance report and fees from the institution, it will be considered for re -inspection. Periodic Inspection: INC conducts peri odical ( after 3 years) inspection of the institution once the institution is found suitable by INC to moniter the nursing education standards and adherence of norm prescribed by INC. Institutions are required to pay annual affiliation fee every year. However, if the institution does not compl y to the norms prescribed by INC for teaching, clinical and physical facilit y, the institution will be declared unsuitable.

3.

PROGRAMMES UNDER I.N.C 1. 3. 4. 5. 6. 7. ANM 2. GNM Post Basic B.Sc. Nursing B.Sc. Nursing M.Sc. Nursing M.Phil Doctorate in Nursing

RESOLUTIONS I. Maximum period for students to complete revised ANM and GNM course is 3 and 6 years respectivel y. II. INC resolved that maximum age for teaching facult y is 70 years subject to the condition that he/she should be physicall y and mentall y fit. III. Admission to married candidate for all the nursing programme allowed subject to the conditions that they should prod uce medical fitness certificate. IV. Relaxation of norms to establish MSc (N) programme: As per INC norm, only those institutions can start MSc programme where at least one batch of students has qualified BSc (N) programme. INC resolved apart from these instit utions the super specialt y hospitals can also open the MSc (N) programme. Even though the institution is not having BSC (N) programme.
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V.

Relaxation of student patient ratio for clinical practice: 1:3 student patient ratio instead of 1:5 student patient ratio . VI. Relaxation of teaching facult y qualification to start a BSC (N) programme. At least 2 MSC (N) qualified teaching facult y to be available to start BSC (N) programme for next 4 years in order to combat acute shortage of nursing and teachers till the positi on of MSC (N) qualified teaching facult y improves. VII. To maintain qualit y of post graduate in nursing, INC resolved not to have MSC (N) programme through distance education. VIII. Institution should have its own building within 2 years of establishments. IX. Maximum No. of 60 seats can be sanctioned to those institutions which are having less than 500 bedded hospital. And 100 seats can be sanctioned to those having 500 bedded hospitals. X. Registration of additional qualificat . INITIATIVES BY I.N.C. 1. Teaching material for Qualit y Assurance Model(QAM) prepared QAM in nursing is the set of elements that are related to each other and comprise of planning for quality, development of objectives setting and activel y communicating standards, developing indica tors, setting thresholds, collecting data to monitor compliance with set standards for nursing practice and appl ying solutions to improve care INC has developed a Qualit y assurance programme for nurses in India. The project was implemented in 2 hos pitals in New Delhi and PGI, Chandigarh for 3 months duration. The impact of QAM model adopted in Chandigarh can be seen in the paper cutting which was published in Tribune on April 19th, 2004 2. Princes Srinagarindra award Mrs. Sulochana Krishnan , Ex- Principal of RAK College of nursing was awarded Princes Srinagarindra, Thailand, award which is an international award to individual(s) registered nurse(s) in honor of princess Srinagarindra, her royal highness and in recognition of her exemplary contribution towards progress and advancement in the filed of nursing and social services Mrs. Sulochana Krishnan name was proposed by INC from India. Development of Curriculum for HIV/AIDS and training for nurses Indian Nursing Council in colla boration with NACO and Clinton foundation is developing a curriculum for training of nurses in HIV/AIDS areas. It will be a 6 day training programme. The pilot study was conducted in Mumbai and Hyderabad. National Consortium for Ph.D. in Nursing cons tituted 6 study centres recognized under National consortium for Ph.D in nursing. MOU has been signed between INC, WHO and RGUHS National consortium for Ph.D. in Nursing has been constituted by Indian Nursing Council (INC) in collaboration with Raj iv Gandhi Universit y of Health Sciences and W.H.O, under the Facult y of Nursing to promote doctoral education in various fields of Nursing. Applications for enrolment in PhD in nursing were invited from eligible candidates by advertising in the national
26

3.

4.

leading dailies from all over the country by the RGUHS. 125 appeared for the entrance test conducted on 07th January 2007. 5.MOU(Memorandum of Understanding) signed between INC and Sir Edward Dunlop Hospitals Ltd for advancing standards of nursing education and practices in India to meet challenges currentl y faced by Nursing. Memorandum of Understanding (MOU) is entered at New Delhi on 11th April 2006 between Indian Nursing Council and Sir Edward Dunlop Hospitals (I) Ltd. for developing the strategic framework for advance standards and investment plan for advancing standards of nursing education and practices in India with the following objectives. Provide training Graduate, Post -graduate, and PhD courses. Organizing Research Activities. To help fill gaps in India and internationall y benchmarked standards of nursing education and practice, including credentialing etc., so that Indian nurses can directl y be accepted to meet international standards. Train the facult y so as to provide high qualit y teaching staff to training institutes in the country. Steps taken up to enter into MRA under the Comprehensive Economic Cooperation Agreement (CECA) between India and Singapore which was signed in June 2005 and has come into force from 1st August 2005. In that, it has been agreed that India and Singapore would enter into mutual recognition agreements (MRAs) in Medical, dental and nursing services in the healthcare sector All State Registrars were invited to a ttend the two days meeting. TO objective was to ensure the uniformity and to maintain the qualit y of nursing education in the country. It was also aimed to understand the problem/issues of each state nursing council and evolve consensus between INC and SNRC. The Indian Nursing Council (INC) initiated the live register in the state of Tamil Nadu. The primary objective of the project is to conduct nurses census i.e., to collect the data regarding number of working nurses as defined by INC. INC decided to conduct the pilot study in the Sivaganga District of Tamil Nadu. 266 were found trained registered nurses out of 841 nurses.

1. 2. 3. 4.

5.

6.

7.

8.

STATE NURSING COUNCILS Registration in state nursing council is very necessary for every nurse. It is necessary to be registered in order to funct ion officially as a professional nurse. Registration councils are functioning in all the states of India and they are affiliated to I.N.C. A register of names of professional nurses is maintained by each state nurses Registration Council. These na mes are also put into the Indian Nurses Register maintained by the Indian Nursing Council. Nurses, midwives, auxiliary nurse midwives
27

and health visitors are registered. All degree holding nurses also have to get the registration in state council. The present functions of the State Nurses Registration Council are: Recognize officiall y and inspect schools of nursing in their states. Conduct examinations. 1. 2. Prescribe rules of conduct, take disciplinary actions, etc. Maintain registers of Graduate nurses, nurses holding degrees in nursing, midwives revised auxiliary nurse midwives or multi -purpose workers and health visitors. The State Nursing Council is an independent body. Though the State Nursing Council functions independentl y; it has to obtai n approval from state government for all the By Laws passed by it and decisions taken. The State Nursing Councils are administrativel y headed by the Registrar who usuall y is a nurse. There is deput y registrar who also is a nurse. There is a staff o ncsisting Accountant and other staff as clerks and peons to help him in his day to day work and functions. The President and Vice -President is elected by members from amongst themselves. The elections procedures for all the categories are laid down by statutory provisions in ByLaws of the Councils. Some of the members on the council are still nominated by the Government whereas majorit y is elected by following the electoral procedures. Functions of the Registrar of the State Nursing Counci l To draw a programme for examinations of various t ypes of educational programs at all centers at the same time. To prepare a time schedule for written and practical examinations, to prepare Roll number sheets of students and send them to various exa mination centers. After examiners have drawn the question papers, to get them printed under strict confidential atmosphere and keep up the secrecy regarding them. To prepare examination results and communicate the results to concerned institutions. To prepare the diploma certificates and registration certificates of nurses who have been qualified for both. To arrange for inspections to ascertain that the institutions are carrying out the educational programs as per syllabus, conditions and r ules and regulations lay down by State Council.

1. 2. 3. 4. 5. 6.

TRAINED NURSES ASSOCATION OF INDIA (TNAI) The T.N.A.I. is the national professional association of nurses. The association had its beginning in the association of nursing superintendents which was fo unded in 1905 at Lucknow. The organisation composed of 9 European Nurses holding administrative post in hospital. They saw the need to develop nursing as a profession and also do provide a forum where professional nurses meet and plan to achieve thes e ends. The first president was Miss Allen Martian. First Secretary: Miss Burn.
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Objectives: a. Uphold the dignit y and honor of nursing profession. b. Promote a sense of espirit de -corps among all the nurses. c. Enabling member to take counsel together on matters relating to their profession. The association of nursing superintendents therefor e sought the help and co operation of nurses through out the country. A decision was made in 1908 to establish a trained nurses association at the annual conference at Bombay and accordingl y association was inaugurated in 1909. These two organizations operated under the same leadership until 1910, when TNA elected its own officers. In 1922, the two organisations were brought together as the Trained Nurses Association of India. The aims of TNAI are similar to those of original organisation. These aims centre on the needs of the individual and the problems of the nursing profession as a whole. These aims include the following: 1. To standardize, upgrade, develop nursing education and to elevate nursing education. Development of various colleges of nursing in the different states of India is a result of this function of the national organization of nursing that is, the TNAI. Thus the TNAI has contributed greatl y to meet this aim. 2. To improve the living and working conditions of the nurses and also develop the educational conditions available for nursing. To improve the economic standards of the nurses in India. The state government in ever y state has been directed by TNAI to appoint a nurse as the nursing director. 3. To provide registration for qualified nurses and to provide reciprocit y of registration within different state in the country and within different countries. The TNAI has established the following organization The association has established the following organizations: a. Health visitor league (1922) b. Midwives and auxiliary nurses: Midwives Association (1925) c. Student Nurses Association (1929 -30) Membership: The membership consists of: Full Members: Full y qualified Registered Nurses Associate Members: Health visitors, midwives and A.N.Ms. Affiliate Members: Student nurses and members of the affiliated organizations e.g. Christian nurses league. Membership of TNAI is obtained by application and submission of copy of ones state registration certificate. One can appl y for a life membership.

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BENEFIT FROM T.N.A.I. MEMBERSHIP 1. 2. 3. 4. Various professional issues like representation to central pay commission. Holding National level conferences, scientific and business sessions. Low cost publications for members and students. Continuing education programme for updating knowledge on various topics at regular interval. 5. Socio-economic welfare programme for destitute members. 6. Research stu dies conducted regularl y for the benefit of the members. 7. At home with patron of TNAI member at Rashstarlpati Bhawan every year on nurses day celebrations. 8. Scholarship for TNAI member and students nurses. 9. Annual grant to state branches to hold activities. 10. One fourth railway concession for TNAI members. 11. The guest room facilities at the headquarters and also in some states. PUBLICATION o Hand Book of T.N.A.I. , published in1913 o Nursing Journal of India published monthl y. WHO Day, International Nursing Day and International Womens Day and other related activities are celebrated with the initiative of T.N.A.I. in all states of country. STUDENTS NURSES ASSOCIATIONS (SNA) The student nurses associations were establi shed in 1929 which is a nation wide organisation. In 1954, SNA celebrated the silver jubilee and number of unit was 117. Now SNA have more than 506 units. SNA having separate biennial conference. There is a full time secretary for SNA at national level. OBJECTIVES OF S.N.A. 1. To help student to uphold the dignit y and ideals of the profession for which they are qualifying. 2. To promote a corporate spirit among student for the common good. 3. To furnish nurses in training with advice in their case of study leading to professional qualification. 4. To encourage leadership abilit y and help students to gain a wide knowledge of the nursing profession in all its different branches and aspects. 5. To help the student to increase their social contacts and general knowledge in or der to assists them to take their place in the world when they have furnished their training. 6. To increase professional, social and recreational developments and arranging meetings, games and sports. 7. To provide a special section in the Nursing Journal of I ndia for the benefit of students. 8. To encourage student to compete for prizes in the student nursing exhibition and to attend national and regional conferences.
30

The whole organization of SNA is similar to that of TNAI. Local units are established in the institution. The Diary of various events is kept by SNA Secretary. The diary for all the students are presented at the time of national conferences, the diaries from all the units are presented. Later on, the SNA unit moves to the national level as the TNA I. MANAGEMENT OF S.N.A. The governing body of the association shall be the council of TNAI which will receive the recommendations of the General Committee of the SNA for consideration. The General Committee of SNA shall consist of: 1. President of TNAI or o ne of the Vice-President if President wishes to delegate this responsibilit y. 2. Vice Presidents of SNA State Branches, Hony. Treasurer of TNAI, National SNA Advisor who must be a full member of TNAI, State Branch SNA Advisors, Secretaries of SNA State Branches, Secretary General of TNAI. The General Committee shall meet once in a year at the time of TNAI council meeting. SNA General Body At National Level Comprises i) Members of SNA General Committee ii) 3 representative from each unit i.e. SNA Vice President, SNA Secretary and SNA Advisor iii) All SNA delegates attending the conference SNA General Body at State Level It consists of i) State SNA Executive Committee Members (State Branch President, Vice Presiden t, Advisor, Secretary, Treasurer and Programme Chairperson) ii) SNA Unit representative (Vice President, Secretary, SNA Advisor) SNA Units Each SNA Unit should elect its own members of Executive Committee in its GBM (General Body Meeting) and these member s are SNA Unit Advisor, Vice President, Secretary, and Programme Chairperson. The SNA General Body Meetings should be held at regular intervals The agenda for these meetings will be according to the needs of unit members and objectives of SNA. SNA unit adv isor is responsible to see that as soon as a nurse has graduated, she is given an SNA to TNAI form for membership in TNAI. This form must be signed by the Nursing Head of the Institution and sent to Secretary General of TNAI. Membership The student nu rse can obtain membership of student nurses Association during their training period and SNA membership can be transferred to TNAI membership. The membership fee in SNA is quite less, which is easil y met by the nursing student. They can take membersh ip in TNAI after completion of basic education by obtaining a certificate from the institution in which they have studied within 6 month after completion of studies. ACTIVITIES OF SNA
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A wide variet y of activities are encouraged for SNA keeping in view th e objectives of association and to strengthen curricular and co -curricular components as follows.

A.

ORGANISATION OF MEETINGS & CONFERENES: At the TNAI conference two representatives of SNA from each state are invited as observer and these students representative are vice -president and secretary of the state branches. They are invited to attend business meetings as observer. Three to four days conference is held for SNA members bienniall y. Member discuss and find solution for various problem faced by the students. These conferences are held bienniall y at state level. At the units usuall y the meeting is held monthl y or bi - monthl y. MAINTENANCE OF DIARY This is a biennial record book drawn up for the use of unit secretari es. The diaries are assessed annuall y by the state, SNA advisers and two best diaries are sent by state to the national SNA advisor for biennial evaluation and awards. These diaries are assessed for professional, educational, extra - curricular, social, cultural and recreational aspects. EXHIBITION Exhibition is very useful and very popular activit y of the association. All categories of students are eligible to participate either individuall y or in groups. They can prepare models, charts & p osters on the subjects taught in their course of studies. Now, their activit y is competed at the state level and one best entry under each category and section is entertained at national level. PUBLIC SPEAKING AND WRITING Public Speaking and writing are encouraged to increase self confidence and help them gain skill in communication through debates, panel discussions, seminar on the theme of conference. Students are also encouraged to write for nursing general of India on professional topic. PROJECT UNDERTAKING At the time of celebration of international nurses day students are given project work on health related topics. Regular project work is also given by institution to students. PROPAGATION OF NURSING PROFESSION Other professional and general public should be invited to celebration of professional and non professional activities such as nurses week, WHO day. The other activities such as variet y entertainment programme, game, sports etc. are organized by nurses to a cquaint general public with nursing profession. FUND RAISING To meet the expenses at head quarter and SNA state level unit, it is necessary to raise the fund through voluntary donations. SOCIO CULTURAL AND RECREATION ACTIVITIES To Channelise your student energy, fine arts activities such as drama, dance, music and painting are arranged and competitions are also held at state and national level. Sports and games competitions are also held.
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B.

C.

D.

E.

F.

G.

H.

OTHER ACTIVITIES These can be in the form of quiz on general knowledge and professional topics, article writing, poetry writing, smile competitions etc. Hobbies such as sewing, stitching, knitting etc. should also be arranged.

INTERNATIONAL PROFESSIONAL ORGANISATIONS INTERNATIONAL COUNCIL OF NURSES (ICN) MISSION To represent nursing worldwide, advancing the profession and influencing Health policy. INTRODUCTION The ICN is federation of national nurses association (NNAs), representing nurses in more than 128 countries. Founded in 1899 , ICN is the worlds first and widest reach international organization for health professionals. Operated by nurse for nurses, ICN works to ensure qualit y nursing care for all, sound health policies globall y, the advancement of nursing knowledge and the presence world wide of a respected nursing profession and a competent and satisfied nursing workforce. ICN GOALS 1. To influence nursing, health and social policies, professional and socio economics standards world wide. 2. To assist national nurses associat ions (NNAs) to improve the standard of nursing and the competence of nurses. 3. To promote the development of strong national nurses associations. 4. To represent nurses and nursing internationall y. 5. To establish, receive and manage funds and trust which contrib ute to the advancement of nursing and of ICN. IN SHORTS 3 MAIN GOALS To bring nursing together world wide. To advance nurses and nursing world wide. To influence health policy CORE VALUES: 1. Visionary leadership 2. Inclusiveness 3. Flexibilit y 4. Partnership 5. Achievement The ICN code for nurses is the foundation for ethical nursing practices through out the world. ICN standard, guidelines and policies for nursing practices, education, management, are globall y accepted as per basis of nurses policy.
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ICN advances nursing, nurses and health through its poli cies, partnership, advocacy and leadership development, ICN is particularl y active in:

PROFESSIONAL NURSING PRACTICE Advanced nursing practice HIV/AIDS, TB and malaria Womens health Primary health care Famil y health Safe Water

NURSING REGULATIONS Code of ethics, standards and competencies. Continuing Education SOCIO ECONOMIC WELFARE FOR NURSES Occupational health and safet y Human resources planning and policies Carrier development International trade in professional services GOVERNANCE OF ICN Meetings ICN meets every 4 years. The quadrennial meetings are called as "Congresses" and when they are in session, the organisation is called as the International Congress of Nurses. The ICN board of directors numbers15 and is comprised of the president, three vice president and 11 members elected on the basis of ICN voting area.

FUNCTION 1. To provide policy directions to fulfill the objectives of ICN

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2. To establish categories of membership and determine their rights and obligations. 3. To act upon recommendations of the board of directors relating to admission and
readmission of member associations into ICN. 4. To receive and consider information from the boar d regarding ICN activities. 5. To receive nominees for the board and to elect the board. 6. To act upon proposed amendments to ICN constitution. 7. To act upon recommendation of the board of director s for the amount of NNAs dues. 8. To act through mail or any written communication on ICN business that requires immediate attention. PUBLICATION- International Nursing Review AMERICAN NURSES ASSOCIATION (ANA) ESTABLISH: 1911 PURPOSE: To improve qualit y of nursing care ACTIVITIES Establish standards for nursing care Develop educational standard Promote nursing research Establish a professional code of ethics. Oversee a credentialing system. Influence Registration affecting health care. Protect the economic and general welfare of registered nurses. Assist with professional development of nurses by providing continuing education programme. MEMBERSHIP Federation of state nurses association Individual registered nurses can participate in ANA by joining their respective state nurses association. PUBLICATION American general of nursing American Nurses. CONCLUSION It is to conclude that the knowledge of all above discussed organization is must for every nursing personnel. So that by utilizing this knowledge we can update our knowledge and can advance th e nusrsing practices, taking this profession to the higher standards.

EDUCATIONAL PREPARATION FOR NURSES

35

MEANING:Educational preparation for nurses means preparing the nurses at university level and school of nursing, at hospital level and at community level.

Why educational preparation is necessary for nurses. Nursing is interpreted in different ways by different people. It is still thought by many people that nursing is only taking care of sick person. It is only helping the doctor in treatment of the patients.

No medical service is complete without nursing or without trained nurses. Nursing comprises of several responsibilities like dealing with patients of medical illness, clients having surgeries, psychiatric or pediatric patients. Nursing also involves other duties like maintaining patients, dispensing medication, setting up the equipments of an operation theatre and many other routine jobs.

Growth of health industry The demands for nurses is also increasing making a career in nursing. Schools, colleges, hospitals, community health centers need trained and qualified

nurses.

Statistics of nurses (Source Indian Nursing Council 1986) Last 40 years have produced 4271 B.Sc. nursing and M.Sc nsg.degree nurses.Around 200,000 General nurses are produced. For large infrastructure of health centres, for 600 million population of rural India around 100,000 of ANM/FHW are produced till date. Studies reveal nurses dissatisfaction with staffing because they are overloaded with work. This is because of the lack of nursing personnel So, there is need for educational preparation of nurses. Total nursing manpower required for urban and rural nursing services given by high power committee upto 2006 was Nurse midwives : 743114, Public health nurses : 34875 Health supervisor : 107960 ANM / Health worker : 323882 Criteria for selection in nursing:

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Candidates who wish to apply for nursing courses, should pass physics and chemistry and biology as main subjects.

Major Courses in nursing: The major courses their duration and their eligibility requirements are:

Name of Course ANM/Health Worker G.N.M. B.Sc Nursing

Duration 18 Months 3 Years 4 Years

Eligibility 10th Standard 10+2 with Biology, Physics and Chemistry 10+2 with Biology, Physics and Chemistry

Auxiliary Nurse Midwifery Program:It is a nursing programme with the duration of 18 months. It was first started at S. Marys Hospital Taran Taran in Punjab in 1951. Initially, very few training centers undertook to give this course, but the financial aid given by the Govt. of India under the scheme for preparing personnel for Primary Health Centers gave a great impetus to the training programme. General Nursing Midwifery Programme The Indian nursing council at its meeting in 1950 came out with some important decisions relation to the future pattern of Nursing Training in India. One the important decisions was that there should be only two standards of training of nursing and midwifery. So, the General Nursing and Midwifery course was started.

Basic B.Sc Nursing It is the nursing programme at university level. It was first started in 1948 in Rajkumari Amrit Kaur College of Nursing, New Delhi. Similar Course in B.Sc Nursing were started by other universities also. After the completion of these major courses, there are other certificate courses and master degrees in Nursing and doctorate in Nursing.

Name of Course Post basic B.Sc Nursing M.Sc Nursing

Duration 2 years 2 Years

Eligibility 1 yrs experience with diploma in nursing B.Sc Nursing with 1 Year experience
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M.Phil in Nursing

Ph.D in Nursing

2 Years part time , 1 year Regular 3 years 2 years

M.Sc Nursing

After MSc Nursing After M.Phil Nursing

1. Post Basic Post Certificate B.Sc Nursing:-.

The need for higher training for certificate nurses was stressed by Mudaliar Committee, and the two years Post Basic certificate B.Sc. Degree programme after G.N.M. was started in 1962. 2. Post Graduation Education:

Two years formal course in Master of Nursing programme was started in 1959 in Raj Kumar Amrit Kaur College of Nursing and one can choose specialty according to his/her choice. 3. M.Phil Nursing Programme:

M.Phil Nursing programme is first started in Raj Kumari Amrit Kaur, College of Nursing on Oct. 15, 1986. This is the programme for one and half year for regular candidates and two years for part time candidates. 4. Ph.D. Programme:-

Ph.D programme was started in few colleges like College of Nursing P.G.I., College of Nursing CMC vellore, R.A.K. College of Nursing, Delhi. It is a 3 years programme after M.Sc Nursing and 2 years programme after M.Phil in Nursing. Continuing Education Meaning:It is any extension of opportunities for reading, study and training to any person and adult following their completion of or withdrawal from full time school/or college programmes. Continuing education is an educational activity primarily designed to keep the registered nurses abreast of their particular field of interest and do not lead to any formal advanced standing in the profession (Nursing Thesarus of the International Nursing Index.) Continuing education in nursing consists of planned learning experience beyond a basic nursing educational programme. These experiences are designed to promote the development of knowledge, skills and attitudes for the enhancement of nursing practice, thus improving health care to the public (ANA). Need for continuing education in nursing 1. Phenomena of Change:38

Basically the need for continuing education emerges from phenomena of change, Change in what is known about man and how he functions in health and illness, changes in the ways in which people meet the challenge to survive in a dynamic age, and change in the objectives. Organization and financing of health services.

2. Altered professional roles:As the society changes and as new technologies and knowledge is emerges, the professional roles and altered. The individual who avoid chance of aquiring new knowledge, he meet the challenge of change, he cannot adopt himself according to the changing demands.

3. Effective and wise leadership and competent practitioners:-

For the development of good leaders, continuing education must be there in nursing educational according to the demands of society she has to become competent practitioner. 4. To fulfill needs of nurse practitioner The nursing profession itself and larger society highlight the need for planned programmes of continuing education. These include charging functions of the nurse, an increasing trend toward specialization. The nurse and responsibility of continuing education With the scientific advancement, technologic innovations, social changes and with the emergence of new patterns of health care, traditional roles of nurses are under close scrutiny and some must inevitably give way to new roles. If goal of providing the best possible health care for all people is to be achieved, nurses must become involved in creating new solutions for problems both old and new. They must justify and initiate charges needed for the improvement of nursing case. This must become the responsibility of every nurse. Philosophy of Continuing Education:-

It has been believed that the system of higher education which provides the basic preparation for the members of a profession must also provide opportunities for practitioners to keep abreast of advances in their field.

Philosophy of Continuing Education in Nursing

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It encompasser various aspects of life and is not limited the professional education. Continue education is concerned with development of the nurse as a person, a practitioner and a citizen. These are closely interrelated but each must be considered in identifying Philosophy of Education . Nurses philosophy of life, nursing and education, belief etc. will influence the philosophy of continuing nursing education. It focuses on the individual learner. Philosophy in though of relating to basic belief. Actions are guided by ones belief, how one teaches relates to his belief about learning and education . Philosophy is based on value, social change the thoughtful teacher recognizes that ones philosophy of education is always an emerging one rather than a static one. Learning must be a continuous process through out the lifespan, not limited to formal courses of study . Planning for continuing Education A successful continuing education programme is a result of careful and detailed planning. . Planning is essential if learning needs of nurses are to be met and if available resources are to be met and if available. Planning is required at all levels, local, state, regional and national and eventually international to avoid duplication of efforts. Planning help to keep a minimum gap in meeting the continuing education needs of nurses. Planning must be on going or continuous because rapid technologic advances and proliferation of knowledge demands continuous planning to meet ever changing learning needs.

Planning Process:Nurses identify most closely with planning for client care, but the principles of planning apply to a wide variety of situations various approaches may be used in planning for continuing education. The Planning Formula 1. What is to be done? Get a clear understanding of what your unit is expected to do in relation to the work assigned to it. Break the units work into separate jobs in terms of the economical use of men, equipment, space, materials and money you have at your disposal. 2. Why is it necessary?

When breaking the units into separate jobs, think of the objectives of each job. This may suggest alternate methods or the possibility of eliminating parts of jobs or whole jobs. 3. How is it to be done? In relation to each job, look for better ways of doing it in terms of the utilization of men, materials, equipment and money.
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 4. Where is to be done? Study the flow of work and the availability of the materials and equipments best suited men for doing the job. 5. When is it to be done?

Fit the job into a time schedule that will permit the maximum utilization of men, materials, equipment and money, and the completion of the job at the wanted time. 6. Who should do the job? Determine what skills are needed to do job. Successfully, select a train the man best fitted for the job. Nursing Education :Nursing education is the professional education for the preparation of nurses to enable them to render professional nursing care to people of all ages, in all phases of health and illness. Aims of Nursing Education : To provide the professional nursing care to people of all ages, in all phases of health and illness in a variety of setting. To prepare the nurses for providing care at institutional level. To prepare the nurses for rendering community services through primary health centre. To prepare integration of health and social aspect, theory and practice in generalized public health nursing. To provide and adequate, sound scientific foundation, intelligent nurses to understand the functioning of body and mind in health and disease. To prepare nurses who will be able to work cooperatively with team members who are engaged in health and welfare work To insure opportunities for initiative and resourcefulness, sense of responsibility for oneself and others and broad professional and cultural interest. Role of Nursing Education Nursing education is the professional education for the preparation of nurses to enable them to render professional nursing care to people of all ages, in all phases of health and illness, in a variety of settings. Nursing education impart scientific and up to date knowledge in the area of medical, social, behavioral and biological sciences. Nursing education helps the nurses to inculcate the appropriate nursing skills and the right attitude to the students. Theoretical and practical knowledge is essential for rendering intelligent and efficient nursing care. Nursing education prepare nurses as a good leaders to provide qualitative care. Nursing education helps to implement health care programmes and health care services in community. Nursing education helps to improve the professional development of each nurse and their profession. Nursing education helps the nurse to develop as a person of self-awareness, self direction, and self motivation through curricular and extra-curricular activities. Nursing education prepare nurses in participating scientific nursing research investigations, its results will be added up to the body of nursing knowledge.
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Nursing education inculcate democratic values, eg. Respect to individuality, equality, toleration, cooperative living, faith in change. Nursing education enable the nurses to co-operate with team members who re engaged in health and welfare work. Nursing education enable the nurse to understand the functioning of body and mind in health and disease. Nursing education prepare the individual to earn his/her livelihood and make himself/herself selfsufficient and efficient economically and socially.

Career Opportunities For the nurse means opportunities for a nurse to develop her own career in nursing. There was a time when professional nurses had very little choice of service because nursing was mostly centered in the hospital and bedside nursing. Many nurses served as staff nurses only with practically no chance of change or promotion. The Opportunities for a nurse can be set as: Hospital Nursing Services In School of Nursing In college of Nursing In Community Health Nursing Nursing service in Industry. Nursing service as private duty nurse. Nursing service in the red cross society. Nursing service for military personnel. Nursing service abroad. Opportunities for male nurses.

1. Hospital Nursing Services a) Staff Nurse (3 yrs G.N.M./ Psychiatric Nursing Diploma/Certificate, recognized by INC. b) Senior Staff Nurse:- (G.N.M. or B.Sc Nursing and have experience as staff Nurse of not less than 5 years. c) Nursing Superintendent Grade II (Experience as a senior staff Nurse). d) Nursing Superintendent Grade-I (should have experience as Nursing Superintendent Grade-II) 2. Nursing Services in the School of Nursing a) Nursing Tutor(B.Sc Nursing or M.Sc Nursing) or a diploma in Nursing education and administration. b) Clinical Instructor (B.Sc Nursing or M.Sc Nursing with or without experience). c) Principal , School of Nursing (M.Sc Nursing or B.Sc Nursing and should have teaching experience in school of nursing not less than 5 years.) d) Public Health Nurse or Community Health Nurse (Diploma in Public Health Administration) 3. Nursing Services in the College of Nursing: Principal, College of Nursing (M.Sc nursing or equivalent degree or Ph.D in Nursing or other doctraite degree and teaching experience in college not less than 5 years) Lecturer (M.Sc Nursing) Senior Lecturer:- Experience as Junior Lecturer.
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Assistant Professor:- (M.Sc Nursing or Ph.D in Nursing with any speciality) and have teaching experience in the college of Nursing not less than 5 years). Clinical Instructor (B.Sc Nursing or M.Sc Nursing with or without experience) Professor (M.Sc Nursing or Ph. D in Nursing with any speciality and should have teaching experience in the college of nursing not less than 5 years.)

4. In Community Health Nursing Community Health Nurse/ Community Nursing Officer (B.Sc Nursing or G.N.M) Health Supervisor Nurse Midwife (G.N.M or B.Sc Nursing) 5. Nursing service in Industry Industrial Nurse (G.N.M & B.Sc Nursing Experienced) 6. Nursing Service as a Private Duty Nurse (B.Sc Nursing /Post Basic B. Sc Nursing) 7. Nursing Service in the Red Cross Society 8. Military Nursing Services (G.N.M/ B.Sc Nursing or M.Sc Nursing) and were given the rank from Lieutenant to Brigadier. 9.Nursing Service in abroad:- (G.N.M./B.Sc. Nursing/ M.Sc Nursing with or without experience) 10.Nursing Services in other areas:Like research and writing and editing books, full time secretaries on the state level with the TNAI (Rich experience in the profession) 11.Opportunity for Male Nurses:They are valuable in activities of professional organizations where travel is often necessary. Scope of Nursing Education Increase in health consciousness in India, the quality of health services has also improved. So, skilled and specialized nurses can get excellent employment opportunities in government or private hospitals. Nurses can also get employment in clinics, nursing homes, orphanages, old age homes, industries, military services, schools and other places. Nurses can get specialized duties like taking care of patients in paediatric, orthopedics, psychiatry, obstetric and other sections. Nursing education provides the scope in teaching, supervising and higher level of administration. Nursing education has great scope for male nurses. They are valuable in activities of professional organizations where travel is necessary. Nursing has great scope in abroad. They can find jobs in specialized field like surgical, medical, ICU, CCU and Emergency Room (ER) Nurses get high pay packet in abroad.
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Nurses get many opportunities for studying and settling there in abroad.

Conclusion : It is concluded that every individual who want to be a nurse must have some special education and nurses can have variety of career opportunities and have wide scope in nursing.

ROLE OF RESEARCH, LEADERSHIP AND MANGEMENT IN NURSING INTRODUCTION Nurse means to foster or cherish; to treat or handle with care; to bring up; to train; to preserve. So the term nurse suggests attendance and service. In 1966, Virginia Henderson gave her concept of the unique function of the nurse as follows: The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge, and to do this, in such a way as to help him gain independence as quickly as possible. ROLE OF RESEARCH IN NURSING The root meaning of the word research is to search again or to examine carefully. Research is diligent, systematic inquiry or study to validate and refine existing knowledge and develop new knowledge. Acc to Gowin and Millman (1969) Research is an abstraction and selection from an infinite variety of possible things that one might study. Accoriding to Arnold Lancester Research may be defined as planned, systematic search for information for the purpose of increasing the total body of mans knowledge. It involves looking for information which at the time is not available or for which that has no generally accepted evidence. According to Notter Research is a process systematically searches for new facts and relationships. MEANING OF NURSING RESEARCH Nursing research is one area of research which includes the breadth and depth of the disciplines of nursing, the rehabilitative, therapeutic and preventive aspects of nursing as well as the preparation of practioners and personnel involved in the total nursing spheres. Nursing research is directed toward helping well people to improve their status and stay healthy, as well as assisting clients who are sick or disabled by an illness to maintain or improve their health. According to Vreeland Nursing research is concerned with systematic study and assessment of nursing problems or phenomena, finding ways to improve nursing practice and patient care through creative studies, initiating and evaluating change and taking actions to make new knowledge useful in nursing. According to Polit and Hungler
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Nursing research is a process in which the researcher scientifically collects data to be used in the clinical, administrative or instructional area in order to find solutions to nursing problems, evaluate nursing practices, procedures, policies or curriculum, assess the needs of the patients, staff or students, and make decisions to change or continuous various nursing process which in turn advances the scientific knowledge in nursing field. Nursing research is defined as a scientific process that validates and refines existing knowledge and generates new knowledge that directly and indirectly influences nursing practice. Development of nursing research from Nightingale to the present: Nurses participation in research has changed drastically over the last 150 years. Initially, nursing research evolved slowly from the investigations of Nightingale in 19th century to the studies of nursing education in 1930s and 1940s and the reaesh of nurses and nursing roles in 1950s and 1960s.in 1970s and 1980s an increasing number of nsg studies focused on clinical problems were conducted. Clinical research continues to b a major focus for 1990s. FLORENCE NIGHTINGALE: Nightingales (1859) initial research focused on the importance of a healthy environment in promoting the patients physical and mental wellbeing. She studied aspects of environment such as ventilation, cleanliness, purity of water and diet to determine the influence on patients health. Nightingale also collected and analyzed morbidity and mortality data of soldiers of Crimean war. The research of Nightingale enabled her to change the attitudes of military and society toward the care of sick. She made a major impact on patients health. She used the research knowledge to make significant changes in society such as testing public water, improving sanitation, preventing starvation and decreasing morbidly and mortality. Nursing research from 1900 to the 1960s The American Journal of nursing was first published in 1900, and in 1920s and 1930s case studies began appearing in this journal. in 1950,ANAs study on nursing functions and activities findings were reported in Twenty Thousand Nurses Tell Their Story and based on which ANA developed statement on functions, standards and qualifications for professional nurses in 1959. During 1950s clinical research began expanding in nursing specialty groups as community health, psychiatric mental health, medical-surgical, pediatrics and obstetrics, developed standards of care. The increase in nursing research activity during 1940s prompted the publications of first nursing journal, nursing research in 1952. In 1950s and 1960s, nursing schools began introducing research and steps of research process at the baccalaureate level. The number of nurses with Masters degree with research background also increased during this period. In 1953 the Institute for research and Service in Nursing Education was established at Teachers College, Columbia University, New York that provided learning experiences in research for doctoral students. In 1960s a number of clinical studies focuses on quality care and development of measurement criteria of patient outcomes were performed. An additional research journalThe International Journal of nursing studies was published in1963.In 1965; the ANA sponsored the first series of nursing research conferences to
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promote the communication of research findings and use of these findings and use of these findings in practice. Nursing research in the 1970s: In late 1960s and 1970s nurses developed models, conceptual frameworks and theories to guide nursing practice. In 1978 China started publishing the journal Advances In nursing science that included nursing theorists work and related research that provided direction for future nursing research. In 1970 ANA established Commission on Nursing Research .In 1972 this commission established the Council of Nursing Researchers to advance research activities provide an exchange of ideas and recognize excellence in research. It also sponsored research programs nationally and internationally. In 1970s Sigma Theta Tau, the international research honor society for nursing, sponsored national and international research conferences. IMAGE published by Sigma Theta Tau, in 1967 includes research articles and summarizes of research conducted on selected topics .two additional research journals first published in 190s are Research in Nursing and Health in 1978 and Western Journal of Nursing Research in 1979. Nursing research in the 1980s and 1990s: In 1980s the focus was on conducting clinical research and clinical journals began publishing more studies. A new research journal published in 1987, Scholarly Inquiry For Nursing Practice and two in 1988, Applied Nursing Research and Nursing Science quaterly.The little of the clinical research knowledge was used in practice in 1980s.During 1982 and 1983 materials from federally funded project, Conduct And Utilisation Of Research in Nursing (CURN) were published to facilitate the use of research to improve nursing practice.in 1983 first volume of Annual Review of Nursing Research was published. Another priority in 1980s was to obtain increased funding for nursing research. The ANA created The National Institute for Nursing Research (NINR) in 1985.The purpose of this centre was to conduct, support and dissemination of information regarding basic and clinical nursing research, training and other programs in patient care research the NINR seeks more money for nursing research so that studies in the priority Areas can be funded. In 1990s, numerous high quality studies are being conducted to develop a scientific body of knowledge for nursing. Importance of research in nursing: Nursing is accountable to society for providing high quality care and seeking ways to improve that care. Through nursing research, scientific knowledge can be developed to improve nursing care, patient outcomes, and health care delivery system. Nurses need scientific knowledge to improve their decision making regarding what care to provide patients and how to implement that care. A solid research base is needed to document the effectiveness of selected nursing interventions in treating particular patient problems and promoting positive patient outcomes .Nurses also need research findings to improve the delivery of health care services. Research efforts contribute to professional autonomy for nursing i.e. Freedom to make Discretionary and binding decisions within ones scope of practice through selection, generation and testing of a unique body of knowledge which will provide professional autonomy and power. The knowledge generated through research is essential to provide a scientific basis for description, explanation, prediction and control of nursing practice. DESCRIPTION
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It involves identifying the nature and attributes the nature and attributes of nursing phenomena and sometimes the relationships among these problems. Through selected research methods, nurses are able to describe what exists in nursing practice, discover new information for use in the discipline. EXPLANATION In explanation the relationships among variables are clarified reasons for occurrence of certain events are identified. For example: research has indicated that elderly patients are at high risk of developing pressure ulcers related to level of mobility and support services can be used to explain the incidence of pressure ulcers in elderly patients and this knowledge can also be used in selecting nursing interventions to prevent pressure ulcers. PREDICTION Through prediction the probability of a specific outcome in a given situation can be estimated. However, it does not necessarily enable to modify or control the outcome. CONTROL Control is to manipulate the situation to produce the desired or predicted outcome. Control can be described as the ability to write the prescription to produce desired results. Nurses could prescribe certain interventions to patients and their families to achieve high quality outcomes. Example: based on research of Meek (1993), nurses could prescribe slowly stoke back massage to promote comfort and relaxation in hospice patients. So, we can say that research enables nurses to promote high quality patient outcomes essential to the development of nursing profession. Research documenting the efficacy and cost effectiveness of nursing interventions is critical for gaining the attention of reimbursement and policy bodies. Nurses can become successful in obtaining health care dollars for their services only if they have a sound practice based on research. ROLE OF RESEARCH IN NURSING Nursing research is needed to discover, verify, structure and restructure the professional knowledge through systematic inquiry. Research is the only way to: Build a body of nursing knowledge Validate improvement in nursing Make health care efficient as well as cost effective. 1. To mould the attitudes and intellectual competence and technical skills: Nursing is service to individual, families, and therefore society. It is based on arts and sciences which mould the attitude, intellectual competencies and technical skills of individual nurse into the desired and to help people, well or sick and cope with their health needs. 2. Filling the gaps in knowledge and practice: Most of the medical and nurses leaders believe that gap is existing between existing knowledge that is affecting nursing and its application. This gap exists in both nursing education and nursing service. To meet the new challenges, investigate unsolved problems and to scrutinize the changes in nursing. The individual nurse must actively seek to understand and apply the basic principles of research. 3.Fostering a commitment, accountability to clientele:
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The ultimate goal o a profession is to improve the practice of its member so that services provided to clientele should have greatest impact. This can be done by continual development of scientific body of knowledge fundamental to its practice that cans b instrumental in fostering commitment and accountability to profession and clientele. 4. Providing basis for professionalism: Nursing has established itself as a profession. The increasing awareness of nurses to include research as an integral part of professional nursing behavior is rapidly increasing. Nurses are extending base of knowledge as a part of professional responsibility and are endorsing scientific investigations to broaden the body of knowledge. Research provides abstract knowledge that is foundation for establishing nursing as a profession. 5. Providing basis for professional accountability: The quality of nursing care can be improved only if scientific accountability becomes part of tradition. Accountability is essential for nurse teacher in dealing with students, for nurse practioner dealing with patients and for nurse administrator dealing with clients or professionals of health care delivery system. It also includes scientific literature for new knowledge so that application of this knowledge becomes part of nursing practice. 6. Identifying the role of nurse in changing society: Nowadays consumers of health care are recognizing health care as a right than privilege due to spiraling costs of health care so there is a need to evaluate the efficacy of presently existing nursing practices in all areas to modify or abandon the practices that have no effect on health status and provide nursing services acc. to needs of clients. 7. Discovering new measures for nursing practice: Practice oriented research is key to discover for improving nursing practice that will improve the quality of nursing care. Scientific studies are needed to understand, explain the functions and forms of nursing care in meeting the needs of society and helping individuals regain or maintain health. 8. Helping to take prompt decisions by the administration to related problems: Nursing administrators are more frequently looking to the findings from research in solving persistent problems in organization, delivery and evaluation of client or patient care. Research in nursing administration can be useful in organizing nursing personnel in most efficacious manner. 9. Helping to improve the standards in nursing education: Nursing educators utilize the findings from research in structuring programs of study, in developing course contents and in designing methods of teachings. 10. Defining the existing theories and discovering new theories. The primary test of nursing research is to develop and refine nursing theories which serve as a guide to nursing practice and which can be organized into a body of scientific nursing knowledge. So, the research nursing helps the nurse practioners, administrators and educators to understand the phenomena with which they deal and to explain, predict and control the occurrences of phenomena. Research aids nurses to be accountable to patients. Scientific inquires provide information that facilitates effective nursing decisions. Nursing research clarifies the forms and functions of profession in meeting the health needs of the society. NURSES RESPONSIBILITY IN RELATION TO RESEARCH:
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The Code of Ethics for nurses states The nurse participates in the advancement of the profession through contribution of practice, education, administration and knowledge development. Ideally every nurse should participate in research, but practically all should use research results to improve their practices. All registered nurses should do the following: 1. Read and interpret report of research in their own nursing fields, so that they can keep up-to-date with current knowledge, and where appropriate, base their own policy and practice on their research findings, to do this they must familiar with research concepts and knowledge. 2. Identify areas of nursing where research is needed, nurses should be aware of the boundaries of their knowledge and situations in which lack of information is a serious detriment to effectual decision-making. 3. Collaborate intelligently with researchers (nurses and others) whose work brings them into contact with nursing, assist them as possible, and particularly where patients are involved, be aware of ethical issues which may not always be apparent to research workers themselves. 4. Discuss with patient any research in which they are being asked to participate in the same way as nurses are called upon to discuss with the patients the diagnostic and therapeutic measures prescribed by medical staff. In addition a nurse teacher must: 5. Use research findings as a basis for deciding what to teach and incorporate research findings into their teaching 6. Use research findings as a basis for deciding hoe to teach, make use of psychological theorie of learning and techniques of educational assessment. 7. Plan and supervise students project work in a way which will help the students to develop the ways of thinking, questioning, observing, analyzing and testing which are the elements of research. In addition nurse administrators should: 8. Have information about resources (financial, human, mechanical) available for carrying out research and be able to decide nursing research priorities, to make the best possible use of these resources. 9. Initiate and facilitate research in areas where research is needed provide the appropriate climate, have sufficient understanding of research methods to know what type of research is appropriate to the investigation of particular problems and from where specialist advice may be sought. 10. Monitor the progress of research project to ensure that the work is being carried out is consistent with the agreed objectives. In addition some nurses should: 11. Acquire skill in application of research technique, so that they can make use of existing research tools, e.g. patient-opinionate or question are, personality inventors, to carry out similar studies for themselves. 12. Become trained research workers capable of designing tools for nursing research, of leading unit and multidisciplinary research teams and of taking part in planning and formulating research policy for the nursing and midwifery profession in both intra and inter professional capacity. Thus, every nurse regardless of educational preparation can be involved in and benefit from nursing research. LEVELS OF EDUCATIONAL PREPARATION AND LEVELS OF PARTICIPATION IN NURSING RESEARCH Level of preparation H: Level of research participation Student nurse Consumer BSC nurse Problem identifier, data collector
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MSC nurse Doctoral nurse Postdoctoral nurse

Replicator, concept tester Theory generator funded program director

ROLE OF LEADERSHIP AND MANAGEMENT IN NURSING Nursing is a major component of health care delivery system and nursing services are necessary for every client seeking care of any type including health promotion, diagnosis, treatment and rehabilitation. So the nurses must be good leaders and managers to provide quality care to the patients.

LEADERSHIP Leadership is the art of getting others wants to do something you are convinced should be done. The origin of the word lead is to go. The verb to lead can define in several ways to guide, to run in specific direction, to direct, to be first, and to open play. Leadership can be defined as the process of moving or groups in some direction through mostly noncoersive means. Gardner (1990) says that the leadership as process of persuasion and by which an individual (or leadership team) induces a group to pursue objectives held by the leader or shared by the leader or shared by the leader and his or her followers. Bennis (2001) says that the leader vision so palpable and seductive that others eagerly sign on. Tourengeau (2003) used a broader definition stating that leaders are those who challenge the process, inspire a shared vision, enable others to act, model the way and encourage the heart. A leader is a person who influences and guides direction, opinion and course of action. The leaders: Often do not have delegated authority but obtain their power through other means, such as influence Have a wider role Are frequently not parts of formal organization? Focus on groups process, information gathering, feedback and empowering others. Emphasizing interpersonal relationships Direct willing followers Have goals that may or may not reflect those of the organization.

NEED OF LEADERSHIP IN NURSING As the profession makes big strides forward into the new millennium the need for quality nursing leaders at all levels and in all areas and in all areas of profession is rising. Leaders are needed in hospitals, professional organizations, is community and in educational institutions. There is need to develop leadership skills in nursing because:-

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Raise the consciousness of nurses: The nursing leadership is required to raise the consciousness of nurses through an ongoing critique of present system and to offer philosophical and practical rationales for fundamental change based on nursing values. For team building: Leadership techniques are required for team building at the organizational level, ensuring success in all aspects of nursing and maintaining high quality in areas of nursing services, nursing education and nursing administration as a whole. It is needed to align employees in support of goals, for group interaction and blend efforts of diverse specialties. Foundation block for nursing practice: Leadership skills are foundation blocks for nursing professional practice. Nurses can exercise leadership in various ways. It is not limited to formal role. Nurses may be able to lead at bedside, in client teams and management teams. Increase the body of knowledge: It helps the nurses to increase knowledge of business, human resource, organizational behavior and health care system issues in addition to clinical knowledge and skills. She can practice leadership skills if she knows public speaking project planning, management of resources and developing resolutions and position papers. For advocacy in nursing: Leadership is required to convey the standards and ethics of nursing profession and advocate for and contribute to advances in nursing education. To provide direction :Leadership is required for directing for the staff and people towards common goals by use of assignments, orders, policies, procedures, rules, regulations, standards, opinions, suggestions and questions to direct their behavior. Supervision: It helps in providing supervision and contribution towards continuous growth of supervision by inspecting the work of other nurses and evaluating their performance and approving correct performance. Inspiring the staff: Nursing leadership is required to inspire staff and fulfill their personal and institutional goals, create an atmosphere where one would live and work in a dignified manner. Role model: nursing leader is a role model to set an example by own actions and as an advocate for patients and staff. Nursing leadership can be improved in following ways Fundamental changes are necessary in our attitude towards risk taking, assertiveness and different in opinion. We need to create environment that would least tolerate diversity of the behaviors, personality differences. o Power at high level: increased recognition of role of nursing has usually come through appreciation of their significant contribution to make towards health. o Prepare nurses for collective bargaining: by removing wide variations in many nursing organizations and associations. o Make INC and state nursing councils strong and autonomous bodies. o A definite number of nurses to be prepared for top management level: courses for head nurses and nursing superintendent. o Leadership without authority does not get recognition: nursing administrators must have authority to reward as well as to initiate punitive measures to subordinates acc. to need. o Nursing should have say in planning of nursing care of patients and insist change in doctors orders and contribute towards effective patient care. o Team spirit must be encouraged between the staff by enforcing and highlighting of handing over and taking over.
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o Nurse Managers should be provided with adequate resources such as phone, computers in well maintained office, financial and clerical support that are important symbols of position and leadership. o Nursing education should match with nursing service provided in institute\state. o The professional associations must prepare nurses to be well informed in labor relations, collective bargaining, public relations, legal aspects of nursing, ethical issues and nursing standards, media awareness and use, improvement in interactive skills with doctors, patient and administrator. o To have better coordination and obtain better professional output nursing personnel must be under control of nursing administrator and becomes a self governing autonomous body. ROLE OF NURSING LEADERS The nurse leaders must: Widen nursing horizons: it is needed to establish lines of communication with other professionals, sectors, and public and policy makers. Interact with like-minded groups and other professional groups, participate and hold more interprofessional meetings and conferences. o To enhance professional knowledge and skill: take clinical specialization from colleges to hospitals and community, engage in clinical and field based research rater than education related topics, write widely on nursing and about nursing , publish more journals ,newsletters and books. o Strive towards professional autonomy: for nurses have to take and accept more responsibility in practice; take up and encourage independent practice; learn and practice accountability and form network of all nursing organizations. o Need to learn new skills: like public speaking and assertiveness; political influencing and advocacy for health; negotiations, economical and financial management; networking and linking; writing and publication. MANAGEMENT The word manage comes from the word hand. Managing means handling things. Acc. to Joseph Massie (1978): Management is defined as the process by which a cooperative group directs action towards common goals.Acc. to George (1988): Management is distinct process consisting of planning, organizing, actuating, activating, and controlling, performed to determine and accomplish the objectives by the use of people and resources. Acc. to O.Tead Management is a process and agency which directs and guides the operations of an organization in realizing established aims. Acc . to James Lunde Management is principally the task of planning, coordinating, motivating, controlling the efforts of others towards a specific objective. Managers are basically leaders possessing skills. Leadership is one function of management.Management lays more emphasis on control i.e. control of hrs, costs, salaries, overtime, use of sick leave, inventory and supplies. A manager guides, directs, motivates others and a leader empowers others so it can be said that every manager is a leader. Usually the managers: Have an assigned position within the formal organization. Have a legitimate source of power due to delegated authority that accompanies their position. Are expected to carry out specific functions. Emphasize control, decisionmaking, decision anslysis,and results. Manipulate individuals, the environment money, time and other sources to achive organizational goals.
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 Have a greater formal responsibility and accountability for rationality and control than leaders. Direct willing and unwilling subordinates. Managers are more often associated improving productivity, establishing order and stability and making things run smoothly. Management is process of getting work done through others. The role of managers is to coordinste the efforts of lower level employees i.e. subordinates to advance the goals of organization. Henri Fayol (1925) first identified the management functions of planning, organization, command, coordination and control. Luther Gulick (1937) explained on Fayols management function in his introduction of seven activities of management-planning, organizing, staffing, directing, coordinating, reporting, budgeting, as denoted by mnemonic POSDCORB. In nursing it can be applied as a nurse manager can spend part of day working on budget (planning), met with staff about changing patient management delivery system from primary care to team nursing (organizing), altered the staffing policy to include 12 hr shifts (staffing), held a meeting to resolve a conflict between nurses and physicians (directing), and gave an employee a job performance evaluation (controlling). FUNCTIONS OF MANAGEMENT

PLANNING

BUDGETING

ORGANISING

MANAGEMENT

REPORTING

STAFFING

COORDINA-TING

DIRECTING

Planning: it is working out a broad outline, the things that need to be done and the methods of doing them to accomplish the purpose set for the enterprise. Organizing: it is the building up the structure of authority through which the entire work to be done is arranged into well defined subdivisions and coordination. Staffing: it is appointing suitable persons to the various posts under the organization and the whole of personnel management. it is appointing suitable persons to the various posts under the organization and the whole of personnel management. Directing: it is making decisions and issuing orders and instructions embodying them for the guidance of the staff.
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Coordinating: it is the interrelating the various parts of the work and eliminating of overlapping and conflict. Reporting: it includes keeping oneself and the subordinates informed through records, research and inspection. Budgeting: it helps the nurse supervisor to set the budget for the nursing services. Problem solving: it helps the nurses to solve the conflicts within themselves by providing different measures of decision making. Manage day to day operations: it helps the nursing supervisor to perform the daily activities like nursing rounds, duty roster preparation etc. Empower staff: it is helping others to become all they are capable of being. It is enabling the individuals to do what they do the best. Maintain quality: it is effective in maintaining the quality of nursing services provided to the patients by evaluating, monitoring or regulating the services rendered to the consumers. Controlling: it helps to set the standards, measuring performance against those standards, reporting the results and taking action. Delegating: it is transfer of certain specified functions by the superior to the subordinates authority. It is assigning responsibility and authority to co-worker and ensuring his accountability. Evaluating: the evaluation is the final step of a programme. It helps needs evaluation to do best of his ability.

NEED OF MANAGEMENT IN NURSING Health care is a business and its success depends on nursing participation in changing system for delivering cost effective care and creating strategies to ensure client receive quality care. Nursing has been required to respond to changing technological and social forces e.g. managerial responsibilities evolved in response to an increased emphasis on business of health care. Because of changing trends in health care delivery the nurse manager role is becoming critical to effective, quality patient care and to confront these expanding responsibilities and demands the nurse manager must take new dimensions to facilitate quality outcomes in patient care and meet the institutional goals and objectives. Nurses irrespective of their primary job must assume responsibility functions that are inherent in every nursing job. The nurses in the past used to follow the directions and orders of administrators and physicians but the changing trends in community needs to produce nursing administrators who think independently and can solve problems as well as direct others in goal setting and achievement. The increasing complexity of delivery of patient care requires nurse to be a good manager and needs to be an effective communicator. The managerial activities include delegation, management of people, time and resources for the achievement of organizational goals. Nurse needs to be manager to manage change, resolve conflicts and making organizational goals, focus on care of patient, support of organization, profession and oneself as a professional. Management in nurses makes the nurses able to understand the conditions promoting and innovating the expression of talent among team members. Management helps the nurses to make decisions in organization and encourage nurses to determine ways to make the delivery system to function at its best.
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 Management skills help the nurses to provide visibility for organizational goals, to mediate conflict, serve as coach, and monitor results. It provides opportunity for persons to manage their own work and give clear directions to nursing personnel. The role of management in nursing is to provide opportunities for managers to manage their own work and give clear directions to nursing personnel to assume responsibility in every area of nursing.

CONCLUSION From the above reasons, the nurses must be prepared to look into matters of research, leadership and management. Managerial concepts are needed by nurses at all levels, focus on how to deal with people, how to manage resources and how to manage ones job. Research is needed to change the outlook of nursing profession and widen the horizons of nursing profession. QUALITY ASSURANCE IN NURSING Introduction The field of quality assurance is an old as modern nursing. Florence Nightingale introduced the concept of quality in nursing care in 1855 while attending the soldiers in the hospital during the Crimean war. It is a matter of pride for nurses that the nursing profession has attained a distinct position in the search for quality in health care. Quality is rapidly becoming concern to both consumers and the providers of the services. In health care quality is being demanded and expected and providers are judged by the quality of services.and hence there is a need to sensitize and train nursing personnel to provide quality care CONCEPT OF QUALITY IN HEALTH CARE Quality: Quality is defined as the extent of resemblance between the purpose of healthcare and the truly granted care (Donabedian 1986). In an economic dimension quality is the extent of accomplished relief case with a justified use of means and services (Williamson 1999) Government and those who pay of the care will see quality as a weighing out between results and costs to fulfill certain expectations in health care. CONCEPT OF QUALITY ASSURANCE: 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 members of profession are regulating services provided by nurses. Quality assurance is a judgment concerning the process of care, based on the extent to which that cares contributes to valued outcomes. (Donabedian 1982). Bull 1985 defined quality assurance as the monitoring of the activities of client care to determine the degree of excellence attained to the implementation of the activities.
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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). In health care quality assurance is being demanded and expected and providers are judged by the quality of services.and hence there is a need to sensitize and train nursing personnel to provide quality care. . The purpose and objectives and the suggested training program for nursing personnel to enable them to provide quality care is given below

PURPOSES To introduce code of ethics and professional conduct for nurses in India to the nursing To prepare nursing personnel for implementation of quality assurance model in nursing OBJECTIVES

personnel

At the end of the training program the participant will be able to: State the code of ethics and professional conduct for nurses in India Recognize the significance of following code of ethics and professional conduct in nursing practice Explain QAM as pre-requisite for quality nursing care Describe practices standard for nurses and their rationale Identify the legal boundaries for nursing practice Prepare nursing care plan following nursing process approach Appreciate the importance of practicing standard safety measures Identify appropriate communication techniques to be used in given interpersonal situation Plan and conduct patient teaching session Identify appropriate management techniques to be used for managing resources in given situation Appreciate the importance of continuing education and research for development of self , others and of the profession Describe the institutional disaster preparedness plan and nurses role

Approaches for a quality assurance program: Two major categories of approaches exist in quality assurance they are 1. General 2. Specific 1) General Approach: It involves large governing of official bodys evaluation of a persons or agencys ability to meet established criteria or standards at a given time. 1) Credentialing: A person generally defines it as the formal recognition of professional or technical competence and attainment f minimum standards by a person or agency According to Hinsvark (1981) credentialing process has four functional components
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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 professionals practice. Law has mandated licensure of nurses since 1903. 3) Accreditation: National league for nursing (NLN) a voluntary organization has established standards for inspecting nursing educations programs. In the part the accreditation process primarily evaluated on agencys physical structure, organizational structure and personal qualification. In 1990 more emphasis was placed on evaluation of the outcomes of care and on the educational qualifications of the person providing care. 4) Certification: Certification is usually a voluntary process with in the professions. A persons educational achievements, experience and performance on examination are used to determine the persons qualifications for functioning in an identified specialty area. 2) SPECIFIC APPROACHES: Quality assurances are methods used to evaluate identified instances of provider and client interaction. 1.) Peer review committee: These are designed to monitor client specific aspects of care appropriate for certain levels of care. The audit has been the major tool used by peer review committee to ascertain quality of care. 2) The audit Process - (Stan hope Han Caster 2000) Follow up of problem Topic study selected Recommendations for correcting deficiencies, explicit criteria selected for quality care. Peer review of all cases not meeting criteria. Records reviewed 3) Utilization Review (UR) Utilization review activities are directed towards assuring that care is actually needed and that the cost appropriate for the level of care provided. Three type of Utilization Review (UR) is there: 1) Prospective: It is am assessment of the necessity of care before giving service. 2) Concurrent: a review of the necessity of care while the care is being given.
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3) Retrospective: is analysis of the necessity of the services received by the client after the care has being given. U.R has been used primarily in hospitals to establish need for client admission and the length of hospital stay. The UR process includes the development of explicit criteria that serves as indicators of the need for services and length of services. Advantages of Utilization Review: 1. It is designed to assist clients to avoid unnecessary care. 2. It may serve to encourage the consideration of care options by providers, such as home health care rather than hospitalization 3. It can provide guidelines for staff of program development. 4. It provides a measure of agency accountability to the consumer. The major disadvantage to UR is that not all client are fit for the classic picture presented by the explicit criteria that serves as the basis for approval or denial of care. 4) Evaluation Studies: Three major models have been used to evaluate quality they are:1. Donabedians structure- process-outcome model 2. The tracer model 3. The sentinel model Donabedian introduced 3 major method of evaluating quality care. A) Structural evaluation: This method evaluates the setting and instruments used to provide care such as facilities, equipments and characteristics of the administrative organization and qualification of the health providers. The data for structural evaluations can be obtained from the existing documents of an agency or from an inspector of a faculty. B)Process evaluation: This method evaluates activities as they relate to standards and expectations of health provider in the management of client care, data for this can be collected through direct observations of provider encounters and review of records, audit, check list approach and the criteria mapping approach are used to establish the client encounter protocol. C) Outcome Evaluation: The net changes that occur as a result of health care or the net results of health care. The data of this method can be collected from vital statistical records such as death certificates or telephone client interviews, mailed questionnaire and client records. The Tracer method: is a measure of both process and outcome of care. To use the tracer method, one must identify a volume of client with a particular characteristic resuming specific health care management. Physicians and nurse practitioners, to identify persons with certain illness such as HTN, ulcers, UTI and to establish criteria for good medical and nursing management of the illnesses have used the tracer method. This method provides nurses with data to show the differences in outcome as a result of nursing care standards.
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The Sentinel method: It is an outcome measure for examining specific instances of client care the characteristics of this method are, a) Cases of unnecessary disease, disability deaths are counted. b) The circumstances surrounding the unnecessary event or the sentinel is examined in detail. c) In review of morbidity and mortality are used as an index. d) Health status indicator such as changes in social, economic, political and environmental factors are reviewed which may have an effect on health outcomes. Client satisfaction: Client satisfaction can be assessed using person or telephone interviews and mailed questionnaire. Data from client satisfaction surveys are used to measure structure, process and outcome of care gives. Incident review: During a patients hospitalization several incidents may occur which have a bearing on the treatment and patients final recovery. The critical incidents may be, - Delayed attendance by a physician /nurse - In correct medications - Lack of cleanliness and asepsis leading to infection - Carelessness in carrying out nursing procedures e.g. Hot and cold applications. The report should contain the name, age exact time and place, description of how it occurred any precaution taken, conditions of patient before and after the incident etc since these reports are of legal value it should be written carefully given importance to all the details and should be filed safely. Risk management: It can be defined in a program that is developed for the propose of eliminating or controlling health care situations that has the potential to inure endangers or create risk to clients. The philosophical intent of such a program would be to do the client no harm, that is to administer safe care of whichever clients, groups or populations are being served. Risk management activities are directed towards the identifications, analysis and evaluation of situations to prevent injury and subsequent financial loss. Malpractice litigation It is a specific approach to be imposed on the health care delivery systems by the legal systems. Malpractice litigation results from client dissatisfaction with the provider and with the content of care received. Quality improvement Principles and Conditions for total Quality Management Principles - Continuous quality improvement - Knowledge of customer expectation needs - Processes of customer supplier relationship - Belief in people - Statistical analysis
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- Costs of poor quality Conditions in the work environment: - Employer involvement - Improvement - An environment that supports risk taking - Team work - Data collection and analysis skills - Group interaction skills - Structure and management to enable improvement - Tools to facilitate the improvement. Framework for quality Quality in Nursing Practice: The joint commission on Accreditation of health care organizations (JCAHO) 1997 defines quality improvement (QI) as an approach to the continuous study and improvement of the process of providing health care services to meet the needs of clients and others. Steps in quality improvement: 1)Quality defined: Before the nurse manager and staff can measure trends in nursing practice, they first must know the standards or guidelines that define quality. Professional standards: They are authoritative statements used by the profession in describing the responsibilities for which its practitioners are accountable (Peters 1995) A. Policies: Policies are non-negotiable aspects of practice that allow for no professional judgment or interpretation is their implementation (Peters 1995) E.g.Professional dress policy, informed consent, advanced directives. B) Job descriptions: defined as the qualifications and responsibilities for individuals within a position or job category. E.g. Clinical director, staff nurse etc. C) Outcomes: Outcomes are the conditions to be achieved as a result of care delivery. An outcome tells whether interventions are effective, whether clients progress, how well standards are being met, and whether changes are necessary. a) Professional outcome: a measure of the professional caregiver performance. b) Client outcome: a measure of client status after receiving care. c) Developing quality improvement team: This team composed of staff from all departments with in a hospital. Components of Q.I programs. JCAHOs 10 steps for Q I 1. Establish responsibility and accountability for a Q.I program. 2. Define the scope of service for a clinical area 3. Define the key aspects of service for the clinical area. 4. Develop quality indicators to monitor the outcomes and appropriateness of care delivered.
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5. Establish thresholds for evaluation of indicators 6. Collect and analyze data from monitoring activities. 7. Evaluate results of monitoring activities to determine the need for change in practice. 8. Resolve problems through development of action plans. 9. Reevaluate to determine if the plan was successful 10. Communicate Q.I results to the organization MODELS OF QUALITY ASSURANCE 1) A System Model for implementation of unit Based Quality assurance: The implementations of the unit based quality assurance program, like that of any other program, and involve making changes in organizational structure and individual roles. One method of facilitating and structuring the change process is the system approach in which the task is broken down into manageable components based on defined objectives. The basic components of the system are 1. Input 2. Throughput 3. Output 4. Feedback 1 Previous Quality assurance program Structural change process Unit based quality assurance program. System model for unit based quality assurance (from Wayne P.I Quality Assurance Unit based approach 1984). 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. The boundaries of the system define its integration in the environment is to the other tasks and goals of nursing department, to the process of nursing science in relation to evaluation. Their boundaries should be semi-permeable so that they allow necessary information and energy into and out of the change process. 2) American Nurses Association Model : The ANA has developed QA model in 1977 which has wide spread applicability in any healthcare setting and can be used as guide to implement QA program. The first step in developing QA program is continuing education. Many staff nurses and supervisors have not been prepared in the academic setting to develop standards of practice when a quality assurance program is implemented, the continuing education needs of all staff should be ascertained. Quality is not assured if only a small committee evaluates care and understands quality assurance program. 3) ANA Quality Assurance Model: ANA quality Assurance Model (from Susan Clemens, Diana Geeber: Comprehensive, family and community health nursing, 3rd edition Pg. 851) The basic components of the ANA model can be summarized as follows:
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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 provides 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, an objective of organization. The philosophy and objectives of an agency serves to define the structural standards of the agency. Standards of structure are defined by licensing or accrediting agency. Another standard of structure includes the organizational chart, which shows supervisory methods, communication patterns, staff patterns and sometimes staff assignments. A group internal or external to the agency does evaluation of the standards of structure. The evaluation of process standards is a more specific appraisal of the quality of care being given by agency care provides. An agency can choose to use the standards of care set forth by the providers, professional organization such as the ANA nursing standards or the agency can use the nursing process and apply it to the activities of the nurses as the activities correspond to the procedures of care defined by the agency. The primary approaches for process evaluation include the peer review committee and the client satisfaction survey. The techniques included are direct observation, questionnaire, and interview, written audit and videotape of client and provide encounter. The evaluation of outcome standards reveals the end results of nursing care. To be able to identify the net changes in the clients health status as a result of nursing care will give nursing profession data to show the contributors of nursing to the health care delivery system. Research studies using the tracer method or the sentinel method to identify client outcomes and client satisfaction surveys are approaches that may be used to evaluate outcome standards. Technique used in client classification systems that are admission data of the clients, level of dependence or problems and discharge data that may show changes in the level of dependence. 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, utilizations 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.
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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. In the recent findings if more than one cause of the deficiency has been identified; action may be needed to deal with each contributing factor. 7) Take Action: It is important to firmly establish accountability for the action to be taken. It is essential to answer the questions of who will do? What? By when? This step then concludes with the actual implementation of the proposed courses of action. 8) Reevaluate: The final step of QA process involves an evaluation of the results of the action. The reassessment is accomplishment 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 improved the deficiency or the deficiency was remedied, positive reinforcement is offered to those who participated and the decision is made about when to again evaluate that aspect of care. If the deficiency is not remedied, the problem solving process is repeated Developing quality indicators: A quality indicator is a quantitative measure of an important aspect of service that determines whether the service conforms to established standards or requirements. The quality indicator is the focus for the quality improvement program, with the staff monitoring criteria that will show whether indicator standards have been met. There are three types of indicators- Structure, process and outcome. Structure Indicators: Evaluate the structure or systems for delivering care .An example is adherence in checking if emergency casts are adequately stocked or if forms documenting restraint use are completed correctly. Process Indicators: Evaluate the manner in which care is delivered (E.g. the process of pain assessment, recovery of clients from sedation and clients referral to community services). Outcome indicators:
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Evaluate the end result of care delivered E.g.: incidence of nosocomial infection and adherence to medication therapy. Outcomes are the most important in any quality improvement program, but structural and process indicators cannot be ignored. Processes of care are obviously closely related to outcomes and the structure in which a process occurs, enhances or hinders the effectiveness of care (Donabedian 1988). When a unit-based team selects a quality improvement indicator, it is important that the indicator be relevant. It is often appropriate to measure a process as well as the expected outcome, to know if standards of care are being met. E.g.: In a medicine unit, staff may choose to measure their success in implementing the process of diabetes Instructions early while also measuring the outcome of whether clients learn to administer insulin correctly. When a unit based team sits-together to select quality indicators for a quality project, it helps to ask what processes and related outcomes are in need of improvement and are most likely to make a significant contribution to how nursing care is being practiced. Processes to improve may include the following. A weak process that is causing problems (E.g.: poor pain management for clients with sickle cell anemia). A stable process that is adequate, but that can benefit for improvement (E: calculating time for ambulatory surgery clients). A process linked to negative outcome (E.g.: care of intravenous access sets with the occurrence of phlebitis. Establishing Thresholds for Evaluation: After selecting a quality indicator, staff members must determine ways to quantitatively measure the indicator. The occurrence of an indicator or the percentages of times the indicator is observed (E.g.: the number of clients having surgery who can successfully explain their discharge instructions) is a common measure. A threshold is a standard for determining whether a problem exists. A measurement that falls below the threshold indicates problems. Staff will then thoroughly review the factor interfering with successful client education and adherence. When quality is an ongoing process staff continuously work to improve outcomes or performance by raising thresholds. It is important to understand that almost all processes have variation. For e.g.; consider the process of diabetic instruction and the associated outcome of clients administering insulin. Possible variations in the process might include the time when teaching begins, materials used in instruction and learner motivation. Outcome variations might include accuracy in injections site selection and proficiency in preparing the insulin in a syringe. Setting specific thresholds may not always be achievable. The intent in any quality improvement program is to seek ways to continuously improve. This includes defining the acceptable level of performance and allowing for normal variability. Data collection and Analysis: The process of data collection and analysis can be simple or complex. The importance however is in obtaining accurate results that help in making appropriate decisions regarding quality issues. Many organizations have made quality improvement so important that formal research studies are conducted. In this case the process of data collection and analysis is very formal and well designed. Statistical techniques are used to determine if problems that have been identified are significant. Similarly if a quality improvement project involves the introduction of a new practice or procedure, statistics can show whether the improvement made a significant difference in outcomes. When formal research is not conducted, staff may become involved in simple evaluation studies involving the collection of data on frequencies and percentages for a predetermined number of clients or cases. Evaluation studies offer valuable information on practice trends and whether problems are evident. What is important in data collection is to collect data on the right criteria and to then have adequate data from which
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to make decision. Quality improvement teams usually have access to resources within three organizations that can help determine how much information is needed for QI analysis. Evaluation of Care: Monitoring of quality indicators evaluates whether a specifically defined process reaches desired outcomes. If results exceed or meet a threshold or if performance is within controls for a process, no problem has been identified and process is performing well. When thresholds for satisfactory care are not met or when performance is below the control limits set, staff must try to find the cause of problems. When a process is not working well, one of the models for QI (E.g. FOCUS PDCA) may be used. This allows the staff to find the aspect of process to improve, organize an expert team who knows the process, clarify knowledge about the process, understand any sources of variation and select an improvement or solution. The process may take several team meetings before the group can agree on the actions to take. In the case of diabetic instruction, it would be important to have staff nurses, dieticians, diabetes nurse specialists and pharmacists involved as a part of QI team. Once the problem is identified, additional team members may be needed. The team collaborates to discover what are the factors associated with practice problems. Eventually the team recommends approaches for improving the process with the goal of achieving desired outcomes. Resolution of Problems: After evaluating quality problems, staff develop action plans to improve the process and outcomes. It is important to establish actions that will be successful. E.g. the action of merely notifying staff that a problem exists is unlikely to change practice or improve outcomes. An action plan should be more direct. In FOCUS PDCA, staff plans the action or improvement to make do or implement the change, check or analyze results of change and then act on the findings. E.g. The Q.I team may discover that clients are not administrating insulin correctly because they do not have all of the necessary information (Staff are not beginning teaching as soon as clients learn that insulin will be a form of therapy. Staff is also found to have trouble acquiring necessary teaching materials for instruction). In this case the team may recommend having the pharmacy send instructional materials when insulin is sent to the unit and having a clinical pharmacist assist with instruction on insulin therapy. The staff nurses and nurse specialist may develop a practice protocols that outlines specific content to teach until the client learns to administer injections. Collectively the team may develop innovational approach that is designed to get appropriate information to clients more quickly and efficiently so that learning can take place. Evaluation of Improvement: After implementing an action plan, the staff must reevaluate its success. In the E.g. Staff members may repeat monitoring of the teaching process and the results of client testing to see if improvement has been made. The change may be positive or negative. Communication of Results: The results of QI activities must be communicated to staff in all appropriate organizational departments. If findings and results are not communicated, practice changes will likely not occur. Regular discussions of QI activities through staff meetings, newsletters and memos are examples of communication strategies. Often a QI study reveals information requiring organization wide change. In this case the organization must
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be responsible for responding to problem with the resources needed to make changes. Revision of policies and procedures, modification of standards of care and implementation of system changes are examples of ways that an organization may respond. 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 uncooperative 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 that 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, help to document patient satisfaction with respect to variables that are a) Delay in attendance by nurses and doctors. b) Incidents of incorrect treatment
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f) g)

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 of 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 Lack of written job description and job specifications Lack of in-service and continuing educational program QUALITY ASSURANCE MODEL IN INDIA: Nurses who are trained as per Indian nursing council regulations and registered with state nursing registration councils are safe to provide care Inc has developed a quality assurance program for nurses in India. The program is expected to develop mechanisms for ensuring quality of nursing practice QUALITY ASSURANCE MODEL IN NURSING Quality assurance model in nursing is the set of elements that are related to each other and comprise of planning for quality development of objectives setting and actively communicating standards developing indicators, setting thresholds, collecting data to monitor compliance with set standards for nursing practice and apply solutions to improve care PHILOSOPHY OF QUALITY ASSURANCE MODEL IN NURSING Indian nursing council believes that nurse will Do good for person /receiver of care, do no harm, maintain respect for life and human dignity, believe in human justice and fairness to individuals in terms of access to resources and care and protect the vulnerable Have moral obligation to provide services as per the prescribed of the regulatory body / health care system/ organization /institution even if it is in conflict with her personal beliefs and values Be responsible and accountable for providing quality care in line with set standards Be committed to understanding of dynamic nature of her / her role in interdisciplinary health team Be obliged to create public awareness and consider social expectations before making decisions for providing nursing care Be obliged to include receiver in making choices in planning and implementation of care Work in conjugation with legislation, accreditation and political system Have obligation to promote education of self and others Be committed to advancement of profession

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Nurse is expected to practice in adherence to existing health care delivery system at national / state and institutional level within the framework of QUALITY ASSURANCE MODEL in nursing

PURPOSE OF QUALITY ASSURANCE MODEL To ensure quality nursing care provided by nurses in order to meet the expectations of the receiver, management and regulatory body It also intends to increase the commitment of the provider and the management GOALS OF QUALITY ASSURANCE MODEL Develop confidence of the receiver that quality care is being rendered as per assurance Develop commitment of the management towards quality care Increase commitment of providers to adhere to set standards for nursing practice and strive Strengthen documentation of nursing care Promote optimum utilization of resources in providing cost effective nursing care

for excellence

Quality assurance setting standards For more than 100 years, a authors have written about the evaluation of nursing practice as a process with minimal elements of 1. Setting standards 2. Comparing nursing practice to such standards 3. Instituting changes to increase the adherence to the standards EVOLUTION OF STANDARDS: The first to write about standards in English language was Florence Nightingale whose notes on nursing what it is and what it is not was first published in England in December 1859. In it she frequently called for change to achieve high standards. Nightingale developed a multitude of standards of nursing care in the 19th century whether a family member as some one far such service provided the care. Notes on nursing have standards regarding. Noise and its control around sick. Consistency of food and when it should be served. Type of bed and mattress to be used, as well as prospects about the bed linens Position of the bed in relation to windows so that the patient can look out. Cleanliness of the room. Personal cleanliness. Though Nightingale made no comparison between her standards and the existing conditions, within 6 months she reduced the mortality to 2%. In other words a quality assurance as quality control process was used. Much has been done since that time to isolate the concept of setting standards from the larger process
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of evaluation. Establishing schools of nursing after 1873 was quite an indirect approach in terms of setting standards for practice and meaning improved compliance. Almost two decades after schools of nursing has been established. Efforts were again made to set standards for them. This in turn improved the care of side in the hospitals, because schools of nursing were intimately associated within the hospitals. Eldredge addressed the quality of nursing care in 1932 predominantly in terms of the quality of care given by students in hospitals. She defined quality of nursing care in terms of the quality of care given by students in hospitals. She defined quality of nursing care in terms of outcomes of nursing practice although not in the measurable outcomes used today. After the World War II the attention was again focused on establishing standards and upgrading nursing care. In the 1950s as the nursing process emerged, as an identifiable entity with the specific elements evaluation of care was almost always included as a step in nursing process. Orlando identified function, process and principles of professional nursing. She stressed on the evaluation of nursing process. Carrier and Sitzman in 1971 included evaluation as the final point in the six-step process of the nursing care plan. In 1973 the ANA legitimized the nursing process. Thus started the era for the evaluation of the nursing profession for better quality care of the patient and quality assurance of the profession itself.

STANDARDS Definition: Standard is an established rule as basis of comparison in measuring or finding capacity, quality context and value of objects in the same category. Standard is a broad statement of quality. It is a definite level of excellence as adequately required, aimed at or possible. Standard is a predetermined baseline condition as level of excellence that comprises a model to be followed and practiced. It is used as a measurement tool. Professional Standards of Nursing Practice: Professional standards of nursing practice as established by professional nursing organization exist to guide the nurse in providing case. A standard in a model of established practice, which has general recognition and acceptance among, registered professional nurses and is commonly accepted as correct standards of practice, are agreed on levels of competence as determined by the ANA and specially nursing organizations [ANA, 1996]. Standards are defined as authoritative statements that describe a common level of care as performance by which the quality of practice can be determined or measured. Standard help define professional practice (Hubes 1996). Importance of standards in Nursing: It is an authoritative statement by which the quality of nursing practice, service and education can be judged. In nursing practice, standards are established criteria for the practice of nursing. It is a guideline and a guideline far is a recommended path to safe conduct an aid to professional performance. It provides a baseline for evaluating quality of nursing care, increase effectiveness of care and improve efficiency. Standard, help supervisors to guide nursing staff to improve performances Standards may help to clarify nurses, Area of accountability
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Standards may help nursing to clearly define different levels of care Standard is a device for quality assurance as Quality control. PURPOSES OF STANDARDS: The purposes of publishing, circulating and enforcing nursing care standards are to Improve the quality of nursing Decrease the cost of nursing Determine the nursing negligence CHARACTERISTICS OF STANDARDS 1. Statement must be broad enough to apply a wide variety of settings. 2. Must be realistic, acceptable and attainable. 3. Members of the nursing profession must develop nursing care. 4. Must be understandable and stated in unambiguous term. 5. Must be based on current knowledge and scientific practice. 6. Must be reviewed and revised periodically. 7. Must be directed towards an optimal standard. NURSING CARE STANDARDS can be divided into ends and means standards 1. End Standards: The end standards are patient oriented; they describe the change as desired in a patients physical status or behavior. 2. Mean Standards: The mean standards are nursing oriented, they describe the activities and behavior designed to achieve end standards. End standards require information about the patients. A mean standard calls for information about the nurses performance. NURSING CARE STANDARDS can be classified according to frame of references, relating to nursing structure, process and outcome. 1. STRUCTURE STANDARD: A structural standard involves the setup of the institution. The philosophy, goals and objectives, structure of the organizations, facilitates and equipment and qualifications of employees are some of the components of the structure of the organization. Example, recommended relationship between the nursing department and other departments in a healthy agency are structural standards, because they refer to the organizational structure in which nursing is implemented. It includes people, money equipment, staffing policies etc. The use of standards based on structure implies that if the structure is adequate, reliable and desirable, standard will be met as quality care will be given. 2. PROCESS STANDARD Process standards describe the behaviors of the nurse at the desired level of performance. A process standard involves the activities concerned with delivering patient care. These standards measure nursing action or of
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actions involving patient care. The standards are stated in action verbs that are in observable and measurable terms. E.g. : the patient demonstrates. The focus is on what was planned, what was done and what was communicated as recorded. In process standard there is an element of professional judgment ie determining the quality as the degree of skill. It includes nursing care technique, procedures, regimens, and processes.

3. OUTCOME STANDARDS: Descriptive statements of desired patient care results are outcome standard, because patients results are outcome of nursing intervention. An outcome standard measures changes in the patient health status. This change may be due to nursing care, medical care or as a result of variety of services offered to the patient. Outcome standards reflect the effectiveness and results rather than the process of giving care. Thus structural standards are agency or group oriented, process standards are nurse oriented and outcome. NURSING AUDIT: Introduction: Quality in product services, is the demand of the day as per a famous statement .You cannot insert quality into the product; quality must be built into the product as service.The level of quality is determined at the point of service, which is experienced and perceived by the clients and reflected through the audit process. History of Nursing Audit: Before 1955 very little was known about the concept of Nursing Audit. George Groward a physician was the first one to pronounce the term medical audit in 1918. Ten years later Thomas. R. Pondon HD established a method of Medical Audit based on procedures used by financial account. The 18th report of Nursing Audit of the hospital published in 1995. DEFINITION: According to Ganong & Ganong; Nursing audit is a method for assuring documentation of the quality of nursing care in keeping with the standards of the agency, the nursing department, and the professional, governmental and accrediting groups. According to Phaneuef (1976). A method for evaluating quality of care through appraisal of nursing process as it is reflected in the patient care records for discharged patients. According to Eclison: Nursing audit refers to assessment of the quality of clinical nursing. PURPOSES OF NURSING AUDIT: 1. Necessitating adequate documentation of nursing care provided to the client through the entire nursing process.
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2. Directing attention to the design and utility of the charting record. 3. Encouraging the use of the problem oriented nursing system. 4. Supporting and becoming an integral part of nursing by objective program 5. Facilitating the co-operative planning and delivery of client care by physicians and nursing employees. 6. Increasing the priority for results oriented performance evaluation program for nursing service employees. 7. Enriching and providing direction to in service education effects. 8. Providing a specific management technique in carrying out evaluation and control function. 9. Identifying ways to improve patient care. 10. Providing a meaningful ways for nursing staff members to participate and achieve career growth. CONCEPT OF NURSING AUDIT: Nursing Audit mainly comprises of 1) Debit 2) Credit

I. Debit: Debit is all negative activities in nature e.g.. Hospital infection. II. Credit: Credit mainly involves all positive activities in nature E.g. Satisfactions of care

Debit Items of Nursing Audit: 1. Death of the client not justifiable as otherwise could have been prevented. 2. Complications due to the neglect of nursing care. 3. Complications of diseases leading to morbidity. 4. Hospital infection 5. Errors in treatment 6. Clients discharged against medical advice. 7. Absence of total client care. 8. Lack of application of nursing process. Credit Items in Nursing Audit: i) No: of recovered patients ii) Shortens stay in the hospital iii) Expansion of health knowledge in client population. iv) Research as need for problem oriented care approach. v) Regular follow up in the community. vi) Measures to improve the public image vii) Well maintained nursing audit

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AUDIT CYCLE: Set standards Implement Audit Cycle Observe practice Change Compare with standard

2. Measurement of Actual Practice against Criteria This means to secure the charts from medical records (possibly by random selection, collect the necessary data, measure the result against set standards. 3. Evaluation of the results 4. Action taken to correct deficiencies 5. Follow up and reassessment 6. Report to nursing service administration and needed staff. TYPES OF NURSING AUDIT: The nursing audits are mainly of two types 1. Concurrent audit 2. Retrospective audit 1. Concurrent Audit: The concurrent audit has also been called as the open chart audit because it is done while the patient is receiving care. It is a process audit that evaluates the quality of ongoing care being perceived by clients by looking at the nursing process.

2. Retrospective Audit: Refers to an in-depth assessment of the quality, after the client has been discharged, having the client chart as a source of data. Focuses on 2 factors: Discharge status and complications .The 3 components of discharge status are: Heath, Activity, Knowledge OTHER TYPES OF NURSING AUDITS: (i) Structure audit: The inspection of the management process as carried out and documented by the nurse manager. (ii) Process audit: In this type of audit inspection of the nursing process, as carried out and documented by staff nurses to evaluate competence with established standards of nursing care. (iii) Outcome audit: It mainly identifies client outcomes (satisfactory and unsatisfactory and the patterns of nursing care that appears to be responsible. EXAMPLE OF AN AUDIT SUMMARY:
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To: Ward or unit: Date: From: Audit Committee Signed Chairman Re: Audit Topic Quality Control Check of Nursing Process - Number of open charts audited - Number of clients observed / interviewed - Number of personnel observed / interviewed

ADVANTAGES OF NURSING AUDIT: - Method of measurement - Functions are easily understood - Scoring system is fairly simple - Results are easily understood - Assess the work of all those involved in recording case. - May be useful tool as part of a quality assurance program in area where accurate records of case are kept. DISADVANDAGES OF NURSING AUDIT: - It is not so useful in areas where the nursing process has not been implemented. - Many components overlap making analysis difficult - It is time consuming - Requires a team of trained auditors. - Deals with a large amount of information. - Only evaluates record keeping Moree K, what nurses learn from nursing audit, Nursing out look, January 1988, 26 (1) 48. S.Sridhar. Quality assurance in nursing Indian Journal of Nursing and Midwifery Vol. 2 Sept 1988. INDIAN NURSING COUNCIL (2006), TEACHING MATERIAL FOR QUALITY ASSURANCE MODEL: NURSING EDITION 1ST, INDAIN NURSING COUNCIL PUBLICATIONS PAGE 8,9 FUTURISTIC NURSING Introduction:Many new trends in nursing are likely to develop in the near future. Some can predicted with certainly while others may be unexpected these trends of the future will result from very rapid changes take place in all areas of life. You will have to make a constant effort to keep informed through all available sources. It is the only way which will help you to know what is happening at present and what may come in the near future. Modern Nursing:The art of using the latest technology and science to promote quality of life as defined by patients and families through out their life experiences from birth to the end of life. Aspects of future of Nursing Nursing Education Nursing Services
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NURSING EDUCATION Future directions for nursing Education In 1993, three major organizations issued statements and reports about nursing education for the twenty first century. Their reports addressed the new directions of nursing education needed to take in the future. Although the three organizations advocated somewhat different approaches and strategies, several common themes emerged in their reports common emphasis included the following eight points. These eight areas of emphasis remain as important today as they were first identified in 1993. 1. Schools should recruit diverse students and facilities that reflect the multicultural nature of society. 2. Curricula and learning activities should develop students critical thinking skills. 3. Curricula should emphasize students abilities to communicate from interpersonal families and inter disciplinary colleagues. 4. The number of advanced practice nurses should be increased and curricula should emphasize health promotion and health maintenance skills for all nurses. 5. Emphasis should be placed on communitybased care increased accountability state of the art clinical skills and increased information management skills. 6. Cost effectiveness of care should be focus in nursing curricula. 7. Faculty should develop programme that facilitate programme articulation and career mobility. 8. Continuing faulty development activities should support excellence in practice teaching and research. Future direction for medical education The University of Queensland hosted the first Australian National Medical Education Colloquium in August 2005. The priority directions for medical education identified by plenary speaker were: 1 Student centered learning Adaptive curriculum Teaching Innovations System approach Finless to practice Medical Education Student centered learning Harden highlighted the importance of student centered learning as being pivotal to thinking about learning and teaching the suggested that medical institutions includes a bank of learning objects (e.g. x-ray images, videos) curricula maps, virtual patients and guided learning that is responsive to the learning needs of individual students. Adaptive Curriculum An adaptive curriculum modifies and personalizes learning by designing teaching and learning experiences in response to the specific needs of the individual students. Harden explained that concepts of just for me learning and just in time learning are accommodated by technology when the learner is ready the teacher will appear via technology. Teaching Innovations Innovations in medical education extend to curriculum technology assessment and professionalism. The curriculum model of the future should be student centered problem or task based, inter professional, community based and elective driven with core and student selected components.
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System Approach Aretz stressed the need for medical education programs to prepare gradates who are responsible to both the needs to the health system in which they will function and needs of patients they will treat currently medical students spend most time in teaching hospitals but they will eventually work in the community, where most patients present and are treated. Fitness to practice According to Walton, fitness to practice is an issue with which all medical schools are currently grappling overall we are probably handling the issues of knowledge and clinical skills quite well. There is still debate about what it really means what its components are and what we need to do much better. Medical Education Research In order to validate the effectiveness of new teaching approaches medical education research must emphasis appropriate methodology. Parideaux said that very little research is undertaken of our teaching programs in medical schools. He challenged to make medical education research in integral part of their school service. Nursing Services By the year 2020- less than 15 years from now a study from occupational Health and Safety Administration predicts that the need for registered nurses in nursing homes will increase 66% for licensed practical and vocational nurses by 72% and the need for certified nursing assistants will increase by 69%. For nurses working in home health settings which include managed care nursing home settings- those numbers are even higher will above 250% increase at every level of licensing. On site Nurse in Senior Housing Many senior dont need round the clock nursing care, but do need some nursing supervision. Senior housing communities often have an on site nurse who is available in case of an emergency. The nurse on site will also often consult with doctors to help and manage any medical care that they need. Regents Blue Ribbon Task Force on the future of Nursing In April 2001, New York State Board of Regents named a Blue Ribbon Task Force on Future of the Nursing, chaired by Regent Diane. The Regents Blue Ribbon Task Force has a critical role in addressing the current nursing shortage, solutions to the problem and the long term future of nursing. The leaders from education, health care government were the members of the Task Force. The task force has released their findings and recommendations for resolving those looming health care crises. The task force recommends the following solutions to the nursing shortage. Recruitment Expand the nursing workforce by recruiting additional numbers of men, non-practicing nurses and recent high school graduates. Education Provide additional academic and financial support systems to increase and pool of nursing school graduates and creates career leaders. Technology Increase the application of labor saving technology to eliminate unnecessary, duplicative paper work and communication of patient information, thereby improving workplace conditions.
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Data Collection Develop a reliable central source of data on the future need for nurses in the workforce upon which employers, policy makers, researchers and legislators may base pubic policy and recourse allocations. Clarify existing laws and regulations Scope of practice for Nurses Issue practice guidelines to clarify the legal scope of practice of nursing including those tasks which do not require licensure. These guidelines will reaffirm the individual practitioners responsibility for patient care. Future of Nursing Career Predications are that in 10 or 20 years it will look nothing like it does today! with new technologies and drugs, changes in insurance and health care policies and the shortage in nurses, the profession will have to reinvest itself. Many nursing functions will be automated such as documentation and updating patient records, smart beds to monitor vital signs and voice activated technology. This would give nurses more time to provide a human touch to their patients. As results of nursing shortages Health care facilities will be forced to use their nurses judiciously nurses will spend more time at the bedside as educators and care coordinators to refocus on the patient. They will need to know how to access knowledge and transfer it to the patient and their loved ones. The changes in technology will possibly attract more men and minorities into the profession. Greater emphasis must be placed on supporting teaching careers and recruiting educators to relieve the serious shortage of nursing school faculty. More loans and scholarships for masters and PhDs would have to be in place. As technology and research progresses nurses would focus more on preventing the illnesse rather than treatment. The nursing shortage and rising health care costs will also put pressure on the health care system to change from an illness model to a wellness and prevention mod If the nursing shortage continues Hospitals may have to be reserved only for the very sickest. They will also serve more prominent roles in clinics, consulting firms, insurance companies. Nurses would probably to much more population based or community Health care. They will provide community education and work with employers and insurance payers to develop programs that save money as well as promote health. TECHNOLOGICAL ADVANCEMENT TECHNOLOGY CHANGED THE NURSING Technology has facilitated change and improvements in health care at a more rapid pace than ever before with each passing year, the pace of that change and accumulation of knowledge increase exponentially. Nurse now tends to be specialists rather than generalists because the equipment they use is so specialized. In addition, computers have helped tremendously because they have taken away the need for nurses to remember so much information. They also allow nurses to check information against orders, which makes providing health care safer advanced monitoring tools have improved efficiency. Technology can make it more challenging to make sure the art of nursing in not over-shadowed by science. If we merely take care of the physical person and miss the target in the spirit of the person we fail as a profession.

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Futuristic Cyber Nursing: In Future:2 When you arrive at work, your I.D. tag is automatically detected and you are clocked in as you walk through the door. The patient is being monitored by automatic vital signs. You do your assessment verbally into your hand held device that converts it to readable notes on the computers' main system. At patients bed side, you can get chemistry, hematology with a small hand held device that requires no blood drawn. You just place the sensor on the patients skin and you have auto results. You verbalize your order into the hand held which goes directly to pharmacy which fills the orders automatically directly to patient's room. Most diagnosis will have a system for auto care plans upon patient admission. Patients have a bedside computer to access educational tools and progress of their recovery or stay. Nurses getting laptops and using intranet to do their jobs. This is a way to spend more time with patients and less time for doing paperwork.

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BIBLIOGRAPHY

1. 2. 3. 4. 5. 6.

Basavanthappa BT, Nursing Administration , 1st edition , published by Jaypee Brothers. PP1417,114-117,1-3516-517, 521-522,543-56. Neerja K.P., Text book of Nursing education, 1st edition, published by Jaypee Brothers.PP- 9-12, 159,388. Trained nurses association of India, Nursing in India, published by Aravali Printers and publisher pvt. Ltd. New Delhi, PP 145. www.google.com Potter & Perry. Fundamentals of nursing. Ed. 5th. Mosbys. 2001(1);401-23 The Foundations of Nursing Vol. 1st Published by B.I Publications Pvt. Ltd. pp-45-71.

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