Organisation in Nursing Administration

UNIT-IV
Organisation:
CONCEPTS,PRINCIPLES, OBJECTIVES,TYPES,THEORIES,etc…
Meaning: the word organization may convey at least 3 meanings:
Firstly it may refer to the activity of management in arranging people, tasks and resources
in the most orderly and efficient manner.
Secondly it may also name the arrangement itself, the outcome of the organizing activity.
Thirdly, it may describe any number of businesses, behavioural and humanistic concepts.
Definition: Organisation is „a group of people working together and with each other
towards the achievement of the common goals‟.
Koontz and O’Donnell, ‘essentially as the creation and maintenance of an intentional

structure of role’.
From the above definitions it is clear that,
 Any organisation must have defined goals or objectives.

 The functionaries shall endeavour to achieve those goals and objectives.
 The structure of duties and activities necessary for the conduct of or operation of
activities without which the organisational objectives cannot be achieved.
The organisation must
1) Reflect objectives and plans of the organisation.

2) Reflect the authority available to various categories of managers belonging to
different management levels.
3) Reflect its environment.
4) Be manned with trained and appropriate people, commensurate with their job
requirements.
Organisation has four connotations:
Administrative function, as a system, as an operation and as a result.
1.Administrative Function : organisation is a process of identification and grouping of

activities with determination and establishment of authority relationships for these
group of activities as well as arranging for men, materials, machines and money.
2. as a system, orgn consists of many interrelated and interdependent subsystems; each

system and subsystem has the component of:
a) input: human resources, material resources, information and energy serve as input.
b) throughput: the methods through which functions are carried out.
c) Output: the actual outcome.
d) management component: the system sees that the desired outcomes are obtained.
3. in an operational: organisation is involved with determination and defining of duties

and responsibilities of the personnel and establishment of interrelationship between the
various activities within the organisation.
4. result: a gp of people working together to accomplish the laid down common objectives
or goals with in a defined and specific framework.
Steps in organisation
1. Determination of objectives for each activity.

2. Deciding on the various types of activities to be undertaken with in the framework
of the formulated plan to attain the goals of the organisation.
3. Grouping of activities , their similarity, interrelationships, competencies and

capacities required in performance of these activities, its importance in relation to
achievement of organizational goals.
4. Deciding different groups of activities in terms of

- The number of staff
- The eligibility requirement of staff
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Mr. Channabasappa.K.M. PCON
- The seating arrangements

- The material and supplies, consumable and non consumable required to perform
these activities.
- The machines and equipment required
- The funds required
- Methods for maintaining the morale of the performers.
5. Determining the authority, responsibility and accountability of different members

of the staff.
 Determining the lines of authority with the channels of communication.
 The relationship between different members, departments, supervisors, peers
and subordinates including professional members – vertical or line
relationship, horizontal or lateral relationships.
 Developing an organizational chart based on the above.
 Planning of the items listed above.
 Allotment of duties to individuals.
6. Integration between the identified group of activities through relationships and

organized communication system.
Characteristics of an organisation:
 Group of people
 Common goals or objectives
 Division of work
 Vertical and horizontal relationship (the relationship between supervisor and
subordinates or the relationship between different departments and divisions).
 Chain of command with laid down channels of communication. (flow of authority

from the higher to the lower levels of management in the hierarchy).
 Group dynamics - interations that takes place between the individuals and gps
within the orgn, based on their values, needs, sentiments, attitudes, beliefs and
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interests. Its a social, self generating and dynamic interative process gives rise to a
informal groups.
Importance:
 Assists administration in gearing the human, material and financial resources

towards fulfilment of the objectives of the enterprise.
 Provides the structure within which the functions of planning, staffing, directing,
coordinating and controlling are performed.
 Helps in growth and development of the establishment, in planning for need based
change through appropriate division and allotment of work.
 Makes optimum use of all resources, determines needs for innovative and new
technologies in terms of cost effectiveness and accomplishment of objectives of the
establishment.
 Encourages individual growth and development of personnel according to
individual potentials through job enrichments, training and participation from
them.
 Invites creative and innovative ideas to work through adopting human relations
approach.
 Also once the authority, responsibility and accountability are determined for each
worker, a person is required to work on his/her own which helps in confidence
building, creative thinking and motivation).
Principles of organisation
1. Principle of chain of command:

 Communication flows through the chain of command or channel of
communication tends to be one way downward..
 In a modern nursing organization, the chain of command is flat, with line
managers, technical, clerical staffs that support the clinical staff. The
communication flows freely in all directions, with authority and responsibility
delegated to the lowest operational level.
 This principle supports a centralised authority that aligns authority and
responsibility.
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 The organizations are established with hierarchial relationships, within which the
authority flows from top to bottom in order to be satisfying to members,
economically effective and successful in achieving the goals.
2. Principle of unity of command:

 An employee has one supervisor / one leader and one plan for a group of activities
with the same objective.
 Also called principle of responsibility. The organisational set up should be
arranged in such a way that a subordinate should receive the instruction or
direction from one authority or boss.
 Primary nursing and case management modality support this principle. (Many
professional nurses engage in matrix organisations in which they answer to more
than one supervisor).
 In the absence of unity of command

The subordinate may neglect his duties. It will result in the non completion
of any work.
There is no guidance available to the subordinates and there is no
controlling power for the top executives of the organisation.
Further some subordinates will have to do more work and some others will
not do any work at all.
3. Principle of span of control:
 Span of control refers to the maximum number of members effectively supervised
by a single individual. (The number of members may be increased or decreased
according to the nature of work done by the subordinates or the ability of the
supervisor.
 The span of control enables smooth functioning of the organisation.
 Person should be a supervisor of a group that she can manage in terms of numbers,
functions, and geography. The more highly trained the employee, the less
supervision is needed.
 Employees in training need more supervision to prevent blunders.
 When different levels of nursing employees are used, the nurse manager has more
to coordinate.
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 In the past the nurse managers had a narrow span of control. They were responsible
for one nursing unit and a limited number of staff.
 Recently the span of control has increased to the point that the nurse managers
have to cover several nursing units and departments with a large number of
employees.
 This is also called span of management or span of supervision . This principle is
based on the principle of relationship.
4. Principle of specialization or division of work:
 Each person should perform a single leading function.
 There is a division of labor: a differentiation among kinds of duties.

 Specialization is the best way to use individuals and groups.
 Division of work means that the entire activities of the organisation are suitably
grouped into departments and sections. (The dept and sections may be further
divided into several such units so as to ensure maximum efficiency).
 This will help to fix up the right man to the right job and reduce waste of time and
resources).
 The work is assigned to each person according to his educational qualification,
experience, skill and interests.
 He should be mentally and physically fit for performing the work assigned to him.
The required training may be provided to the needy persons.
 It will result in attaining specialisation in a particular work or area.
5. Hierarchy or scalar chain:

 It is the order of rank from top to bottom in an organisation.
 This is also called a chain of command or line authority. (Normally, the line of
authority flows from the top level to bottom level. It also establishes the line of
communication).
 Each and every person should know who is his supervisor and to whom he is
answerable.
6. Centrality :
It relates to the position or distance the person has on the organisational chart from
other workers.
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7. Unity of objectives:
 An establishment or enterprise exists to achieve certain laid down
objectives. The orgn requires to be geared towards fulfilment of these
objectives.
 Hence this principle dictates that it is essential for the organisational
objectives to be formulated in clear, unambiguous, achievable and
measurable terms which should be understood by all concerned.
8. Definition of jobs/ principle of definition:
 It is necessary to define and fix duties, responsibilities and authority of each
worker.
 In addition to that, the organisational relationship of each worker with
others should be clearly defined in the organisational set up.
9. Principle of balance: There are several units functioning separately under one
organisational set up. The work of one unit might have been commenced after
the completion of the work by another unit. So it is essential that the sequence of
work should be arranged scientifically.
10. Principle of equilibrium balance:

In certain periods, some sections or departments are overloaded and some
departments are underloaded. During this period, due weightage should be given
on the basis of the new workload. The overloaded sections or departments can be
further divided into subsections or subdepartments. It would entail in the
effective control over all the organisational acivities.
11. Principle of continuity:

 Administration is a continuing or ongoing process – recycling the
structure of the organistion based on the economic, environmental and
socio-political changes.
 There should be a reoperation of objectives, readjustments of plans and
provision of oppurtunities for the development of future management.
This process is taken over by every organisation periodically.
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12. Principle of exception:
Implies routine decision making should rest with lower levels of
management within the policy framework and only unusual or
exceptional matters should be referred to the higher levels of
management for taking decisions.
The junior officers are disturbed by the seniors only when the work is
not done according to the plans laid down. It automatically reduces the
work of middle level officers and top level officers. So the top level
officers may use the time gained by reduction in workload for framing
the policies and chalking out the plans of organisation.
13. Principle of unity of direction:

 Also called principle of co-ordination.
 The major plan is divided into sub plans. Each sub plan is taken up by a
particular group or department. All the gps or depts are requested to
cooperate to attain the main objectives or in implementing major plan of
the organisation.
14. Principle of communication:

A two way communication flow from top to bottom levels and from bottom to
top levels is a prerequisite to obtain an effective organisational set up.
15. Principle of flexibility: to meet the challenges of the increasing and changing
demands of the environment, an organisation structure is subjected to change. As
such rigidity has to be avoided and flexibility is essential in the organisation
structure, so that changes can be brought about without disrupting basic design
of the structure.
Classification of organisation
The organisation can be classified on the basis
 of authority and responsibility assigned to the personnel

 and the relationship with each other.
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In this way organisation can be either formal or informal.
Formal organisation:
Provides a framework for defining responsibility, authority, delegation and accountability.
Depending on the organizational philosophy, the formal structure may be rigid or loose.
The formal organisation represents
 the classification of activities within the enterprise,

 indicates who reports to whom and
 explains the vertical journal of communication which connects the chief executive
to the ordinary workers.
 An organisational structure clearly defines the duties, responsibilities, authority
and relationships as prescribed by the top management. (In an organisation, each
and every person is assigned the duties and given the required amount of authority
and responsibility to carry out this job).
 It creates the coordination of activities of every person to achieve the common
objectives. It indirectly induces the worker to work most efficiently.
 The interrelationship of staff members can be shown in the organisation chart and
manuals under formal organisation.
Characteristics of formal organisation:
 It is properly planned.
 It is based on delegated authority.
 It is deliberately impersonal.
 The responsibility and accountability at all levels of organisation should be clearly
defined.
 Organisational charts are usually drawn.
 Unity of command is normally maintained.
 It provides for division of labour.
Advantages of formal organisation:
1. The definite boundaries of each worker is clearly fixed. It automatically reduces

conflict among the workers. The entire building is kept under control.
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2. Overlapping of responsibility is easily avoided. The gaps between the
responsibilities of the employees are filled up.
3. Buck passing is very difficult under the formal organisation. (Normally exact
standards of performance are established under formal organisation. It results in
the motivating of employees).
4. A sense of security arises from classification of the task.
5. There is no choice for favouritism in evaluation and placement of the employee.
6. It makes the organisation less dependant on one man.
Keith davis observes that formal organisation is and should be our paramount
organisation type as a general rule. It is the pinnacle of man‟s achievement in a
disorganised society. It is man‟s orderly, conscious and intelligent creation for human
benefit.
Criticisms:
 In certain cases, the formal organisation may reduce the spirit of initiative.
 Sometimes authority is used for the sake of convenience of the employee without
considering the need for using the authority.
 It does not consider the sentiments and values of the employees in the social
organisation.
 It may reduce the speed of informal communication (rules/reg‟s).
Informal organisation:
 Informal organisation is an organisational structure which establishes the

relationship on the basis of the likes and dislikes of officers without considering
the rules, regulations and procedures.
 These types of relationships are not recognised by officers but only felt. The
friendship, mutual understanding and confidence are some of the reasons for
existing informal organisation.
(For eg., a salesman receives orders or instructions directly from the sales manager
instead of his supervisors).
 The informal organisation relationship or informal relations give a greater job
satisfaction and result in maximum production.
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 According C.J. Bernard, „informal organisation brings cohesiveness to formal

organisation.
 It brings to the members of the formal organisation a feeling of belonging, status of
self respect and gregarious satisfaction.
 Informal organisations are important means of maintaining the personality of the
individual against certain effects of formal organisation which tends to
disintegrated personality.
Characteristics of informal organisation:
1. Informal organisation arises without any external cause ie., voluntarily.

2. It is a social structure formed to meet personal needs.
3. Informal organisation has no place in the organisation chart.
4. It acts as an agency of self control.
5. Informal organisation can be found on all levels of organisation with in the
managerial hierarchy.
6. The rules and traditions of informal organisation are not written but are commonly
followed.
7. Informal organisation develops from habits, conduct, customs and behaviour of
social groups.
8. Informal orgn is one of the parts of total organisation.
9. There is no structure and definiteness to the informal organisation.
Advantages of informal organisation:
 It fills up the gaps and deficiency of the formal organisation.

 Informal organisation gives satisfaction to the workers and maintains the stability
of the work.
 It is a useful channel of communication.
 It encourages the executives to plan the work correctly and act accordingly.
 It fills up the gaps among the abilities of the managers.
Disadvantages of informal organisation:
 It has the nature of upsetting the morality of the workers.

 It acts according to mob psychology.
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 It indirectly reduces the efforts of management to promote greater productivity.
 It spreads rumour among the workers regarding the functioning of the organisation
unnecessarily.
Difference between formal and informal organisation
Formal organisation Informal organisation
It arises due to delegation of authority. It arises due to social interaction of people.
It gives importance to terms of authority It gives importance to people and their

and functions. relationships.
It is created deliberately It is spontaneous and natural.
The formal authority is attached to a The informal authority is attached to a

position. person.
Rules, duties and responsibilities of No such written rules and duties followed in
workers are given in writing. informal organisation.
Formal organisation comes from outsiders Informal organisation comes from those
who are superior in the line of persons who are objects of its control.
organisation.
Formal authority flows from upwards to Authority flows upwards to downwards

downwards. from or horizontally.
Formal organisation may grow to Informal organisation tends to remain

maximum size. smaller.
It is created for technological purpose. It arises from man‟s quest for social
satisfaction.
It is permanent and stable There is no such permanent nature and

stability.
Types of organisation (Levels of Organisation):
Broadly there are 3 types of organisation:
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1. Line organisation
2. Staff organisation
3. Functional organisation.
An institution or enterprise may adopt one or other type of organisation or more than
one type of organisation depending upon its needs.
Line organisation:
 It is the oldest and the simplest form of organisation.
 It is also known as the military or scalar organization.
 Line functions -where superior exercises direct supervision over a subordinate – an
authority relationship in direct line or steps.
 The line of authority is straight and vertical and each person at the same level
performs the same functions.
 In an enterprise or institution, the chief executive leads the entire organisation.
Here the maximum authority rests on the top or highest levels of management and
the quantum of authority decreases in a step ladder fashion for the subsequent
levels of management in the hierarchy.
The line or straight or vertical line of authority serves as the channel of:
i) Command
ii) Communication
iii) Direction
iv) Coordination
v) Control And accountability
 The departments/divisions are formed depending upon the responsibilities involved
and work to be carried out by each department / division.
 each department and each division is headed by a divisional/departmental head.
The following two figures will describe the functions of a line organisation
Board of Director/Management
Chief executive
Manager manager manager manager manager

Production materials marketing finance admn
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Supervisor supervisor supervisor supervisor supervisor
Staff staff staff staff staff
Medical superintendent
Nursing superintendent
Deputy nursing superintendent
ANS ANS ANS ANS

Surgical medical paediatric outpatients
Division division division division
Ward sister W/S W/S W/S

Staff nurse S/N S/N S/N

Line organization in hospital nursing services
 There are possibilities that more subsections/ divisions may exist under each
branch.
 In this type of organisation the direction flows from top, transmitted through the
managers to the supervisors and then to the workers or staff.
 The hierarchy is maintained as per the figures shown.
 There is no scope for downward to upward or upward to lower downward
movements. (The authority is only the chief executive and what he describes must
be carried out. If one has to say something to the lower level he/she can only
approach the immediate boss and not anyone above).
 Only one supervisor issues command and the number of persons normally limited
less than one supervisor.
There are advantages or merits:
 Simplicity
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 Unity of control
 Better discipline
 Fixed responsibility: responsibities are well defined and persons are accountable
to someone in the line form.
 Flexibility: the executives generally enjoy autonomy and freedom with in their
defined sphere of activities.
 Prompt decision: because of the chain of command, unified control and fixed
responsibilities, it is possible to take prompt decisions.
Demerits:
 Lack of specialization: this system does not provide any scope for employing
specialists.
 Overloading or overreliance: the departmental head is all in all of his department/
division in this type of organisation.
 Inadequate communication: there is no down to upward communication in this
type of organisation.
 Favouritism: since one man is the decision maker and also opinion maker it is
possible he/she may be influenced by a few people.
Functional organisation:
Under line organisation, a single person is incharge of all the activities of the concerned
dept.
 Here the person incharge finds it difficult to supervise all the activities efficiently.
The reason is that the person does not have enough capacity and require training.
 In this the functional departments are created at the factory, office or enterprise
level to deal with the problems of business at each successive level. (Although the
expert and specialized services are mainly concentrated on the top, every section or
unit can make use of their services).
 The functions under this type of organisation may be classified as purchasing,
marketing, production, research and development, finance, office management,
personnel etc in a business enterprise.
 Functional dept as patient care services, pharmaceutical services, laboratory
services etc in a hospital setting.
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Although agreed to be a scientific type of system, there are certain prerequisites for
this system:
 All activities must be divided into functions carefully and then allotted to
functional departments.
 Only interrelated jobs are allotted to one department
 There should be no duplication i.e activity allotted to one dept cannot be allotted to
another.
The figure below illustrates a functional organization:
M.D or Genel.Mg
Chief Admn. Service
Recruitment finance training office public relations
Staff and workers
 Functional organisation, follows the scientific management method to overcome

the limitations of line organisation, (F.W.Taylor, the father of scientific
management, recommended a functional organisation of activities at the top level).
 According to Taylor, a foreman should not be burdened with looking after all the
activities of work. Instead he should be assisted by a number of specialists in
solving the problems.
 Various specialists are selected for various functions performed in an organisation.

 Workers, under functional organisation, receive instructions from various
specialists. The specialists are working at the supervision level.
 Thus, workers are accountable not only to one specialist but also to specialist from
whom instructions are received.
 Directions of work should be decided by functions and not by mere authority.
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The need for functional organisation arises out of :
1) The complexity of modern and large scale organisation.

2) A desire to use the specialisation in full.
3) To avoid the workload of line managers with complex problems and decision
making.
Characteristics of Functional Organisation:

 The work is divided according to specified functions.
 Authority is given to a specialist to give orders and instructions in relation to

specific function.
 Functional authority has right and power to give command throughout the line with
reference to his specified area.
 The decision is taken only after making consultations with the functional authority
relating to his specialised area.
 The executives and supervisors discharge the responsibilities of functional

authority.
Advantages of functional organisation:
1. Benefit of specialisation:
Under the functional organisation, each work is performed by a specialist. It helps
to maintain efficiency of the organisation. Each work is divided among the workers
scrupulously.
2. Application of expert knowledge:
Planning function and execution function are divided separately and each function
is entrusted to a specialist in the line organisation. So the specialists can use their
expert knowledge in the actual performance of work.
3. Reducing the work load:

Each person is expected to look after only one type of work. Hence the quality of
work and effective control over the work are achieved.
4. Efficiency:
Since each worker is responsible for each work, the workers can concentrate on the
work allotted to them. They could assure proficiency in the work.
5. Adequate supervision:
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Each staff member is incharge of a work. So he can devote enough time to
supervise the workers.
6. Relief to line executives:
The instructions are given by the specialist directly to the actual workers. Hence
the line executive does not have any problems regarding the routine works.
7. Mass production: large scale production can be achieved with the help of
specialisation and standardisation.
8. Economy: each specialist is responsible to the performance of the work. Wastage
in the production can be avoided and the expenditure could be considerably
reduced.
9. Flexibity: any change in the orgn can be introduced without any difficulty.
Disadvantages of functional orgn

1. Complex relationship: a single worker is working under 8 specialists it is very
difficult for the worker to be responsible to all persons. This results in conflict
between the workers and the specialists.
2. Discipline: it is very difficult to maintain discipline among the workers when a
single worker has to serve many masters.
3. Over specialisation: There might be overlapping of authority and divided
responsibility.
4. Ineffective coordination: the extent of authority of a specialist is not correctly
defined. It creates problems while getting the cooperation among the specialists.
5. Speed of action: when the control of a worker is divided among the specialists, the
speed of action of the workers may be hampered.
6. Centralisation: eight specialists are guiding and directing the workers to perform
the work. So the workers do not have any scope for doing the job on their own.
This leads to the centralisation of authority.
7. Lack of responsibility: if there is any defect in the performance of work, the
management is not in a position to fix the responsibility for it. The reason is that
none of the eight specialists is ready to own the responsibility. They may shift the
responsibility to any one among themselves for the poor performance of work.
8. Poor admn: since many specialists control the same gp of workers no effective
admn of workers could be ensured.
It is very suitable to a business unit which is engaged in manufacturing activities.
C. The line and staff organisation:
In order to strike a balance between the line and functional organisation, it is believed that
the best system to adopt in any progressive and elite organization is the line and staff
organisation.
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 The line officers have authority to take decisions and implement them to achieve
the objectives of the orgn.
 The line officers may be assisted by the staff officers while framing the policies
and plans and taking decisions.
 In the fast developing industrial world, the line officers are not in a position to
acquire the technical knowledge. For eg., while taking decisions regarding the
production, technical knowledge is needed to take correct decisions.
 This type of gap may be bridged with the help of staff officers. The staff officers
may be experts in a particular field.
 Then the line officers can get expert advice from the staff officers before taking the
final decisions.
 Here there is scope for having experts and advisors to advice the commander or
leader of the team whenever and wherever required. The suggestions are honoured
and implemented by the manager to the extent possible.
 The staff or workers are permitted to voice their views in this type of organisations.
Their views and concerns are appreciated, implemented wherever necessary.
 While maintaining the line type of organisation it also takes care of the staff and
coordination between / among the staff with in hierarchial framework makes a
good organisation.
 Staff or worker and their functions get lot of prominence in this type of
organisation.
Staff functions can be divided into 2 areas.
A) Staff advice and b) staff service.
While staff advice relates to staff functions at the higher levels; the staff service
relates to staff functions at lower levels.
Normally there are two types of staff:
General staff: they are normally located at the head quarters or regional offices to assist,
support and advise top management on day to day activities and problems in the
organisation in general and are shared by different divisions.
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Specialised staff: each line official has special assistants or advisors to provide advice and
services to the executives with whom they are attached.Nurses, doctors and other
professionals belong to the category of staff advice, in the industrial concerns.
Merits:
Expert‟s advice becomes available to the line management.
 There is benefit of planned specialization.

 Line managers get more time to devote to their own functions. This results in
greater efficiency.
 Chances of advancement of employees become better as more jobs become
available.
Demerits:
 Staff tend to assume line authority and thus may become a cause of friction
between the two.
 Sometimes staff do not give sound advice because the staff are not accountable for
the implementation of the advice.
 Staff steal credit, although the direction and planning are done by the manager
through sheer hard work and intelligence.
 Staff fail to see the whole picture as they lack the mind of relating advice to the
task and objectives of the enterprise.
Figure:
Advisor specialist Chief administrator

Specialist Advisor
In hosp mgmt
hospital
All heads of depts Dy.Chief (admn) Nsg suptdt Dy.chief (finance &
surgery, accounts)
Medicine, obs & gyn,
paediatrics
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(Here the Heads of departments of surgery, medicine etc and nursing superintendent while
acting as line managers for their respective departments, act as specialised staff for
advising matters related to their respective disciplines like surgery, medicine, nursing etc.,
......... shows staff authority.
Fig 2.
Marketing
(L) manager
Personal asst
to the (S)
(L) managing (personal staff)
Asst managing director
director
Works Company
secretary Sales Personnal
manager (L) (L) manger
(L) (S)element fn
accountant manager
(L)operators (L) clerks (L) sales rep

Training Employme
(S) officer nt officer
(S)
Clerks(s) clerks(s)
 Committee organisation
 Project organisation:
Matrix organisation:
 Matrix structures are characterised by teams built directly into the organisational
structure.
 These teams are coordinated both vertically (within the hierarchy) and horizontally
(among the groups involved).
 The team has formal authority to make and enforce decisions.
 Matrix structure involves less rigid adherence to rules and procedures.
 Free form organisational structures are called matrix organisations.
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 The matrix organisation design enables timely response to external competition
and to facilitate efficiency and effectiveness internally through cooperation among
disciplines.
Characteristics:
1. Maintenance of old-line authority structures.

2. Specialist resources obtained from functional areas.
3. Promotion of formation of new organisational units.
4. Occurrence of decision making at the organisational level of group consensus, the
middle management level.
5. The matrix manager exercising authority over the functional manager.
6. Cooperative planning of program development and allocation of resources to
accomplish program objectives.
7. Assignment of functional managers to teams that respond to the chief of the
functional discipline and matrix manager.
Advantages:
1. Improved communication through vertical, horizontal control and coordination of

interdisciplinary patient care systems.
2. Increased organizational adaptability and flexibility to respond to environmental
changes.
3. Increased efficiency of resource use with fewer organisational levels and decision
making closer to primary care operations.
4. Improved human resource management because of increased job satisfaction with
achievement and fulfilment, improved communication, improved interpersonal
skills and improved collegial relationships.
Disadvantages:
 Potential conflict because of dual or multiple lines of authority, responsibility and

accountability relationships.
 Role ambiguity.
 Loss of control over functional discipline due to multidisciplinary team approach.
22
Adhocracy:
 Adhocracy models of organisation are like matrix models. There are simple teams
or task forces that exists on an adhoc basis.
 They are formed, complete their goals and are disbanded.
 New groups are then formed to meet changing and dynamic mission and
objectives. It employs participatory management.
Theories of organisation
Organisation theory means the study of the structure, functioning and performance of
organisation and the behaviour of individual and groups within it.
The various theories of organisation are given below:
1. Classical theory
2. Neo-classical theory
3. Modern theory
4. Motivation theory
5. Decision theory
Classical theory:
The classical theory mainly deals with each and every part of a formal organisation. The
classical theory was found by the father of scientific management. Frederick W. Taylor.
Next, a systematic approach to the organisation was made by Monney and Reicey.
The classical theory is based on the following 4 principles:
A. Division of labour
B. Scalar and functional processes
C. Structure
D. Span of control
23
Classic organisational theorists believe that the size, structure, division of labour, number
of supervisory levels and span of control are key variables in determining the success or
efficiency of an organization.
L
Figure
L L
L S L S L S
L S L
L
S L L
L L
L
S S S S S S
S S
It is based on the belief that breaking down the operation into specialized components is
necessary for the assignment and completion of responsibilities.
Creating these specialized segments demands coordination that is best handled by

delegation of authority to supervisory personnel such as the nursing administrator or a
head nurse.
Structure is essentially the height of the organisation as compared to its width, whereas
span of control defines the number of employees managed by the supervisor.
A flatter organisation may increase the span of control while decreasing the levels of
authority. Most health care facilities are moving in the direction of a flatter organizational
design.
Classic orgn theory differentiates staff and line relationships. Those with line roles, such
as a head nurse, have direct responsibility for employees and services.
24
Line authority has traditionally been defined as the right to hire and fire. In contrast the
clinical specialist, has traditionally held a staff position, indirectly responsible for the same
services through employee education, consulting and role modelling.
Criticism:
Lack of decision making oppurtunities for employees is a result of structure itself. Often
the individual who makes the decisions and the individual who implements them occupy
different positions on the organisational chart.
This criticism has led to a study of the psychology of work behaviour and research into
employee participation as a means of increasing motivation and commitment.
This theory is based on authoritarian approach.
It does not care about human element in an organisation.
It does not give 2 way communication.
It underestimates or ignores the influence of outside factors on individual behaviour.
The generalisations of classical theories have not been tested by strict scientific methods.
The motivational assumptions underlying the theories are incomplete and consequently
inaccurate.
NEO CLASSICAL THEORY:
This theory is developed to fill the gaps and deficiencies in the classical theory.
It is concerned with human relations movement.
Study of organisation is based on human behaviour such as how people behave and why
they do so in a particular situation.
It points out the practical difficulties of the working of scalar and functional processes.
The main contribution of this theory highlights the importance of the committee
management and better communication.
Besides this theory emphasised that workers should be encouraged and motivated to
evince active participation in the production process.
25
The feelings and sentiments of the workers should be taken into account and respected
before any change is introduced in the organisation.
The classical theory is production oriented while neoclassical theory was people oriented.
Contributions of neoclassical theory:
Person should be the basis of an organisation.
Organisation should be viewed as a total unity.
Individual goals and organisation goals should be integrated.
Communication should be moved from bottom to top and from top to bottom.
People should be allowed to participate in fixing work standards and decision making.
The employee should be given more power, responsibility, authority and control.
Members usually belong to formal and informal groups and interact with others with in
each group or subgroup.
Criticism:
A survey conducted by AMA indicates that most of the companies reported found little or
nothing useful in behavioural theory.
According to ernest dale, „ neither classical theory nor neo classical theory provides clear
guidelines for the actual structuring of jobs and provision for coordination.
Modern organisational theory:(Flatter organization)
It was organised in the early 1950s. This theory composed of the ideas of different
approaches to management development.
The approach is fully based on empirical research data.
The approach reflects the formal and informal structures of the organisation and due
weightage is given to the status and roles of personnel in an organisation.
Like general systems theories, this theory studies the
26
1. Parts in aggregates and the movement of individuals and out of the system.
2. The interaction of individual with the environment found in the system.
3. The interaction among individual in the system.
Modern organisational theorists suggests that an essential element in understanding and

predicting organizational behaviour is the ability to predict the behaviour of the persons
within an organization.
These theorists contend that motivation, satisfaction, leadership and the manner in which
conflicts are resolved are key to organizational harmony and success.
Unlike the classic approach which focuses on structure and function, this approach
maximises the value of the individual.
It recognises that each employee has a set of unique processes, feelings, and thoughts that
may not fit with those of the organisation and may create tension among between
employer and employees.
The supervisor‟s role becomes one of initiating activities that help the employee and
supervisor to succeed together.
Figure:
L
L L
S L S S S S L S
S S S S S S
S S S S S S
Helping employers and employees to work together has been the focus of a variety of
theorists who are convinced that the structure and process of an organisation is a single
phenomenon.
27
For instance, douglas Mcgregor (1960) developed two fictional supervisory belief
systems, labelled theory X and Y, to describe relationships between supervisors and their
employees.
Supervisors who believed in theory X controlled and directed the behaviour of employees,
whereas those who believed in theory Y provided an atmosphere that encouraged
participation in decision making by controlling not the employee but the surrounding work
environment.
Mcgregor attempted to integrate the goals of the organization with those of the employees,
argyris(1972) pointed out the ways in which organisational structure restricts employee
development. For instance, one nurse may be better suited to work in the technical
atmosphere of the operating room, whereas another achieves and succeeds as a
professional in psychiatric nursing care.
A mismatch in either case would inevitably lead to tension between the nurse and the
health care facility.
These tensions require the employer action to be resolved.
Issues the supervisor might consider include the rates of absenteeism, turnover, and the
role of labor unions.
The employer may suggest relocating the employee to another section to give that
individual a better chance of succeeding.
One of the most important beliefs in modern organisational theory is that the individual
must fit the organisation and organisation must fit the individual,
Another central belief is that organisations are systems that function through relations of
many parts.
According to senge, systems thinking is a discipline for seeing wholes. Drawn from the
fields such as engineering, social sciences and cybernetics, system thinking focuses on
relations rather than on direct cause and effect, and on change over time rather than on
single events.
28
Systems thinking suggests that individual behaviour can have collective consequences
within an organisation. In health care organisations, this means that everyone within the
organisation influences the effectiveness of the organisation as a system.
Criticism of modern theory
This theory puts old wine into a new bottle.
It does not represent a unified body of knowledge. There is nothing new in this theory
because it is based on past empirical studies.
This theory forms only the questions and not the answers.It is based on behavioural,
social and mathematical theories. These are management theories in themselves.
4. Motivation theory: it is concerned with the study or work motivation of

employees of the organisation. The works are performed effectively if proper
motivation is given to the employees. The motivation may be in monetary and non
monetary terms. The inner talents of any person can be identified after giving
adequate motivation to employees. Maslow‟s hierarchy of needs theory and
honberg‟s two factor theory are some of the examples of motivation theory.
5. Decision theory: decision making theory. This theory is given by

Herbert.A.Simon. he was awarded nobel prize in the year of 1978 for this theory.
He regarded organisation as a structure of decision makers. The decisions were
taken at all levels of the organisation and policy decisions are taken at the higher
levels of organisation.
Simon s suggested that the organisational structure be designed through an
examination of points at which decisions are made and the persons from whom
information is required if decisions should be satisfactory.
Organisation structure
Organizing is the second administrative function which is considered to be a process of

creating a structure or platform where various people can work together to attain their
common objectives effectively.
29
These people work together and combine their efforts consciously and harmoniously
towards attainment of the common goals of the establishment which is termed
organisation also.
There are two distinct features in this process:
1. Determining the divisions of work within the establishment and formation or

constitution of units and subunits or departments in the context of the
organisational strategies and objectives.
2. Establishing the pattern of authority relationships within the organization that will
link the top level managers to the bottom most level of work force. This is essential
for distribution and coordination of the various task required to be performed
within the organisation. This network or pattern of relationships within an
esatblisment is known as the organisation structure.
Content:
The organisation structure should indicate:
1. Well defined relationships (vertical, horizontal and lateral) of all categories of staff
belonging to all levels of management as well as the workforce.
2. Well defined duties and responsibilities of all categories of personnel – both
management and workforce.
3. Hierarchial relationship between the supervisors and the subordinates within the
establishment.
4. Assignment of tasks to individuals, divisions and department.
5. Coordination of activities and tasks.
6. Policies, rules, regulations, procedures and methods for performance of tasks and
activities as well as for evaluation of performance.
Functions:
Providing well defined authority relationships and delegation of authority(right to do or

the right to command others to do).
Definition of delegation:
30
Delegation is defined as assigning authority to a person who thereby assumes the right to
perform a task including decision making task and is accountable for the task.
Authority in an organisation may be defined as the right to command people within the
organization and use organisational resources for performance of tasks and activities
within the framework of the organizational policies, rules, regulations and procedures.
Develops and describes channels and patterns of communication between the management
and the workforce, between supervisors and subordinates, between the divisions and
departments within the organization.
Decides and identifies decision making centres within the organization for different
decision areas and communicates the same to all concerned.
Effects balance within the organization for different decision areas and communicates the
same to all concerned.
Encourages creativity and innovation through clearcut authority relationships and inviting
participation from those having potentials.
Provides oppurtunities for growth and development of the organization through capacity
building, maintaining a constant level of quality performance and consciously making
efforts to meet the needs and demands of the changing economic and environmental
climate.
Adapts to change, makes use of available and cost effectiveness new technologies that are
beneficial for the organisation; encourages operational research and studies to obtain prior
and valid information on the changing requirements and consequent notifications
necessary in the organization structure.
Committees in an organisation:
Committees can be formed for many reasons. i.e, to resolve a particular problem for a
particular period (adhoc committees), permanent committees like finance committee,
personnel selection committee, establishment committee to deliberate upon and resolve
issues on a regular basis (standing committees).
Organisational charts
31
 Organisation charts and manuals are prepared for the purpose of describing the
organization structure.
 These are used as tools of management control.
 They give full information on a particular organisation.
 An executive finds out his exact place in the organisation structure from the charts
and manuals.
 It shows the responsibility and authority of an executive. He knows his superior for
whom he is responsible and his subordinates whom he has to supervise.
J.Batty defines, “an organisation chart is a diagrammatic representation of the framework

or structure of an organisation”.
Terry defines, “an organisation chart is a diagrammatical form which shows the
important aspects of an organisation including the major functions and their respective
relationship, the channels of supervision and the relative authority of each employee who
is incharge of each respective function”.
Contents of organisation charts
1. Basic organisation structure and flow of authority.

2. Authority and responsibilities of various executives.
3. The relationship between the line and staff officers.
4. Names of components of organisation.
5. Positions of various office personnel.
6. Number of persons working in the organisation.
7. The present and proposed organisation structure.
8. Ways of promotion.
9. The requirements of management development.
10. Salary particulars
TYPES OF ORGANISATION CHART: all use a spatial relationship (i.e, a distance

between) to illustrate differences in rank, authority or status.
1. Basic(Vertical chart): the basic relationship is that between superior and

subordinate, and usually this is shown vertically. The lines of command flows
32
from the top level to the bottom in vertical lines. This vertical chart is in the
form of a graph. This type is followed in companies.
Superior-supervisor,etc
A
Subordinate-operator,clerk,etc
This fig shows superior/subordinate relationship.
2.Horizontal chart: the lines of command flows horizontally. In this, the supervisor is
on the left side of the chart and the subordinate on the right side or vice versa. This is
not followed in any organisation.
3. Master and supplementary charts:

 a chart that shows the entire organisation is called master chart.
 It gives the clear picture of the organisation and major sections or divisions
in the organisation.
 A chart which shows a particular section or division of the organisation is
called supplementary or unit chart.
 It shows the details of relationship, authority and duties within the specified
area.
Scalar chain: most organisations that a manager or supervisor is likely to encounter will
have more than two members. Henry fayol produced what he called the „scalar chain or
chain of grades or steps‟ and his chart looked like a triangle without a connecting base
line.
A
B L
C M
D N
E O
F P
G Q
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This chart looks odd to our eyes: as we have seen, we do not often meet a situation
where nearly every manager(i.e, F,E,D,C,B,L,M,N,O,P) has only one subordinate.
However it would appear fayol,s chart was even more abstract than the type of charts we
use commonly today.
It does however help us to understand that:
1. Authority and powerflow from the top (A) downward.

2. Accountability flows upward.
 Authority is the right or power to make decisions or give instructions or
orders.
 Accountability is the obligation to give an account of the stewardship of the
authority given, to a supervisor. Such supervisors are in turn are
accountable to their superiors.
This reporting or accounting chain is what fayol refers as to the scalar chain, and
some contemporary writers the ‘job task pyramid’.
The ‘T’ chart:
The job task pyramid idea becomes a little clearer if we use a‟T‟ chart, the most
widely used and understood map of the organization.
In its most basic form it consists of a series of inverted letter „T‟s (taking a ruler,
we can quite quickly draw a pyramid shape around the chart.)
Fig 2: Basic „T‟ chart or job task pyramid

manager
Supervisor Supervisor supervisor

A B C
1 2 3 4 5 X Y P Q R S T
The 3 supervisors are of pretty equal status, and the numbers of staff each control
are similar.
Wheel charts:
34
Sometimes, it is more useful to indicate, in addition to a superior/ subordinate relationship,

a geographical one.
Consider a firm with a head office in Birmingham and factories in London, Bristol,
Liverpool, Glasgow, Newcastle and Ipswich.
We could envisage such an organisation as a wheel with the group production director(A)
in the centre, and the factories at the ends of the various spokes.
GL
LP NC
BRIS IPS
LON
Modified ‘T’ chart:
There are many ways of setting out relationships, and we are at liberty to combine
„T‟ charts with wheel chart (or any other variety).
The implication here is that London, Liverpool, Newcastle, and Glasgow do not
communicate with each other fig 2.1:
The illustration in fig 2.2 then we might feel that London, Liverpool etc., do
communicate.
Group managing director

FIG 2.1
Director Director Production Director

A B Director C
LON LP NC GL
FIG 2.2
PRODUCTION DIRECTOR
LON LP NC GL
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MODIFIED T CHART
Circular concentric charts:
 Here we place the top person in the centre and jobs at different levels are
shown in concentric circles surrounding the central job.
 The position of the top executive is shown in the centre of the chart.
 The subordinates of this top executive are shown in all directions outward
from the centre.
 It derivates the status of different levels of subordinates and shows clearly
each person‟s responsibility.
 It is the best representation of relationship existing among the employees in
an organisation structure.
Fig 2.3:
buyer
Produc
Chief
manager
Managing
Director
Personnel manager
36
The spatial implication here is the nearer the centre you are, the greater your position,
power and authority; conversely those at the outside of the circle have lower status and
position.
You can use any device you like to picture or model the organization, always provided
the chosen method is:
a) Appropriate
b) Accurate (about the aspects to be shown)
c) Easily understood.
The charts should describe, not prescribe, and there are inherent shortcomings in every
model.
Principles of organisation chart:
1. Observation of lines of authority by top executives: the executives should never by

pass the lines of authority. The executives should give orders or obtain information
by following the lines of authority.
2. Observation of lines of authority by subordinates;
3. Defining lines of position: the position of each individual in an organisation
should be clearly stated. The staff should be assured that there would not be
overlapping and two persons would not be appointed to the same position when
their authorities and responsibilities are different.
4. Non-assignment of same duty twice: an individual should not be compelled to
work under two masters for the same work performance.
5. Avoid unique concentration of duty: all work or maximum work should not be
concentrated in a single point. The work should be divided according to the duties
and responsibilities of each worker and the administrative relationship with others.
6. Organisation charts should be above personalities: a position should not be
assigned to a person since he is the son or relative of any one of the top executives
37
of the organisation. Importance should be given to an organisation than to an
individual.
7. Simple and flexible: understandable. Size and nature of the organisation may be
changed in course of time. Need may arise for periodical modification in the
organisation chart. Then the existing organisation chart should permit these
modifications.
Advantages of organisation charts:
1. They give a clear picture of the organisation in a simple way.

2. They show the levels of authority and relationship prevailing among employees at
a glance.
3. Dual reporting relationships and overlapping positions come to light in the
preparation of organisation chart.
4. Instructing work is simplified.
5. Newly hired personnel can understand their role in the organisation and behave
accordingly.
6. Strengths and weaknesses of an organisation are evaluated.
7. It act as authoritative sources of information.
8. The lines of authority shown are definite and formal.
9. The lines of promotion can be understood.
10. Organisation charts help planning and improve communication both inward and
outward.
11. Correct methods of checking and balances in the organisation are provided.
12. The degree of contribution to organisation and acheivements can be identified.
13. The obstacles to the efficient functioning of the mgmt can be found while drawing
the organisation chart.
14. The outsiders can have a quick understanding of each department and orgnal
disputes can be solved in the organisation.
Limitations of organisation charts:
1. Most of the org charts are like photos taken in an instant.

2. The organisation charts create more rigidity of relationship prevailing among the
employees of the organisation.
38
3. It is very difficult to maintain and ensure that the organisation charts uptodate. The
employees of the organisation are very reluctant to put up with the organisation
changes.
4. The organisation charts don‟t show the informal relationship existing among the
organisation staff members.
5. If the charts are not correctly prepared, they will lead to misleading inference. A
false picture may be developed by following the oversimplified organisation
structure.
6. There is no differentiation between line officers and staff officers in an
organisation chart.
7. The organisation charts produce a psychological complex such as superiors,
inferiors etc., in the minds of the employees.
8. The relationship shown in an organisation chart does not actually prevail among
the employees.
9. The words and lines used in an organisation charts give different meanings to
different people.
Organisation manuals:
Organisation manual is a document prepared in an organisation to furnish information on a

particular organisation.
A brief history of the organisation is given in this manual. It is usually prepared in the
form of small booklet.
Any person can
Developing an organisational structure:
An organisational structure for a division of nursing must meet the needs of that division
as written in the statements of mission, philosophy, vision, values and objectives.
Most existing institutions already have an organisational structure. Before the structure is
changed, the nurse managers should engage in a systematic analysis as well as some sound
thinking about altering the organisation‟s design and structure, starting with objectives and
strategy.
39
Minimum requirements of an organisational structure:
1. Clarity: N‟s sd know where they belong, where they stand in relation to the quality
and quantity of their performances, and where to go for assistance.
2. Economy: there should be the smallest possible number of overhead personnel
necessary to keep the division and units operating and well maintained.
3. Direction of vision: nurse managers must direct their vision and that of their
employees toward performance, towards the future and towards strength. Nurses
must understand their own tasks and the common tasks of the organisation. They
should see that their tasks fit the common tasks so that the structure helps
communication.
4. Decision making: nurses should be organized to make decisions on the right
issues and at the right levels. They should be organized to convert their decisions
into work and accomplishments. The chair of the department of nursing and the
staff make all nursing decisions and see that nursing work is done.
5. Stability and accountability: nurses should be organized to feel community
belonging. They can adapt to show objectives requiring changes in their functions
and productivity.
6. Perception and self renewal: nursing services should be organised to produce
future leaders. The organisational structure should produce continuous learning for
the job each nurse holds and for promotion.
To apply design principles that are appropriate, the nurse manager uses a mixture of all
that are productive, including the following:
 Organizational needs derive from the statements of mission and objectives and
from observation of work performed.
 Organisational design and structure develop to fit organizational needs, so that
people perform and contribute to achieving the work of the division of nursing.
 A formal organization should be flexible and based on policy that promotes
individual contributions to the achievement of organizational objectives.
 A formal organization is efficient when it promotes achievement of objectives with
a minimum of unplanned costs or outcomes.
40
 A formal organisation should build the least possible number of management

levels and forge the shortest possible chain of command. This eliminates stresses
and levels of friction, slack and inertia.
The standards for evaluating departmentation of authority in nursing division,
department, service or unit.
Organizational effectiveness
The product or output of an organization is termed as organizational effectiveness.

There should be a relationship between organizational effectiveness and
organizational performance.
Nurse managers define the goals and provide the resources for both organizational
effectiveness and organizational performance.
The goals have many dimensions, which include the following.

1. Patient satisfaction with care
2. Family satisfaction with care
3. Staff satisfaction with work
4. Staff satisfaction with rewards, intrinsic and extrinsic.
5. Staff satisfaction with professional development: career, personal and
educational.
6. Staff satisfaction with organisation
7. Management satisfaction with staff
8. Community relationships
9. Organizational health
Organisational climate:
The organisational climate is the personality of an orgn, the perceptions and feelings
shared by members of the system.
It can be formal, relaxed , defensive, cautious, accepting, trusting and so on.
It is employer‟s subjective impressions or perceptions of their organisation.
41
Practicing nurses create or at the very least, contribute to the creation of the climate
perceived by the patients.
Manager creates the climate in which practicing nurses work. If managers trust them,
practicing nurses will provide their managers with good information to keep their
managers informed.
The following are 6 sociological dimensions of organisational climate:
1. Clarity in specifying certification of the organization‟s goals and policies. This is

facilitated by a smooth flow of information and management support of employee.
2. Commitment to goal achievement through employee involvement.
3. Standards of performance that challenge, promote provide and improve individual
performance.
4. Responsibility for one‟s own work, fostered and supported by managers.
5. Recognition for doing good work.
6. Teamwork- a sense of belonging, mutual trust and respect.
The environmental dimensions of climate incude: room attractiveness, illumination

and the shape of the furniture.
Practicing nurses want a climate that will give them job satisfaction. They achieve
job satisfaction when they are challenged and their acheivements are organised and
appreciated by managers and patients. They achieve satisfaction from a climate of
collegiality with managers and other health care providers, a climate in which they
have input into decision making.
Practicing nurses want a climate that provides good working conditions, high
salaries and oppurtunities for professional growth through counselling and career
development experiences that will enable them to determine and direct their
professional futures.
They want a climate of administrative support that includes adequate staffing and
shift options.
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The following activities promote a positive organizational climate:

1. Developing statements of the organization‟s mission, philosophy, vision, goals
and objectives with input from practicing nurses, including their personal
goals.
2. Establishing trust and openness through communication that includes prompt
and frequent feedback and stimulates motivation.
3. Providing oppurtunities for growth and development, including career
development and continuing education programs.
4. Promoting team work.
5. Asking practicing nurses to state their satisfactions and dissatisfactions during
meetings and conferences and through surveys.
6. Marketing the nsg orgns to the practicing nurse, other employees and the
public.
7. Following through on all activities involving practicing nurses.
8. Analyzing the compensation system for the entire nsg orgn and structuring it to
reward competence, productivity and longevity.
9. Promoting self esteem, autonomy and self fulfilment for practicing nurses,
including feelings that their work experiences are of high quality.
10. Emphasizing programs to recognize practicing nurses contributions to
organization.
11. Assessing unneeded threats and punishments and eliminating them.
12. Providing job security and an environment that enables free expression of ideas
and exchange of opinions.(threats and recriminations, which may occur as
down scaled performance reports, negative counselling, confrontation, conflict
or job loss, are not part of a positive organisational climate).
13. Being inclusive in all relationships with practicing nurses.
14. Helping nurses overcoming their short comings and develop their strengths.
15. Encouraging and supporting loyalty, friendliness and civic consciousness.
16. Developing strategic plans that include decehtralization of decision making and
participation by practicing nurses.
17. Being a role model of performance desired for practicing nurses.
43
2.ORGANIZING NURSING SERVICES AND PATIENT CARE
INTRODUCTION
“A hospital may be soundly organized, beautifully situated and well equipped, but if the
nursing care is not of high quality the hospital will fail in its responsibility.”
Jean barrett
Who is the effective member of the patient care team? Sir William Osler said that the
nurse is one of the greatest blessings of humanity. Nursing has a large, important and unique role
in the health care delivery system of a country. Nursing care is extremely important for good
patient outcome. While the physician plans the treatment and surgeon carries out the operation, it
is the nurse who gives 24 hrs / round the clock nursing care and looks after the needs of the
patient. The success of the patient care depends upon the competence of the nursing staff.
Organizing the high level of nursing care is a big challenge for the nursing service administrator.
Setting of standards and goals for providing care to patients depends upon the philosophy of
nursing in order to organize the patient care.
OBJECTIVES
♪ General objective:
At the end of the seminar the student will be able to understand about the organizing of
nursing service and patient care and its detail.
TERMINOLOGIES:
Case method In this method, nurses assume total responsibility for meeting all the
needs of assigned patients during their time on duty.
Modular nursing The patient unit is divided into modules or districts, and the same team of
caregivers is assigned consistently to the same geographic location
Nursing service It is the part of the total health organization which aims at satisfying the
nursing needs of the patients/community.
Objective The goal intended to be attained (and which is believed to be attainable).
Organizing It involves grouping activities together and assigning the responsibility of

each group of activity to a manager who has adequate authority to
fructify the activity/task at hand.
Patient classification Patient classification system (PCS), which quantifies the quality of the
system nursing care, is essential to staffing nursing units of hospitals and nursing
homes.
Patient care Care of the sick and injured and restoration of the health of a diseased
person without any decimation.
44
ORGANIZING NURSING SERVICES

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

WHO expert committee on nursing defines the nursing services as the part of the total
health organization which aims to satisfy major objective of the nursing services is to provide
prevention of disease and promotion of health.
PHILOSOPHY OF NURSING SERVICE IN HOSPITAL

The department of nursing services of hospital recognizes and appreciates the objectives
of the hospital and acknowledges that the primary purpose of nursing is to provide the highest
quality care services.
 The quality in nursing care and management of nursing services is achieved

through professional nurses who assist in the development of comprehensive
programs of delivering nursing care.
 The quality of nursing care services is clearly and directly related to continuing
growth and development of nursing personnel.
 High quality of nursing care can be best provided by a mixture of professional and
non professional personnel who are organized into self directed work teams.
 To ensure continuous improvement of nursing care quality, the role of professional
nurse must include responsibility of nursing research and nursing education.
OBJECTIVES OF NURSING SERVICE

The first component of nursing service administration is the planning and it should be
based on clearly defined objectives. The objectives of nursing service department are as follows:
Objectives in relation to Patient care
The primary emphasis is on total patient care that is:
 To give highest possible quality care in terms of total patients need which include
physical, psychological, social, educational and spiritual needs by collaborating
with other health tem members.
 To assist the physician in providing medical care to the patients.
 To provide preventive and rehabilitative services.
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 To provide round the clock nursing care to all the patients.
 To render timely and appropriate nursing service to emergency patients.
 To provide cost effective quality care as per the needs of patients.
 Confidentiality and privacy of each patient should be maintained.
 Constant monitoring and evaluating is of utmost importance to improve patient
care continuously.
Objectives in relation to Education
 Planning of education and training programme for nurses are must for professional
growth and development needs through in-service education and research support.
 To provide regular staff development, in-service education and guidance services
for all members of nursing staff.
 To conduct regular orientation programme for new entrants and for those have
been on the job for a long time.
 To conduct training for operating procedure of latest gadgets and on handling
sophisticated bio-medical equipment.
Objectives in relation to Administration and Organization
 To make regular supervision through rounds.
 To ensure that the essential equipment is provided in functional status for nursing
care services.
 To provide regular flow of essential supplies to render quality nursingcare.
 To have a proper system of rotation of staff, provision for annual leave and days
off for the nursing staff without hampering patient care.
 Establish a communication system for nursing personnel, other health worker,
patients, health authorities, government authorities and public.
 Ensure that each nurse identifies her job responsibilities and accountability.
 Counseling for health personnel, patients and the public.
 The formulation of policies, standards, goals of nursing service, education and
practice.
 Maintaining proper documentation of the personnel employed in nursing service.
Objectives in relation to Research
 Establish a system for collection of essential information, research and studies
concerning all aspects of nursing.
 To contribute in research programme conducted by hospitals and by other health
personnel.
 To encourage and support the nurse to conduct research projects/ activities.
Objectives in relation to Performance appraisal
 Appraise the performance of nursing service personnel regularly against set
standards and performance indicators objectively with a view to maintain quality-
nursing services.
PRINCIPLES OF NURSING SERVICE

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

◘ To assist the individual patient in performance of those activities contributing to
his health or recovery that he would otherwise perform unaided has had the
strength, will or knowledge.
◘ To help and encourage the patient to carry out the therapeutic plan initiated by the
physician.
◘ To assist other members of the team to plan and carry out the total programme of
care.
The organization of nursing care constitutes a subsystem for achieving the hospital‟s overall
objective. Nursing care of patients generally takes forms:
 Technical
 Educational
 Trusting relationship
The director of nursing service is delegated the authority and responsibilities for
organizing and administrating the nursing services in hospital. It is her duty to institute the
essential characteristics of good nursing services in her institute such as:
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Written statement of purposes and objectives of nursing services
Plan of organization
Policy and administrative manuals
Nursing practice manual
Nursing service budget
Master staffing pattern
Nursing care appraisal plan
Nursing service administrative meetings
Adequate infrastructure facilities, supplies and equipment
Written job description & job specifications
Personnel records
Personnel policies
Health services
In–service education
Co-ordination
Advisory committee
Purposes and objectives of the nursing service:

The purposes should be in accordance with the hospital philosophy regarding patient
care and approved by administration. It must characterize the principles of excellence in
service, in practice and leadership. Objectives are specific, practical, attainable,
measurable and understandable to all the nursing staff.
Plan of organization:
Every hospital has the basic system of coordination of vast number of activities
i.e. the Director of Nursing service, she is responsible for maintaining standards for patient
care in terms of quality nursing service must be familiar with the formal organizational
structure of the hospital and its relationship in various department and their functions. The
plan of organization should indicate inter as well as intra-department relationship. The
plan also should indicate area of responsibility and to whom and for whom each person is
accountable and the channels of communication.
Policy and administrative manuals:
The policy and procedure manual are required for the operation of the hospital.
Policies are established within the department to guide the nursing staff, which includes
duty hrs, rules and regulations etc. These are periodically revised and reviewed at regular
intervals.
Nursing practice manual:
This the written procedure available as evidence of the standards of performance
established by nursing service organization for safe and effective practice after taking into
consideration the best use of available resources. Liberal use of diagram and precautions in
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nursing manual helps to keep instruction direct and exact. The advantages are ensure
economy of time effort & material and provides basis for training for new personnel to
acquire knowledge and current skill.
Nursing service budget:
It is required for personnel budget, nurse‟s welfare activities, staff
development programme, equipment and capital expenditure, supplies and
expenses. Budget preparation should includes analysis of past operation and
anticipating the future revenue and expenses.
Master staffing pattern:
It is the number and composition of nursing personnel assigned to work in a hospital
in different department / wards at a given time. This helps the director to visualize the
equitable distribution of nursing personnel among various nursing unit. It serves as a guide
for planning daily, weekly and monthly schedules.
Nursing care appraisal plan:
Employing various techniques such as supervision, ward rounds, conference,
anecdotal record, rating scale, checklist, suggestion box and peer review can do
performance appraisal of nurses. This is done to improve the quality of service provided,
determine the job competence and to enhance staff development.
Nursing service administrative meetings:
This meeting gives opportunity for free communication, planning and evaluation of
the nursing service through regular meeting of the director of nursing with total nursing
staff. The purposes are regular exchange of view between management and nursing
service for improving working condition, welfare of patient and improvement in methods
and organization of work.
Adequate infrastructure facilities, supplies and equipments:
The director of nursing evaluates periodically the adequate resources and arranges new
facilities needed for patient care in discussion with the hospital administrator.
Written job descriptions and job specifications:
In job description the responsibility are clearly spelt out as precisely including the job
content, activities to be performed, responsibility and result expected from various role
required by the organization. It is useful for reducing conflict, frustration, overlapping
duties and acts as a guide to direct and evaluate person.
Personnel records:
Personnel records include the information relating to the individual such as
recruitment and selection, medical records, training and development, transfer records,
promotion, disciplinary action records, performance records, absenteeism data, leave
record and salary records, etc.
Personnel policies:
It reflects an analysis of the total job of nursing in accordance with the types of
functions to be performed. It also indicates the qualitative and quantity of service to be
maintained and the purpose for which the hospital exist.
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Health services:
Supervision of health of each employee by means of pre-employment physical
examination, periodic examination, immunization and provision of diagnostic, preventive
and therapeutic measures. The education of employee in the principle of health and
hygiene so that they may develop healthy habit of living and working.
In-service education:
It is the essential components of staff development programme, which aims at
augmenting, reinforcing nurse‟s knowledge, skill and attitude. It includes orientation
programme, skill training, leadership and management training, on the job training, staff
development.
Co-ordination:
Regular consultation and discussion between the heads of departments and with
members of the medical staff could be an integral part of the administration.
Advisory committee:
Each committee has a clear statement and its membership is appropriate to the
purpose. After carefully weighing the advice of the committee, she makes the final
decision about the matter within her area of responsibility and becomes accountable for
implementation.
ORGANISATION OF NURSING SERVICES:
DIRECTOR (hospital) DIRECTOR OF HEALTH

SERVICE
Chief Nursing Officer Asst. Director of Health Service
Nursing Superintendent Nursing Superintendent Grade-I
Deputy Nursing Superintendent Nursing Superintendent Grade-II
Assistant Nursing Superintendent Head Nurse
Ward Sister - Clinical Supervisor Staff Nurse
Staff nurse Student nurse
ORGANIZING NURSING SERVICE AT VARIOUS LEVELS

The organization of nursing service varies from institution to institution.
Organizational set-up at Directorate General of Health Services
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DGHS
Addl.DG (PH) Addl.DG (N) Addl.DG (M)
ADG ADG ADG

(Community Nsg service) (Nsg-education & research) (Hospital Nsg service)
DADG DADG DADG

Community & Nsg officer Principal Nsg.Supdt
PHN Supervisor Senior Tutor Dy.Nsg.Supt
PHN Tutor
Asst.Nsg.Supt
LHV Clinical Instructor Ward sister
ANM Staff Nurse
Organizational set-up of Nursing Service at Central Level

Secretary, Health
Director Nursing Service
Joint/Deputy Director Nursing services
ADNS ADNS ADNS

DADNS DADNS DADNS

DADNS DADNS DADNS

Dist. Nsg officer DADNS Nsg.Supdt
PH. Nsg officer Principal Dy.Nsg.Supt
PHN at PHC Senior Tutor Asst.Nsg.Supt
LHV Tutor Ward sister
ANM Clinical Instructor Staff Nurse
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Organizational set-up of Nursing Service at State Level
Director Nursing Services
Deputy Director Nursing Services
Assistant Director Nursing Services
Deputy Assistant Director Nursing Services
DMO DNO DHO
ADNO (Hosp&Nsg.Edu) ADNO (Community)
Nsg Supt/Dy.Nsg.Supt Principal tutor Dist.PNO

Asst.Nsg.Supt Tutor PHN Supervisor (CHC)
Ward Sister Clinical Instructor PHN (PHC)
Staff Nurse LHV
ANM
KEYS:
 DGHS - Director General of Health Services
 Addl. DG (PH) - Additional Director General (Primary Health)
 Addl. DG (M) - Additional Director General (Medical)
 Addl. DG (N) - Additional Director General (Nursing )
 ADG - Assistant Director General
 DADG - Deputy Assistant Director General
 PHN - Primary Health Nurse
 LHV - Lady Health Visitor
 ANM - Auxiliary Nurse Midwives
 ADNS - Assistant Director Nursing Service
 DADNS - Deputy Assistant Director Nursing Service
 DMO - Director of Medical Office
 DNO - Director of Nursing Office
 DHO - Director of Health Office
ROLE AND FUNCTION OF NURSE ADMINISTRATOR

The Principal Matron of the hospital will be responsible to the Commandant of the
hospital for the following duties:
♪ Administration
♣ Organizes, directs and supervises the nursing services both day and night.
♣ Coordinates assignments of staff.
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♣ Establishes the general pattern of delegation of responsibilities and

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

♠ Lack of adequate training.
♠ Problem of personnel management.
♠ Inadequate number of nursing staff.
♠ Shortage of trained manpower.
♠ Lack of motivation.
♠ No involvement in planning.
♠ No career mobility.
♠ Poor role model.
♠ No research scope.
♠ Professional risk/hazards.
♠ No autonomy in nursing activities.
Day to day problem in nursing services
♠ Shortage of nurses.
♠ Lack of motivation.
♠ Negative attitude.
♠ Lack of training.
♠ Lack of team approach.
♠ Inactive participation of program
♠ Lack of interpersonal relationship
♠ Less involvement in patients care by the nursing supervisors.
♠ Lack of supervision.
ORGANIZING PATIENT CARE

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

 The services rendered by members of the health profession and non-professionals under
their supervision for the benefit of the patient.
OR
 The prevention, treatment and management of illness and the preservation of mental and
physical well-being through the services offered by the medical and allied health
professions.
PATIENT CLASSIFICATION SYSTEMS

Patient classification system (PCS), which quantifies the quality of the nursing care, is
essential to staffing nursing units of hospitals and nursing homes. In selecting or implementing a
PCS, a representative committee of nurse manager can include a representative of hospital
administration. The primary aim of PCS is to be able to respond to constant variation in the care
needs of patients.
Characteristics
 Differentiate intensity of care among definite classes.
 Measure and quantify care to develop a management engineering standard.
 Match nursing resources to patient care requirement.
 Relate to time and effort spent on the associated activity.
 Be economical and convenient to repot and use.
 Be mutually exclusive, continuing new item under more than one unit.
 Be open to audit.
 Be understood by those who plan, schedule and control the work.
 Be individually standardized as to the procedure needed for accomplishment.
 Separate requirement for registered nurse from those of other staff.
Purposes
◘ The system will establish a unit of measure for nursing, that is, time, which will be
used to determine numbers and kinds of staff needed.
◘ Program costing and formulation of the nursing budget.
◘ Tracking changes in patients care needs. It helps the nurse managers the ability to
moderate and control delivery of nursing service
◘ Determining the values of the productivity equations
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◘ Determine the quality: once a standards time element has been established, staffing
is adjusted to meet the aggregate times. A nurse manager can elect to staff below
the standard time to reduce costs.
Components
The first component of a PCS is a method for grouping patient‟s categories.
Johnson indicates two methods of categorizing patients. Using categorizing
method each patient is rated on independent elements of care, each element is
scored, scores are summarized and the patient is placed in a category based on the
total numerical value obtained. Johnson describes prototype evaluation with four
basic categories for a typical patient requiring one –on- one care. Each category
addresses activities of daily living, general health, teaching and emotional support,
treatment and medications. Data are collected on average time spent on direct and
indirect care.
The second component of a PCS is a set of guidelines describing the way in which
patients will be classified, the frequency of the classification, and the method of
reporting data.
The third component of a PCS is the average amount of the time required for care
of a patient in each category.
A method for calculating required nursing care hours is the fourth and final
component of a PCS.
Patient Care Classification
Area of care Category I Category II Category III Category IV
Eating Feeds self Needs some help in Cannot feed self but is Cannot feed self any
preparing able to chew and may have difficulty
swallowing swallowing
Grooming Almost Need some help in Unable to do much for self Completely
entirely self bathing, oral hygiene … dependent
sufficient
Excretion Up and to Needs some help in In bed, needs bedpan / Completely

bathroom getting up to bathroom urinal placed; dependent
alone /urinal
Comfort Self Needs some help with Cannot turn without help, Completely
sufficient adjusting position/ bed.. get drink, adjust position dependent
of extremities …
General Good Mild symptoms Acute symptoms Critically ill

health
Treatment Simple – Any Treatment more than Any treatment more than Any elaborate/
supervised, once per shift, foley twice /shift… delicate procedure
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simple catheter care, I&O…. requiring two nurses,

dressing… vital signs more often
than every two
hours..
Health Routine Initial teaching of care of More intensive items; Teaching of resistive
education & follow up ostomies; new diabetics; teaching of apprehensive/ patients,
teaching teaching patients with mild adverse mildly resistive patients….
reactions to their illness…
MODES OF ORGANIZING PATIENT CARE / METHODS OF PATIENT ASSIGNMENT

The most well known means of organizing nursing care for patient care delivery are,
Case method or Total patient care
Functional nursing
Team nursing
Modular or district nursing
Progressive patient care
Primary nursing
Case management
Each of these basic types has undergone many modifications, often resulting in new
terminology. For example, primary nursing has been called case method nursing in the past and is
now frequently referred to as a professional practice model. Team nursing is sometimes called
partners in care or patient service partners and case managers assume different titles, depending
on the setting in which they provide care. When closely examined most of the newer models are
merely recycled, modified or retitled versions of older models. Choosing the most appropriate
organizational mode to deliver patient care for each unit depends on the skill and expertise of the
staff, the availability of registered professional nurse, the economic resources of the organization
and the complexity of the task to be completely.
CASE METHOD
Features:
It was the first type of nursing care delivery system. In this method, nurses assume total
responsibility for meeting all the needs of assigned patients during their time on duty. It involves
assignment of one or more clients to a nurse for a specific period of time such as shift. The patient
has a different nurse each shift and no guarantee of having the same nurses the next day. Nurse‟s
responsibility includes complete care including treatments, medication and administration and
planning of nursing care. This is the way most nursing students were taught – take one patient and
care for all of their needs. This model is used in critical care areas, labor and delivery, or any area
where one nurse cares for one patient‟s total needs. Here nurses were self-employed when the case
method came into being, because they were primarily practicing in homes. It lost much of that
autonomy when healthcare became institutionalized in hospitals and clinics and now called as
private duty nursing.
Merits:
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♣ The nurse can attend to the total needs of clients due to the adequate time and
proximity of the interactions.
♣ Good client nurse interaction and rapport can be developed.
♣ Client may feel more secure.
♣ RNs were self-employed.
♣ Work load can be equally divided by the staff.
♣ Nurse‟s accountability for their function is built-it.
♣ It is used in critical care settings where one nurse provides total care to a small
group of critically ill patients.
Demerits:
♠ Cost-effectiveness.
♠ The greater disadvantage to case nursing occurs, when the nurse is inadequately
trained or prepared to provide total care to the patient.
♠ Nurse may feel overworked if most of her assigned patients are sick.
♠ She/he may tend to „neglect‟ the needs of patient when the other patients „problem‟
or „need‟ demands more time.
FUNCTIONAL NURSING
Features:
This system emerged in 1930s in U.S.A during WWII when there was a severe shortage of
nurses in US. A number of Licensed Practice Nurses (LPNs) and nurse aides were employed to
compensate for less number of registered nurses (RNs) who demanded increased salaries. It is task
focused, not patient-focused. In this model, the tasks are divided with one nurse assuming
responsibility for specific tasks. For example, one nurse does the hygiene and dressing changes,
whereas another nurse assumes responsibility for medication administration. Typically a lead nurse
responsible for a specific shift assigns available nursing staff members according to their
qualifications, their particular abilities, and tasks to be completed.
Charge Nurse
RN RN LPN UAP
Medication Nurse Treatment Nurse Vital signs Nurse Hygiene
Nurse
Patients assigned to the team
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Merits:
♣ Each person become very efficient at specific tasks and a great amount of work can
be done in a short time (time saving).
♣ It is easy to organize the work of the unit and staff.
♣ The best utilization can be made of a person‟s aptitudes, experience and desires.
♣ The organization benefits financially from this strategy because patient care can be
delivered to a large number of patients by mixing staff with a large number of
unlicensed assistive personnel.
♣ Nurses become highly competent with tasks that are repeatedly assigned to them.
♣ Less equipment is needed and what is available is usually better cared for when
used only by a few personnel.
Demerits:
♠ Client care may become impersonal, compartmentalized and fragmented.
♠ Continuity of care may not be possible.
♠ Staff may become bored and have little motivation to develop self and others.
♠ The staff members are accountable for the task.
♠ Client may feel insecure.
♠ Only parts of the nursing care plan are known to personnel.
♠ Patients get confused as so many nurses attend to them, e.g. head nurse, medicine
nurse, dressing nurse, temperature nurse, etc.
TEAM NURSING
Features:
Developed in 1950s because the functional method received criticism, a new system of nursing
was devised to improve patient satisfaction. Care through others became the hallmark of team
nursing. Team nursing is based on philosophy in which groups of professional and non-
professional personnel work together to identify, plan, implement and evaluate comprehensive
client-centered care. In team nursing an RN leads a team composed of other RNs, LPNs or LVNs
and nurse assistants or technicians. The team members provide direct patient care to group of
patients, under the direction of the RN team leader in coordinated effort. The charge nurse
delegates authority to a team leader who must be a professional nurse. This nurse leads the team
usually of 4 to 6 members in the care of between 15 and 25 patients. The team leader assigns tasks,
schedules care, and instructs team members in details of care. A conference is held at the
beginning and end of each shift to allow team members to exchange information and the team
leader to make changes in the nursing care plan for any patient. The team leader also provides care
requiring complex nursing skills and assists the team in evaluating the effectiveness of their care.
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Charge Nurse RN
Team Leader RN Team Leader RN
RN LPN NA RN LPN NA
Group of Patients Group of Patients
Advantages:
♣ High quality comprehensive care can be provided to the patient
♣ Each member of the team is able to participate in decision making and problem
solving.
♣ Each team member is able to contribute his or her own special expertise or skills in
caring for the patient.
♣ Improved patient satisfaction.
♣ Feeling of participation and belonging are facilitated with team members.
♣ Work load can be balanced and shared.
♣ Division of labour allows members the opportunity to develop leadership skills.
♣ There is a variety in the daily assignment.
♣ Nursing care hours are usually cost effective.
♣ The client is able to identify personnel who are responsible for his care.
♣ Barriers between professional and non-professional workers can be minimized, the
group efforts prevail.
Disadvantages:
♠ Establishing a team concept takes time, effort and constancy of personnel. Merely
assigning people to a group does not make them a „group‟ or „team‟.
♠ Unstable staffing pattern make team nursing difficult.
♠ All personnel must be client centered.
♠ There is less individual responsibility and independence regarding nursing
functions.
♠ The team leader may not have the leadership skills required to effectively direct the
team and create a “team spirit”.
♠ It is expensive because of the increased number of personnel needed.
♠ Nurses are not always assigned to the same patients each day, which causes lack of
continuity of care.
♠ Task orientation of the model leads to fragmentation of patient care and the lack of
time the team leader spends with patients.
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MODULAR NURSING
Features:
Modular nursing is a modification of team nursing and focuses on the patient‟s
geographic location for staff assignments. The concept of modular nursing calls for a smaller
group of staff providing care for a smaller group of patients. The goal is to increase the
involvement of the RN in planning and coordinating care. The patient unit is divided into modules
or districts, and the same team of caregivers is assigned consistently to the same geographic
location. Each location, or module, has an RN assigned as the team leader, and the other team
members may include LVN/LPN or UAP. The team leader is accountable for all patient care and
is responsible for providing leadership for team members and creating a cooperative work
environment. The success of the modular nursing depends greatly on the leadership abilities of the
team leader.
Merits:
♣ Nursing care hours are usually cost-effective.
♣ The client is able to identify personnel who are responsible for his care.
♣ All care is directed by a registered nurse.
♣ Continuity of care is improved when staff members are consistently assigned to the
same module
♣ The RN as team leader is able to be more involved in planning & coordinating
care.
♣ Geographic closeness and more efficient communication save staff time.
♣ Feelings of participation and belonging are facilitated with team members.
♣ Work load can be balanced and shared.
♣ Division of labor allows members the opportunity to develop leadership skills
♣ Continuity care is facilitated especially if teams are constant.
♣ Everyone has the opportunity to contribute to the care plan.
Demerits:
♠ Costs may be increased to stock each module with the necessary patient care
supplies (medication cart, linens and dressings).
♠ Establishing the team concepts takes time, effort, and constancy of personnel.
♠ Unstable staffing pattern make team difficult.
♠ There is less individual responsibility and autonomy regarding nursing function.
♠ All personnel must be client centered.
♠ The team leader must have complex skills and knowledge.
PROGRESSIVE PATIENT CARE:

Features:
It is a method in which client care areas provide various levels of care. The central theme
is better utilization of facilities, services and personnel for the better patient care. Here the clients
are evaluated with respect to all level (intensity) of care needed. As they progress towards
increased self care (as they become less ethically ill or in need of intensive care or monitoring)
they are marred to units/ wards staffed to best provide the type of care needed.
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Principal elements of PPC are:
i) Intensive care or critical care: Patients who require close monitoring and intensive care round
the clock, e.g. patients with acute MI, fatal dysarythmias, those who need artificial ventilation,
major burns, premature neonates, immediate post or cardiothoracic, renal transplant, neurosurgery
patients. These units have 9-15 numbers of beds, life-saving equipment and skilled personnel for
assessment, revival, restoration and maintenance of vital functions of acutely ill patients. Nursing
approach in these units is patient-centered.
ii) Intermediate care: Critically ill patients are shifted to intermediate care units when their vital
signs and general condition stabilizes, e.g. cardiac care ward, chest ward, renal ward.
iii) Convalescent and Self Care: Although rehabilitation programme begins from acute care
setting, yet patients in these areas participate actively to achieve complete or partial self-care
status. Patients are taught administration of drugs, life style modification, exercises, ambulation,
self-administration of insulin, checking pulse, blood glucose and dietary management.
iv) Long-term care: Chronically ill, disabled and helpless patients are cared for in these units.
Nurses and other therapists help the patients and family members in coping, ambulation, physical
therapy, occupational therapy along with activities of daily living. Patients and family who need
long-term care are, cancer patients, paralyzed and patients with ostomies.
v) Home care: Some hospital/centers have home care services. A hospital based home care
package provides staff, equipment and supplies for care of patient at home, e.g. paralyzed patients,
post-operative, mentally retarded/spastic patient and patient on long chemotherapy.
vi) Ambulatory care: Ambulatory patients visit hospital for follow up, diagnostic, curative
rehabilitative and preventive services. These areas are outpatient departments, clinics, diagnostic
centers, day care centers etc.
Merits:
♣ Efficient use is made of personnel and equipment.
♣ Clients are in the best place to receive the care they require.
♣ Use of nursing skills and expertise are maximized.
♣ Clients are moved towards self care, independence is fostered where indicated.
♣ Efficient use and placement of equipment is possible.
♣ Personnel have greater probability to function towards their fullest capacity.
Demerits:
♣ There may be discomfort to clients who are moved often.
♣ Continuity care is difficult.
♣ Long term nurse/client relationships are difficult to arrange.
♣ Great emphasis is placed on comprehensive, written care plan.
♣ There is often times difficulty in meeting administrative need of the organization,
staffing evaluation and accreditation.
PRIMARY CARE NURSING
Features:
It was developed in the 1960s with the aim of placing RNs at the bedside and
improving the professional relationships among staff members. The model became more
62
popular in the 1970s and early 1980s as hospitals began to employ more RNs. It supports a
philosophy regarding nurse and patient relationship.
It is a system in which one nurse is caring for all the needs of a patient or more
within a 24 hour from admission to discharge. He or she is responsible for coordinating
and implementing all the necessary nursing care that must be given to the patient during
the shift. If the nurse is not available, the associate nurse responsible for filling in for the
nurse‟s absence will provide hospital care to the patient based on the original plan of care
made by the nurse. In acute care the primary care nurse may be responsible for only one
patient; in intermediate care the primary care nurse may be responsible for three or more
patients This type of nursing care can also be used in hospice nursing, or home care
nursing.
Patients
Total patient care 24 hrs/day
Communicates with Consults with physician

PRIMARY
supervisors or other healthcare
NURSE
providers
Associate (days) Associate (afternoon) Associate (evenings)

when primary nurse is when primary nurse is when primary nurse is
not available not available not available
Advantages:
♣ Primary Nursing Care System is good for long-term care, rehabilitation units,
nursing clinics, geriatric, psychiatric, burn care settings where patients and family
members can establish good rapport with the primary nurse.
♣ Primary nurses are in a position to care for the entire person-physically,
emotionally, socially and spiritually.
♣ High patient and family satisfaction
♣ Promotes RN responsibility, authority, autonomy, accountability and courage.
♣ Patient-centered care that is comprehensive, individualized, and coordinated; and
the professional satisfaction of the nurse.
♣ Increases coordination and continuity of care.
Disadvantages:
♠ More nurses are required for this method of care delivery and it is more expensive
than other methods.
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♠ Level of expertise and commitment may vary from nurse to nurse which may
affect quality of patient care.
♠ Associate nurse may find it difficult to follow the plans made by another if there is
disagreement or when patient‟s condition changes.
♠ It may be cost-effective especially in specialized units such as the ICU.
♠ May create conflict between primary and associate nurses.
♠ Stress of round the clock responsibility.
♠ Difficult hiring all RN staff
♠ Confines nurse‟s talent to his/her own patients.
CASE MANAGEMENT
Features:
The case manager (RN or social worker with managerial qualification) is assigned
responsibility of following a patient‟s care and progress from the diagnostic phase through
hospitalization, rehabilitation and back to home care. For eg; case manager for cardiac surgery
patients assists them go through diagnostic procedures, pre-operative preparations, surgical
interventions, family counseling, post-operative care and rehabilitation. Case managers are
employed by third party payers (e.g. insurance companies) by the hospital authorities (e.g. for
heart surgeries, renal transplant, reconstructive surgeries, etc.), by clubs, industrialists and
associations or by individuals, e.g. geriatric, family or private patients case managers. No direct
care by the manager whose main roles are of teaching, advocacy and coordinating with health care
providers. Case manager (nurse) ensures quality care that is holistic and assisting the patient to
attain self care status according to his/her potential. It emphasizes achievement of outcomes in
designated time frames with limited resources.
Case management involves critical paths, variation analysis, inter shift reports, case
consultation, health care team meetings, and quality assurance. Critical paths visualize outcomes
within a time frame. Variation analysis notes positive or negative changes from the critical paths,
the cause, and the corrective action taken. Case consultation may be indicated when the client‟s
condition differs from the critical path as noted in the inter shift report. Case consultation is
conducted about once a week for a few minutes immediately after inter shift report to deal with
variations.
Health care team meetings provide an interdisciplinary approach to problem solving. The
case manager needs to identify no more than three priority goals and decide what team members
should be present after considering the patient, family physician, social service, various therapists,
and others involved. The case manager should set the time and place for the meeting, make the
arrangements, and post the date, time, place, and people to attend. The case manager calls the
meeting to order, states the goals, initiates discussion, documents the plans, and sets time limits for
follow through. The variance between what is expected and what happened is assessed for quality
assurance.
Responsibilities of case managers:
♥ Assessing clients and their homes and communities.
♥ Coordinating and planning client care.
♥ Collaborating with other health professionals in the provision of care.
64
♥ Monitoring client progress and client outcomes.

♥ Advocating for clients moving through the services needed.
♥ Serving as a liaison with third party payers in planning the client‟s care.
Merits:
♣ Case management provides a well coordinated care experience that can improve
the care outcome, decrease the length of stay, and use multiple disciplines and
services efficiently.
♣ Provides comprehensive care for those with complex health problems.
♣ It seeks the active involvement of the patient, family and diverse health care
professionals
Demerits:
♠ Nurses identify major obstacles in the implementation of this service, financial
barriers and lack of administrative support.
♠ Expensive
♠ Nurse is client focused and outcome oriented
♠ Facilitates and promotes co-ordination of cost effective care
♠ Nursing case management is a professionally autonomous role that requires expert
clinical knowledge and decision making skills.
FACTORS INFLUENCING THE QUALITY PATIENT CARE
Many variable factors influence the number of nurses needed on a ward in order to render a
high quality of patient care.
◘ The total number of patient to be nursed
◘ The degree of illness of patients (physical dependency)
◘ Type of service: medical, surgical, maternity, pediatrics and psychiatric
◘ The total needs of the patients
◘ Methods of nursing care
◘ Number of nursing aids and other non professional available, the amount and
quality of supervision available
◘ The amount, type and location of equipment and supplies
◘ The acuteness of the service and the rate of turnover in patients according to the
degree or period of illness.
◘ The experience of the nurses who are to give the patient care.
◘ The number of non-nurses who involve in the patient care, the quality of their
work, their stability in service.
◘ The physical facilities
◘ The number of hours in the working week of nurses and other ward personnel and
the flexibility in hours
◘ Methods of performing nursing procedures
◘ Affiliation of the hospital with the medical school
◘ Methods of assignment-individual, team or functional method
◘ The standards of nursing care.
65
CONCLUSION
Nursing is vital aspect of health care and needs to be properly organized. A nurse is in
frequent contact with of the patients hence his/her role in educational aspect and service aspect in
restoring health and confidence of the patient is of utmost importance. The quality of nursing care
and the management of the nursing staff,
BIBLIOGRAPHY:
 Basavanthappa B T. Nursing administration. Ist edn. New Delhi: Jaypee brothers;
2000.
 Chandra Ballabh. Encyclopedia of Hospital & Health Science Management. New
Delhi: Alfa Publishers; 2008.
66
3. PLANNING AND ORGANIZING HOSPITAL UNITS AND

ANCILLARY SERVICES (SPECIFICALLY CSSD, LAUNDRY,
KITCHEN, LABORATORY SERVICES, EMERGENCY
DEPARTMENT)
INTRODUCTION:
A hospital is a human invention, and as such can be reinvented at any time. Hospitals
design has been subject to many changes over the past 100 years or so in both layout and
size. In the early 20th century hospitals were basically places where the very sick spent
their last days. But today, emerging concepts of a hospital are calling for designs that
promote wellness and wellbeing rather than merely the treatment of diseases.
Health care organization, medical and pharmaceutical advances and medical technology
developments and patient expectations are continuously changing at a fast pace. The
implications of these changes on the planning and design of health care facilities are direct
and evident and the design response to them manifests itself in emerging planning
concepts and ideas.
Planning and organization of hospital units:
A hospital is responsible to render an essential service. In fulfilling this responsibility,
hospital planning should be guided by certain universally acknowledged principles. The
principles are usually irrespective of the level of planning, i.e. whether at national level,
state level or individual hospital level.
Aims of hospital planning:
 To enlarge the existing hospital by introducing new facilities.
 To increase utilization of hospital facilities.
 To increase population coverage
 To increase productivity of hospital
 Modernization of the already existing facilities
 To reduce the cost of operations and maximize efficiency of services.
Guiding principles in planning:
Patient care of high quality: it can be achieved by the hospital through adopting
following measures:
a. Provision of appropriate technical equipments and supplies.
b. An organizational structure that assigns responsibility and requires
accountability for various functions within the organization.
c. A continuous review of adequacy of care provided by physicians, nursing
staffs and paramedical personnel.
Effective community orientation: this should be achieved by the hospital by
adopting following measures:-
67
a. A governing board made up of persons who have demonstrated concerns
for community and leadership ability.
b. Policies that assure availability of services to all people.
c. Participation of the hospital in community programmes to provide
preventive care.
Economic viability: this is achieved by adopting measures like:-
a. A corporate organization that accepts responsibility for sound financial
management in keeping with desirable quality of care.
b. A planned programme of expansion based solely on demonstrated
community need.
c. An annual budget plan that will permit the hospital to keep pace with times.
Orderly planning: orderly planning should be achieved by the hospital by
following:-
a. Acceptance by the hospital administrator of primary responsibility for short
and long-range planning with support and assistance from competent
financial, organizational and functional advisors.
b. Preparation of a functional programme that describes the short range
objectives and facilities, equipments and staffing necessary to achieve
them.
Sound architectural plan: it is achieved by the following:-
a. Selection of a site large enough to provide for future expansion and
accessibility of population.
b. Recognition of the need of uncluttered traffic patterns within for movement
of staff, patients and visitors and efficient transportation of supplies.
Medical technology and planning: development in medical technology is taking
place so rapidly that now the use of sophisticated technology determines the
professional status.
Classification of hospitals:
Hospitals in general are classified into two categories depending upon the agencies which
finance them:
1. Government or public hospitals: they are managed by government services, either
central or state or public, municipal or departmental bodies that are financed from
the overall budget for public services.
2. Non-government hospitals: they are managed by individuals, charitable
organizations, religious groups, industrial undertakings etc.
On the basis of ownership patterns, non-governmental hospitals are classified as:
 Private (personal)
 Partnership
 Private (family) trust
 Public charitable trust
 Cooperative society
 Private limited company
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 Public limited company

Hospital planning process:
i. Conceptualization of hospital: here the imagination or idea of the originator takes
into a practical shape, and compares his dreams with the existing hospitals of
country or outside world, tries to fit dreams into any such project.
ii. Support groups: once the idea is developed, the entrepreneur, discuss project, and
then finds support groups to join hands and complete the project.
iii. Temporary organization and securing funds: a group should be formalized called
as a hospital trust, which must be registered under the society‟s act or companies
act. The originator is the chairman and others are members who are assigned
different tasks.
A detailed work out as to how much capital will be required for establishing the
hospital.
iv. Geographical, environmental and miscellaneous factors:

Meteorological information: temperature, rainfall, humidity
Geographical information: existing road and rail communications, susceptibility to
quakes/floods, building height restrictions due to proximity of airports.
Miscellaneous availability: trained manpower, water, sewage disposal.
v. Hospital design:
 Bed planning: it should be realized that the hospitals are not only utilized by the
population in the vicinity but also will constitute the indirect population in the
larger catchment area. About 85% bed occupancy is considered optimum.
 Hospital size: as a very large hospital of 1000 beds or more becomes extremely
unwidely to operate, and a small hospital of 50 or less are not profitable. From
functional efficiency point of view, it is advisable to plan two separate hospitals of
400 beds, each with a scope of future expansion, rather than a single one of 800
beds.
 Land requirements: in rural and semi-urban areas, plentiful land may be available
permitting the hospital to grow horizontally, whereas in urban areas there will
always be great premium on land and only avenue will be a vertical growth.
No. of beds Land in acres Storey of building
50 beds 10 acres Single storey
100 beds 15-20 acres -do-
200 beds 20-25 acres Double storey
500 beds 55-70 acres 3-5 storey
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700 beds 80-90 acres 4-6 storey
1000 beds 90-100 acres 6-9 storeys
 Public utilities: the national building code of ISI suggests 455 liters of water per
consumer per day (LPCD) for hospitals up to 100 beds and 340 LPCD for hospitals
of 100 beds and over.
Additional availability of water in case, staff quarters and nurse‟s hostel are a part
of hospital campus. The hospital sewage disposal is connected to the public sewage
disposal system, otherwise it needs to build and operate its own sewage disposal
plant.
It is preferable that power supply should be available on a multi-grid instead of
uni-grid system in general use, to ensure a continuous supply of electricity to
hospital at all times. Electricity requirement is 1 KW per bed per day2.
 Approval of plan by the local authorities: once the detailed plan has been
formulated, the local bodies are consulted and persuaded for approval of plans.
vi. Circulation routes: the utility and success of hospital plans depend on the
circulation routes on hospital site and within building. there are two types of
circulation in the hospital :-
Internal circulation: the circulation space involves corridors, stairways and lifts.
Corridors with less than 8 ft. Width are not desirable in hospitals and protective
corner beading is a necessity in hospital corridors.
External circulation: only one entrance to the hospital for vehicular traffic from the
main road is desirable. the entrance and exit points should be wide enough to take
two lanes of traffic, one entry for clarity of all visiting traffic and one exit for
security from administrative viewpoint.
vii. Distances, compactness, parking and landscaping: distances must be minimized for
all movements of patients, medical, nursing and other staff, for supplies aiming at
minimum of time and motion.
Functional efficiency depends on the compactness of the hospital which is
achieved by constructing multistoried as they are convenient due to compactness as
compared to horizontal development of hospital which demands more land
involving extra costs and installation of services, roads, water supply, sewage etc.
One car parking space per 2 beds is desirable in metropolitan towns, lesser in
smaller urban areas while much less in semi-urban and rural areas. Separate
parking for 3-wheelers and scooters, employees and staff parking areas separate
from public parking should be considered.
viii. Zonal distribution and inter-relationship of departments: the departments which

come in close contact with the public (e.g. outpatient department, emergency and
casualty) should be isolated from the main in patient areas and allotted areas closer
70
to the main entrance. The supportive services like X-ray and laboratory services
need to be located near the OPD‟s. From the main entrance should be main
inpatient zone consisting of ICU, wards, OT and delivery suit. The other
supportive and clinico-administrative department in the hospital consists of
hospital stores, kitchen and dietary department, pharmacy etc. these departments
should be preferably grouped around a service core area.
ix. Gross space requirements: gross total area (building gross)-780-1005 sq ft, add
walls, partitions: 95-125 sq ft. a building gross square footage figure includes
everything a building‟s perimeter viz. stairs, corridors, wall thickness and
mechanical areas.
On average, space will be required for a reception and enquiry counter in the main
waiting area near the OPD entrance. The bed distribution is calculated as:
Bed:population= A x S x 100
365 x PO
Where, A= number of in-patient admissions per thousand population per year
S= average length of stay (ALS)
PO= percentage occupancy
Bed distribution among various specialties will vary from hospital to hospital and
conforms to following range:
Medical: 30-40%
Surgical: 25-30%
Obstetrical: 15-18%
Pediatric: 10-12%
Miscellaneous: 10-15% (including eye and ENT)
x. Climatic consideration in design: in very hot climate buildings need to be cooled in
summer by artificial means. Some natural cooling can be achieved by building
orientation and design. The building should be open, and oriented in such a way
that even a slight breeze can pass through the building to cool its insides. Another
way is to keep thick walls and small windows where the thick walls absorb the heat
during day and dissipates during night, and small windows minimize the amount of
radiated heat entering the building.
xi. Equipping a hospital: hospital equipment covers a broad range of items necessary
for functioning of all services. the universal application of equipment in the
hospital can be classified as:
Physical plant: it includes lifts, refrigeration and air-conditioning, incinerators,
boilers, kitchen equipments, mechanical laundry, central oxygen etc.
Hospital furniture and appliances: beds, stretchers, trolleys, bedside lockers,
movable screens, operation tables, instrument trolleys etc.
71
General purpose furniture and appliances: it includes office machines (typewriters,
calculators, filing system, and computers), office furniture, crockery and cutlery.
Therapeutic and diagnostic equipments: it includes equipments for general use (BP
instruments, suction machines, glassware washers etc.) and equipment interacting
with patients during diagnostic and therapeutic procedures (defibrillators, X-ray
machines etc.)
xii. Cost evaluation of construction of hospital: the most common method of
estimating the cost is on the basis of per bed cost. It will also vary in type of
facilities the hospital provides, like teaching, training and research facilities.
Outpatient department:
Outpatient department is the one where all patients except those who require emergency
treatment, come for service in the hospital.
Planning and organization of the OPD:
Location: it should be easily accessible to those who come for outside, and should be a
separate wing for OPD attached to the hospital accessible from the main entrance to the
hospital with direct approach from the main road.
Space: the space requirement will depend upon the land available and location of the
hospital. Generally 0.66-1 sq ft area per annual outpatient attendance should be provided
for OPD. If there are 3 lakhs visit in a year, the total space requirement for OPD will be 2-
3 lakh sq ft or 4.5-6.8 acres.
Size: the size of OPD depends upon the volume of attendance, clinics provided and extent
of facilities like blood bank, emergency department.
Zones of OPD:
 FUNCTIONAL ZONE: this zone is mainly used by the patients attending the
OPD, attendants and relatives. This area includes parking area, entrance hall,
waiting space, enquiry and registration, and medical social services.
 ADMINISTRATIVE ZONE: this zone is required in a large hospital to plan,
organize, supervise, evaluate and co-ordinate the facilities being provided. the
various functional units of this zone are
 Office of the OPD in-charge
 Administrative control nurses station
 Cash counters
 Medical record room
 DIAGNOSTIC AND SUPPORTIVE ZONE: the various functional units in this
area are:
 Clinical laboratory
 Imaging section
 AMBULATORY ZONE: This is a zone where the patients come in direct contact
with the doctors and paramedical staff for consultancies, advice and treatment. it
includes units like:
 Clinics for various medical disciplines
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 Pharmacy
 Treatment room
 Minor OT
 STAFF ZONE: this zone is used exclusively by the staff members only. It includes
duty rooms, stores, housekeeping and conference room.
Functional management:
 OPD timings: it is recommended that OPD shall work 6 days in a week with
facilities of morning and evening clinics. The morning timings is usually from
8am-12 pm, whereas the evening hours shall be from 3pm to 5 pm, and specialty
clinics from 2 pm to 4pm. overcrowding and waiting time of the patients and
relatives must be minimized.
 Records: a unit record system combining both in-patients record and continuous
out patient record is recommended.
 Public relations: public complaints can be minimized and defused through public
relations, the entire staff of OPD including public relations persons should act as
agents.
 Facilities in OPD:
 The waiting lines should have enough furniture so that patients don‟t have
to stand in queues but can sit comfortably.
 The general procedure and rules should be painted on boards or walls for
the public.
 The registration area should be easily recognized and reachable.
 Health education messages can be promoted through TV-VCR system,
closed circuit TV and also to reduce the boredom of the waiting patients
and their relatives in OPD.
 Staffing of OPD: It includes the medical staff (consultant, professor, senior
lecturers, medical officers, residents, junior and senior should be available),
nursing staff (usually one nurse/OPD/clinic), paramedical staff (for injection room,
dressing room, registration and MRD), receptionists and medico social worker.
Planning and organization of Wards:
A ward is the most important part of hospital where the sick persons are kept for
supervised treatment. It is also a nodal point for research in medicine and nursing field,
training and teaching of medical, nursing and paramedical personnel.
Types of wards:General wards: in these wards, patients with non-specific ailments,
requiring no life saving care are admitted. The nurse patient ratio of 1:5 in big wards, and
catering to the patient‟s routine investigation, treatment and care needs.
a. Specific wards: these include patients admitted for specific care due ti illness or
social reasons. It includes:
 Emergency ward
 Intensive care unit
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 Intensive coronary care unit
 Nursery
 Special septic nursery
 Burns ward
 Post operative ward
 Post natal ward
b. Units with specialist nursing, treatment and equipment: wards like burn ward,
transplant ward functions at national or regional centers where particular service
skills are concentrated.
Ward planning:
 Physical facilities: it includes:
 Size of ward: size of the ward depends on- types of patient (an area of 100-
120 sq ft/bed is required and smaller rooms of 2-4 beds are preferable),
requirement of ward staff (a small ward will have same requirement
throughout the day, helped by a head nurse and a clerk for administrative
and clerical responsibilities)
 Patient housing area: this is an area where patients are kept for treatment.
 The area per bed within the ward is 80 sq ft/bed but in acute ward it
is 100 sq ft/bed
 Space left between two rows of bed is 5 ft.distance between two
beds is 31/2 to 4 ft.
 Clearance between wall and side of bed is 2ft.
 Length of bed is 6‟6”, width of the bed is 3‟.
Size of rooms:
 Single bed room should have a size of 125 sq ft/bed
 2 bed room 160 sq ft/bed
 ICU 120-150 sq ft/bed
 Obstetrics and orthopedics 120 sq ft/bed
 support service area: this section of ward includes:

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

on of the ward resources to produce maximum output, namely care and comfort of
patients. It includes:
 Strategic management: responsibility of giving a strategic direction to a
ward lies within the nursing unit set up in each ward. Strategy formulation
for ward has to be done in the context and parameters defined by the
strategy, direction, resources and constraints of hospital.
 Operational management: whereas strategic management gives an anchor
and direction, operational management works towards the strategy. The
responsibility of operational management of a ward rests with the ward
head nurse/ nursing unit with the help of other ward personnel like ward
clerk. It includes objectives of providing comfort and good care to the
patients and long term objective of improvement and establishment of
systems in functioning of the ward.
Central Sterile Supply Department (CSSD):
Definition of CSSD: A CSSD is a department that furnishes all supplies required for the
nursing units and departments of a hospital- theatres, wards, out-patient and casualty
departments with complete, sterile equipment ready and available for immediate treatment
of patients.
These supplies include sterile linens, sterile kits, operating room packs, needles, syringes
and other medical surgical supplies. In addition, the personnel in this department clean,
76
inspect, repair, assemble, wrap and sterilize special treatment trays for various nursing
units.
Planning and organizational consideration of CSSD:
Planning of CSSD: the CSSD should be planned in all hospitals above 100 beds. Theatre
sterile supply unit (TSSU) is to meet emergent and large requirement of OT and is
established inside OT complex. In large hospitals like 500 beds and above, TSSU is
established in addition to the CSSD in service area.
Bed size of the hospital Location of CSSD
Up to 100 beds In operation theatre
100-500 beds CSSD centrally located in service area
Above 500 beds CSSD in service area and a separate unit for OT
to be called theatre sterile supply unit ( TSSU).
The following areas are to be provided in CSSD:

i. Equipment storage room
ii. Receiving counter and clean up room
iii. Needles and syringes processing room
iv. Gloves assembling room with rubber goods processing room
v. Clean work area including sterilizers
vi. Sterile storage area and issue counter
vii. gauze and dressing assembly area
Percentage distribution of the space is as follows:
 Clean area including sterilization- 40%
 Sterile storage area-15%
 Equipment storage-14%
 Fluids, needles and syringes- 14%
 Receiving and clean up area-12%
 Glove processing area-5 to 7%
 Additional 25% space located for future expansion
Layout:
 Location should be where the most rapid means of transportation of supplies and
equipment is possible.
 There should be avoidance of back tracking of sterile goods.
 There should be a continuous flow of equipment from the receiving counter to the
dispensing counter.
77
 The contamination of sterile goods should be avoided.
 Sterilizing area should be the last area before the sterile storage and dispensing
counter.
 The receipt and issue counters are separated by a corridor to avoid contamination.
Counter of receipt of
Decontamination and
used items
cleaning area
Processing
Separation of sterilized items by a partition or corridor
Packing of items
Distribution point Sterilized items store Sterilization
Area requirements:
It is recommended that the area of 1.64 sq.m/bed for a CSSD would be appropriate up to
400 bedded hospitals, and for more than 400 beds an area of 1 sq.m/bed would be
sufficient.
The manual of IGNOU has recommended following functional area for a 100 bedded
hospitals:
Facilities In sq.meter
10.50
entrance
7.00
lockers
7.00
Staff change room
7.00
Dirty receipt and disassembly
17.50
Washing, disinfection and decontamination
10.50
assembly
10.50
Linen processing
14.00
sterilization
21.00
Sterile storage
10.50
distribution
7.00
Trolley wash
10.50
Trolley bay
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17.50
Bulk store
3.50
Duty room
3.50
toilet
164.50
Total per 100 bed hospital
Staffing pattern:
One CSSD worker per 30 beds plus one supervisor is recommended. In 200-300 beds
hospital, you need 10-15 persons. Staff for 1000 bedded hospitals is:
Supervisor – 1(senior most and trained technician)
Asst. Supervisor- one of the senior technician
Technicians – 6 (promoted attendants)
Sweepers- 15
Clerk- 1
Equipments and materials required:
 Hot and cold running water
 Cleaning brushes and jet water gadgets
 Ultrasonic washers
 Hot air oven for drying instruments and sterilization
 Globe processing unit
 Instrument sharpener like needle sharpening machines
 Stem sterilizers and boiler for steam
 Autoclaves of various sizes including gas autoclave
 Testing equipment
 Chemicals to clean materials
 Wall fixtures like sinks, taps
 Trolleys for supply of sterilized items and separate trolleys for collection of used
items are needed
Methods of sterilization:
Sterilization is a process of freeing an article from all living organisms including bacteria,
fungus, using dry or wet heat, chemicals or irradiation.
a. Steam sterilization: autoclaving is the commonest method
b. Hot air sterilization: Vaseline and oils cannot be sterilized with steam. these items
are exposed to hot air to 160-1800c for 40 minutes.
c. Gas sterilization with ethylene oxide
d. Sub atmospheric pressure sterilization with formalin: it is meant to disinfect
instruments like endoscopes. the temperature required is 900c for 10-30 minutes.
e. Chemical sterilization with activated glutaraldehyde
f. Gamma irradiation sterilization: it is used for disposable goods but is a costly
method.
g. Formaldehyde steam sterilization
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Inventory management:
i. Stock: to ensure the availability of sterilized items to the hospital units, five times
the average daily requirements. The replacement and procurement of condemned
items should be laid out so that situation of „stock out‟ can be avoided.
ii. Issue of materials: the principle of „first in- first out‟ ensures proper rotation of
supplies in CSSD and prevents any item from being kept for longer time so that its
sterilization date expires.
iii. Distribution of sterile items: the method that can be used for distribution of sterile
items are:
 Grocery system: in case CSSD is open 24 hrs, wards and departments can
send requisition to CSSD and stock is supplied accordingly.
 CSSD is open for limited hours:
 Clean for dirty exchange system: one clean item is provided for
each item in the ward used.
 Milk round system: it includes daily topping up of each ward/
department stock level to a pre determined level decided by users.
 Basket system: a basket with daily requirement of ward is changed
everyday irrespective sterile items used or not, and the items of the
whole basket is sterilized every day.
 In case the items are to be stocked in wards, the date of sterilization is

written on each item so that the unused items are returned to CSSD for re-
sterilization after 72 hrs.
iv. Quality control methods:

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

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

linen and storage room
room
Toilet Washer
Laundry Staff room Store of Store of spare

manager detergent linen
Linen mending Hydro extractor
Issue area Storage of Pressing and Drier

clean linen laundering
Ancillaries:
Laundry manager‟s office
Stores
Tailoring bay
Worker‟s rest room
Toilet
Boiler room
Material and decor:
 The route of soiled linen from the using points to the laundry and the flow of clean
linen from laundry to the using points should be planned as to minimize the
possibility of contamination of clean linen.
 The laundry should be grouped into specific separate areas.
 Laundry manager‟s office should be located as centrally as possible to properly
supervise the entire laundry operations.
 The walls should have large vision panels to allow full view of each area.
 A toilet, locker and shower facilities should be provided in the soiled linen
receiving, sorting and washer loading room and clean linen processing room.
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 Supply storage room should be adjacent and connected to the soiled linen
receiving, sorting and washer loading room.
 Sufficient space should be provided for the storage of one week‟s supply of
detergents, bleaches and others.
 The floor for the laundry should have smooth, slip resistant and water proof
surface, the walls should have a smooth washable surface free from all corners,
edges or projections which create maintenance problems.
 Utility services like piping, electrical wiring should be designed and sized with
appropriate consideration for future expansion.
 The steam supply system should be designed to deliver steam to the equipment in
right quantity at a desired temperature.
 Hot water should be available at 1800F by the pipeline to the laundry at the
required temperature from the boiler room.
 The power supply to the laundry is usually 220 or 440 volts in three phases , four
wire alternative system and must be accessible
 Lighting should be free of glare and shadows.
 Fire extinguishers should be located in the laundry near the clean linen and the
processing areas.
 There is a need for flow of drains in the sorting and washing areas.
 Ventilation system must be able to provide a comfortable environment for the
workers.
 Sewing and mending room should be located near to the clean linen and pack
preparation room.
Laundry management:
The management of laundry contributes to morale of the staff and patients with fresh
laundered linen:
a. Sequence of operation:
Collection of laundry by laundry staffs in trolley with clean and dirty linen
separately and is sorted out as soiled, infected and foul linen to avoid
nosocomial infection.
Disinfection is done using disinfectants for infected linens.
Sluicing and washing: sluicing is done for foul linen in sluice machine and
then the linen along with those that are disinfected are put in washer for
cleaning.
Hydro-extractor: it is then put in extractor for removing extra water.
Drier tumbler: the linens are put for drying.
Pressing: the linens are pressed
Mending: the torn linen is sent for repair or condemnation and replacement.
Repaired linen is again washed in washer and washing cycle after that is to be
completed.
Distribution to ward is done by laundry staff after it is ready for use.
b. Linen distribution system:
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 Topping up: in this, the ward is given certain number of stock of linen
based on 24 hours requirement and shortfall of linen due to use is topped up
by the laundry staff everyday and used ones are collected.
 „Clean for dirty‟ exchange: the issue of clean linen to exchange number of
pieces of dirty linen.
 Exchange trolley system: this is expensive and not used in India. In this,
total trolley is supplied which has 24 hours requirement and next day fresh
trolley is supplied with same number of pieces and old trolley is taken back
to laundry irrespective as how many pieces have been used and linen is
brought and washed.
c. Quality control of laundry services: the quality assurance of laundry should be
developed since laundry is important from where infection can be transmitted to
other patients, which should be seen by the hospital infection control committee.
d. Policies and procedures:
 Collection and distribution system of linens with periodicity to each ward
and department.
 Detailed instruction about handling infected and foul linen.
 Charter of duty of each person handling laundry and training schedule of
staffs.
 Sluicing and disinfection procedures.
 Operation of laundry machines.
 Maintenance and service contracts of machines.
 Provision of detergents
 Procedure for condemnation of linen and procurement of new linen
 Fire safety drills and fire extinguishing measures
 Record of distribution, collection, inventory of detergents and linen
procured/condemned.
 Security arrangements for laundry.
 Regular physical verification of linen and fixing responsibility of any type
of loss.
Kitchen services:
A hospital dietary service includes most importantly a production unit that converts raw
material into palatable food. The preparation and distribution of food from store to spoon
has many challenges for the administration such as proper preparation, cost accounting,
pilferage and wastage.
Functions of dietary services:The dietary services cater for the following:
therapeutic diet
in-patient catering
diet counseling
education and training
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Staff requirements:
Category of employees Beds
100 200 300 500 750
Chief dietician - - - - 1
Senior Dietician - - - - 1
Dietician - - - 1 1
Asst. dietician 1 2 3 5 7
Steward - - 1 1 1
Storekeeper(ration) - - - 1 1
Storekeeper(general) - - - 1 1
Clerk/typist - - - 1 1
Head cook 1 1 1 2 2
Therapeutic cooks - - 2 2 3
Cooks 4 6 8 10 16
Asst. cook 6 14 20 28 32
Cleaners, waiters 4 4 6 8 10
Store attendants - 1 1 2 2
Sweepers 1 1 2 2 3
Fig. 1 shows staff requirement

Location and space requirement:
Location: the dietary department should be located on the ground floor near wards where
the diets need to be taken and also accessible to road as supplies are to be carried to
storage area.
Space requirement:
Hospital kitchen is divided into number of divisions which have a particular activity. The
broad areas are supplies receiving area, storage area, cooking area, pots and pan wash,
garbage disposal, LPG stove and refrigeration facilities, housekeeping, dietician, steward
offices and circulation area.
Following space requirements are recommended for different size of hospitals:
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 200 beds or less: 20 sq ft per bed
 200-400 beds: 16 sq ft per bed or 18 sq ft per bed
 500 beds and above: 15 sq ft per bed
Functional areas in department:
a. Recipient area: this is the place where all provisions are off loaded. these are
checked for right quality and quantity, hence area should have unloading points,
ramps, trolleys and weighing scales.
b. Storage area: this area where the provisions are categorized and stored in separate
areas. the areas should have enough shelves and bins:
 Dry provisions like flour, dal, sugar, oil etc.
 Fresh provisions like vegetables, milk, butter, meat etc.
They are further divided based on temperature requirements:
 items to be stored at room temperature like onion, potato etc
 Items require cool temperature (8-100c is maintained) for which walk-in
cooler can be provided to store milk, eggs, butter etc.
 Deep fridge where temperature is below 00c fish and meat should be
stored.
c. Day store: it is an area where provisions for one days cooking issued to the cooks
are stored.
d. Preparation area: it is an area where provisions are cleaned, washed, soaked; meat
is chopped, cut and sliced etc. the items like kneader, weighing scale, slicer etc has
to be provided.
e. Cooking area: it should have pressure cooker, cooking range oven etc.
f. Service area: the food is put in service pots in trolleys and if it is a centralized
distribution system, it is put in service trays, with specifying the name of patients.
g. Washing area: this is meant for washing cooking and service pots, hence should
have liberal hot and cold water.
h. Disposal area: the area where all garbage and left over food is collected for
disposal.
Fig 2. - The figure explains the layout of kitchen
Recipient area of Office store Walk-in cold Dry store Fresh store
provisioning keeper store
Dry store Preparation area
Dietician Trolley+
Cooking area
Supervisor pot wash
area
Staff room Distribution area and service
Staff toilet
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Wards
Distribution of diet:
a. Centralized service: the food is set in individual tray centrally at dietary
department including therapeutic diet of patients and are transferred to wards in
trolleys and served to the patients.
b. Decentralized service: the food is sent to wards and served as per the need of the
patient.
Dietary store management:
 Storage of food items: for dry storage, the temperature should be 700c, with
adequate ventilation has to be insured. The storing shelves, bins should be placed
10” above the floor.
 Purchase of food products: the items can be purchased from open market or
through calling tenders. The items to be purchased should have AG MARK OR
IDI. For this, an internal purchase committee may be constituted by the hospital
administration.
 Equipment planning: equipment purchase depends on the objectives and basic
functions of the department, workload and availability of the personnel, and quality
standards. Modern gadgets like mixer grinders, pressure cookers, dish washers etc.
Should be a part of hospital kitchen.
 Financial control:
 The first thing to be done for an effective financial control is to control the
labor costs.
 Menu planning should be done in such a way that it reduces the inventory,
selection of items common to many areas of patient care, reduced handling,
wastage, use of automation or more equipment requiring less operational
staff are some measures that can be put to practice for an effective financial
control.
Laboratory services:
The basic function of laboratory services is:
 To assist doctors in arriving at or confirm a diagnosis and to assist in the treatment
and follow-up of patients.
 The laboratory not only generates prompt and reliable reports, and also functions
as store house of reports for future references.
 It also assists in teaching programmes for doctors, nurses and laboratory
technologists.
 It carries out urgent tests at any part of day or night.
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Functional divisions:
The hospital laboratory work generally falls under the following five divisions:
a. Hematology
b. Microbiology
c. Clinical chemistry/ biochemistry
d. Histopathology
e. Urine and stool analysis
Functional planning:
It covers the following activities:
 Determining approximate section wise workload.
 Determining the services to be provided.
 Determining the area and space requirement to accommodate equipment, furniture
and personnel in technical, administrative and auxiliary functions.
 Dividing the areas into functional units i.e. Hematology, biochemistry,
microbiology etc.
 Determining the number of work stations in each functional units.
 Determining the major equipments and appliances in each unit.
 Determining the functional location of each section in relation to one another, from
the point of view of flow of work and technical work considerations.
 Identifying the electrical and plumbing requirements for each area/ work station.
 Considering utilities i.e. lighting, ventilation, isolation of equipments or work
stations.
 Working out the most suitable laboratory space unit, which is a standard module
for work areas.
Organization:
 Location: it is preferable to have hospital laboratory planned on the ground floor
and so located that it is accessible to the wards. In large hospitals, the entry of
outpatients to the laboratory can be obviated by opening a sample collection
counter in the outpatient service area itself.
 Outpatient sample collection: it should be located in the outpatient department
itself. The design of this area should include waiting room for patients,
venepuncture area and specimen toilets separately for male and female patients,
along with provision of containers with appropriate preservatives and keeping
record of each patient.
 Area/space: in a small hospital, the laboratory facility consists of a room in which
all the routine urinalysis, hematology and clinical chemistry investigations are
carried out. As the hospital size increases, the requirement of technical and
administrative services also increases with the necessity for departmentalization of
the laboratory. The requirement of space for the laboratory consists of :-
 Primary space: this space is utilized by technical staff for the primary task
of carrying professional work.
88
 Secondary space: it is utilized for all supportive activities.

 Administrative space, i.e. Offers for the pathologists and others, staff toilets
etc.
 Circulation space: it is the space required for uncluttered movement of
personnel and materials within the department between various technical
work stations, rooms, stores and other auxiliary and administrative areas.
 Laboratory space unit (LSU): it is a module of space and all calculations for
technical work areas and some auxiliary area are based on LSU. For
allocation of primary space, one of the most suitable sizes of a LSU is one
measuring 10‟ x 20‟ giving a LSU module of 200 sq. ft. a rectangular
module is functionally more efficient because in the same overall space, it
can accommodate longer runs of benching due to its longer perimeter.
 Layout: structural flexibility should be achieved by use of movable or adjustable
benching systems in association with an installation of service mains that has been
designed to permit the repositioning of outlets.
 Administrative and auxiliary areas: the administrative area (the area is the central
collection point for receiving specimens and is the reception and interaction area
for patients and hospital staffs) is separated from the technical work area so that
the non-laboratory personnel need not enter the technical areas.
 Reception and sample collection: this is the area should be well ventilated and
lighted, should have a chair where the patient can sit in comfort and where his arm
can be stretched for the phlebotomy, a bed where the patient can lie down for
pediatric collection or aspiration cytology.
 Bar-coding system for samples: this system is used to trace the samples. The
sample is received and then bar coded, and then sent to processing area. This
protects patient identity.
 Specimen toilet: it is provided for the collection of urine and stool specimens.
 Pathologist office: it is so placed that the pathologist can have an easy access to the
technical areas particularly histopathology unit.
 Glass washing and sterilizing unit: small labs collect blood in bottles that are
washed and reused. This is partitioned into washing and sterilizing area, containing
sterilizer, pipette washer and sinks.
 Report issue: the reports should be issued in printed format. The hospital lab
software can be made as per the requirement of the hospitals.
 Utility services: it includes water, gas and compressed air systems. Piping systems
should be easily accessible for maintenance and repairs with minimum disruption
of work. For safety purpose and to facilitate repairs, each individual piping system
should be identified by color, coding or labeling.
 Internal design and fitments:
a. Work benches: the height of the work bench on which the technicians sit
while working (revolving stools) vary from 75-90 cm depending upon the
height of the workers.
89
b. Lighting: natural light should be used to the fullest. Each work bench
should be provided with adequate electric points especially fluorescent
fixtures that give uniform illumination and minimize heat.
c. Storage: each laboratory bench length should have storage space for
reagents, chemicals, glass wares and other items, provided in the form of
under bench drawers, cupboards etc.
d. Partitions: it may be required between some laboratory spaces.
e. Air conditioning: whole or at least histopathology section of the laboratory
should be air conditioned due to accumulation of formalin vapors or else a
powerful exhaust system should be installed.
f. Working surface/ flooring: the surface of work benches should be resistant
to heat, chemicals, stain proof and easy to clean. Floor should be easy to
clean, and not slippery. Flexible vinyl flooring is preferred for laboratory
floor coverings.
Staffing: the hospital laboratory services should be under the control and
direction of a doctor with qualifications in pathology or a PG degree in the new
discipline of “laboratory medicine”.
Number of personnel: staff requirement of laboratory technicians can be
worked out empirically on the basis of generally accepted norm which is about
30 tests per day per technician.
Equipment:
Some of the core instruments that are needed are:
 Colorimeters/ spectrophotometers: they were used in old days, are now
replaced by new auto-analyzers these days.
 Auto analyzers: it is used maximum in biochemistry works.
 Cell counter: it gives a more complete blood picture. The principle of
the instrument is to pass the cells through a thin capillary.
 Centrifuge
 Refrigerators
 Pressure sterilizers
 Pipette washers
 Analytical balance
 Semi auto analyzer
 ELISA reader
 Blood gas analyzer
 PCR instrument
 Flow cytometer
Policies and procedures:
Laboratory samples: samples to be examined falls in two categories:
 Samples collected by nursing staffs in nursing units
 Samples obtained by lab. Personnel.
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All requests for lab. Examinations must be in writing.

Sample receiving: in the reception area, all samples of blood, urine, body fluids etc
should be received at the reception counter. Sufficient racks and hand washing
facility should be provided in this area.
Request forms: all request forms should be uniform in size and contain only
pertinent information.
Time for accepting specimens: a time schedule for accepting certain types of
specimen will facilitate the operations of the laboratory.
Containers: all specimens sent should be in proper containers. Instructions on the
time of taking specimens, minimum volume required, type of container etc. Should
be posted at the nurse‟s station in wards.
Identification of specimen: the lab. Personnel should be responsible for proper
disposition of all specimens and requests within the lab. to identify the specimen
received, the specimen and request form should be numbered with same number
and is also entered in the request register.
Reports and records: lab. Personnel should give reports only to authorized ward/
OPD personnel and never directly to patients. A daily record register should be
kept of all examinations performed in the lab. In order to maintain a monthly and
yearly account of the work done.
Blood bank services: it should be controlled by the officer in charge and the
technical supervisor, to ensure that all are aware of the establishment of written
procedures for identification of blood samples, storage facility etc.
Outpatient samples: it is necessity in large hospitals where the volume of workload
from outpatient department is considerable.
HIV: necessary safety precaution should be clearly understood by all concerned
while drawing blood samples from suspected HIV and hepatitis patients.
Liaison with clinicians: differences between the patients lab. reports as compared
to their clinical status arises which should be discussed in the medical audit
committee.
Motivation and cross-training: the in charge should discuss professional, technical
and administrative matters concerning the laboratory during periodical meetings
with staff. The lab. Policy must lie down that all staff is cross-trained to work in all
the different sections of the laboratory.
Waste disposal: histopathology and microbiology laboratory waste be considered
as hazardous waste and should be disposed accordingly.
Optimal utilization of laboratory services: to better utilize the laboratory services, a
constant emphasis is needed on ordering only the appropriate tests required for
diagnosis or prognosis based on clinical judgment and filling the required form s
completely.
Quality control: as a part of quality control function, standard operating procedure
should be laid down by the in charge pathologist for each function and each
functionary in the laboratory.
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Emergency services:
An emergency department must be developed as a mini hospital within a hospital i.e.
Independent and self sufficient in day to day working.
Planning and organizational considerations:

1. Location: there are two essential location requirements:
 It must be on ground floor and easily accessible to both ambulatory and ambulance
patients, and there should be minimal separation between it and radiology
department.
 Secondly, the emergency department should have ready access to the acute patient
care areas, eg. Operation theatre, ICU, blood bank etc.
Emergency department must be designed; usually 1000 sq.ft is required for daily patient
load of 100 patients.
2. Stretcher, trolley, wheelchair store: a store for stretcher, trolley and wheelchairs
should be located adjacent to the entrance.
3. Ambulance attendants, police, mass media room: an equipped room of about 10 m2
near the entrance hall with attached toilet serves the needs of above personnel.
4. Work area: it should be spacious with enough room for personnel and patients.
5. Waiting area for emergency department patients: the main function of this is to be
the passageway to patient examination and treatment area.
6. Waiting area for relatives: patient relatives should not be allowed in the work areas
of emergency department. Waiting room with recreational facilities may be
provided.
7. Visitor‟s toilet: it should be provide near the main waiting space.
8. Nurse‟s station and administrative office: this should be next to the entrance and
manned on 24 hr. basis. It should be provided with multiple telephones, bulletin
board with duty roster of doctors on call and directive pertaining to the emergency
department should be displayed. Nurses work room should be well stocked with
drugs, IV fluids.
9. Examination and treatment area: this area should always be in readiness to receive
patients at all times, and should consist of a large room and number of separate
smaller rooms for examination and treatment. It should be well illuminated space
with oxygen supply, resuscitation equipment, suction, portable X-ray,
electrocardiographs, and Boyle‟s apparatus.
10. Equipment:
 Stretchers
 On-the wall oxygen unit
 On-the wall suction unit
 BP apparatus, otoscope, stethoscope, opthalmoscope etc.
 Spot lights
 Utility table
 Airways and resuscitation bags
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11. Resuscitation room: the patient is to be stabilized in this room before shifting to
treatment or recovery room, or to ICU or nursing unit. It should be well equipped
with resuscitation equipment, ECG machine and X-ray viewing screening with
facility for performing minor operative procedures.
12. Operation room: a self sufficient operation room to serve patients who need minor
surgery and no admission or who are critically ill etc. in emergency department.
13. Fracture room: a separate fracture room equipped similar to OT and additional
facilities for reduction of closed fractures under local anesthesia can be planned
with hospitals with turnover of emergency patients in excess of 15,000 per annum.
14. Plaster room: it is needed for treatment of fractures and application plasters.
15. Care of burns: a separate room with 20 m2 area should be reserved for immediate
care of burn patients. An observation ward of about 6-8 beds for patients to be kept
under observation overnight or 24 hrs.
16. Isolation room: for obstetric patients, pediatric patients.
17. Other rooms: these should be planned based on the local needs:
 Room for dead bodies
 Pantry-7 m2
 Storage space
 Utility and soiled linen room-7 m2
 Cleaners room-house keepers room 4m2
 Change room duty rooms 9m2
 Conference room and reference library 8m2
Staffing pattern:
 Full time emergency physicians, especially trained in emergency medicine
 A well staffed emergency department needs 8 nurse shifts of 8 hours each
per 100 daily patients‟ visits. Additional staff nurses is required if there is
observation ward attached.
 For registration and records, usually 3 clerks work in day and afternoon
shift, and one during night.
 Security should be available round the clock
 Public relations and social worker should be available to take care of the
anxious and disturbed patients and their relatives.
Medico-legal aspects of emergency department:
a. Negligence: it is the breach of duty owed by a doctor to his patients to exercise
reasonable care/skills resulting in some bodily, mental or financial disability.
b. Duty to treat all: according to the recent supreme court decision, no doctor can
refuse giving first aid treatment to accident victims or any other patients.
c. Problem areas in emergency department:
Consent to treatment: a written consent must be obtained from the patient
to treat him, with the patient‟s knowledge regarding procedures.
93
Medical records: medical records and proper record keeping are high
priority in any hospital. Proper documentation of patient‟s case history with
informed consent is necessary.
Reporting to authorities: all medico-legal cases e.g. Assault and battery,
child abuse, accidents etc. Should be reported to proper authorities e.g.
Police. The cases of AIDS and venereal diseases should be reported to
health authorities.
BIBLIOGRAPHY:
i. A.G Chandorkar. Hospital administration and planning. 2nd edition. Paras medical
publisher. New Delhi. 2009. pg no. 67-72,153-166,167-179,181-195.
ii. B.M.Sakharkar. principles of hospital administration and planning. 2nd edition.
jaypee brothers medical publishers ltd. 2009. pg.no-195-207.
iii. D C Joshi, Mamta Joshi. Hopsital administration. Jaypee brothers medical
publishers pvt ltd. New Delhi. 1st edition. 2009. pg. no. 186-208.
iv. The nightingale times. volume II. pg. 32
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4. DISASTER MANGEMENT
INTRODUCTION
A disaster is a severe disruption, ecological and psychosocial, which greatly

exceeds the coping capacity of the affected community. In common daily usage the term
„disaster‟ refers to a great misfortune causing a widespread damage and suffering.
Disasters are not confined to a particular part of the world, they can occur anywhere and at
any time. Major emergencies and disasters have occurred throughout the history and as the
world‟s population grows and resources become more limited, communities are
increasingly becoming vulnerable to the hazards that cause disaster. Disasters have been
an integral part of human experiences, since the beginning of time, causing pre-mature
death, impaired quality of life, and altered health status. Disasters are not confined to a
particular part of the world. They occur at any time, any where. Emergencies and disasters
do not only affect health and well being of people. Frequently large number of people are
displaced killed or injured or subjected to risk of epidemics. As the part of country‟s
overall plan for disaster preparedness all nurses must have a basic understanding of
disaster science and the key components of disaster preparedness.
OBJECTIVES
At the end of the seminar the participants will be able to
Define disaster
Enumerate the types of disaster
Enlist the characteristic of disaster
Explain the phases of disaster
Elaborate the principles of disaster management
Describe the phases of disaster management
Explain the disaster cycle
Enlist the effect of disaster
Explain the nurses role in disaster management
TERMINOLOGIES
 Substantial- large in size, value or importance

 Inventory- a detailed list of all the things in a place
 Remedy- a successful way of curing an illness or dealing with a problem or
difficulty
 Euphoria- extreme happiness, sometimes more than is reasonable in a particular
situation
 Disillusion- to disappoint someone by telling them the unpleasant truth about
something or someone that they had a good opinion of, or respected
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DEFINITIONS OF DISASTER
A disaster can be defined as any occurrence that cause damage, ecological

disruption, loss of human life, deterioration of health and health services on a scale,
sufficient to warrant an extraordinary response from outside the affected community or
area.
(W.H.O.)
An occurrence of a severity and magnitude that normally results in death, injuries
and property damage that cannot be managed through the routine procedure and resources
of government.
FEMA (Federal Emergency Management Agency)

A disaster can be defined as an occurrence either nature or manmade that causes
human suffering and creates human needs that victims cannot alleviate without assistance.
American Red Cross
(ARC)
United Nations defines disaster is the occurrence of a sudden or major misfortune
which disrupts the basic fabric and normal functioning of a society or community.
DISASTER NURSING
It can be defined as the adaptation of professional nursing skills in recognizing and

meeting the nursing, physical and emotional needs resulting from a disaster.
“Disaster Nursing is nursing practiced in a situation where professional supplies,

equipment, physical facilities and utilities are limited or not available”.
The overall goal of disaster nursing is to achieve the best possible level of health for
the people and the community involved in the disaster.
„DISASTER‟ alphabetically means:
D – Destructions
I – Incidents
S – Sufferings
A - Administrative, Financial Failures.
S – Sentiments
T – Tragedies
E - Eruption of Communicable diseases.
R - Research programme and its implementation
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GLOBAL SCENARIO
Any disaster is a second major human problem after war. Approximately 20 major
disasters strike the world yearly. Most common are floods, cyclones and earthquakes.
The Asia-Pacific region witnesses a large number of natural disasters. It reports

around 60% of total disasters in the subcontinent.
Indian scenario: India is a disaster-prone country. It has already faced the largest number
of disasters till now and around 31 major earthquakes.
YEAR TYPE PLACE DEATH
2004 Tsunami Andhra, Tamilnadu, Andaman 10,749 and

&Nicobar island, Kerala,
Pondicherry. 5460 missing
2004 Flood Assam, Bihar, Gujarat N.A
2001 Earth-quake Bhuj, Gujarat 16480 killed and 144,927

injured.
1999 Fire Delhi 32 and 100 injured
1999 Super cyclone Orissa 2000
1993 Earth-quake Latur,Maharashtra 8000 and 14000 injured
1991 Earth-quake Garhwar, Uttaranchal 1000
1984 MIC gas Bhopal, MP 3800
TYPES OF DISASTER
1. Natural Disasters
2. Man-made Disasters
 Natural Disasters
These are unavoidable. The impact can be extremely powerful and can cause
substantial, physical disruption, social disruption, and many secondary stressors such as
loss of both home and income.
Types of natural disaster
 Meteorological
 Hurricanes, cyclones, tornadoes and typhoons
 Snowstorms, floods, heavy rains
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 Drought and famine
 Topographical
 Earthquakes
 Landslides : It is a volcanic mudflow or lahar. The 1953 Tangiwai disaster
was caused by a lahar, as was the 1985 Armero tragedy in which the town of
Armero was buried and an estimated 23,000 people were killed
 Tsunami
 Environmental
 Epidemics: An epidemic is an outbreak of a contractible disease that spreads at
a rapid rate through a human population.eg: The H1N1 Influenza (Swine Flu)
Pandemic 2009.
 Man-made Disasters
Types of Man-made Disasters
 Technological
 Industrial accidents
 Security related
Technological: They are more deadly than natural. They are sudden in onset and produce a
reaction of shock.
Industrial accidents: Airplane crashes, dam failure, leakage of poisonous gas Eg: Methyl
Isocynate (MIC) leakage in Union Carbide Corporation Plant Bhopal
Security related: These are related to violence, war and mass shooting, chemical and
radiological bombing.
Terrorism adds a new dimension to this category. Such types of acts cause threat
which is sudden, focused or unfocused leading to substantial destruction and social
disruption.
CHARACTERISTIC OF DISASTER
There are mainly six variables by which disaster can be understood they are.
 Predictability
 Controllability
 Speed of Onset
 Length of forewarning
 Duration of impact
 Scope and intensity of impact
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1. Predictability
It is influenced by the type of disaster. A hurricane has a high degree of

predictability in industrialized countries, and earthquakes are less foreseeable than
floods.
2. Controllability
It refers to the degree to which interventions can be used to control the
disaster, such as using dams for flood control; earthquakes have very little
controllability.
3. Speed of Onset
Speed of onset is quick with floods whereas hurricanes are generally slow
to develop.
4. Length of forewarning
It is the period between warning and impact communities in the path of a
hurricane may have 24 hour warning, where as a tornado warning may provide
only a few minutes of preparation.
5. Duration of impact
Duration of impact also varies, a tornado may be on the ground for few
minutes, where as a floods impact usually lasts for days.
6. Scope and intensity of impact
It refers to geographic and social space dimension. A disaster such as a
tornado may be limited to a mile or two, but a flood may involve hundreds of
miles. The population density of an area influences this variable that can lead to
widespread consequences.
PHASES OF DISASTER
The life cycle of disaster is generally referred to as disaster continuum, and is

characterized by three major phases, namely:
1. Pre-impact phase (before)

2. Impact phase (during)
3. Post-impact phase (after)
This life cycle provide the foundation for the disaster timeline. Specific action taken
during these three phases along with the nature and scope of the planning, will affect the
extent of the illness, injury and death that occur.
1) Preimpact:
a) Occurs prior to the onset of the disaster.

b) Includes the period of threat and warning.
c) May not occur in all disaster.
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2) Impact Phase:
a) Period of time when disaster occurs, continuing to immediately following

disaster.
b) Inventory and rescues period.
 Assessment of extent of losses.
 Identification of remaining sources.
 Planning for use of resources and minimizing further injuries and
property damage.
3) Post impact phase
a) Occurs when majority of rescue operations are completed.

b) Remedy and recovery period.
c) Lengthy phase that may last for years.
 Honeymoon phase - feeling of euphoria, appearances of little effect by
disaster.
 Disillusionment phase - feeling of anger, disappointment and
resentment.
 Reconstruction phase - acceptance of loss, copping with stereo,
rebuilding.
Challenges to disaster planning:
There are problems, issues, and challenges commonly encountered across several
types of disasters. These issues and challenges can be effectively addressed in core
preparedness activities, and include the following;
 Communication problems.
Communication in terms of sharing information among organization and
across a lot of people is a major priority in any disaster planning initiative. Failure
of the communication system may occur in the event of a disaster, resulting from
one of many situations, including damage of infrastructure by the disaster itself, as
well as lack of operator familiarity, excessive demands, inadequate supplies and
lack of integration with other communications providers and technologies.
 Triage, transportation, and evaluation problems.

 Leadership issues.
 The management, security of and distribution of resources at the disaster site.
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A detailed process for the efficient and effective distribution of all types of
resources, including supplemental personnel, equipment and supplies among
multiple organizations and the establishment o a security perimeter around a
disaster site should also be included in the plan.
 Advance warning systems and the effectiveness of warning messages.

Advance warning systems and the use of evacuation from areas of danger
save lives and should be included in community disaster response plans whenever
appropriate.
 Coordination of search and rescue efforts.

 Media issues.
 Effective triage of patients
 Distribution of patients to hospitals in an equitable fashion.
 Patient identification and tracking.
 Damage or destruction of the health care infrastructure.
 Management of volunteers, donations, and other large numbers of resources.
 Organized improvisational response to the disruption of major systems.
 Finally, encountering overall resistance to planning efforts.
DISASTER MANAGEMENT
PRINCIPLES OF DISASTER MANAGEMENT
The principles of disaster management are:
1.Disaster management is the responsibility of all spheres of government.
No single service or department in itself has the capability to achieve comprehensive

disaster management. Each affected service or department must have a disaster
management plan which is coordinated through the Disaster Management Advisory
Forum
2.Disaster management should use resources that exist for a day-to-day purpose.
There are limited resources available specifically for disasters, and it would be neither
cost effective nor practical to have large holdings of dedicated disaster resources.
However, municipalities must ensure that there is a minimum budget allocation to enable
appropriate response to incidents as they arise, and to prepare for and reduce the risk of
disasters occurring.
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3.Organizations should function as an extension of their core business.
Disaster management is about the use of resources in the most effective manner. To
achieve this during disasters, organisations should be employed in a manner that reflects
their day-to-day role. But it should be done in a coordinated manner across all relevant
organisations, so that it is multidisciplinary and multi-agency.
4.Individuals are responsible for their own safety.
Individuals need to be aware of the hazards that could affect their community and the
counter measures, which include the Municipal Disaster Management Plan, that are in
place to deal with them.
5.Disaster management planning should focus on large-scale events.
It is easier to scale down a response than it is to scale up if arrangements have been

based on incident scale events. If you are well prepared for a major disaster you will be
able to respond very well to smaller incidents and emergencies, nevertheless, good multi
agency responses to incidents do help in the event of a major disaster.
Disaster management planning should recognize the difference between incidents

6.
and disasters.
Incidents - e.g. fires that occur in informal settlements, floods that occur regularly, still
require multi-agency and multi-jurisdictional coordination. The scale of the disaster will
indicate when it is beyond the capacity of the municipality to respond, and when it needs
the involvement of other agencies.
Disaster management operational arrangements are additional to and do not

7.
replace incident management operational arrangements
Single service incident management operational arrangements will need to continue,
whenever practical, during disaster operations.
8.Disaster management planning must take account of the type of physical

environment and the structure of the population.
The physical shape and size of the Municipality and the spread of population must be
considered when developing counter disaster plans to ensure that appropriate prevention,
preparation, response and recovery mechanisms can be put in place in a timely manner.
Disaster management arrangements must recognise the involvement and potential

9.
role of non- government agencies.
Significant skills and resources needed during disaster operations are controlled by non-
government agencies. These agencies must be consulted and included in the planning
process.
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OTHER PRINCIPLES:
 Prevent the disaster
 Minimize the casualties
 Prevent further casualties
 Rescue the victims
 First aid
 Evacuate
 Medical care
 Reconstruction
Phases of disaster management:
PHASES OF DISASTER MANAGEMENT

These are fundamental aspects of disaster management
1. Disaster Preparedness
2. Disaster impact
3. Disaster Response
4. Rehabilitation
5. Disaster Mitigation
DISASTER PREPAREDNESS
Disaster preparedness is an ongoing multisectoral activity. This consists of

strengthening the capacity of a country to manage efficiently all types of emergencies, so
that the resources should be able to provide assistance to the victims and bring back the
life to normal. The preparedness should start from the community people because many
times the external agency may not arrive for days to the affected area, specially if
transportation and communication are affected.
Preparedness should be in the form of money, manpower and materials
 Evaluation from past experiences about risk
 Location of disaster prone areas
 Organization of communication, information and warning system
 Ensuring co-ordination and response mechanisms
 Development of public education programme
 Co-ordination with media
 National & international relations
 Keeping stock of foods, drug and other essential commodities.
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Eg: Indian Meteorological department (IMD) plays a key role in forewarning the disaster
of cyclone-storms by detection tracing. It has 5 centres in Kolkata, Bhubaneswar,
Vishakapatanam, Chennai & Mumbai. In addition there are 31 special observation posts
setup a long the east coast of India.
The International Agencies which provides humanitarian assistance to the disaster

strike areas are United Nation agencies.
 Office for the co-ordination of Humanitarian Affair (OCHA)
 World Health Organization (WHO)
 UNICEF
 World Food Programme (WFP)
 Food & Agricultural Organisation (FAD)
Eg: Non Governmental Organizations
 Co-Operative American Relief Every where (CARE)
 International committee of Red cross
 International committee of Red cross
DISASTER IMPACT
Medical treatment for large number of causalities is likely to be needed only after
certain type of disaster. Most injuries are sustained during the impact, and thus, the
greatest need for emergency care occurs in the first few hours. The management of mass
causalities can be further divided into search and rescue, first aid, triage and stabilization
of victims, hospital treatment and redistribution of patients to other hospital if necessary.
Search, rescue and first aid
After a major disaster, the need for search, rescue and first aid is likely to be so great
that organized relief services will be able to meet only a small fraction of the demand.
Most immediate help comes from the uninjured survivors.
Field care
Most injured person‟s coverage spontaneously to health facilities, using whatever

transport is available, regardless of the facilities, operating status. Providing proper care to
the casualties requires that the health service resources be redirected to this new priority.
Bed availability and surgical services should be maximized. Provisions should be made for
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food and shelter. A centre should be established to respond from inquiries from patient‟s
relatives and friends. Priority should be given to victim‟s identification and adequate
mortuary space should be provided.
Triage
Triage consists of rapidly classifying the injured on the bases of severity of their
injuries and the likelihood of their survival with prompt medical intervention.
Sorting casualties for the purpose of assigning priorities.
Triage should be carried out at the site of disaster in order to determine

transportation priority and admission to the hospital or treatment center where the patients
needs an priority of medical care will be reassessed.
Golden hour
A seriously injured patient has one hour in which they need to receive Advanced
Trauma Life Support. This is referred to as the golden hour Triage helps to support this
golden hour concept by identifying the most seriously injured patients so that they may be
treated/transported first.
Immediate or high priority:
Higher priority is granted to victims who‟s immediate or long term prognosis can
be dramatically affected by simple intensive care.
 Immediate patients are at risk for early death

 They usually fall into one of two categories. They are in shock
from severe blood loss or they have severe head injury
 These patients should be transported as soon as possible

 If the patient passes the RPM assessment, they are placed in the delayed category
Delayed or medium priority:
 Because patients are categorized, “Delayed” does not mean that they may not have
serious injuries; It just means that they are not at high risk for death
 Delayed patients may have injuries that span a wide range
 They may not be able to join the walking wounded because of a broken ankle
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 They may have severe internal injuries,but are still compensating
 It is important that the delayed patients are frequently reassessed and further
prioritized for transport. This will usually be done in a central treatment area
 Delayed patients have:
 Respirations under 30/minutes
 Capillary refill under 2 seconds
 Can do-follow simple commands
Minor or minimal or ambulatory patients:
 Patients with minor lacerations, contusions, sprains, superficial burns are identified
as “minor/minimal”
 These patients will not suffer significant morbidity if no medical intervention is
performed
Expectant or least priority:
Morbid patients who require a great deal of attention with questionable benefit
have the lowest priority.
 Patients with whom there are signs of impending death or massive injuries with
poor likelihood of survival are labeled as expectant
 These are patients with penetrating head wounds, high spinal cord injuries, second
or third degree burns with greater than 60 percent of total body surface area,
profound shock with agonal respirations
Colour code:
The most common classification uses the internationally accepted four colour code
system.
 Red indicate high priority treatment or transfer

 Yellow signals medium priority
 Green indicate ambulatory patients
 Black indicates dead or moribund patients
. Triage should be carried out at the site of disaster, in order to determine transportation
priority, and the admission to the hospital or treatment centers, where the patient‟s needs
and priority of medical care will be reassessed. Ideally, local health workers should be
taught the principles of triage as part of disaster training.
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Person with minor or moderate injuries should be treated at their own homes to avoid
social dislocation and the seriously injured should be transported to hospital with
specialized treatment facilities
Tagging
All patients should be identified with tags stating their name, age, place of origin, triage
category, diagnosis, and initial treatment.
Identification of dead
Taking care of the dead is an essential part of the disaster management. A large number
of deaths can also impede the efficiency of the rescue activities at the site of the disaster.
Care of the dead includes:
1) Removable of the dead from the disaster scene;
(2) Shifting to the mortuary;
(3) Identification;
(4) Reception of relatives. Proper respect for the dead is great importance.
The health hazards associated with cadavers are minimal if death results from trauma
are quite unlikely to cause outbreaks of disease such as typhoid fever, cholera or plague. If
human body contaminated streams, well or other water sources as in floods etc., they may
transmit gastroenteritis or food poisoning to survivors. The dead bodies represent a
delicate social problem.
DISASTER RESPONSE
This is carried out under the following phases
RELIEF PHASE
This phase begins when assistance from outside starts to reach the disaster area. The
type and quantity of humanitarian relief supplies are usually determined by two main
factors:
 The type of disaster, since distinct events have different effects on the population,
and
 The type and quantity of supplies available locally.
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Immediately following a disaster, the most critical health supplies are those needed for
treating casualties, and preventing the spread of communicable diseases. Following the
initial emergency phase, needed supplies will include food, blankets, clothing, shelter,
sanitary engineering equipments and construction material. A rapid damage assessment
must be carried out in order to identify needs and resources. Disaster managers must be
prepared to receive large quantities of donations. There are four principle components in
managing humanitarian supplies:
a) Acquisition of supplies;
b) Transportation;
c) Storage; and
d) Distribution.
The relief phase mainly includes Epidemiologic surveillance and disease control,
Vaccination and nutrition.
Epidemiologic surveillance and disease control
Disasters can increase the transmission of communicable diseases through following

mechanisms:
1. Overcrowding and poor sanitation in temporary resettlements. The accounts in

part, for the reported increase in acute respiratory infections etc. following the
disasters.
2. Population displacement may leads to introduction of communicable diseases to

which either the migrant or indigenous populations are susceptible.
3. Disruption and the contamination of water supply, damage to sewerage system and
power systems are common in natural disasters.
4. Disruption of routine control programmes as funds and personnel are usually

diverted to relief work.
5. Ecological changes may favour breeding of vectors and increase the vector
population density.
6. Displacement of domestic and wild animals, which carry with them zoonoses that
can be transmitted to humans as well as other animals. Leprosies cases have been
reported following large floods. Anthrax has been reported occasionally.
7. Provision of emergency food, water and shelter in disaster situation from different
or new source may itself be a source of infectious disease.
Outbreak of gastroenteritis, which is the most commonly reported disease in the post-
disaster period, is closely related to first three factors mentioned above. Increased
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incidents of acute respiratory infections also common in displaced population. Vector-

borne diseases will not appear immediately but may take several weeks to reach epidemic
levels.
Displacement of domesticated and wild animals increases the risk of transmission of

zoonoses. Veterinary services may be needed to evaluate such health risks. Dogs, cat and
other domestic animals are taken by their owners to or near temporary shelters. Some of
these animals may be reservoirs of infection such as leptospirosis; rickettsiosis etc. wild
animals are reservoirs of infections which can be fatal to man such as equine encephalitis,
rabies, and infections still unknown in humans.
The principles of preventing and controlling communicable diseases after a disaster are to
a) Implement as soon as possible all public health measures, to reduce the risk of
disease transmission;
b) Organize a reliable disease reporting system to identify the outbreaks and to

promptly initiate control measures; and
c) Investigate all reports of disease outbreak rapidly.
Vaccination
Health authorities are often under considerable public and political pressure to begin
mass vaccination programmes, usually against typhoid, cholera and tetanus. The pressure
may be increased may be by the press media and offer vaccines from abroad.
The WHO does not recommend typhoid and cholera vaccines in routine use in endemic
areas. The newer typhoid and cholera vaccines have increased efficacy, but because they
are multi-dose vaccines, compliance is likely to be poor. They have not yet been proven
effective, as a large- scale public health measures. Vaccination programme requires large
number of workers who could be better employed elsewhere. Supervision of sterilization
and injection techniques may be impossible, resulting in more harm than good. And above
all, mass vaccination may leads to false sense of security about the risk of the disease and
to the neglect of effective control measures. However, these vaccinations are
recommended for health workers. Supply safe drinking water and proper disposal of
excreta continue to be the most practical and effective strategy.
Significance increases in tetanus incidence have not occurred after natural disasters.
Mass vaccination of population against tetanus is usually unnecessary. The best protection
is maintenance of a high level of immunity in the general population by routine
vaccination before the disaster occurs, and adequate wound cleaning and treatment. If
tetanus immunization have received more than 5 years ago in a patient who has sustained
an open wound, a tetanus toxoid booster is an effective preventive measure. In previously
unimmunized injured patients, tetanus toxoid should be given only at the direction of
physician. If routine vaccination programmes are being conducted in camp with large
number of children, it is prudent to include vaccination against tetanus.
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Natural disasters may negatively affect the maintenance of on going national or regional
eradication programme against polio and measles. Disruption of these programmes should
be monitored closely. If cold- chain facilities are inadequate, they should be requested at
the same time as vaccines. The vaccination policy to be adopted should be decided at
senior level only.
Nutrition
A natural disaster may affect the nutritional status of the population by affecting one or
more components of food chain depending on the type, duration and extent of the disaster,
as well as the food and nutrition content existing in the area before catastrophe. Infants,
children, pregnant women, nursing mothers and sick persons are more prone to nutritional
problems after prolonged drought and after certain type of disasters like hurricanes, floods,
land or mudslides, volcanic eruptions and sea surges involving damage to crops, to stocks
or to food distribution systems.
The immediate step of ensuring that the food relief programme will be effective
includes:
a) Assessing the food supplies after the disaster;
b) Gauging the nutritional needs of the affected population;
c) Calculating daily ration foods and need for large population groups;
d) Monitoring the nutritional status of the affected population.
REHABILITATION PHASE
This should be started from the time of onset of disaster to see that the normal conditions
of life are restored as early a possible services are a follows
Rehabilitation starts from the very first moment of a disaster. Too often, measures decided
in a hurry, tend to obstruct re- establishment of normal conditions of life. Provisional by
external agencies of sophisticated medical care for temporary period has negative effects.
On the withdrawal of such care, the population is left with a new level of expectation
which simply cannot be fulfilled.
In first weeks after disaster, the pattern of health needs will change rapidly, moving
from causality treatment to more routine primary health care. Services should be
recognized and restructured. Priorities also shift from health care towards environmental
health measures. Some of them are as follows:
Water supply
A survey of all public water supplies should be made. This include distribution system
and water source. It is essential to determine physical integrity of system components, the
remaining capacities, and bacteriological and chemical quality of water supplied. The
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main public safety aspect of water quality is microbial contamination. The first priority of
ensuring water quality in emergency situations is chlorination. It is the best way of
disinfecting water. It is advised to increase residual chlorine level to about 0.2 – 0.5 mg/
liter. Low water pressure increases the risk of infiltration of pollutants into water mains.
Repaired mains, reservoirs, and other units require cleaning and disinfection.
Chemical contamination and toxicity are a second concern in water quality and
potential chemical contaminants have to be identified and analyzed. The existing and new
water sources require the following protection measure:
1) Restrict access to people and animals, if possible, erect a fence and appoint a
guard;
2) Ensure adequate excreta disposal at a safe distance from water resource;
3) Prohibit bathing, washing and animal husbandry, upstream of intake points in

rivers and streams;
4) Upgrade wells to ensure that they are protected from contamination
5) Estimate the maximum yield of wells and if necessary, ration the water supply.
In many emergency situations, water has to be trucked to disaster site or camps. All
water tankers should be inspected to determine fitness, and should be cleaned and
disinfected before transporting water.
Food safety
Poor hygiene is the major cause of food borne – diseases in disaster situations. Where
feeding programmes are used kitchen sanitation is of utmost importance. Personal hygiene
should be monitored in individuals involved in food preparation.
Basic sanitation and personal hygiene
Many communicable diseases are spread through faecal contamination of drinking

water and food. Hence, every effort should be ensure the sanitary disposal of excreta.
Emergency latrines should be made available to the displaced, where toilet facilities have
been destroyed. Washing, cleaning and bathing facilities should be provided to the
displaced persons.
Vector control
Control programme for vector borne diseases should be intensified in the emergency
and rehabilitation period, especially in areas where such diseases are known to be
endemic. Of special concern are dengue fever and malaria, leptospirosis, and rat bite fever,
typhus, and plague. Flood water provides ample breeding opportunities for mosquitoes.
A major disaster with high mortality leaves a substantial displaced population, among
who are those requiring medical treatment and orphaned children. When it is not possible
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to locate the relatives who can provide care, orphans may become the responsibility of
health and social agencies. Efforts should be made to reintegrate disaster survivors into the
society, as quickly as possible through institutional programmes coordinate by ministries
of health and family welfare, social welfare, education and NGOs.
DISASTER MITIGATION
This involves lessening the likely effects of emergencies. These include depending
upon the disaster, protection of vulnerable population and structure. For examples,
improving structural qualities of schools, houses and such other buildings so that medical
causalities can be minimized. Similarly ensuring the safety of health facilities and public
health services including water supply and sewerage system to reduce the cost of
rehabilitation and reconstruction. This mitigation compliments the disaster preparedness
and disaster response activities.
DISASTER MANAGEMENT CYCLE
The components of disaster management cycle are as follows.
1. Preparedness
2. Disaster impact
3. Response
4. Rehabilitation
5. Reconstruction
6. Mitigation
Risk reduction phase
Before a disaster
DISASTER
IMPACT
PREPAREDNESS RESPONSE
MITIGATION
REHABILITATION
RECONSTRUCTION
Recovery phase after disaster
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DISASTER-EFFECTS
1. EFFECTS OF MAJOR DISASTERS
1. Deaths
2. Disability
3. Increase in communicable disease
4. Psychological problems
5. food shortage
6. Direct environmental risk
7. Socioeconomic losses
8. Shortage of drugs and medical supplies.
2. COMMON INJURIES ASSOCIATED WITH DISASTERS
 Crush injuries, bruises
 Fracture pelvis, thorax, spine, arms, skull
 Burns
 Suffocation
 Hypothermia
 Communicable disease problem
 Epidemics -Malaria, Japanese encephalitis, Measles ,ART,

Tuberculosis, parasitic disease, plague, diarrhea etc.
3. EMOTIONAL OR PSYCHOLOGICAL PROBLEMS
Anxiety, depression, etc. are common following disasters known as “Post disaster
Syndrome”
4. PROBLEMS IN VECTOR CONTROL
Disruption of routine vector control programmes occur as funds and manpower are
diverted towards relief work. Resultant environmental and ecological alterations following
disasters favour breeding of vectors and increase in or population density.
5. FOOD SHORTAGE LEADING TO NUTRITIONAL PROBLEMS
Damage and disruption of food supplies, damage to crops, lack of availability,

disruption of food distribution system etc. may lead to nutritional problems.
Vitamin deficiency eg: xerophthalmia, blinders.
6. SHORTAGE OF DRUGS AND MEDICAL SUPPLIES
Essential drugs, medical equipments, surgical facilities, etc may be lacking

following disaster
113
7. ENVIRONMENTAL DISRUPTION
Breakage of water sources, pollution of water supplies rapture of piper, sewage etc.
chemical contamination of water supplies may happen. Problems with sanitary disposal of
excreta may be encountered.
8. PSYCHOLOGICAL REACTIONS TO A DISASTER
Preschool (1to 5yrs Night terrors

Fearfullness
Clinging to parents
Night terrors
Early childhood Aggressive behaviour at home or school
Stomachache, headache
Clinging or Wheezing
Poor concentration in school
Rebellion in home
Pre adolescence (11 to 1yrs) Stomach ache / head ache
Loss of interest in friends
School problems
Distressing
Adulthood Intrusive memories of disast

Loss of interest
Flashback in activities
of upsetting feelings
Adolescence (14 to 18 yrs Delinquent

Intense distressbehaviour
at reminder
Poor concentration
Lack of interest in pleasure
114
DISASTER DRILL
Definition
A disaster drill is an exercise in which people simulate the circumstances of a disaster so
that they have an opportunity to practice their responses.
Disaster drills can range from earthquake drills in schools to multi-day exercises
which may span across entire communities, including detailed simulations and a chance to
work with the same equipment which would be utilized in a disaster.
Disasters are unpredictable by nature. Sometimes communities get advance
warning, as in the case of some disasters caused by severe weather, while in other cases,
disaster can strike in an instant in the form of an earthquake or a severe fire. If people do
not practice their responses, they will usually not be prepared when disaster does happen;
while a disaster drill may not anticipate every potential scenario, it gives people an idea of
how to behave during a disaster.
Features
On a basic level, drills can include responses by individuals to protect themselves, such
as learning how to shelter in place, understanding what to do in an evacuation, and
organizing meet up points so that people can find each other after a disaster.
Disaster drills handle topics like what to do when communications are cut off, how to
deal with lack of access to equipment, tools, and even basic services like water and
power, and how to handle evacuations.
It also provides a chance to practice for events such as mass casualties which can occur
during a disaster.
Regular disaster drills are often required for public buildings like government offices
and schools where people are expected to practice things like evacuating the building
and assisting each other so that they will know what to do when a real alarm sounds.
Community-based disaster drills such as whole-city drills provide a chance to practice
the full spectrum of disaster response. These drills can include actors and civilian
volunteers who play roles of victims, looters, and other people who may be
encountered during a disaster, and extensive planning may go into such drills. A
disaster drill on this scale may be done once a year or once every few years.
Benefits
 Used to identify weak points in a disaster response plan
 To get people familiar with the steps they need to take so that their response in a
disaster will be automatic.
115
ROLE OF NURSE IN DISASTER MANAGEMENT
DISASTER PREPAREDNESS -NURSES ROLE
1) To Facilitate preparation with community

Facilitating preparation within the community and place of employment within
employing organization the nurse can help initiate updating disaster plan, provide
educational programmes & Material regarding disasters specific to areas.
2) To provide updated record of vulnerable populations within community

The nurse should be involved in educating these populations about what impact the
disaster have / cause on them. Review availability of specific resources, in the event of an
emergency.
3) Nurse leads a preparedness effort

Nurse can help recruit others within the organization that will help when a
response is required. It is wise to involve person in these efforts who demonstrate
flexibility, decisiveness, stamina, endurance and emotional stability.
4) Nurse play multiroles in community

Nurse might be involved in many roles. As a community advocate, the nurse
should always seek to keep a safe environment. She must assess and report environmental
hazards.
Eg: Nurse should be aware of & report unsafe equipment.
5) Nurse should have understanding of community resources

Nurse should have an understanding UP what community resources will be
available after a disaster strikes and how community will work together. A community
wide disaster plan will guide the nurse in understanding what should occur before, during
and of to the response and his or her role with in the plan.
6) Disaster Nurse must be involved in community organization

Nurse who sects greater involvement or a more in-depth understanding of disaster
management can become involved any number of community organizations and the peat
of official response team such as the American Red cross, American Red cross,
Ambulance corps etc.
DISASTER RESPONSE – NURSES ROLE
1) Nurse must involve in community assessment, case finding and referring, prevention,
health education and surveillance
116
2) Once rescue workers begin to arrive at the scene, immediate plans for triage should
begin. Triage is the process of separating causalities and allocating treatment based on
the victims potential for survival. Higher priority is always given to victim‟s potential
who have life threatening injuries but who have a high probability of survival once
stabilized.
3) Second Priority is given to victims who have injuries with systemic complications that
are not yet life threatening but who can wait up to 45-60 minutes of treatment. Last
priority in given to those victims who have local injuries without immediate
complications and who can wait several hours for medical attention
4) Nurse work a member of assessment team

Nurse working as members of an assessment team have the responsibility of give
accurate peed back to relief managers to facilities rapid rescue and recovery.
Ea: Manytimes nurses are required to make homevisite to galties needed information.
Type of information included in initial assessment report include geographical extend of
disasters impact population at risk or affected, presence of contincing hozuds injuries and
dislike, availability of shelter, current leved of sanitation & status of health care
infrastructures.
5) To be involved in ongoing surveillance

Nurse involved in ongoing surveillance uses the following methods to gather
information – interview, observation, physical examination, health and illness screening
surveys, records etc.
DISASTER RECOVERY – NURSES ROLE
1) Successful Recovery Preparation

Flexibility is an important component of successful recovery preaparation.
Community clean up efforts can incure a host of physical and psychological problems.
Eg: Physical stress of moving heavy objects can cause back injury, severe fatigue and even
death from heat attacks.
2) Be vigilant in Health teaching

The continuing threat of communicable disease will continue as long as the water supply
remains threat and the relieving conditions remain crowded. Nurses must remain vigilant
in teaching proper hygiene and making sure vigilant in teaching proper hygiene and
making sure immunization records are up to date.
117
3) Psychological support
Acute and chronic illness can be exacerbated by prolonged effects of disaster. The
psychological stress of cleanup and moving can bring about feelings of severe
hopelessness, depression and grip.
4) Referrals to hospital as needed

Stress can lead to suicide and domestic abuse. Although most people recovery from
disasters, mental distress may persist in those vulnerable populations referrals to mental
health professionals should continue as long as the need exists.
5) Remain alert for environmental health : Nurse must also remain alert for environment
health hazards during recovery phase of a disaster. Home visit may lead the nurse to
uncover situations such as faculty having structure, lack of water supply or lack of
electricity.
6) Nurse must be attentive to the danger

Nurse must be attentive to dangers of live or dead animals and rodents which are
harmful to person‟s health.
Eg: finding snakes in and around homes once water from flood start to reduce.
CONCLUSION
Disasters are of different types which can happen any time ,any where, in the world
causing tremendous after effects such as loss of human life ,economical imbalances, food
scarecity epidemics , forced relocation of population etc. Disasters usually affect the
developing countries comparing with the developed countries. While deserting the matter
we could come to the conclusion that the adverse effects of natural disasters can be
minimized by proper preventive measures alert technologies at high risk areas, proper
mobilization of resources, decreased corruption in the field and also the mock training
programmes in the community
BIBLIOGRAPHY
1. Suryakantha A.H, “Community Medicine with Recent Advances” 1 st

Edition, NewDelhi, Jaypee Brothers Medical Publishers Pvt Ltd. 2009;
Page 814-818
2. Rahim A, “Principles and Practice of community Medicine” 1st Edition,
NewDelhi, Jaypee Brothers Medical Publishers Pvt. Ltd., 2008, Page 595-
600
3. Park K, “Preventive and social Medicine”, 17th Edition, Banarsidas Bhanot
Publishers, Jabalpur, 2002, Page 568-573
118

Organisation in Nursing Administration

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Organisation in Nursing Administration

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UNIT-IV

Meaning: the word organization may convey at least 3 meanings:

Koontz and O’Donnell, ‘essentially as the creation and maintenance of an intentional

From the above definitions it is clear that,

 Any organisation must have defined goals or objectives.

The organisation must

1) Reflect objectives and plans of the organisation.

Administrative function, as a system, as an operation and as a result.

1.Administrative Function : organisation is a process of identification and grouping of

2. as a system, orgn consists of many interrelated and interdependent subsystems; each

b) throughput: the methods through which functions are carried out.

c) Output: the actual outcome.

3. in an operational: organisation is involved with determination and defining of duties

1. Determination of objectives for each activity.

3. Grouping of activities , their similarity, interrelationships, competencies and

4. Deciding different groups of activities in terms of

- The seating arrangements

5. Determining the authority, responsibility and accountability of different members

6. Integration between the identified group of activities through relationships and

 Chain of command with laid down channels of communication. (flow of authority

 Assists administration in gearing the human, material and financial resources

1. Principle of chain of command:

2. Principle of unity of command:

 In the absence of unity of command

 There is a division of labor: a differentiation among kinds of duties.

5. Hierarchy or scalar chain:

10. Principle of equilibrium balance:

11. Principle of continuity:

13. Principle of unity of direction:

14. Principle of communication:

The organisation can be classified on the basis

 of authority and responsibility assigned to the personnel

In this way organisation can be either formal or informal.

Provides a framework for defining responsibility, authority, delegation and accountability.

The formal organisation represents

 the classification of activities within the enterprise,

Characteristics of formal organisation:

Advantages of formal organisation:

1. The definite boundaries of each worker is clearly fixed. It automatically reduces

 Informal organisation is an organisational structure which establishes the

 According C.J. Bernard, „informal organisation brings cohesiveness to formal

Characteristics of informal organisation:

1. Informal organisation arises without any external cause ie., voluntarily.

Advantages of informal organisation:

 It fills up the gaps and deficiency of the formal organisation.

Disadvantages of informal organisation:

 It has the nature of upsetting the morality of the workers.

Difference between formal and informal organisation

Formal organisation Informal organisation

It arises due to delegation of authority. It arises due to social interaction of people.

It gives importance to terms of authority It gives importance to people and their

It is created deliberately It is spontaneous and natural.

The formal authority is attached to a The informal authority is attached to a

Formal authority flows from upwards to Authority flows upwards to downwards

Formal organisation may grow to Informal organisation tends to remain

It is permanent and stable There is no such permanent nature and

Types of organisation (Levels of Organisation):

Broadly there are 3 types of organisation:

Manager manager manager manager manager

Deputy nursing superintendent

ANS ANS ANS ANS

Ward sister W/S W/S W/S