Professional Documents
Culture Documents
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.
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 team members.
To assist the physician in providing medical care to the patients.
To provide preventive and rehabilitative services.
To provide round the clock nursing care to all the patients.
To render timely and appropriate nursing service to emergency patients.
To provide cost effective quality care as per the needs of patients.
Confidentiality and privacy of each patient should be maintained.
Constant monitoring and evaluating is of utmost importance to improve patient care continuously.
Objectives in relation to Education
Planning of education and training programme for nurses are must for professional growth and development
needs through in-service education and research support.
To provide regular staff development, in-service education and guidance services for all members of nursing
staff.
To conduct regular orientation programme for new entrants and for those have been on the job for a long time.
To conduct training for operating procedure of latest gadgets and on handling sophisticated bio-medical
equipment.
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FACTORS INFLUENCING WARD MANAGEMENT.
1. Knowledge of the ward means that knowledge of all the duties and activities to be performed in the ward.
2. Planning the schedule of the ward.
3. Starting the work on time.
4. Preventing interruptions.
5. Establishment of ward routines.
6. Use of democratic method in establishing ward policy.
7. Orientation of new personnel
8. Orientation of hospital
9. Orientation of the ward.
10. Maintenance of the suitable environment.
11. Supplies and equipment’s in a hospital
12. Clear cut, specific orders for medical therapy and nursing.
13. Record keeping and maintaining accurate records.
14. Reporting
15. Maintenance of high morale among all members of the staff.
16. Establishment of good working relationship.
17. Delegating responsibility
18. Assigning duties and responsibilities.
19. Time planning
20. Good teaching.
21. Good supervision.
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ORGANIZING NURSING SERVICE AT VARIOUS LEVELS
Discipline
♣ Ensure that a standard of discipline of nursing staff is high at all times.
♣ Maintain good order and discipline in wards/departments.
♣ Makes daily rounds of the hospital wards/departments and also seriously ill patients. In addition she will
make unscheduled rounds in the hospital in the evenings.
♣ Brings immediately to the notice of the medical superintendent all matters concerning neglect of duty,
insubordination either by nursing staff, patients or visitors or any un-towards incident, which comes to her
notice for taking suitable action as required as per the orders on the subject.
Public Relations
♣ Promotes and maintains harmonious and effective relationship with the various administrative departments of
the hospital and related community agencies.
♣ Maintain cordial relationships with the patients and their families.
Office Routine
♣ Scrutinizes the reports and returns and submits in accordance with existing orders.
Confidential Reports
♣ Initiates the confidential reports of nursing staff on due dates.
♣ Responsible for the nursing budget.
Education
♣ Carries out in-service training for all categories of nursing staff and paramedical personnel and keeps the
records of such trainings.
♣ Conduct various update courses based on the needs.
♣ Encourages the personnel to participate in the continuing education programme.
Welfare
♣ Responsible for health and welfare of nursing staff.
♣ Ensures annual and periodical health examination and maintenance of health records.
Conferences
♣ Responsible for organizing and conducting staff meeting of the nursing staff once in three months.
♣ Holds conference in nursing care problems and discuss policies as regards to working conditions, working hrs
and other facilities.
Supervision
♣ Supervises nursing care given to the patients and all nursing activities within the nursing unit.
♣ Supervises the work of all paramedical staff of the hospital.
Records and Reports
♣ Maintains various records such as duty roster nursing staff, day off book, personal bio-data, leave plan, staff
conference book, courses file etc.
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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.
Nurse administrators are facing lot of health care issues in hospitals, high rocketing health care cost, need for
decreasing length of hospital stay, quality and patient safety, cosumerism and lack of resources for nursing care.
These issues are affecting patients, families and nurses also. the management is constantly seeking reduction of
health cost at the same time intends to bring high quality patient care.
PURPOSE OF PCS
To provide quality and safe patient care.
PCS helps to decide the nursing hours required for each category of patients that will help to bring best possible
patient care outcome as per norms recommended by the health facility.
Enhance staff satisfaction through a stress free work environment.
Monitor changes in patient demographics and care needs.
Provides information on each patient care unit that directs and support staffing decision-making.
Ensures that quality of nursing care is provided in safe environment.
Assesses the level and support services required for each category of patient.
Enhances staff satisfaction through stress- free work environment.
The PCS data generated is used to improve patient satisfaction by providing required time to the patient
according to his/her needs and enhances staff satisfaction by determining staffing needs and thus decreasing
workload.
Monitors the provision of quality nursing care according to international standards in a safe work environment.
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.
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.
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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 Cannot feed self Cannot feed self
in preparing but is able to chew any may have
and swallowing difficulty
swallowing
Grooming Almost entirely Need some help in Unable to do much Completely
self sufficient bathing, oral for self dependent
hygiene …
Excretion Up and to Needs some help In bed, needs Completely
bathroom alone in getting up to bedpan / urinal dependent
bathroom /urinal placed;
Comfort Self sufficient Needs some help Cannot turn Completely
with adjusting without help, get dependent
position/ bed.. drink, adjust
position of
extremities …
General health Good Mild symptoms Acute symptoms Critically ill
Treatment Simple – Any Treatment Any treatment Any elaborate/
supervised, more than once more than twice delicate procedure
simple dressing… per shift, foley /shift… requiring two
catheter care, nurses, vital signs
I&O…. more often than
every two hours..
Health education & Routine follow up Initial teaching of More intensive Teaching of
teaching teaching care of ostomies; items; teaching of resistive patients,
new diabetics; apprehensive/
patients with mildly resistive
mild adverse patients….
reactions to their
illness…
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SELF CARE/MINIMAL CARE- the first classification of patient who are recovering and normally requires
only diagnostic studies, minimal therapy, less frequent observations, and daily care for minor conditions. For
example patient waiting for elective surgery.
MODERATE CARE – the patient in this category is moderately ill or under the recovery stage from a serious
illness or operation. They require nursing supervision or assistance that is related to ambulating and caring for
their own hygiene.
MAXIMUM CARE- Patient needs close attention and complete care all through the shift. The nurse initiate,
supervise and perform most of the patients activities.
INTENSIVE CARE- the last category or classification, wherein the patients are acutely ill and high level of
nurse dependency is required. Intensive therapy and/or intensive nursing care is needed because of the
unstable condition of the patient. Frequent evaluation, observation, monitoring, and adjustment of therapy is
also required. A patient in these levels includes those in critical conditions or in life and death situations.
TYPES
Selfcare/minimal care: the first classification of patients who are normal and mostly ambulatory and able to
manage their care means the basic care. They are self- dependent and help themselves without nurses support.
These categories of patients require minimum nursing acre hours. They require less observation, and
monitoring.
Moderate care: the patients are moderately ill in this category and waiting for recovery. These types of patients
are guided and supported by nurses for early ambulation and self-care.
Maximum care: patients need maximum nursing care hours and medical supervision in this group in all shifts.
They need constant monitoring, supervision and evaluation.
PURPOSE OF ASSIGNMENT
To distribute the to be done for patient care to the nursing staff.
To ensure the cooperation of the nursing personnel by knowing and accepting of the work to be done.
Each of these basic types has undergone many modifications, often resulting in new terminology. For
example, primary nursing has been called case method nursing in the past and is now frequently referred to as a
professional practice model. Team nursing is sometimes called partners in care or patient service partners and
case managers assume different titles, depending on the setting in which they provide care. When closely
examined most of the newer models are merely recycled, modified or retitled versions of older models.
Choosing the most appropriate organizational mode to deliver patient care for each unit depends on the skill and
expertise of the staff, the availability of registered professional nurse, the economic resources of the
organization and the complexity of the task to be completely.
CASE METHOD
Features:
It was the first type of nursing care delivery system. In this method, nurses assume total responsibility for
meeting all the needs of assigned patients during their time on duty. It involves assignment of one or more
clients to a nurse for a specific period of time such as shift. The patient has a different nurse each shift and no
guarantee of having the same nurses the next day. Nurse‘s responsibility includes complete care including
treatments, medication and administration and planning of nursing care. This is the way most nursing students
were taught – take one patient and care for all of their needs. This model is used in critical care areas, labor and
delivery, or any area where one nurse cares for one patient‘s total needs. Here nurses were self-employed when
the case method came into being, because they were primarily practicing in homes. It lost much of that
autonomy when healthcare became institutionalized in hospitals and clinics and now called as private duty
nursing.
Merits:
♣ The nurse can attend to the total needs of clients due to the adequate time and proximity of the interactions.
♣ Good client nurse interaction and rapport can be developed.
♣ Client may feel more secure.
♣ RNs were self-employed.
♣ Work load can be equally divided by the staff.
♣ Nurse‘s accountability for their function is built-it.
♣ It is used in critical care settings where one nurse provides total care to a small group of critically ill patients.
Demerits:
♠ Cost-effectiveness.
♠ The greater disadvantage to case nursing occurs, when the nurse is inadequately trained or prepared to provide
total care to the patient.
♠ Nurse may feel overworked if most of her assigned patients are sick.
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♠ 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.
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.
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♠ Patients get confused as so many nurses attend to them, e.g. head nurse, medicine nurse, dressing nurse,
temperature nurse, etc.
TEAM NURSING
Features:
Developed in 1950s because the functional method received criticism, a new system of nursing was devised to
improve patient satisfaction. Care through others became the hallmark of team nursing. Team nursing is based
on philosophy in which groups of professional and non-professional personnel work together to identify, plan,
implement and evaluate comprehensive client-centered care. In team nursing an RN leads a team composed of
other RNs, LPNs or LVNs and nurse assistants or technicians. The team members provide direct patient care to
group of patients, under the direction of the RN team leader in coordinated effort. The charge nurse delegates
authority to a team leader who must be a professional nurse. This nurse leads the team usually of 4 to 6
members in the care of between 15 and 25 patients. The team leader assigns tasks, schedules care, and instructs
team members in details of care. A conference is held at the beginning and end of each shift to allow team
members to exchange information and the team leader to make changes in the nursing care plan for any patient.
The team leader also provides care requiring complex nursing skills and assists the team in evaluating the
effectiveness of their care.
Advantages:
♣ High quality comprehensive care can be provided to the patient
♣ Each member of the team is able to participate in decision making and problem solving.
♣ Each team member is able to contribute his or her own special expertise or skills in caring for the patient.
♣ Improved patient satisfaction.
♣ Feeling of participation and belonging are facilitated with team members.
♣ Work load can be balanced and shared.
♣ Division of labour allows members the opportunity to develop leadership skills.
♣ There is a variety in the daily assignment.
♣ Nursing care hours are usually cost effective.
♣ The client is able to identify personnel who are responsible for his care.
♣ Barriers between professional and non-professional workers can be minimized, the group efforts prevail.
Disadvantages:
♠ Establishing a team concept takes time, effort and constancy of personnel. Merely assigning people to a group
does not make them a ‗group‘ or ‗team‘.
♠ Unstable staffing pattern make team nursing difficult.
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♠ 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.
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:
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♠ 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.
Features:
It is a method in which client care areas provide various levels of care. The central theme is better
utilization of facilities, services and personnel for the better patient care. Here the clients are evaluated with
respect to all level (intensity) of care needed. As they progress towards increased self care (as they become
less ethically ill or in need of intensive care or monitoring) they are marred to units/ wards staffed to best
provide the type of care needed.
Principal elements of PPC
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.
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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.
Features:
It was developed in the 1960s with the aim of placing RNs at the bedside and improving the professional
relationships among staff members. The model became more popular in the 1970s and early 1980s as hospitals
began to employ more RNs. It supports a philosophy regarding nurse and patient relationship.
It is a system in which one nurse is caring for all the needs of a patient or more within a 24 hour from admission
to discharge. He or she is responsible for coordinating and implementing all the necessary nursing care that
must be given to the patient during the shift. If the nurse is not available, the associate nurse responsible for
filling in for the nurse‘s absence will provide hospital care to the patient based on the original plan of care made
by the nurse. In acute care the primary care nurse may be responsible for only one patient; in intermediate care
the primary care nurse may be responsible for three or more patients This type of nursing care can also be used
in hospice nursing, or home care nursing
Advantages:
♣ Primary Nursing Care System is good for long-term care, rehabilitation units, nursing clinics, geriatric,
psychiatric, burn care settings where patients and family members can establish good rapport with the primary
nurse.
♣ Primary nurses are in a position to care for the entire person-physically, emotionally, socially and spiritually.
♣ High patient and family satisfaction
♣ Promotes RN responsibility, authority, autonomy, accountability and courage.
♣ Patient-centered care that is comprehensive, individualized, and coordinated; and the professional satisfaction
of the nurse.
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♣ Increases coordination and continuity of care.
Disadvantages:
♠ More nurses are required for this method of care delivery and it is more expensive than other methods.
♠ Level of expertise and commitment may vary from nurse to nurse which may affect quality of patient care.
♠ Associate nurse may find it difficult to follow the plans made by another if there is disagreement or when
patient‘s condition changes.
♠ It may be cost-effective especially in specialized units such as the ICU.
♠ May create conflict between primary and associate nurses.
♠ Stress of round the clock responsibility.
♠ Difficult hiring all RN staff
♠ Confines nurse‘s talent to his/her own patients.
CASE MANAGEMENT
Features:
The case manager (RN or social worker with managerial qualification) is assigned responsibility of
following a patient‘s care and progress from the diagnostic phase through hospitalization, rehabilitation and
back to home care. For eg; case manager for cardiac surgery patients assists them go through diagnostic
procedures, pre-operative preparations, surgical interventions, family counseling, post-operative care and
rehabilitation. Case management involves critical paths, variation analysis; inter shift reports, case consultation,
health care team meetings, and quality assurance. Critical paths visualize outcomes within a time frame.
Variation analysis notes positive or negative changes from the critical paths, the cause, and the corrective action
taken. Case consultation may be indicated when the client‘s condition differs from the critical path as noted in
the inter shift report. Case consultation is conducted about once a week for a few minutes immediately after
inter shift report to deal with variations. Health care team meetings provide an interdisciplinary approach to
problem solving. The case manager needs to identify no more than three priority goals and decide what team
members should be present after considering the patient, family physician, social service, various therapists, and
others involved. The case manager should set the time and place for the meeting, make the arrangements, and
post the date, time, place, and people to attend. The case manager calls the meeting to order, states the goals,
initiates discussion, documents the plans, and sets time limits for follow through. The variance between what is
expected and what happened is assessed for quality assurance.
Responsibilities of case managers:
♥ Assessing clients and their homes and communities.
♥ Coordinating and planning client care.
♥ Collaborating with other health professionals in the provision of care.
♥ Monitoring client progress and client outcomes.
♥ Advocating for clients moving through the services needed.
♥ Serving as a liaison with third party payers in planning the client ‘s care.
Merits:
For the patients:
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.
The hospital length of stay of the patient is reduced.
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Using the minimal resources, maximal health care outcome is achieved.
This method enhances continuity of patient care through collaborative practice of diverse health
professionals.
Patients are moved towards self-care, independence is fostered where indicated.
For the nurse:
This method facilitates for nurses professional development and job satisfaction.
Facilitates the transfer of knowledge of expert clinical staff to novice staff.
Demerits:
o Nurses identify major obstacles in the implementation of this service, financial barriers and lack of
administrative support.
o Expensive
o Nurse is client focused and outcome oriented
o Facilitates and promotes co-ordination of cost effective care
o Nursing case management is a professionally autonomous role that requires expert clinical knowledge
and decision making skills.
o Continuity of care is difficult as case manger may not always available.
o Long term nurse patient relationship are difficult to arrange.
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REFERENCES
1. Vati Jogindra. Nursing Management and Administration.1st edition.2013; Jaypee Brothers Medical
Publishers (p) Ltd;New Delhi:
2. Bhaskara Raj Elakkuvana. Management of Nursing Services and Education.3rd edition.Emmess
Medical Publishers; Bangalore:
3. Stanhope Marcia & Jeanette Lancaster, "Public Health Nursing”, 8th edition, 2008; Elsevier publisher
printed in united states of America.
4. Basavanthappa B.T. Management of Nursing Services and Education.Jaypee publication;New Delhi:
5. Basavathappa B.T. Nursing Administration.2nd edition. 2009. Jaypee Brothers Medical Publishers;New
Delhi:
6. L Marquis Bessie, Husto J carol. Leadership roles and management functions in nursing. 7th edition.
2011.Wolters Kluvers India pvt Ltd;New Delhi:
7. Francis CM. Hospital Administration. 3rd ed. Jaypee medical publishers; new delhi:2004. P.125.
8. Alamelu venketraman. Newer trends in management of nursing services and education. 1st ed. Jaypee
health science publisher;New Delhi: 2017. P. 92-99.
9. Jean barrett. Ward management and teaching. Konark publishers. New Delhi: 2006.
10. Nursing administration and management. 1st ed. TNAI. New Delhi: 2007.
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NURSING MANAGEMENT
GROUP DISCUSSION
ON
SUBMITTED TO:
MRS. RESHMI SIBY.
PROFESSOR.
TMMCON
KAVIYOOR
SUBMITTED BY:
2ND YEAR MSC NURSING
TMMCON
KAVIYOOR
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