NABH-Nursing resource management

NABH NURSING RESOURCE MANAGEMENT

1. NABH Nursing Excellence Standards Presented By: Mr. M.S. Reddy Nursing Officer AIIMS, Bhubaneswar.

2. NABH National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India, set up to establish and operate accreditation programme for healthcare organizations.

3. Vision, Mission of NABH To be apex national healthcare accreditation and quality improvement body, functioning at par with global benchmarks. To operate accreditation and allied programs in focusing on patient safety and quality of healthcare based upon national/international standards.

4. Scope of NABH:   Accreditation of healthcare facilities Quality promotion initiatives like Safe-I, Nursing Excellence, Laboratory Certification programs. IEC activities: Public Lectures, advertisement, workshops/ seminars Education and Training for Quality & Patient Safety

5. NURSING EXCELLENCE STANDARDS These are the complete set of standards for evaluation of nursing service for grant of certification • Framework for quality of care for patients and quality improvement for nursing services • Help to build a quality culture at all level of hospital

6. Nursing Excellence is measured in terms of: 1. Nursing Resource Management (NRM). 2. Nursing Care of Patient (NCP). 3. Management of Medication (MOM). 4. Education, Communication and Guidance (ECG). 5. Infection Control Practices (ICP). 6. Empowerment and Governance (EG). 7. Nursing Quality Indicators (NQI).

7. Nursing Resource Management The goal of nursing resource management is to acquire, provide, retain and maintain competent nursing staff in right numbers to meet the needs of the patients and community served by the Organization.

8. Standards Of Nursing Resource Management: The organization will have a documented system of nursing resource planning The organization possess structures and processes for induction. The organization will have process in place In-service education and Continuous Nursing Education (CNE) Programmes . There is a process for credentialing and privileging of nursing professionals, permitted to provide patient care without supervision.

9. An appraisal system for evaluating the performance of nursing staff exists. There should be a provision for acknowledging outstanding performances/ contributions of nursing professionals. There will an established process in place to identify and manage problems related to incompetent, unsafe or unprofessional conduct. The organization will demonstrate workplace safety for nursing professionals. The organization will have a documented and established grievance handling system.

10. 1. The organization will have a documented system of nursing resource planning. The Nursing resource planning supports the organization's current and future ability to meet the care, treatment and service needs of the patient. It shall use recognized methods for determining the adequacy of nursing staffing.

11. Nurse to population / patient ratio in India Nurse / Population WHO Recommendations Nurse/ Patient WHO Recommendations 1: 1100 1: 500 1:40 1:4

12. Composition Of Health Force In India (WHO 2016)

13. The organization will ensure that the plan addresses staffing crisis situations due to attrition, and the hiring plan ensures vacancies are filled up early so that patient care is not compromised.

14. Norms of Staffing (SIU- Staff Inspection Unit) The Staff Inspection Unit (S.I.U.) is the unit which has recommended the nursing norms in the year 1991-92. As per this S.I.U. norm the present nurse-patient ratio is based and practiced in all Central Government Hospitals.

15. The Nurse-patient Ratio as per the S.I.U. Norms S.No Area Nurse Patient Ratio 1 General Wards 1 Staff Nurse/Nursing Sister for every 6 beds ( 1:6 ) 2 Special Wards i . Pediatrics ii. Burns iii. Neuro surgery iv. Cardio thoracic v. Neuro medicine vi . Spinal injury vii . Emergency wards attached to casualty 1 Staff Nurse/Nursing Sister for every 4 beds ( 1:4 ) 3 ICU/ICCU/Nephrology 1 Staff Nurse/Nursing Sister for every 1 beds ( 1:1 )

16. S.No Area Nurse Patient Ratio 4 Labour Room 1 Staff Nurse/Nursing Sister for every labour table ( 1:1 ) 5 O.T .- Major Minor 2 Staff Nurse/Nursing Sister for every functional operation table( 2:1 ) 1 Staff Nurse/Nursing Sister for every functional operation table ( 1:1 ) 6 Casualty Attendance up to 100 patients per day. Thereafter for every additional attendance of 35 patients per day 3 Staff Nurses/Nursing Sister for 24 hours 1 Staff Nurse/Nursing Sister 7 O.P.D. (Injection room) Attendance up to 100 patients per day Attendance up to 120-220 patients per day Attendance up to 221-320 patients per day Attendance up to 321-420 patients per day 1 Staff Nurse 2 Staff Nurses 3 Staff Nurses 4 Staff Nurses

17. INC NORMS(1985) S.No Name of the Post Ratio 1 Chief Nursing Officer 1 CNO for the hospitals more than 500 beds 2 Nursing Superintendent 1 per 400 beds or above 3 D.N.S 1 per 300 beds and 1 additional for every 200 beds 4 A.N.S 1 for 100-150 beds or 3-4 wards 5 Ward Sister 1 for 25-30 beds or one ward. 30% leave reserve 6 Staff Nurse 1 for 3 beds in Teaching Hospital in general ward& 1 for 5 beds in Non-teaching Hospital +30% Leave reserve 7 Extra Nursing staff to be provided for departmental research function. 8 For OPD and Emergency : 1 Staff Nurse for 100 patients (1 : 100 ) + 30% leave reserve 9 For Intensive Care unit (I.C.U.): 1:1 +30% leave reserve 10 It is suggested that for 250 bedded hospital there should be One Infection Control Nurse. For specialized departments, such as Operation Theatre, Labour Room, etc. 1:25 +30% leave reserve.

18. The organization must maintain an adequate number and mix of nursing staff to meet the care, treatment and service needs of the patient. The nursing staff should be commensurate with the workload and the clinical requirement of the patients.

19. Nursing Care Hours Per Patient / Day in India: S.No Area Average Hours Of Care/ Day Professional To Non Professional work Ratio 1 General Medicine 3.5 60:40 2 Medical 3.4 60:40 3 Surgical 3.4 60:40 4 Obstetrics 3.0 60:40 5 Pediatrics 4.6 70:30 6 ER/ICU/CCU/ Recovery Room 6.0 70:30

20. A ward will be unable to provide a good standard of care without a good duty roster Things to consider while making a duty roaster: Determine the total no of nursing staff required Fill busy shifts with the most experienced and skilled staff. Assess the Ability of the staff to cover the needs of the unit Rosters must make appropriate provision for adequate staff supervision, training and clinical handover. Fairness to the staff – fair share of weekends, holiday offs, rotating the staff including assignment to “difficult” or “light” or “undesirable” units or shifts Stability – the schedule must be harmonized with their family or social activities of the staff Flexibility – ability to handle changes brought by emergency leaves

21. The person heading the nursing service should have requisite and appropriate qualifications and experience. The required job specification and job description should be defined for each category of nursing staff.

22. JOB DESCRIPTION:- Contains particulars of the activities to be performed and the characteristics of employees required. NURSING OFFICER: Nursing officer is directly responsible to Senior Nursing Officer (Ward In Charge) for total nursing care of the patient assigned to him/her.  A.          DIRECT PATIENT’S CARE :   Admission and discharge of the patients.  To maintain the personal hygiene of the patients, including bathing, care of mouth, back, nails, hair etc.  Care of pressures points as needed.  To assist the patient in elimination, feeding the weak and debilitated patients.  Writing of diet sheet, Supervision and distribution of diets.  Assist in physiotherapy, ambulation and rehabilitation.   Carry-out patient’s teaching and demonstration according to the need.  Counseling the patients, and relatives.  Care of the dying and dead.  Administration of Medicines and Injections to the patients.

23. Observing, recording and reporting of vital signs . Carry out technical procedures, such as Naso -gastric intubation, Gastric Gavage and Lavage , Oxygen Therapy, Dressing and Irrigation, Enema, Catheterization, hot and cold applications, suction etc. Collecting, labeling and dispatch of specimens. Preparation for and assistance in clinical tests and medical/surgical procedures.  Observation, recording and reporting of all procedures and  tests.  Escorting serious patients to and from the department/wards for investigations.

24. B.           WARD MANAGEMENT :  1.         Handing over and taking over charge of patients, and ward inventory in each shift.  2.         Maintenance of therapeutic environment in the ward.  3.         Keeping the ward clean and tidy.  4.         Routine care and maintenance of dressing trolleys, cupboards, apparatus, mackintosh etc.  5.         Care of clean and soiled linen.  6.         Disinfection of linen, beds, floor and bed pans, and fumigation of rooms etc.  7.         Preparation of room, trolleys, and sets for procedures.  8.         Preparation of surgical supplies.  9.         Maintaining interpersonal relationship with patients, relatives and health team members.  10.       Orientation of new staff/students.  11.       Demonstration and guidance to student nurses.  12.       Participation in staff education and staff meetings.  13.       Participation in professional activities.  14.       Demonstration and supervision of domestic staff.  15.       Report about the medico-legal cases if any admitted in the ward.  To keep the senior nursing officials informed of the happenings / in the ward like fire, absconding patients, theft etc.  16.       Any other duty that may be assigned by Senior Nursing Officer from time to time.

25. 2. The organization possess structures and processes for induction

26. Training need shall be identified on a continual basis by the senior nursing professionals as well as the Clinical Heads as appropriate. The staff will be trained and the same can be recorded in the training records. Every nurse entering the organization is provided induction training.

27. The induction training shall be conducted within 15 days of the staff joining. The contents of this training could be provided to every nursing staff in the form of a booklet. There can be separate induction training at the organizational level and for the respective departments.

28. 3. The organization should have processes in place for In-service education and Continuous Nursing Education (CNE) Programmes

29. The organization will have an training and development policy and the training calendar The organization must have all the records of training. At a minimum, it shall include the title of the training, the trainer(s), list of trainees (with signatures) and the post-training feedback.

30. Nursing professionals shall receive adequate training when there is a change in job responsibilities or when new equipment is introduced. The training should focus on the revised job responsibilities as well as on the newly introduced equipment and technology.

31. All nursing staff should be trained to provide BLS (Basic Life Support) . Nursing professionals working in intensive care/high dependency units shall undergo training in ACLS or PALS or NALS as applicable.

32. Common areas of training Nursing officers Senior Nursing Officers/ ANS/DNS/ NS Patient safety Nursing Process Human Relations in Nursing Ethical and Legal issues in clinical nursing Pre and post operative Nursing Management Stress Management Medication Administration Safety Human Relations in Nursing Materiel Management Ethical and Legal issues in clinical nursing Conflict Management Stress Management Nursing Administration

33. 4. There should be a process for credentialing and privileging of nursing professionals, permitted to provide patient care without supervision.

34. The education, registration, training and experience of nursing staff is recorded and updated periodically. Updation is done after verifying the credentials from the organization which has awarded the qualification/training/ experience. Nursing staff are granted privileges and provide care in consonance with their qualification, training, experience and registration.

35. 5. An appraisal system for evaluating the performance of nursing staff should exist.

36. A recorded performance appraisal system should exist in the organization for nursing professionals. The nursing professionals are made aware of the system of appraisal at the time of induction. Performance is evaluated based on the pre-determined criteria. Performance appraisal is carried out at pre-defined intervals and is recorded. This shall be done at least once a year.

37. 6. There is a provision for acknowledging outstanding performances/ contributions of nursing professionals.

38. National Florence Nightingale Nurses Award winners- 2018

39. Patients, families and staff shall be encouraged to report positive feedback about nursing care delivered in relevant areas. Nursing staff with managerial responsibilities shall ensure that soft skills in nursing, qualities of leadership and professional competence are duly reported to higher authorities.

40. 7. The organizations should have an established process in place to identify and manage problems related to incompetent, unsafe or unprofessional conduct.

41. The process shall include daily monitoring of appearance and ability to impart nursing care, appearance, behaviour and communication. The process shall include analysis of all complaints pertaining to nursing services specifically addressing individual nursing staff. The process shall ensure that there is no victimization and corrective action is focused against the system rather than the individual.

42. The disciplinary policy and procedure is based on the principles of natural justice. Principles of natural justice shall be followed to ensure that a nursing staff against whom there is a complaint, of any sort, has the right to explain himself/herself.

43. 8. The organization should demonstrate workplace safety for nursing professionals

44. Management should provide resources related to workplace safety for nursing professionals. There shall be sufficient change rooms, washrooms & dining facilities for nursing staff. Management shall ensure that there is a mechanism whereby any safety related issues are duly reported.

45. The Management should promote a culture of reporting of safety related issues such that there is no victimization. This also includes setting of a gender harassment committee to ensure workplace safety from sexual harassments. A record of corrective and preventive actions shall be maintained wherever appropriate, with due consideration given to anonymity.

46. ICC / Women Cell, AIIMS, BBSR

47. 9.The organization should have a documented and established grievance handling system.

48. The organization should have a well-defined process for handling nurse (s) grievances The nursing professionals are educated about the mechanisms available for addressing grievances.

49. Grievance Cell, AIIMS ,BBSR

50. The head of the nursing service protects nurse (s) rights The nursing professionals are educated about their rights.

51. Rights Of Nurses: Right to practice in a manner that fulfills their obligations to society. Right to practice in environments that allow them to act in accordance with professional standards and legally Right to a work environment that supports and facilitates ethical practice Right to freely and openly advocate for themselves and their patients without fear of retribution (punishment) Right to fair compensation for their work Right to a work in a environment that is safe for themselves and their patients Right to negotiate, either as individuals or collectively, the conditions of their employment

52. EDUCATION, COMMUNICATION AND GUIDANCE

53. EDUCATION, COMMUNICATION AND GUIDANCE (ECG) Objectives: The organization must ensure that nursing professionals are trained in communication skills. Nursing professionals will able to communicate as and when required with relevant team members to achieve continuity of care. To provide timely guidance to the patients and families about their healthcare needs .

54. Measures to promote ECG All the nursing staff should be trained to meet the patients specific needs. The communication needs of patients who speak different language than the care givers is to be addressed Training is imparted to address the patient's needs with impaired communication. The nursing professionals should be aware of patient rights.

55. PATIENTS RESPONSIBILITIES Providing information regarding past health history Following physicians instructions Participating in decision making Asking for information or clarification if they don’t understand anything fully Responsible to refrain from misbehaving and physical assault with health care workers Making payments wherever applicable Not to disturb the fellow patients Bounding to the hospital rules and regulations

56. Nursing professionals are reminded to maintain the confidentiality of patients information. Maintain privacy of the patients during care. The nursing professionals support individual patient and family beliefs, values and customs and involve the patient and family in decision making processes.

57. Proper handover mechanism is to be established among the care team across shifts regarding patient's status .

58. Nursing professionals communicates with staff in other departments when required to ensure that care plan is implemented. HCO uses predetermined formats for such communication wherever required. Educate the patients on the medical condition, pre and post-operative education, special procedures, preventing healthcare associated infections, when to seek urgent medical attention and home care.

59. Ensure written informed consent wherever essential. Patient and/or family are educated in a language they can understand.

60. Summary: Documented nursing resource plan Induction plan CNE, In-service education Privileging Acknowledgment of contributions Work place safety Grievance handling system Principle of natural justice Confidentiality of information Patients rights Health education