Leadership and
Organization
Nursing Care
Introduction – Nursing Care
The Nursing Director is considered a member of the hospital
leadership. His/her role is essential in achieving high quality patient
care. The Nursing Director is responsible and accountable for the
standard of nursing care in the hospital along with the Medical
Director and Quality Director. All should work as one team to
monitor and observe the standards of clinical care provided to
patients all over the hospital.
The Nursing Director and other nurse Managers together
with the nursing staff and nursing aides are the cornerstone for the
provision of a high quality and safe care for several reasons, the
most obvious of which is that the nursing staff members are the
closest to the patients because of their roles and responsibilities.
Medical staff members are also essential for quality and safe care
but they do not spend the same amount of time besides patients
like the nurses do.
Outline
NR.2
Nursing Director as a Leader
NR.3
Roles of the Nursing Director
NR.4
NR.5
NR.6
NR.7
NR.8
Availability & Accessibility of Nursing Reference Manuals
Nursing Director as Part of the Nursing Staff Recruitment
Sufficiency of Nursing Staff
Nursing Staff Work Schedule
Nursing Staff Cross-training Policy
 Standard
 Substandard
 Standard Intent
NR.2 The nursing director assumes a leadership position in the
hospital.
NR.2.1 The nursing director represents the nursing staff as one of
the hospital leaders.
NR.2.2 The nursing director participates with the other hospital
leaders in the decision making processes, including planning and
budgeting.
NR.2.3 The nursing director participates in the hospital's multidisciplinary structures (e.g., committees such as quality
improvement, infection control and pharmacy and therapeutics).
NR.2.4 The nursing director oversees and assures that
committees' recommendations are implemented at the nursing
level.
Standard Intent
NR.2
The nursing director assumes a leadership position in the
hospital.
Nursing Director is involved in decision making processes. He or
she is one of the hospital leaders, works collectively and
collaboratively with other hospital leaders to develop the program,
polices, and services needed to fulfill the hospital mission, these
include the procurement and management of essential supplies,
financial management, quality management, patient safety, and
others. She or he participates in organization decision making
groups and hospital wide committees such as , leadership
executive, quality improvement and patient safety , infection
control, Pharmacy and therapeutic , and other committees,
oversees committees activities and recommendations and ensure
implementation at nursing level.
NR.3
The nursing director assumes the authority, responsibility
and accountability for assuring proper and effective nursing
services.
NR.3.1 The nursing director establishes, oversees, and
approves nursing policies and procedures and nursing
professional standards of practice and patient care.
NR.3.2 Nursing policies, procedures, and standards include all
nursing units (e.g. intensive care, medical, surgical,
emergency room, operating room, and dialysis units).
NR.3.3 Nursing policies, procedures, and standards are
accessible to all nursing staff at all times.
NR.3
The nursing director assumes the authority, responsibility, and
accountability for assuring proper and effective nursing services.
NR.3.4 Nursing staff are familiar with the nursing policies and
procedures.
NR.3.5 The nursing director ensures participation with other
hospital leaders in the development of practices that promote
patients and staff safety (e.g., infection control, safe medication
management, safe use of medical equipment, and fire safety).
NR.3.6 The nursing director together with other relevant staff
work to develop essential policies and procedures including,
but are not limited to, the following:
NR.3.6.1 Admission procedures.
NR.3.6.2 Basic hygiene of patients and skin care.
NR.3.6.3 Patient and family rights.
NR.3.6.4 How to transcribe physician’s orders.
NR.3.6.5 Patient education.
NR.3.6.6 General infection control policies.
NR.3.6.7 Calling physicians.
NR.3.6.8 Patient transfer (internal and external).
NR.3.6.9 Patient discharge.
NR.3
The nursing director assumes the authority, responsibility, and
accountability for assuring proper and effective nursing
services.
NR.3.7 The nursing director implements an effective method for
organizing the delivery of patient care (e.g. functional, team,
primary care).
NR.3.8 The nursing director ensures the implementation of a
policy and procedure that defines patient care delivery
method(s).
Standard Intent
NR.3
The nursing director assumes the authority, responsibility and
accountability for assuring proper and effective nursing services.
The oversight of nursing services include developing, approving,
implementing, and maintaining policies and procedures and
nursing professional standards of practice and patient care.
Nursing policies and procedures and standards reflect the
department’s goals and services as well as the knowledge, skills,
and availability of staff required to assess and to meet patient
care needs. The nursing director work in collaboration with other
leaders and hospital staff to develop the essential policies (NR.3.6)
tailored to the particular Services and include all Units (e.g.
intensive care, medical, surgical, emergency room, operating
room, and dialysis units).
Standard Intent
NR.3 (cont…)
The nursing director assumes the authority, responsibility and
accountability for assuring proper and effective nursing services.
Nursing policies, procedures and standards must be available at all
times to all nursing staff, There is a process to ensure that staff
members have read and are familiar with policies, procedures,
and plans relevant to their work. This process may be part of the
orientation of staff members to their department and their
responsibilities, or may be part of group wide or hospital wide
special training session. Staff providing patients ‘care should
follow an effective method that organize the delivery of care, such
method need to define in a policy and implemented.
NR.4
Nursing reference manuals and policies are readily available and
accessible to all nursing units.
NR.4.1 There are nursing reference manuals and policies that are
available and accessible to all nursing units. This includes, but is
not limited to, the following:
NR.4.1.1 Nursing policies and procedures manual.
NR.4.1.2 Current nursing practice manuals/books.
NR.4.1.3 Infection control manual.
NR.4.1.4 Safety manual or safety policies.
NR.4.1.5 Operating manuals for the safe use of equipment.
NR.4.1.6 Laboratory services guide.
NR.4.1.7 Dietary manual.
NR.4.1.8 Material Safety Data Sheet (MSDS).
NR.4
The nursing director assumes the authority, responsibility, and
accountability for assuring proper and effective nursing
services.
NR.4.2 Policies and content of manuals are implemented as
evidenced by the daily practice and the patient’s medical record.
Standard Intent
NR.4
The nursing director assumes the authority, responsibility,
and accountability for assuring proper and effective nursing
services.
Information related to the delivery of care and standard of
professional practice must be readily available and accessible
to all nursing units, those information help nurses to perform
their work safely and needed in their daily practices.
NR.5
The nursing director ensures the competency of the nursing
staff.
NR.5.1 The nursing director participates in the recruitment and
hiring of qualified nurses as outlined in the leadership chapter.
NR.5.2
The nursing director monitors the performance of the nursing
staff and assures their ongoing competency.
NR.5.2.1 The nursing department develops policies and
procedures to define the nursing competency assessment program
aiming to ensure that nursing skills and knowledge remain current.
NR.5.2.2 Nursing staff competencies are assessed on an ongoing
basis (at least annually, and whenever needed).
NR.5.2.3 Nursing staff competencies are assessed by using
different methods (e.g. written test, return demonstration, peer
review, feedback from health professionals and supervisors).
NR.5.3 Nursing competencies to be assessed include, but are
not limited to, the following:
NR.5.3.1 Monitoring patient’s vital signs and knowledge of
acceptable deviations from the norm.
NR.5.3.2 Assessment/reassessment of patients according to the
scope of services (e.g. critical care, labor and delivery, and
surgical units).
NR.5.3.3 Medications administration.
NR.5.3.4 Intravenous therapy (insertion, maintenance,
discontinuing).
NR.5.3.5 Infection control guidelines.
NR.5.3.6 Patient falls (assessment of risk and methods to prevent
falls).
NR.5.3.7 Use of pulse oximetry.
NR.5.3.8 Nursing role in cardiac/respiratory arrest.
NR.5.3
Nursing competencies to be assessed include, but are not limited
to, the following:
NR.5.3.9 Nasogastric, gastrostomy and feeding tubes.
NR.5.3.10 Urinary catheters.
NR.5.3.11 Sterile dressings.
NR.5.3.12 Skin care and prevention and care of pressure ulcers.
NR.5.3.13 Nursing role in disaster, fire, and other emergencies.
NR.5.3.14 Use of restraints.
NR.5.3.15 Operation of blood sugar testing equipment.
NR.5.3.16 Managing chemical spills.
NR.5.3.17 Use of blood, blood products, and blood –related
procedures (e.g., phlebotomy and blood administration).
Standard Intent
NR.5 The nursing director ensures the competency of the nursing staff.
Recruiting, evaluating, and appointing nursing staff are best accomplished
through the management of nursing leadership. Nursing Director involves
in recruiting, retaining and maintaining competent staff nurse in right
numbers to meet the needs of the patients and community served by the
organization. Policies and procedures developed to define the nursing
competencies related to the job specific requirement (NR 5.3) staff
providing care to patients are evaluated at the time they begin providing
care, before the probationary or orientation period is completed. This
evaluation of necessary skills, and knowledge and desired work
behaviors, is carried out by the department or service to which the staff
member is assigned, before or at the time of starting to perform work
responsibilities. Ongoing evaluation ensures that training occurs when
needed or at least annually and that the staff member is able to assume
new or changed responsibilities.
NR.6
Sufficient nurses are available to meet the needs of patients.
NR.6.1 The nursing director develops a staffing plan that
maintains an adequate staffing level in all nursing units.
NR.6.2 The staffing plan identifies an evidence-based estimation
of the number of staff needed per shift, considering all relevant
factors (e.g., patient acuity, patient care hours, size of the
hospital, scope of services provided).
NR.6.3 Nursing staff are allocated according to the skill level,
qualifications, patients volume and acuity, and in accordance
with laws and regulations and nursing licensing boards.
Standard Intent
NR.6 Sufficient nurses are available to meet the needs of
patients.
Appropriate and adequate staffing is critical to patient care,
Staff planning is carried out by department/service leaders.
The planning process uses recognized evidence based methods
for determining levels of staffing. For example, a patient acuity
system is used to determine the number of licensed nurses
with pediatric intensive care experience to staff a 10-bed
pediatric Intensive care unit. The staffing plan is written and
identifies the number and types of required staff and the skills,
knowledge, and other requirements needed in each unit, and
is based on patient volume and patient acuity.
NR.7
The nursing department provides regularly updated work
schedule
NR.7.1 There is a nursing scheduling policy that defines:
NR.7.1.1 Duration of working shifts (e.g., 12 hours, or 8 hours).
NR.7.1.2 Assignment of overtime when needed.
NR.7.1.3 On-call requirements.
NR.7.1.4 Vacation schedules.
NR.7.1.5 Method for approving change of schedule.
NR.7.1.6 Participation in education/training activities.
NR.7.1.7 Participation in designated committees, departmental
meetings, and quality improvement activities.
NR.7
The nursing department provides regularly updated work
schedule
NR.7.2 The work schedule provides an adequate number of staff
on every shift.
Standard Intent
NR 7 The nursing department provides regularly updated work
schedule.
The nursing staffing plan should ensure adequate staffing with
pre-identified skills mixture all the times according to the mission
and scope of service. Vacancy rates, staff schedules should be
controlled to ensure safe services 24 hours a day / 7 days a week
and take into consideration assignment of overtime when
required, on-call requirement, vacation schedule, participation in
education, training and designated committees.
NR.8 There is a process for assignment of nurses out of their
normal working areas.
NR.8.1 The nursing director ensures that nurses assigned out of
their normal working area have the competency required for
safe and effective patient care.
NR.8.2 The nursing director maintains a list of cross-trained
nurses and makes it available for all nursing units.
Standard Intent
the nursing staffing plan must consider the reassignment of staff
from one department or service to another in response to
changing patient needs or staff shortages should be based on
their training and competency, this is achieved by developing a
cross training program.
Planned and actual staffing is monitored on an ongoing basis,
and the plan is updated as necessary.