SALAZAR COLLEGES OF SCIENCE AND INSTITUTE OF TECHNOLOGY

211 N. Bacalso Avenue, Cebu City

COLLEGE OF NURSING

Head Nursing
Head Nurses: Albos, Aris Jeannine K. Mainit, Sandy Anne Saz, Nicezel S. Serna, Maria Lavinia

Clinical Instructor: Mrs. McDree Ann Jade L. Banzon, B.S.N., R.N.

Philosophy and Objectives of the Hospital

Philosophy The Nursing staff supports the hospital belief regarding patient care which is to provide the best possible care and treatment to all patients confined in the unit regardless of social status/ economic belief. 1. In the integral wholeness and individuality of man thereby recognizing the physical, emotional, and spiritual needs of each patient which is to be met. 2. That patient is the reason for hospital existence; the restoration and maintenance of health and well-being are the ultimate aim of patient care. 3. That the patients as well as the health workers are part of the social structure thereof will endeavor to work closely with allied profession. 4. The Nursing personnel must be prepared, guided and provided for their work within the context of prevailing local and cultural values and practices to achieve desired quality patient care. 5. The goals can be best attained only through cooperative and coordinated planning, mutual understanding, and conscientious dedications.

Objectives 1. Acquires high technology equipments through donations and/ or purchase. 2. Prescribes cost-effective medications. 3. Confirms laboratory and X-ray procedures. 4. Send more trainees to seminars, scientific lectures, conventions, local and national levels; wet clinics. 5. Conducts research study as a pre-requisite to residency training program graduation. 6. Attendance of personnel to PES/ PERC Seminar. 7. Maintenance of personnel to work under their respective specialization. 8. Development of preventive maintenance program. 9. Increase in hospital income by 2 %. 10. To make available supplies and materials needed in the hospital operation. 11. All personnel to become computer literate & proficient. 12. Maintenance of 50 % re-ordering point of supplies and materials. 13. Creation of a complete databank for all employees.

MISSION
Provide an environment that promotes ethical, quality And cost-effective services through

Competent, Compassionate Medical Care.

VISION
Integrated, holistic and sustainable health care services that uphold social responsibility and global standards to ensure well-being for all.

DESCRIPTION OF THE ORGANIZATIONAL DESIGN

Organizational Design or Structure.It is a formal, guide process for integrating the people, information and technology of an organization. A process by which a group is formed its channel of authority, span of control and lines of communication.

Importance of Organizational Structure A. It enables members what their responsibilities are, so that they may carry them out. B. It frees the manager and the individual workers to concentrate on their respective roles and responsibilities. C. It coordinates all.

Principles of Organizational Design 1. Division of Labor Work of all kinds must be divided and subdivided and allotted to various persons according to their expertise in a particular area. Subdivision of work makes it simpler and results in sufficiency. 2. Unity of command It implies that a subordinate should receive orders and instructions from only one boss. 3. Authority and Responsibility Authority refers to the right of superiors to get exactness from their subordinates whereas responsibility means obligation for the performance of the job assigned. 4. Span of Control
The span of control is the number of subordinates for whom a manager is directly responsible.

5. Contingency Factors
Contingency factors play an important role in contingency planning within an organization. They are what makes a company more prepared for the unexpected situations that can arise all too often within the corporate world. Having a good contingency plan may be what makes the difference between a company coming through a difficult trading period and not making it.

DESCRIPTION OF STAFFING PATTERN

Staffing Pattern. It is the process of determining and providing the acceptable number and mix of nursing personnel to produce a desired level of care to meet the patients demand. It may vary the unit, department and shift and with the patient acuity levels.

Steps in Staffing A. Determine the Number and Types of Personnel Needed B. Recruitment C. Interview D. Induct or Orient the Personnel in Organization Job Offer

Centralized vs Decentralized Staffing

Centralized Staffing Staffing decisions for all units are made by a central office or computer. Tends to be fairer to employees because policies are implemented more consistently and impartially. Frees Manager to complete other functions. Most cost-effective, because it maximizes use of human resources organizationwide.

Decentralized Staffing Staffing is done at unit level, frequently by unit manager. Allows person who knows the individual unit the best to make staffing decisions for that unit. Allows staff to take requests directly to their own manager, which gives them increased autonomy and flexibility. Time consuming for head of the unit.

COMPUTATION OF THE STAFFING PATTERN BOUND FOR 40 HOUR WEEK LAW

Case: 12 Patients/ Bed Capacities in the Stroke Unit. How many staff nurses do we need? Solution: 1. Categorize patient according to level of care needed. o 12 (pts) x 30% o 12 (pts) x 45% o 12 (pts) x 15% o 12 (pts) x 10% = = = = 3.6 5.4 1.8 1.2 patients needing minimal care patients needing moderate care patients needing intensive care highly specialized nursing care

2. Find the Nursing Care Hours (NCH) Needed by Patients at each Level of care per day. o 3.6 pts x 1.5 (NCH @ Level I) o 5.4 pts x 3 (NCH @ Level II) o 1.8 pts x 4.5 (NCH @ Level III) o 1.2 pts x 6 (NCH @ Level IV) = = = = 5.4 16.2 8.1 7.2 36.9 3. Find the total NCH needed by 12 patients per year. o 36.9 x 365 (days/year) = 13, 468.50 NCH/YEAR NCH/day NCH/day NCH/day NCH/day NCH/day

4. Find the actual working hours needed by each nursing personnel per year. o 8 hours/day x 213 (working days/year) = 1,704 (working hours/year)

5. Find the total number of nursing personnel needed. a) Total NCH/Year__ Working Hrs/Year = 13,468.50 1,704 8 x 15% = 1.2 = 8

b) Relief x Total Nursing Personnel=

(Constant: 15% for 40 Hrs/Wk & 10% for 48 Hrs/Wk) c) Total Personnel Needed = 8 + 1.2 = 9.2

6. Determine Professional from Non-Professional. Its ratio in a Tertiary Hospital is 65:35. o 9.2 x 65% o 9.2 x 35% 7. Distribute per shift. PROFESSIONAL (6) o AM o PM (45%) (37%) 3 2 1 NON-PROFESSIONAL (3) 1 1 1 = = 6 3 Professional (Nurses) Non-Professional (Nursing Attendants)

o NIGHT (18%)

Job description of: I. Staff nurse A staff nurse provides professional nursing care in accordance with physicians' orders. Nursing is defined as the protection and promotion of health; the prevention of illness and injury; alleviation of suffering; and advocacy in the care of individuals and communities. a. Essential Tasks Staff nurses are responsible for the treatment of patients, administration of medication and injections, health education, assistance during diagnostic testing, and follow-up. b. Specialization Staff nurses can specialize by work setting (such as ambulatory care), specific health condition (diabetes), organ or body system (orthopedic), or population (geriatric). c. Education The position requires a bachelor's degree in nursing, an associate's degree in nursing or graduation from a diploma school of nursing. d. Licensure State licensure as a registered nurse is required. This is obtained after graduation from an approved nursing program and passing a national licensing exam.

II.

Head Nurse Head nurses are vital to the successful functioning of a medical facility's nursing unit. Head nurses perform a variety of routine and supervisory functions that affect almost every area of a unit's daily operations.They can advance to a supervisory position and work in hospital administration directing the work of other staff nurses. The head nurse or nursing supervisor monitors the work of other nurses and ensures that patients receive proper care. The nurse in a supervisor position performs nursing duties along with the additional administrative duties. a. Function

The head nurse coordinates the activities of the nursing staff in patient areas. The supervising nurse is responsible for the training and scheduling of nurses in the patient area that she supervises. Head nurses work with department heads in other areas of the health-care facility to provide nursing assistance and staff when needed. b. Job Duties The head nurse assigns duties to staff nurses and develops work schedules to ensure that patient areas have a full staff. Nursing supervisors monitor the work performed by staff nurses to ensure that physician instructions are carried out and that patients receive proper care. Nurses receive evaluations from the nursing supervisor on their performance. A head nurse may perform the orientation and training of new staff members in the patient area. The head nurse performs inspections of patient rooms and areas to ensure hospital personnel maintain cleanliness standards. Lead nurses order supplies for the patient area such as drugs, equipment and medical supplies or directs the activities of workers responsible for ordering materials. This includes maintenance of drug records for the patient area.

C. Skills Nursing supervisors demonstrate leadership skills and the ability to evaluate the work of other nurses on the floor. A head nurse uses a combination of direct patient nursing skills with administrative skills to direct the activities of other workers.

III.

Nurse Supervisor Nurse supervisors provide care for patients, but they also oversee the nursing staff. As a nurse supervisor, you ensure that there is adequate staffing in your unit, interact with patient and families, manage issues that arise during your shift, and direct and supervise all aspects of patient care.

a. Training A nurse supervisor is responsible for training staff. You usually plan and organize orientation for new nurses, and you also might be involved in in-service training for existing staff. b. Facility Needs To provide better customer service within the healthcare facility, a nurse supervisor generally researches studies and information on improving nursing care. The nursing supervisor consults with medical staff and administration on nursing problems within the facility, then helps develop strategies for dealing with those issues and ensuring that the needs of patients are met. This can include assisting in the budgeting process. c. Educational Requirements A nurse supervisor typically has master's degree, but some healthcare facilities accept a four-year bachelor's of science in nursing if you have work experience as well as clinical experience. Like all registered nurses, you must pass the National Counsel Licensure Examination (NCLEX--RN) to be a licensed nurse. Nurse supervisors also need strong customer service skills and the ability to listen effectively. IV. Nursing Aide A nurse's aide faces a physically demanding job but has the opportunity to play a compassionate role in a patient's life. Nurse's aides work directly under nursing staff supervision. a. Job Duties Nurse's aides assist patients with activities of daily living including bathing, dressing, eating and transferring in and out of bed. They also measure vital signs, change bed linens and report changes in the patient's condition to medical staff b. Work Environment The job requires hours of walking and standing, heavy lifting of patients and less desirable activities such as emptying bedpans. Nurse's aides are employed mainly in nursing homes and hospitals. c. Education Training is offered at community colleges and through high school vocational courses and can be provided by employers. A high school diploma is generally required. Federal government guidelines state that if a nurse's aide works in a nursing home he must complete 75 hours of training and undergo a competency evaluation.

A SAMPLE OF DEPARTMENTAL POLICY Hospital A Disclosure of Unanticipated Events and Outcomes Interdisciplinary Process Standard Priorities, Communication Standards and Documentation
Title: Management Unanticipated Outcomes and Events Purpose: 1. To provide direction and support to clinicians to minimize patient injury after an adverse unanticipated event. 2. To provide guidance to clinicians in disclosure of unanticipated outcomes and events to families and patients. 3. To provide support to patients, families and staff after an unanticipated outcome or event. Supportive Data: 1. Disclosure of adverse events is associated with decreased patient/family anxiety, ability to provide informed consent for follow up tests or treatments associated with the adverse event, and promotes ongoing cooperation from the patient and family. 2. Healthcare providers who participate in disclosure of adverse events associated with errors have been noted to make better adjustments after an error, are in an improved position for litigation and are more apt to make constructive changes to practice that will reduce the risk of future errors. 3. Healthcare providers involved with non-disclosure of adverse events associated with errors have been noted to have anxiety after the event, loss of confidence, depression and unresolved guilt. 4. Patients and families expect healthcare providers to accept responsibility for their errors, provide simple, honest explanations and apologize for the error. 5. Under the patient bill of rights patients and families are to have access to the names of care providers. When disclosing events and outcomes if a family requests the name of a clinician involved this information is provided. Families and patients do not have a right to disclosure of license numbers and home addresses of involved employees. 6. Unanticipated event is defined as any event that is intercepted prior to completion or actual harm, which is not part of the plan. These events are frequently near miss events. Examples include but are not limited to the following events: a) The wrong patient that is taken to a diagnostic department but the error is discovered before any tests are done. b) A patient sustains an ecchymosis of the neck and face after an unsuccessful attempt at a neck line insertion. c) A mother is presented with the wrong infant and the error is discovered prior to the infant being fed. 7. An unanticipated outcome is defined as a result that significantly differs from what was anticipated as a result of treatment or procedures. Unanticipated outcomes may or may not be associated with errors. 8. Unanticipated outcomes are divided into two severity levels: a. Severity level 1 is associated with no obvious injury and no need for follow up diagnostic test, monitoring or interventions. Examples include but are not limited to the following: 1) A patient is given a wrong medication but it is of no clinical consequence (e.g. colace). 2) An intra-operative medication error that is treated with no adverse outcome for the patient. 3) A patient falls with no signs of injury and does not require a follow up x-ray. b. Severity level 2 is associated with the need for diagnostic testing, a higher level of care and/or treatment or intervention to mitigate the adverse events associated with the unanticipated outcome. Examples of a severity level 2 outcome include but are not limited to the following examples:

7.

9.

10.

a) A patient that receives an overdose of insulin that requires a bolus of dextrose with continuous IV glucose infusion and frequent glucose monitoring in a monitored environment. b) A patient who requires a carotid doppler after the carotid artery is punctured during a an attempted IJ line placement. c) A patient falls and needs a follow up CT scan to rule out a bleed of the head. Prompt notification of the medical team is essential in ensuring that treatment is initiated in a timely manner to minimize patient injury for unanticipated outcomes where actual injury or the potential for serious injury exists. Staff may be reluctant to report adverse events associated with errors if the response of clinicians is negative or punitive. Prompt disclosure of information to the patient and family helps to maintain trust and provide reassurance that there is no cover up. The goal of disclosing information about unanticipated events and outcomes is to reassure the patient and family and to maintain trust. If disclosure of information may increase a patient suffering or anxiety then consider disclosing to the family and get their input about disclosure to the patient. For cognitively competent patients of legal age the primary person to receive communication about unanticipated events and outcomes is the patient. The patient should be consulted about disclosing information about unanticipated events and outcomes to the next of kin or the health care proxy. The patients desire not to have information shared with the family or to personally share the information is respected. If the patient is not of legal age or medical condition prohibits the disclosure of the incident the next of kin or the healthcare proxy is notified as soon as possible. I. Priorities of Managing Unanticipated Events and Outcomes:

a. Notify the medical team and leadership b. Treat the patient as indicated. c. Inform the patient and/or family of the event, its implications for care and follow up test(s) and treatment(s) that will be needed: 1. Notification should be done as close to the event as possible but should take into account that calling the family in the middle of the night may cause undue distress. 2. Patients post procedure or surgery may need to have information shared at a later time to allow anesthesia or sedatives to wear off so that the information can be understood. 3. For unanticipated events and severity level 1 outcomes call the family in the morning if the event occurs in the middle of the night. 4. For severity level 2 outcomes contact the next of kin or healthcare proxy as soon as possible regardless of time. d. Contact risk management for level 2 severity incidents e. Assess family and staff response to ascertain follow up support that may be necessary f. Consult social work or the patient representative for patient and family support as appropriate g. Call the Problem Event Response Team (PERT) to assist with staff support for severity level 2 outcomes. h. Document the events, interventions, information provided and patient/family response.

II. Communication Concepts for Managing Unanticipated Events and Outcomes: A. When informed about errors focus on treating the patient and follow up actions that will minimize patient injury. B. Avoid blame and angry responses. C. Ask open-ended questions that focus on the facts of the case and not the performance of the involved individuals. D. Communicate the information to patients and families in an objective manner stating the facts in understandable terms. Collaborative communication between disciplines is encouraged for events and outcomes that involve multiple disciplines.

E. If waiting for the family to arrive will delay communication phone notification is acceptable. For severity level 2 events, ascertain who is in the home or can be contacted to provide support in the event the family member is very distressed. F. The names of employees involved in unanticipated events and outcomes are not provided to the patient and family unless they specifically request this information. Only the name of the involved practitioners is provided to the family and patients. G. Post incident investigation by the appropriate staff can make a determination about culpability and competence of the involved parties in a more objective manner in a less emotionally charged atmosphere. H. Discussion about financial compensation and liability is outside of the realm of the clinicians and is referred to risk management for follow up. I. 1. Unanticipated Events: Management:

A. At the time the error is intercepted actions are taken to prevent the error from progressing to completion. B. Notify leadership on the nursing unit or in the outpatient department about the error and that it was intercepted prior to completion.

C. Complete an incident report to allow investigation of near miss events for systems issues that will lend themselves to remediation. D. Notify the covering medical team of the event and the patients/families response to the event. E. Assess the patients response to the event to determine if Social Work or the Patient Representative should visit to provide ongoing support. 2. Disclosure: A. Inform the patient of the unanticipated event and factually explain the relevant details in simple understandable terms that will allow the patient to understand the circumstances. B. Avoid blame and accusations of other staff involved in the incident. C. Apologize for any inconvenience and reassure the patient/family that the event is being reported for follow up to see how this can be prevented in the future. 3. Support: A. Contact Social Work or Patient Representative if the patient/familys distress level indicates the need for ongoing discussion. B. Notify the medical team if ongoing support is required 4. Documentation: A. Factually document the event, information provided to the patient and indicate if any other family members are notified and name of the medical team member notified. Indicate the patient/familys response to information and any follow support provided.

II. Unanticipated Outcomes of Severity Level 1: 1. Management

A. Notify the medical team promptly of the discovery of the unanticipated outcome. B. Assess the patients history inclusive of the medication regimen, as appropriate, to ascertain what the potential for harm is associated with the event. C. Initiate treatment, as appropriate, to minimize harm. Examples of intervention include but are not limited to the following: 1. Administer Syrup of Ipecac or perform gastric lavage for patients who have received oral medications with the potential for serious or life threatening adverse effects. 2. Move patients to a monitored environment to provide closer supervision that will allow adverse effects to be detected and treated promptly.

3. Administer antagonists or supportive medications to reverse the effects of medications or prevent the adverse event from progressing to level 2 severity. C. Assess the patient/familys response to the unanticipated outcome to determine if Social Work or the Patient Representative should visit to provide ongoing support. D. Complete an incident report and submit as per procedure. 2. Disclosure A. Inform the patient of the unanticipated outcome and factually explain the relevant details in simple understandable terms that will allow the patient/family to understand the circumstances. Avoid using medical terms and language that will not be understood by the patient and family. B. Tell the patient/family what the implications are for the patient and what is expected as a result of the unanticipated outcome. C. Describe the plan of care and any diagnostic tests or interventions that will be performed to assess injury or potential harm. D. Avoid blame and accusations of other staff involved in the incident. Do not assume liability for the event by making self-blaming statements. E. Apologize for the unanticipated outcome, any inconvenience and reassure the patient/family about the ongoing safety of the patient. F. Inform the patient/family that the event is being reported for investigation to prevent such an occurrence from happening in the future. G. Provide timely follow up in regards to the outcomes of interventions and diagnostic tests. 3. Support: A. Provide adequate time for discussion and questions. Let the patient/family know that if they have questions later that someone will be available to assist them. B. Communicate caring and concern for the unanticipated outcome and the effect this is having on the patient. Explain any actions that are implemented to prevent the unanticipated outcome from recurring for the patient. C. Consider a family meeting if there are several family members involved who are requesting information. D. Contact Social Work or Patient Representative if the patient/familys distress level indicates the need for ongoing discussion. 4. Documentation: A. Factually document the event, the impact on the patient, information provided to the patient and indicate if any other family members are notified and name of the medical team member notified. B. Indicate the patient/familys response to information and any follow support provided. C. Keep in mind that if the unanticipated outcome increases in severity that the chart may become part of a lawsuit and document the information in a manner that would facilitate understanding by a jury. III. Unanticipated Outcomes of Severity Level 2:

1. Management A. Intervene promptly with the discovery of the unanticipated outcome to develop a diagnostic/treatment plan to minimize patient injury. B. Notify the patient/family as soon as reasonably possible. Do not wait until diagnostic test results are available. Inform the patient family of the need for these tests and that, as more information becomes available it will be shared with him/her. C. Assess the patient/familys response to the unanticipated outcome to determine if Social Work or the Patient Representative should visit to provide ongoing support. E. Complete an incident report and submit as per procedure. F. Contact Risk Management in a timely manner to ensure compliance with regulatory agency notification. G. If the unanticipated outcome involves an investigational protocol the IRBA is to be notified within one working day about the unanticipated events and implications for research. H. If it is anticipated that there might be disclosure of the event to the press contact Risk Management so that they can assist in getting public relations department involved.

I. Risk Management will assess the unanticipated outcome for financial implications for the patient and make recommendations about cancellation of billing the patient for costs associated with the unanticipated outcome. 2. Disclosure A. Notify the patient promptly or contact the family. If it is not convenient for the family to come to the hospital tell them of the unanticipated outcome over the phone rather than delaying notification. B. Factually explain the relevant details in simple understandable terms that will allow the patient/family to understand the circumstances. Avoid using medical terms and language that will not be understood by the patient and family. C. Apologize for the unanticipated outcome without assuming blame. Express regret for any inconvenience and reassure the patient/family about the interventions being taken for the ongoing safety of the patient. D. Do not speculate about issues surrounding the unanticipated outcome. Discrepancies in information may undermine the patient/familys confidence in care delivery and increase anxiety and anger. E. Tell the patient/family what the implications are for the patient and what is expected, as a result of the unanticipated outcome as information becomes available. F. Describe the plan of care and any diagnostic tests or interventions that will be performed to assess injury or potential harm. G. Avoid blame and accusations of other staff involved in the incident. Do not assume liability for the event by making self-blaming statements. H. If disclosure is by individuals other than those directly involved with the unanticipated outcome and the family requests the name of the care providers involved provide them with this information. Provide only the individuals name and title. Do not disclose any personal information about the involved employees. I. If the family requests to meet with the individuals involved in the unanticipated outcome or wants punitive action taken against the employee consult Risk Management to develop a follow up plan. J. Inform the patient/family that the event is being reported for investigation to prevent such an occurrence from happening in the future. K. Provide timely communication to the patient/family in regards to the outcomes of interventions and diagnostic tests.

3. Support: A. If the family is notified by phone of the unanticipated outcome assess the family members level of distress and ascertain who is available in the house to provide support. B. Allow the family to visit the patient at the time that is most convenient for him/her regardless of visiting hours. C. Provide adequate time for discussion and questions. D. The higher the level of severity associated with the unanticipated outcome the more overwhelmed the patient and family will be and the less they will be able to take in information. Expect that repetitive explanations may be needed. Let the patient/family know that if they have questions later that someone will be available to assist them. E. Providing consistent clear communication about the unanticipated outcome can be a source of comfort to a distressed patient and family. Clear, accurate documentation of events can facilitate this consistency. F. Communicate caring and concern for the unanticipated outcome and the effect this is having on the patient. Explain any actions that are implemented to prevent the unanticipated outcome from recurring for the patient. G. Consider a family meeting if there are several family members involved who are requesting information. H. As the level of severity increases the need for support for the family and care providers involved in the incident increases. Arrange for Social Work and/or the Patient Representative to visit with the patient/family to assess response to the unanticipated outcome.

I.

J. K.

L. M. N. O.

Contact PERT to interview the involved care providers to assist with support and to inform the involved individuals about the Employee Assistance Program (EAP). Notify EAP about the referral providing details of the incident that do not violate patient or employee confidentiality. Provide support to individuals who choose to self disclose unanticipated outcomes to the family/patient in which they were directly involved. Reassure the individuals involved in the unanticipated outcome that the information from this incident is confidential. Remind others who are involved in caring for the patient after the unanticipated outcome to avoid discussing confidential information about the events outside of the workplace. Assess the employees work schedule and offer him/her time off as a supportive measure and reassure the employee that this is not punitive. Invite employees involved in unanticipated outcomes to root cause analysis meetings and share corrective action plans with them to facilitate closure. Notify the employees immediate supervisor to be aware of increased anxiety and problems coping that may interfere with the employees ability to return to work. Be aware that post trauma stress disorder usually occurs 4-6 weeks after the event.

4. Documentation: A. The purpose of the documentation is to promote patient care and safety, not to place blame. Extreme care should be taken to avoid implied blame for unanticipated outcomes by any other caregiver. B. The documentation of the unanticipated outcome is the responsibility of the responsible Attending during the phase of care that the unanticipated outcome occurs. Attending Anesthesiologists, Cardiac Interventionists, Radiologists, ICU Intensivists etc. may be writing the initial note and discussions with the family at the time of the unanticipated outcome. C. It is an expectation that the attending (or covering attending) physician of record write a note as soon as possible and no later than 24 hours following an unanticipated outcome. This note should clearly document his/her active participation in the care of the patient. An Attending note must be written daily, for as long as appropriate to the patients status, after the unanticipated outcome. D. Factually document the event, impact on the patient, information provided to the patient and indicate if any other family members are notified and name(s) of the medical team members interacting with the patient/family. E. Document assessments and interventions employed in treating the unanticipated outcome. F. Indicate the patient/familys response to information and the referral to Social Work and/or Patient Representative. G. Keep in mind that if the unanticipated outcome increases in severity that the chart may become part of a lawsuit and document the information in a manner that would facilitate understanding by a jury. If questions arise about what to document contact Risk Management for advice.

DESCRIPTION OF DISCIPLINARY PROCEEDINGS

No work no pay policy- The doctrine of no-work-no-pay is a fundamental axiom in industrial relations. The philosophy is very simple. When a person is employed, it is expected that the work assigned will be carried out. When this work is not done, the employee is not eligible for payment of any salary. Even when a general strike or countrywide ban disrupts public transport systems, and consequently employees are unable to reach their workplace, the same principle prevails. Even die-hard trade union leaders respect this principle of equity and natural justice. No work, no pay lays a strong foundation to industrial peace and harmony in the long run.

Salary deduction for unexcused absence- Gross salary and net salary or take home pay, as anyone who work knows, are vastly different figures. This is due in large part to tax deduction taken from your paycheck each pay period.

TOOLS OF DIRECTING Provide basic patient care under direction of nursing staff. Perform duties such as feeding, bathe, dress, groom, or move patient, or change linens. May transfer or transport patients include nursing care attendants, nursing aids and nursing attendants. Tasks:

Administers medications or treatments such as catherizations, suppositories, irrigations, enemas, massages or douches, as directed by the physician or nurse. Answer patients call signal lights, bells or intercom systems to determine patients needs. Apply clean dressings, slings, stockings or support bandages, under the direction of nurse or the physician. Assist nurse of physician in the operation of medical, equipments or provision on the patients care. Change bed linens or make beds. Clean and sanitize patients rooms, bathrooms, examination rooms or the other patient areas. Collect specimens, such as urine, feces, or sputum. Communicate with patients to ascertain feelings or need or emotional support. Feed patients or assist patients to eat or drink.

DESCRIPTION OF THE ORGANIZATIONAL DESIGN

Organizational Design or Structure. It is a formal, guide process for integrating the people, information and technology of an organization. A process by which a group is formed its channel of authority, span of control and line communication. Importance of Organization Structure A. It enable members what their responsibilities are, so that they may carry them out. B. It free the manager and the individual workers to concentrate on their respective roles and responsibilities. C. It coordinate all.

Principles of Organizational Design

1. Division of labor Work of all kinds must be divided and subdivided and allotted to various persons according to their expertise in a particular area. Subdivision of work makes it simpler and results sufficiency. 2. Unity of command It implies that a subordinate should receive orders and instructions from only one boss. 3. Authority and Responsibility Authority refers to the right of superiors get exactness from their subordinates whereas responsibility means obligation for the performance of the job assigned. 4. Span of Control 5. Contingency Factors