PATIENT CARE ISSUES, MANAGEMENT ISSUES, EMPLOYMENT ISSUES

INTRODUCTION

Nursing is defined as providing care to the healthy or sick individuals for preventive, promotive,
curative and rehabilitative needs. The Consumers are patients with complex needs. With increased
awareness of health care, health care facilities and consumer protection Act, patients/clients are
getting awareness about their rights. Nurses also have now the expanded role, with the result the
legal responsibility is increased. Hence, it is important for nursing personnel working in hospital,
community and educational field to develop understanding of Legal and Ethical issues of Nursing.

The law requires nurses to provide safe and competent care.

This care is defined as the level of care that would be rendered by a comparable nurse in a
similar circumstance and is referred to as a standard of care. Every employment environment
for nurses should have standards of care. It is your responsibility to review the standards and
follow them. Reviewing standards of care is an excellent way to determine if you are interested
in working for an organization. If for any reason you do not think the standards are high
enough for quality care to be given, leave the situation immediately.When you do not follow
standards of care, you are probably committing a criminal or civil crime. The situations
discussed in this section are common problems for nurses. You must be aware of them and
thoroughly understand them.

Issues need deliberations and common consensus. They

need to be reviewed periodically. Issues which seem not feasible, and ideal, may become
practice with the change of time. Some of these issues threaten nurses who do not keep up with
the changing development. These issues are base for the future trends in care.

TERMINOLOGY

Issue: An issue is a topic of interest which leads into a discussion and requiring a decision.

Mandatory: Conveying a command. Fraud: Willful and purposeful interpretation or

misinterpreting the outcome of procedure or a treatment.

False Imprisonment: A person cannot be legally forced to remain in health Centers or

hospital.
Act: Act is a written law. When law is passed in the assembly and is approved by Government
it is called as an Act.

Legislation: Legislation as ‘the process of making laws’. Legislation is a method of improving

public services. To control and maintain standard in nursing education and nursing practice.

Legal Responsibility: Legal responsibility refers to the ways in which a nurse is expected to
follow the rules and regulations prescribed for nursing practice. These responsibilities are
described by State, Central Government through service conduct rules based on standards
developed by State Nursing Council and National Nursing Council.

Malpractice: Professional misconduct; negligence performed in professional practice; any

unreasonable lack of skill in professional duties or illegal or immoral conduct that results in
injury or death to the client/consumer.

Negligence: Negligence is described as lack of proper care and attention; carelessness.

MEANING OF LEGAL ISSUES

• Law is standard or rules of conduct established & enforced by government.

• Legal issues in nursing are those in which a person lead to face legal problems in which nurse face
problem when not meeting proper patient care. These are intended to protect the public.

NEED FOR NURSING ETHICS

 Helps the students/ RN to practice ethically.

 Helps the nurse to identify the ethical issues in her work place.

 Protecting patients right and dignity.

 Providing care with possible risk to the nurses health.

 Staffing patterns that limit the patients access to nursing care.

 Ethical reasoning Helps the nurse to respond to ethical conflicts.

 Helps to differentiate right /wrong behavior.

 Guide for a professional behavior.

 Help teachers plan education.

 Prevent below standard practice.

A. PATIENT CARE ISSUES

Nursing covers a wide range of disciplines and health-care issues that are always changing
and at the forefront of what guides this career path. Issues such as health-care reform,
nursing shortages, low salaries and ethics are some of the issues being faced. With nursing
being an integral part of hospitals, nursing homes, home health agencies and colleges, the
discipline has to keep current of changing policies and be prepared to address whatever may
arise.

a. Nursing Shortage

The nursing shortage is a major issue facing the biggest licensed profession in the health-
care system. This shortage will affect health care more each day, as it appears not much is
being done to stop it. Many emergency rooms have longer wait times due to less nursing
staff, and hospital floors are feeling the effects as well. This is affecting patient care
because the number of patients to one nurse is increasing, therefore decreasing the quality
of care. This shortage is being felt in hospitals, nursing homes and home-health agencies.
Nursing has been lobbying for patients by seeking legislation to help with the nursing
shortage and with funding for nursing schools.

b. Health-Care Reform

Nurses have always been involved with health-care reform as advocates for patients. The
American Nursing Association (ANA) has been working to have the voice of nurses heard.
Nurses are in support of a public plan, so Americans who are underinsured or uninsured
will have access to affordable, quality health insurance. The ANA has taken the stand that
health care is not a privilege but a right. It is lobbying for a reduction in cost and an end to
high out-of-pocket costs for services, as well as ending discrimination pertaining to pre-
existing conditions.

c. Low salaries

d. Standard Care

 State Nurse Practice Act

 ANA-Standards of Clinical Nursing Practice

 National Association of School Nurses (NASN)

 School policy and protocols

B. MANAGEMENT ISSUES

Nurses working in doctors' offices and hospitals have a difficult job caring for patients and meeting
the needs of both coworkers and superiors within the institution. Nurse Managers who work in the
medical professional also have a complex and challenging role. It is a considerable challenge to meet
the needs of the organization, the needs of patients, and the needs of the nurse employees.

a. Turnover

Maintaining adequate staffing levels is a major issue in nursing management.

Representatives working in nurse management and leadership are often faced with the
responsibility of controlling turnover rates. Nurses faced with long work hours for
relatively little pay have few motivations to remain in one position and often seek
employment opportunities at competing hospitals and neighboring clinics.

b. Funding

Lack of funding is an issue for many nurse managers who seek to provide sufficient
compensation to existing nurses as well as offer suitable compensation in an attempt to recruit
new nursing professionals for hire. An underfunded institution cannot attract and provide for the
right professionals, and funding inadequacies can also become a detriment to the level of
training provided to medical staff, in addition to the needs for medical equipment and supplies.
When the medical institution's quality of staff and training standards must be lowered because of
budgetary concerns, the overall level of patient care is unavoidably reduced.

c. Workload

Individual nurse manager workload and overall medical workload are issues in leadership.
The medical profession is one that never sleeps and has an almost constant need for
qualified professionals both in hiring and scheduling. Not only do nurse professionals work
long hours and many days per week, but nurse managers and leaders are also faced with an
ever-increasing workload. Dealing with patient concerns, providing training and support to
 nurses, and acting as a liaison between doctors, nurses and medical administration
members can be taxing and stressful. Many nurses are unwilling to enter into the nurse
management field because of the added stress and responsibility. When you add to all that
the secondary stresses of budgetary cutbacks and fewer nurse leadership roles, it means
that existing nurse managers are faced with enormous challenges when it comes to
balancing their leadership functions.

d. Issues regarding malpractice in nursing management

Issues of delegation and supervision
 The failure to delegate and supervise within acceptable standards of professional
practice.

Issues related to staffing

 Inadequate accreditation standards- adequate number of staff members in a time of

advancing patient activity and limited resources.

 Inadequate staffing, i.e. short staffing.

 Floating staff from unit to unit.

e. Ethics

Nurses are held to a high standard of ethics when it comes to patients, co-workers and
themselves. They provide care, promote human rights and values, and help meet the needs
of the less fortunate and vulnerable. A major ethical goal is to also keep patients'
information confidential, and this includes not discussing patients in public places. Another
ethical issue is protecting patients from negligent co-workers who may endanger them. The
individual nurse must not endanger the patient and has to be accountable to the standards
of the field.

f. Effect
Effects of reform, shortages, ethics and salaries are issues that keep nurses constantly
thinking, growing and changing.

Nursing instructors make far less money than nurses in the clinical setting. They also make less
than other educators in different fields. In order for nursing to succeed, there needs to be
qualified candidates educated, but with these low salaries nurses are not flocking to this career
path. Without these types of nurses being adequately filled then qualified candidates will not
have the opportunity to be taught. These salaries need to be increased, and colleges and
universities need to see the value in these instructors.

g. Issues in Nursing Curriculum Development

 Where are we now?

As nursing faculty we need to answer the question and analyze the present situation
whether or not we are on the road to relevant, which means the validation of curriculum or
judgemental process in which an attempts is to be made to ascribe a degree of worth or
value to a curriculum in the context of professional education and preparation of
participants for their professional role.

Walker describes five types of validation

a. Academic validation

b. Professional validation

c. Economic validation

d. Institutional validation

e. Performance validation

Then identify the strengths of present system/situation before starting the program.

Where we want to go?

This deals with the thinking and aspiration for future. Faculty must think whether the
educational program what is designed will help to meet the expectations of individuals,
families and communities in accordance far with the developed countries or not.

What we want to achieve?

Nurse educators must be able to analyze and think critically that we are preparing the students
with the adequate skills to perform their expected roles in all the three domains of professional
tasks such as practical, communication and intellectual skills according to the institutional
goals and educational objectives.

The three types of skills to be achieved:-

  Domain of attitudes (communication skills)

 For example, feelings, values and interpersonal relationships

 Domain of practical skills (imitation control and automatism)

 Domain of intellectual skills(knowledge and recall of facts)

 For example, Interpretation of data and problem solving.

How can we achieve?

The faculty must think the ways by which the curriculum can be developed to which is relevant to
meet the needs of the country.

h. Collaboration issues

The nursing profession is faced with increasingly complex health care issues driven by
technological and medical advancements an ageing population, increased numbers of
people living with chronic disease, and spiraling costs. Collaborative partnerships between
educational institutions and service agencies have been viewed as one way to provide
research which ensures an evolving health care system with comprehensive and
coordinated services that are evidence- based, cost – effective and improve health care
outcomes. These partnerships also ensure the continuing development of the professional
expertise necessary to meet these challenges.

C. EMPLOYMENT ISSUES

Employment issues are defined as any issue which may have an impact on wages, terms and other
conditions of employment.

a. Issues related to Nursing Shortage

The nursing shortage is another international event. Why is there a nursing shortage? There
are many opinions regarding that question. I have been a nurse long enough to recognize
that nursing shortages wax and wane. This shortage is more noticeable, however and it is
lasting longer. The nurse shortage itself is a contributing factor because the shortage
creates staffing problems, mandatory overtime, and constant calls for additional shift work.
National nursing organizations are making strong efforts at stopping the shortage by
mandating better nurse- to-patient ratios, eliminating mandatory overtime, and increasing
salaries and benefits for nurses.
b. Issues in Nurse Migration

Nurse migration has attracted a great deal of political as well as media attention in recent
years. The rights to healthcare as well as workers’ rights are paramount to understanding
the interests of health sector stakeholders, including the consumer or patient, the
government or employer, and the worker or health professional. In this section a discussion
on the right to work and the right to practice is, by necessity, followed by a warning that
cases of exploitation and discrimination often occur when dealing with a vulnerable
migrant population. Additionally, international migration policy issues addressing the
somewhat conflicting sets of stakeholders' rights are presented, and ethical questions
related to nurse migration are noted.

c. The Right to Work and the Right to Practice

Professionally active nurses are important players in an increasingly competitive and

global labor market. Unable to meet domestic need and demand, many industrialized

countries are looking abroad for a solution to their workforce shortages; the magnitude of
current international recruitment is unprecedented (ICN, 2005).

For nurses to practice their profession internationally, they need to meet both professional
standards and migration criteria. The right to practice, e.g., to hold a license or registration,
a professional criteria, and the right to work, e.g. to hold a work permit, a migration
criteria, are sometimes linked. Yet they often require a different set of procedures with a
distinct set of competent authorities.

In the interest of public safety, nurses' qualifications must be screened in a systematic way
to ensure they meet the minimum professional standards of the country where they are to
deliver care. This may be in the form of a paper screen, for example automatic recognition
of qualifications received from a given country or school; tests, such as the NCLEX
licensing exam; supervised clinical practice, as seen in an adaptation period; and/or
successful completion of an orientation course/program.

Language is a crucial vehicle for the vital communication needed both between the patient
and care provider, and also between members of the health team. It is not surprising that in
many countries, a nurse's right to practice is limited if the foreign-educated nurse's
language skills do not support safe care practices. Passing specific language tests are
 required in certain countries. In others, the employer is held responsible for ascertaining
the language competence of the employees/health professionals. Clearly, history has
demonstrated a tendency for migrant flows to be the strongest between source and
destination countries that share a common language (Kingma, 2006). For example, nurses
wishing to migrate from Morocco will tend to go to France while nurses from Ghana will
be attracted by the United Kingdom. As the pools of nurses willing to migrate change, and
as language competency becomes a professional advancement requirement, language
barriers may prove to be less of a constraint, and we may see Chinese nurses working in
Ireland and Korean nurses going to the US.

Foreign nurses also need to meet national security and immigration criteria in-order-to
enter the country and to stay on a permanent or temporary basis, with or without access to
employment. There is no doubt that nurse mobility will be affected by national security
concerns and decisions on how fluid the borders will be maintained. For example a
tightening of border restrictions after terrorism attacks or the opening of borders with new
economic agreements, such as the expansion of the European Union, will continue to
influence nurse migration patterns.

d. Exploitation and Discrimination

One of the most serious problems migrant nurses encounter in their new community and
workplace is that of racism and its resulting discrimination (Chandra & amp; Willis, 2005).
Incidents are, however, often hidden by a blanket of silence and therefore difficult to
quantify (Kingma, 1999). Migrant nurses are frequent victims of poorly enforced equal
opportunity policies and pervasive double standards. Some migrant nurses are experiencing
dramatic situations on the job where colleagues purposefully misunderstand, undermine
their professional skills, refuse to help, and sometimes bully them, thus increasing their
sense of isolation (Allan & amp; Larsen, 2003; Hawthorne, 2001; Kingma, 2006). If we
recognize that international migration will continue and probably increase in coming years,
the protection of workers is a priority issue and should be safeguarded in all policies and
practices that affect migrant health professionals.

e. Essential Terms and Conditions in an Employment contract

An employment relationship has traditionally been governed by the terms and conditions
of the employment contract. Previously, the employer retained sole control in respect of
the terms and conditions of employment to be incorporated into the employment contract.
However, over the years there has been an increase in the implied terms and conditions
which are also read into the contract. Additionally, then there are the statutory terms and
conditions which also apply. A badly drafted employment contract which does not
correctly express the intentions of the employer on such matters as working hours,
prolonged illness, bonus payments, usage of office computer facilities, transfers,
retirement age, confidentiality, conflict of interest, disciplinary action and imposition of
punishment, etc or the omission to mention some of these items in an employment
contract can give rise to serious consequences for employers. This talk will focus on what
are considered as essential terms and conditions which employers must incorporate into an
employment contract and the consequences of failure to do so.

f. Unsatisfactory work performance and termination of employment

The Courts have time and again reiterated that employees enjoy security of tenure of
employment. The maxim "easy to hire difficult to fire" is a truism even in the case of
probationers. No employer having hired a person at considerable cost and having exposed
the person to training, formal or otherwise, will want to terminate the person. However,
when an employee has an attitude problem or whose work performance is not up to the
expectations he cannot be terminated by the employer simply by invoking the termination
clause in the employment contract. The employer has to follow certain rules and
procedures and only at the end of it can he terminate the services of a non-performing
employee. Even then, there are no iron clad assurances that the termination will not be
challenged by the employee at the Industrial Court. How does an employer ensure that he
minimizes the risk of being challenged in Court over a termination of employment due to
unsatisfactory work performance? This talk will attempt to take you out of the labyrinth.

g. Misconduct and imposition of punishment

It has long been held that the employer has the inherent right to discipline his workers.
Should misconduct be committed, the employer after a proper inquiry has been instituted
can impose a suitable punishment, including dismissal if the offence committed was of a
serious nature. The decision on the type of punishment to be imposed is under all
circumstances a subjective one. The Courts will interfere if, among others, the action taken
by the management was perverse, baseless or unnecessarily harsh or was not just or fair.
There have been occasions where employers have imposed the punishment of
 dismissal for misconduct which they have assessed as serious but these cases have been
reviewed by the Industrial Court and the decision of the employer substituted. Given that
imposition of punishment is a subjective matter, what factors or criteria should an
employer apply in determining appropriate punishment for misconduct committed in
employment. This talk, among others, will examine some of the issues to be taken into
account.

i. Sexual harassment at the workplace

Sometime ago this subject matter received a great deal of attention especially with the
launching of the Code of Practice on the Prevention and Eradication of Sexual Harassment
at the Workplace by the Ministry of Human Resources. However, the response to the
adoption of the Code by employers was not encouraging. Some NGO's have called for the
introduction of statutory measures to deal with the problem. Some recent judicial
pronouncements appear to make it difficult to prove sexual harassment had indeed taken
place. Regardless of all these what is the proper attitude that ought to be taken by
employers in this matter. Do employers have a legal responsibility to safeguard their
employees from sexual harassment at the workplace? To what extent can employers dictate
without being accused of encroachment into a person's private life and social interaction.
How is an employer to deal with sexual harassment cases and what standard of proof is
called for when usually harassments are .private and confidential incidents'.

j. Renewal of nursing registration

So that registration office is updated with nurses in practice. Of course re- registration may
qualify its periodicity and qualifications of nurses e.g. clinical experience, attendance at
continuing education etc.

k. Diploma vs degree in nursing for registration to practice nursing

This issue need indepth study of merits and demerits as well as its feasibility before it
could come on the surface.

l. Specialization in clinical area

It could be either through clinical experience or education. Specialization in cure and

specialized care required for patients demand that nurses be highly skilled in the unit.
 Generalization of care seems remote and unacceptable for patients under specialized
treatment.

m. Nursing care standards

Standards must be laid down and followed so that clients understand the quality of care
expected from the nurses.

COMMON CAUSES OF LEGAL ISSUES

 Professional negligence. E.g. ignoring the seriousness.

 Practicing medical without license in the community.

 Obtaining nursing license by fraud or allowing others to use your license.

 Felony conviction for any offence.

 Participating in criminal abortion. E.g. Quacks.

 Not reporting substandard medicine or nursing care.

 Providing patient care while under the influence of alcohol or drugs.

 Giving narcotics without an order.

 Falsely holding oneself as family practitioner of nurse practitioners.

PROCESSES THAT CAN BE USED IN PROFESSIONAL AND LEGAL REGULATION OF

NURSING PRACTICE

Sl. Process
No.

1 Accreditation Education programme is evaluated and recognized by National

Accreditation Board.

2. Licensure The state determines certain minimum requirement to practice as

nurse. (e.g. Negligence, malpractice, wrong treatment and
 alcoholism)

3. Certification Entry level competence. Specific knowledge and experience in

specified areas needed.

4. Standards Guidelines issued by councils, Qualifications, Standards, rules.

5. Nurse Violation of rule care result in disciplinary action

Practice Act

LEGAL SAFE GUARDS AND NURSING PRACTICE

Physician’s Order: Physician is responsible for directing medical treatment. Nurses are
obligated to follow physician’s oders unless they believe that the orders are not accurate or
would be detrimental to the clients. A nurse carrying out an inaccurate order may be legally
responsible for any harm suffered by the client. Verbal orders are not recommended because
they have possibilities for error. If a verbal order is necessary, during an emergency, it should be
written and signed by the physician as soon as possible, usually within 24 hours.

Short- staffing: The issue of inadequate staff may arise sometimes. Legal problems may
arise if there is not enough nurse to provide competent care. If assigned to take care of
more clients than is reasonable, nurse should attempt to reject assignments by informing
the nursing supervisor that they are inappropriate. Nurses should not walk out when staff is
inadequate because charges of ababdonment can be made.ack of experience in taking care
of the type of clients in the new nursing unit. They should also request for an orientation
about the unit.

Floating: Nurses are sometimes required to ‘float’ from the area in which they normally
practice to other nursing units. Nurses who float should inform the supervisor about any

Informed consent: Granted freedom, written or oral form (procedures, expected outcome,
complication, side effects, and alternative treatment.

Contracts: Exchange of promises between two parties. The agreement may be written or
oral. (E.g. patient and his family and health care team.)

Collective bargaining: Policies, legal procedures, up to date knowledge.

 Competent practice: It is most important and best legal safeguard.

List of do’s and don’ts as guidelines for safe practice

Do’s

 Documention of all unusual incidences.

 Report all unusual incidences.

 Know your job description.

 Follow policies and procedures as established by your employing agency.

 Keep your registration updated.

 Perform procedures that you have been taught and that are within the standard scope of
your practice.

 Protect patients from injuring themselves.

 Remain alert and focused.

 Establish and maintain rapport with patients and family.

 Seek and clarify orders when the patient’s medical condition changes.

 Practise safety with physician’s verbal orders.

Don’ts

 Remove side rails from patient’s bed unless there is an order or hospital policy to do
so.

 Allow patients to leave the hospital or nursing home unless there is an order or a signed
release.

 Accept money or gifts from patients.

 Give advice that is contrary to physician orders or the nursing care plan.

 Give medical advice to friends and neighbours.

 Attempt to practice medicine.

 Witness a patient’s will.

 Take medications that belong to patients.

 Worked as a licensed practical/vocational nurse in a state in which you are not

licensed.

ROLES AND FUNCTIONS OF NURSE MANAGER IN LEGAL ISSUES:

The following are the leadership roles and managerial functions of a nurse manager in
legal and legislative issues:-

a. Serve as a role model by providing nursing care that meets or exceeds accepted
standards of care.

b. Is current in the field and seeks professional certification to increase expertise in a

specific field.

c. Reports substandard nursing care appropriate authorities.

d. Fosters nurse/ patients relationships that are respectful, caring and honest, thus
reducing the possibility of future lawsuits.

e. Joins and actively supports professional organizations to strengthen the lobbying

efforts of nursing in health care legislation.

f. Practices nursing within the area of the individual competence.

g. Prioritizes patient’s rights and welfare first in decision- making.

h. Demonstrates vision, risk taking, and energy in determining appropriate legal

boundaries for nursing practices thus defining what nursing is and should be in the
future.

i. Is knowledgeable responding sources of law and legal doctrines that affect nursing
practice?
j. Delegates to subordinates wisely, looking at the managers scope of practice and that of
those they supervise.

k. Understands and adheres to institutional policies and procedures.

l. Practices nursing with scope of state nursing within the scope of the state nurse practice
act.
 m. Monitors subordinates to ensure that they have a valid, current and appropriate license
to practice nursing.

n. Uses foresee ability of harm in delegation and staffing decisions.

o. Increases staff awareness of intentional torts and assists them in developing strategies
to reduce their liability in these areas.

p. Provides educational and training opportunities for staff on legal issues affecting
nursing practice.

CONCLUSION:

The above mention administration practice are highly indispensible for effective operation of
the hospital and the maintaining and practicing the above mention procedures give to the
nurses for acquittal from the misuse of legal responsibility. It assists in maintaining a standard
of nursing practice by making accountable under the law.

JOURNAL ABSTRACT

A. Ethical problems in nursing management: The role of codes of ethics

Abstract

The aim of this study was to identify the ethical problems that nurse managers encounter in
their work and the role of codes of ethics in the solutions to these difficulties. The data were
collected using a structured questionnaire and analysed statistically. The target sample
included all nurse managers in 21 specialized health care or primary health care organizations
in two hospital districts in Finland .The most common ethical problems concerned resource
allocation as well as providing and developing high quality care. This was the case in different
managerial positions as well as in types of organization. Professional codes of ethics were used
more often for problems related to patients’ care compared with issues of resource allocation.
Nurse managers at middle or strategic management levels used codes of ethics more often than
those in charge of a ward. More research is required to investigate ethical decision making in
nursing management, especially with regard to problem solving. In addition, new guidelines
and continuing education in ethics are important for management personnel.

B. Ethical problems in nursing management

Abstract
Elina Aitamaa, (May 10, 2015) conducted a study on Ethical problems in nursing
management: The views of nurse managers .Nurse managers have responsibilities relating to
the quality of care, the welfare of the staff and running of the organization. Ethics plays
significant role in these responsibilities. Ethical problems are part of daily management, but
research in this area is limited. The aim of this study was to identify and describe ethical
problems nurse managers encounter in their work to get more detailed and extensive view of
these problems. The data consisted of nine interviews with nurse managers at different
management levels in primary healthcare and specialized healthcare organizations, and it was
analysed by inductive content analysis. Permission to conduct the interviews including ethical
approval was given at all participating organizations according to national standards. The
respondents were informed about the aim of the study, and voluntary participation, anonymous
response and confidentiality were explained to them. Four main categories were found:
conflicts in practical situations, lack of appreciation, disregard of problems and experienced
inadequacy. Problems could also be divided to patient-related, staff-related, organization-
related and other problems. The findings correspond with results from earlier studies but add
knowledge of the nature and details of nurse managers' ethical problems. New information is
produced related to the ethical problems with nurse managers' own courage, motivation and
values. Nurse managers identified a variety of different ethical problems in their work. This
information is useful in the development of ethics in nursing management.

REFERENCE:
Books
 K.Deepak, Textbook on Nursing Management, 2nd edition, Emmess Medical Publishers,
Bangalore,p.p-479-484.
 BT Basavanthappa, Nursing administration , 2nd edition, New Delhi: Jaypee Brothers Medical
Publishers; 2009, p. no-809-13.
 BT Basavanthappa, Management of Nursing Services & education, 1st edition, New Delhi:
Jaypee Brothers Medical Publishers; 2011, p. no-578-80.
 Masih shabnam, Essentials of Nursing Management,2nd edition, Lotus Publication,2017, New
delhi, p. no-334.
 Raj D. Elakkuvana Bhaskara et.al, Management of Nursing Service and Education, 3rd edition,
EMMESS, Bangalore,2015,P No.318-21.

Journal
 Elina Aitamaa, Riitta Suhonen,Pauli Puukka, Helena Leino-Kilpi (2019 Jun 24) 'Ethical problems
in nursing management', BMC Health Services Research, Volume 19(PMC6591814), pp. 1-11.

 Elina Aitamaa , Helena Leino-Kilpi, Pauli Puukka, Riitta Suhonen ( 2010 Jul;17) 'Ethical
problems in nursing management: the role of codes of ethics', pubmed, VI - 17(PMID:
20610580), pp. 469-82.

 Joan Kemp BA MSc SRN RCNT RNT (March 1984) 'Nursing at night', Journal of Advanced
Nursing onlinelibrary.wiley.com, volume-9(Issue-2), pp. 217-223.

 Win Tadd (1998) 'Ethical Issues in Nursing and Midwifery Practice', Link.springer.com, 1, pp.
280.

Website:
 Mr. Migron Rubin (Feb 5, 2017) issues related to patient care, Available
at: www.slideshare.net (Accessed: Leadership & Management).
 Sujata Mohapatra (2014) ISSUES IN NURSING, Available at: www.slideshare.net (Accessed:
Nov 11, 2014).
 Mr. Mirgon Rubin (2017) Legal & ethical issues in nursing- issues in india, Available
at: www.slideshare.ne (Accessed: 14 Nov. 2017).