ADMINISTRATION AND MANAGEMENT

OF PSYCHIATRIC UNITS INCLUDING

EMERGENCY

SUBMITTED BY
Suparna Singh Ghosh
Ranu Adhikari
M.Sc. Nursing 2nd Year
Student
Govt. College of Nursing
Burdwan , Purba Bardhaman
 
Introduction:
Psychiatric hospital also known as mental hospital or psychiatric
wards. This hospital specializing in the treatment of serious mental
disorders, such as clinical depression, schizophrenia and bipolar
disorder etc. Psychiatric hospital vary widely in their size and
grading. Modern psychiatric hospitals provide a primary emphasis on
treatment and attempt where possible to help patients control their
own lives in the outside world, with the use of a combination of
psychiatric drugs and psychotherapy.
History:
Modern psychiatric hospitals evolved from, and eventually
replaced the older lunatic asylums. The development of the
modern psychiatric hospital is also the story of the rise of
organized institutional psychiatry. In the late 19th the early 20th
centuries, terms such as “madness’’ “lunancy’’ all of which
assumed a unitary psychosis were split into numerous mental
diseases of which catatonia, melancholia and dementia.
LAY-OUT OF PSYCHIATRIC UNIT
TYPES
There are a number types of modern psychiatric hospitals,
but all of them house people with mental illness of widely
variable severity.
- Crisis stabilization
- Open units
- Medium term
- Juvenile wards
- Long term
- Halfway houses
- Political imprisonment
- Secure units
 FUNCTIONS OF PSYCHIATRIC
HOSPITAL
1.Out patient services-
-Maximum facilities of outpatient services
-Minimum documentation in case records should be
maintain
-Essential drugs should be given
-Facilities for giving modified ECT
-Facilities for observation about 10 emergency cases
-Ambulance services
-Other facilities like canteen, drugs store etc.
2. In patient services
- Maximum number of beds should not be more than 20
- Separate cot, mattresses and pillow should be provided
- There should be 3ft distance between cots
- Provide locker
- Patient should be encourage to wear their own clothes
- There should be separate plate and tumbler
- Medication should be given in bedside
- Bed linen should be changed at least once in a week
- Special pay wards should be developed
- There should be ICU in every hospital for about 10 beds.
Hospital Support Services
Kitchen and dietary
Laundry
Medical store/pharmacy
Medical record section
Hospital necessity stores
Central sterile supply department
Rehabilitation services
Security and Safety
The potential suicide of patients is a special concern
of psychiatric facilities. Design to address this and
other safety and security issues includes,
-Plumbing, electrical and mechanical device
- Control of entrance and exit
- Eliminate the use of door knobs
- Solid material specified ceilings handles.
Generally, zones of risk, in which patients may cause harm to
themselves or others, identify an approach to addressing security
needs based upon areas of greatest concern.
Zones of high risk are those in which patients are alone and
unsupervised, such as the patient room, toilet room or shower, or a
seclusion room. 
Medium-risk zones include those in which patients may have some
supervision, are in small groups and are rarely alone, such as in group
rooms, day rooms, laundry or the dining room.
Low-risk zones are those in which patients are observed and
accompanied, such as in corridors, or where patients are not allowed,
such as staff spaces, clean and soiled rooms and housekeeping rooms.
The potential suicide of patients is a special concern of psychiatric facilities. The facility
must not unwittingly create opportunities for suicide. Design to address this and other
safety and security issues includes:
•       Plumbing, electrical, and mechanical devices designed to be tamper-proof
•       Use of breakaway shower-rods and bars, no clothes hooks
•       Elimination of all jumping opportunities
•       Control of entrances and exits by staff
•       Provision for patient bedroom doors to be opened by staff in case of emergency
•       Laminated glass for windows in inpatient units
•       Fiber-reinforced gypsum board for walls
•       Special features in seclusion rooms to eliminate all opportunities for self-injury,
including outward opening door with no inside hardware
•       Careful consideration of appropriate locations for grab bars and handrails. Where they
must be used in unsupervised spaces, and patient profile justifies extra care, special designs
are available that preclude their use for self-injury.
•       Eliminate the use of door knobs and handles
•       Solid material specified ceilings
 Building Attributes
The design of a successful psychiatric facility should:

•       Promote staff efficiency by minimizing distance of necessary travel between frequently used
spaces.

•       Allow easy visual supervision of patients by limited staff. Nurse stations on inpatient units
should be designed to provide maximum visibility of patient areas.

•       Include all needed spaces, but no redundant ones. This requires careful pre-design
programming.

•       For inpatient units, provide a central meeting area or living room for staff and patients and
provide smaller rooms where patients can visit with their families.

•       Make efficient use of space by locating support spaces so that they may be shared by
adjacent functional areas, and by making prudent use of multi-purpose spaces
Cont……

• Giving each inpatient the ability to control his immediate environment as much as possible,
i.e. lighting, radio, TV, etc.

• Providing computer stations for patient use when patient profile and treatment program allow.

•       Designing a "way-finding" process into every project. A patient's sense of competence is

encouraged by making spaces easy to find, identify, and use without asking for help. Color,
texture, and pattern, as well as artwork and signage, can all give cues.

•       Providing exercise equipment for patient use where appropriate for the program of care.

•       Providing access to kitchen facilities, preferably on the unit, where snacks or meals can be
prepared by patients, when patient profile allows.
 Operational Consideration

Bring the services to the patients and maximize

therapeutic opportunities
Consistent with the goal of recovery and the desire to treat patients in
the least restrictive setting possible, there is a general trend for
patients in inpatient mental health settings to have shorter lengths of
stays. To maximize treatment services, patient engagement, and
interdisciplinary care processes in an inpatient setting, there should be
adequate treatment, therapy, and staff space on the inpatient unit,
thereby minimizing movement and separation of the patient and
service provider.
Create Non-Institutional Treatment Environment
Creating a more familiar, therapeutic environment helps reinforce the recovery
focus of the program and reduce institutional stigma often associated with mental
health treatment facilities. To this end, interior and exterior features of mental
health facilities are increasingly home-like in appearance and feel. Inpatient and
residential facilities, where feasible, are single story or village-like, with multiple
exterior courtyards bringing in more natural light and views of nature. The
interior design embodies safe, residential components, with improved aesthetics,
ventilation, and noise control. Traditional inpatient environments with enclosed
areas and physical barriers between staff and patients, such as enclosed nursing
stations, are typically not needed or favored in most inpatient facilities today and
are being replaced with open concept nursing stations of reduced size that blend
into a more open environment and promote normal social interaction and
engagement.
Private Patient Rooms and Bathrooms
Many inpatient mental health facilities in the private sector are moving toward
having exclusively, or primarily, single occupancy rooms. An inpatient facility with
all private patient rooms allows more patient assignment flexibility, enhances
patient privacy, and reduces disruptions and incidents related to a shared patient
bedroom. Single occupancy patient rooms have the benefit of being more private
and having less noise, which may be agitating to some patients and can disturb
sleep.

On Stage and Off Stage Design

The “on-stage, off-stage” concept separates, where possible, patient pathways (“on-
stage”) throughout the facility from materials management, food service and clean
materials delivery within the facility, as well as staff support areas (“offstage”). This
minimizes noise, disruption and distractions in areas actively used by patients.
Use of Technology
Technology in mental health facilities provides benefits in enhancing security,
communications, and patient care.
 Security enhancements include: door control, inventory control, and facility
monitoring.
 Communication enhancements include: access to continuously updated patient
treatment documentation by all appropriate members of a patient’s
interdisciplinary care team.
The patient care includes “telemental health.” “Telemental health” refers to
remote visual/audio communication between the patient and care team
professionals. Individual consultations may utilize personal computers with a
camera. This technology is important to ensuring continuity of care for those
patients living in remote or rural areas. All inpatient, residential, and outpatient
facilities should have audio- and video-conferencing capability for both individual
and group use.
Units staffing pattern of psychiatric unit
Staffing
The minimum essential staff ratio recommended
• Doctor
• Clinical Psychologist
• Nurse
• Ward aids
• Sweeper
• Dietician
• Cook
• Laundry supervision
• Pharmacist
• Medical records officer
• Occupational therapist
• Electrician
Team and Authority
 Staffing for an inpatient program depends on the mission of the program,
severity of the illness, the degree of impairment and the complexity of the
situation. Program focus and physical design interact with program staffing. The
responsibility for balancing these interactive factors rests with the program
administrative team.
 At a minimum, the program administrative team with the responsibility for the
entire treatment program must include a qualified psychiatrist, and a qualified
psychiatric nurse.
 The program must be consistent with a hospital administration as conveyed by an
appropriate representative of the administration.
 The program is developed by the administrative team and approved by the medical
staff and hospital administration.
 Staffing and program organization and other ancillary services such as psychology,
education, social work, paediatric medicine and occupational therapy, need to be
professionals in those disciplines.

 The staff of various disciplines must meet the facility's specific written criteria for
credentials and clinical privileges.
 The administrative team has the responsibility for a program of continuous quality
improvement.
Members of the Mental Health Team:-
1. Psychiatrist
2. Psychiatric nurse clinical specialist
3. Registered nurse in a psychiatric unit
4. Clinical psychologist
5. Psychiatric social worker
6. Psychiatric para-professionals
· Psychiatric nursing aids / attendants
· ECT Techniques
· Auxiliary personnel
· Occupational therapist
· Recreational therapist
· Diversional play therapist
· Creative art therapist
· clergymen
 Psychiatrist:-
The psychiatrist is a doctor with post-graduation in psychiatry with 2-3 years of
residence training. The psychiatrist is responsible for diagnosis, treatment &
prevention of mental disorders, prescribe medicines & somatic therapy & function
as a leader of the mental health team.
Psychiatric nurse clinical specialist:-
The psychiatric nurse clinical specialist should have a master degree in nursing,
preferably with post –graduate research work. She participates actively in primary,
secondary & tertiary prevention of mental disorder & provides individual, group &
family psychotherapy in a hospital & community setting. She also takes up the
responsibility of teaching, administration & research.
Registered nurse in a psychiatric unit:-
The registered nurse undergoes a general nursing & midwifery program or B.Sc
nursing / post-basic B.Sc nursing program with added qualification such as
diploma in psychiatric nursing. Diploma in nursing administration etc. This nurse is
skilled in caring for the mentally ill, gives holistic care by assessing the patient’s
mental, social, physical, psychological & spiritual needs.
 Clinical psychologist:-
The clinical psychologist holds a doctoral degree in clinical
psychology & is registered with the clinical psychologist’s
association. She/he conducts psychological, diagnosis tests,
interprets & evaluates the finding of these tests & implements a
program of behavior modification.

Psychiatric social worker:-

The psychiatric social worker is a graduate in social work &
post-graduate in psychiatric social work. She/he assesses the
individual, the family & community support system, helps in
discharge planning, counseling for job placement & is aware of
the state laws & legal rights of the patient & protects these rights.
 Child and Adolescent Psychiatric Technician
Also known as a child care worker, mental health specialist, child care specialist, mental
health associate.

Credentials:

 Educational credentials vary. Extensive pre-service and ongoing in-service training is

essential. The assignment of clinical responsibilities must consider careful evaluation
of the combination of training, experience and personal characteristics such as
maturity, empathy and objectivity.
 Basic Functions:
 Establish and maintain behavioural supervision of children.
 Maintain implementation of safe, therapeutic milieu.
 Implement specific assigned aspects of the treatment plan.
 Observe, assess, and document the patient's status.
 Assist in planning and supervision of leisure activities.
 Participate in the observation and documentation of the patient's
treatment.
 Psychiatric para-professionals
a. Psychiatric nursing aids / attendants:-They have high school training &
     

are trained on the job. They aid maintaining the therapeutic environment &
provide care under supervision.

b.     ECT Techniques:-They undergo training for 6-9 months. Their function is

to keep ready the ECT under the supervision of a psychiatrist or anesthetist.

c.      Auxiliary personnel:-They are volunteer housekeeper or clerical staff &

require in-service education to interact with the patient therapeutically.

d.     Occupational therapist:-Occupational therapist goes through specialized

training. He /she has a pivotal role to play by using manual & creative
techniques to assess the interpersonal responses of the patient. Patients are
helped to develop skill in the area of their choice & become economically
independent. They are helped to work in sheltered workshop.
  e. Recreational therapist:-The recreational therapist plans activities to
stimulate the patient’s muscle co-ordination, interpersonal relationship &
socialization. These approaches are need-based.

f.       Diversional play therapist:-Makes observation of a child / patient during

his play. The behavior of the child while playing, the type of toys & his reaction
toward the doll, beating, calling or throwing are the focus of attention.

g.     Creative art therapist:-He/she is an art graduate & encourages the patient

to express his work freely with colors & analysis the use of various colours,
drawing of various scenes etc. this therapy helps in diagnosis & also in
bringing the repressed feelings of the patient to the conscious level. 

h.     Clergymen:-These are religious persons who may be asked to come to the

hospital unit once a week (depending on the patient’s religious faith) & have a
spiritual talk with the patient.
 

Planning of equipment and supplies

Functional, accurate and safe clinical equipment is an essential
requirement in the provision of health services. Well maintained
equipment will give nurses greater confidence in the reliability of
its performance and contribute to a high standard of
client care. Equipment management is an important issue for
cost and safety in hospitals operations. Planning of
equipment and supplies recommends that at the outset of each
project; identify project goals, including clinical priorities,
budget, schedule and phasing.
Medical equipment and supplies:
 Equipment are defined as those items necessary for the functioning of all services of the
facility such as accounting and records, maintenance of buildings and grounds, laundry,
public waiting rooms, public health and related services.
 The term equipment is used for more permanent type of article and may be classified as
fixed and movables. Fixed equipment is not a structure of the building, but it is attached
to the walls or floors (egg; steriliser,) Movable equipment includes furniture, instruments
etc.
 Supplies are those items that are used up or consumed; hence the term consumable is
used for supplies. The supplies in hospital include drugs, surgical goods (disposables,
glass wares), chemicals, antiseptics, food materials, stationeries, the linen supply etc.
Definition of planning equipment and supplies:
Planning of equipment and supplies is defined as process of selection
and organization of the article or items used in the
diagnosis, treatment, and monitoring of patients in order to ensure
that they are safe, available, accurate, and affordable.
Need of planning equipment and supplies:
Medical equipment and supplies planning includes all the related policies
and procedure govern activities from selection and acquisition through to
the incoming inspection, acceptance, maintenance and eventual retirement
and disposal of medical equipment. Planning and management of all
equipment and supplies used in hospital is need to be done to;

 ensure that equipment and supplies used in patient’s care are

operational, safe, and properly configured to meet the mission of the
medical treatment facility.
 manage safety and cost of articles.
 overcome the problems in nursing care or other patient
related activities due to inadequacy in equipment and supplies.
 stabilize fluctuations in consumptions.
 provide reasonable level of client services.
 satisfy the demands during the period of replenishment.
 know about possible legal or licensure issues.
 Phases of equipment management:
A typical life cycle of medical equipment has the following phases:

1.Planning phase:
The following conditions that should be met to help the decision process in
planning phase:

Demonstrated clinical needs.

Availability qualified users.
Approved and reassured source of recurrent operating budget.
confirmed maintenance services and support.
Adequate environment support.
A clear-cut policy should be there on acquisition, utilization and
maintenance of equipment need to be established. This will help to
reduce any future problems arising out of contracts, spare parts and
maintenance of equipment acquired locally, internationally.
Procurement phase:
Standardize on models or manufacturers of equipment.
Specify the conditions and special requirements in the purchase order to
specify the supplier withhold payment if specified conditions are not met.

3.Incoming inspections:
Incoming inspections should be carefully checked for possible damages;
compliance with specifications in the purchase order; and delivery of
accessories, spare parts and operating and service manuals.
Equipment inventory and documentation system:
It provides information to support different aspects of medical
equipment management;
Inventory entries should include accessories, spare parts and
operating and service manuals.
Make copies of the manuals for distribution to the users, while the
originals of the manuals should be kept at the technical document
library for safekeeping.
5.Commissioning and acceptance:
Commissioning can be carried out by hospital technical staff. if they are
familiar with that item of equipment. If commissioning by the suppliers
is needed, the process should be monitored by hospital technical staff so that
any technical matters can be noted and recorded.

6.Monitoring of use and performance:

A link should be maintained between user and supplier and observe any supplier’s
technical services. 
Maintenance:
Proper maintenance of equipment is essential to obtain sustained benefits and to
preserve capital investment. Equipment must be maintained in working order and
periodically calibrated for effectiveness and accuracy. Proper maintenance has a direct
impact on the quality of care.

8.De-commissioning:
Repair existing old equipments.
Dismantle old units if required.
De-Commisioned equipment must be deleted to keep the inventory current.  
General utility services in the hospital
1.Electric supply and installations: A hospital must have a steady electrical
supply at a stable voltage. Voltage fluctuations play havoc with sophisticated
electronic equipment, endoscope, sterilisers, X-ray equipment etc. While planning
hospital departments, provision should be made for voltage stabilisation in areas
with heavy concentration of electrical and electronic equipment. This is preferred
over using voltage stabilisers with individual equipment. There should be an
emergency generator capable of supplying power to all emergency areas of the
hospital. This generator should be of right capacity and kept in working order by
periodic test runs.
2. Water supply: Since safe water supply is not always assured, hospitals must
have their own purification system. Also there should be plumbing system.

 3. Disposal of waste–liquids and solids: Disposal of waste both solid and
liquid is a totally neglected area. A hospital incinerator good for the
waste management.

 4. Refrigeration, air conditioning, ventilation and environment

control: Air conditioning is required for protection of sophisticated electronic
equipment, X ray, machines etc.
 5. Transport:
Lifts are needed for vertical transport. There should be separate lifts for patients,
visitors, staff and supply. Patients lift should accommodate a standard hospital bed.
Sides of the lift must be protected to prevent damage by trolleys. Lift
surfaces and flooring should be capable of easy cleaning and disinfection.
Ventilation, communication and emergency escape system should be provided on
all lifts. As for horizontal transport also trolleys and ramps with gentle gradient are
useful.
6. Supply of medical gases, compressed air, hot water, vacuum
suction and gas plants:
Piped supply of medical gases, compressed air, vacuum suction, hot water,
steam, necessitates thoughtful planning at all stages to consider problems of

 Easy uninterrupted safe supply

 Fire and explosion hazards
 Easy of servicing and maintenance without disrupting hospital services.
7. Laundry: A hospital laundry has 2 separate areas, with provision for
decontamination and sterilising of soiled linen.

8. Fire hazard: There should be consideration of ventilation, exhaust systems and

adequate earthing of all electrical installation.

9. Communication: Public telephone and internal telephones are required in

each hospital.

10. Repairs workshop: There should be provision for repair and maintenance
of necessary equipments used in the hospital.
 
 Materials used in hospitals
Hospital material medical side Hospital material management side
 

 Perfusion materials  Computer, fax, telephone, stationary items

 Surgical disposables  Public address items overhead projector
 Instruments  Audio-visual systems
 Drugs, medicine, oxygen, linen
 
 Biomedical equipment
 Disinfecting items  

 Computers, telephone and fax

 Food and beverage materials
 Anaesthetic equipment
 Electro medical equipment
 Glass ware, dental machines
 Surgical dressing utensils
 Artificial limbs, bandages, cots for patient, furniture
 Engineering items and many others.
Essential equipment for a 50 bedded district hospital (WHO) 
1. Scope of services

o Essential clinical services- medicine, surgery, paediatrics., OBG, and acute

psychiatry (when necessary)
o Optional clinical services – oral surgery, orthopaedic surgery, otolaryngology,
neurology and psychiatry.
o Essential clinical support- anaesthesia, radiology and clinical laboratory
o Optional clinical support services- pathology and rehabilitation including
physiotherapy.
2. Essential medical equipment
o Diagnostic imaging equipment – it includes x-ray and ultrasound
equipment. X-ray equipment can be stationary in one room or
mobile
o laboratory equipment– microscope, blood counter, analytical
balance, calorimeter(spectrophotometer), Centrifuge – a small
centrifuge that can accommodate six 15ml tubes should be available.
 Water bath – used for stabilising temperature at 25, 37, 42, or 56 degree
Celsius.
Incubator/oven- a small hot air oven to carry out standard cultivations
and sensitisations.
o Refrigerator – an ordinary household refrigerator with a freezer unit, for
storing preparations, vaccines, blood etc.
o Distillation and purification apparatus - it should be made of metal that
resists acid, and alkali and should be free standing.
3. Electrical medical equipment.
o Portable electrocardiograph
o Defibrillator (external)
o ECT equipment
o Portable anaesthetic unit– 2 small aesthetic units should be obtained, complete
with a range of masks.
o Respirator – it should be applicable for prolonged administration during post
operative care.
o Dental chair unit- a complete unit should be available to carry out
standard dental operations.
o Suction pump – one portable and one other suction pump are required.
o Operating theatre lamp- one main lamp with at least 8 shadows lamp and
an auxiliary of 4 lamp units.
o Delivery table- it should be standard and manually operated.
o Diathermy unit– a standard coagulating unit which is operated by hand or foot
switch, with variable poor control.
4. Other equipment
o autoclave– for general stabilisation
o Small sterilisers- for specific services- eg. Stabiliser
o cold chain and other preventive medical equipment
o ambulance
5. Small, inexpensive equipment and
instruments
Equipment and instrument, such as BP apparatus, oxygen
manifolds, stethoscope, diagnostic sets and spotlights.

 
Role of nursing managers in maintaining equipment and supply:
The nurse manager should apply system approach for maintaining equipment and
supply in nursing unit.

INPUT:

The main objective of input component is to ensure adequate supply of equipment ad

supplies of nursing unit. The nurse managers need to:

 Take active part in estimating the demand of equipment and supply.

 Be aware of hospital policy for requirement, indenting, stock etc.
 Nursing norms for equipment and supply as per nursing council.
 Develop ward policy as per requirement.
 Communicate higher authority about the gap between demand
and supply.
 Conduct meetings with superiors and subordinates for
requirement.
 Prepare guidelines for handling and taking over for the staff.

 
 
 PROCESS:

Objective:

To maximize the proper utilization of available equipment and supply by the staff and
proper maintenance of equipment and supplies.

 Maintain current inventory of functional/in working order equipment and supplies.

 Send requisition monthly, weekly, daily as per the policy developed.
 Have inventory control, maintain buffer stock for emergency.
 Do proper distribution for evening, night shift.
 Conduct supervisory round.
 Check daily and periodically the functioning of emergency and general
equipment and life-saving equipment.
 Assign and delegate the work to junior staff.
 Make them accountable for any loss and misuse of equipment and supplies.
 Ask them to use the articles for rendering patient care.
 Communicate all the team members about the ‘out of stock’ and non-
functioning of equipment.
 Develop orientation plan for the patient and their relatives about the
availability and non-availability of particular article, equipment and supplies
and ward policy.
 Maintain record and report of equipment and supplies.
 Regularly maintain the equipment and supply.
 Condemn the non-functioning and outdated equipment as per policy.
 Check all the work has been done.

OUTPUT:

Objective:

To render quality patient care;

 All the staff should be aware of policy: hospital, ward related to equipment and supply.
 There should be adequate supply of equipment and supplies without any interruption.
 Equipment s should be in working order.
HOSPITAL POLICIES AND PROCEDURES
(1) The governing body must ensure that a written policies and procedures manual is
maintained. In addition to meeting the requirements of rule. Policies and Procedures for all
facilities, the manual must include the following elements:
(a) A quality assurance procedure for the assessment of the quality of care. This procedure must
ensure appropriate treatment has been delivered according to acceptable clinical practice;
(b) A written program description which must be available to staff, patients and members of
the public.
The description must include, but need not be limited to, the following:
1. Characteristics of the persons to be served,
2. Referral process,
3. Program rules for patients, and
4. Referral mechanisms for services outside the facility (both medical and non-medical); And
(c) Procedures to ensure how the patient’s parents, guardian, members of the immediate family
or other responsible adult are to be notified in the case of any unusual occurrence including
serious illness, accidents or death.
 Standards of Mental Health
Nursing

 Professional Practice Standards

 Professional Performance Standards

 
Standard I: Theory
The nurse applies appropriate
theory that is scientifically
sound as a basis for decisions
regarding nursing practice.
Standard II: Data Collection
The nurse continuously collects data that
are comprehensive, accurate and
systematic.
Standard III: Diagnosis
The nurse utilizes nursing diagnoses and/or standard classification
of mental disorders to express conclusions supported by recorded
assessment data and current scientific premises. Nurses' logical
basis for providing care rests on the recognition and identification
of those actual or potential health problems that are within the scope
of nursing practice.
Standard IV: Planning
The nurse develops a nursing care plan
with specific goals and interventions
delineating nursing actions unique to
each patient's needs. The nursing care
plan is used to guide therapeutic
intervention and effectively achieve the
desired outcomes.
Standard V: Intervention
The nurse intervenes as guided by the
nursing care plan to implement nursing
actions that promote, maintain or restore
physical and mental health, prevent
illness and effect rehabilitation.
a. Psychotherapeutic interventions:
 

The nurse uses psychotherapeutic

interventions to assist patients in regaining
or improving their previous coping abilities
and to prevent further disability.
b. Health teaching:
 

The nurse assists patients, families

and groups to achieve satisfying and
productive patterns of living through
health teaching.
c. Activities of daily living:
 
The nurse uses the activities of daily
living in a goal directed way to foster
adequate self-care and physical and
mental well-being of patients.
d. Somatic therapies:
 

The nurse uses knowledge of somatic

therapies and applies related clinical
skills in working with patients.
a.Therapeutic environment:
 

The nurse provides, structures and

maintains a therapeutic environment in
collaboration with the patient and other
health care providers.
a.Psychotherapy:
 

The nurse utilizes advanced clinical expertise in

individual, group and family psychotherapy, child
psychotherapy and other treatment modalities to function
as a psychotherapist and recognizes professional
accountability for nursing practice.
Standard VI: Evaluation
The nurse evaluates patient responses to
nursing actions in order to revise the database,
nursing diagnoses and nursing care plan.
Professional Performance Standards
Standard VII: Peer Review
The nurse participates in peer review and other
means of evaluation to assure quality of nursing
care provided for patients.
Standard VIII: Continuing Education
The nurse assumes responsibility for
continuing education and professional
development and contributes to the
professional growth of others.
Standard IX: Interdisciplinary Collaboration
The nurse collaborates with other health care providers
in assessing, planning, implementing and evaluating
programs and other mental health activities.
Standard X: Utilization of Community Health Systems
The nurse participates with other members of the community in
assessing, planning, implementing and evaluating mental health
services and community systems that include the promotion of the
broad continuum of primary, secondary and tertiary prevention of
mental illness.
Standard XI: Research
The nurse contributes to nursing and the mental health field
through innovations in theory and practice and participation in
research.
QUALITY ASSURANCE
Quality assurance is a management system designed to give
maximum guarantee and ensure confidence that the service
provided is up to the given accepted level of quality, the
standards prescribed for that service which is being achieved with
a minimum of total expenditure.
(British Standards Institute)
QUALITY ASSURANCE
"Quality assurance is the monitoring of the activities of client
care to determine the degree of excellence attained to the
implementation of the activities". (Bull, 1985) 
OBJECTIVES OF QUALITY ASSURANCE :-
According to Jonas (2002), the two main objectives are:-

 To ensure the delivery of quality client care

 To demonstrate the efforts of the health care providers to
provide the best possible results.
APPROACHES OF QUALITY ASSURANCE:-
I. General approach
II. Specific approach
I.GENERAL APPROACH
a) Credentialing:
b) Licensure
- It is a contract between the profession and the state in which
the profession is granted control over entry into an exit from the
profession and over quality of professional practice.
c) Accreditation
- It is a process in which certification of competency, authority, or
credibility is presented to an organization with
necessary standards. National league for nursing (NLN) a voluntary
organization has established standards for inspecting nursing
education's programs.
d) Certification:-Certification is usually a voluntary process with in
the profession. A person's educational achievements, experience and
performance on examination are used to determine the person's
qualifications for functioning in an identified specialty area.
 II) SPECIFIC APPROACH: -
These are methods used to evaluate identified instances of
provider and client interactions.

a) Audit- An audit is a systematic and official examination of a

record, process or account to evaluate performance. Auditing in
health care organization provides managers with a means of
applying control process to determine the quality of service
rendered. Nursing audit is the process of analyzing data about the
nursing process of patient outcomes to evaluate the effectiveness
of nursing interventions.
b) Peer review-
Comparison of individual provider‘s practice either with practice
by the provider‘s peer or with an acceptable standard of care. To
maintain high standards, peer review has been initiated to
carefully review the quality of practice demonstrated by members
of a professional group.

c) Utilization Review (UR):

Utilization review activities are directed towards assuring
that care is actually needed and that the cost appropriate for
the level of care provided.
Three types of Utilization Review (UR) are there:

a. Prospective

b. Concurrent

c. Retrospective
FACTORS AFFECTING QUALITY ASSURANCE IN NURSING CARE:-

1)Lack of Resources:

2)Personnel problems

3)Improper maintenance:

4) Unreasonable Patients and Attendants

5) Absence of well informed population

6) Absence of accreditation laws

7) Lack of good and hospital information system

8) Absence of patient satisfaction surveys

9)Lack of nursing care records

QUALITY ASSURANCE CYCLE:-
QA is a cyclical, iterative process that must be applied flexibly
to meet the needs of a specific program. The process may
begin with a comprehensive effort to define standards and
norms or it may start with small-scale quality improvement
activities.
1. Planning for Quality Assurance:-
This first step prepares an organization to carry out QA
activities. Planning begins with a review of the organizations
scope of care to determine which services should be addressed.

2. Setting Standards and Specifications:-

To provide consistently high-quality services, an organization
must translate its programmatic goals and objectives into
operational procedures. In its widest sense, a standard is a
statement of the quality that is expected.
 3. Communicating Guidelines and Standards:
Once practice guidelines, standard operating procedures, and
performance standards have been defined, it is essential that staff
members communicate and promote their use. This will ensure that
each health-worker, supervisor, manager, and support person
understands what is expected of him or her.

4. Monitoring Quality:-
Monitoring is the routine collection and review of data that
helps to assess whether program norms
are being followed or whether outcomes are improved. 
5. Identifying Problems:
Program managers can identify quality improvement
opportunities by monitoring and evaluating activities.

Defining the Problem:

The team must define it operationally-as a gap between
actual performance and performance as prescribed
by guidelines and standards. The problem statement
should identify the problem and how it manifests itself. It
should clearly state where the problem begins and ends.
7. Choosing a Team:
Once a health facility staff has employed a participatory approach to
selecting and defining a problem, it should assign a small team to
address the specific problem. The team will analyze the problem,
develop a quality improvement plan, and implement and evaluate
the quality improvement effort.

8. Analyzing and Studying the Problem to Identify the Root Cause:-

Achieving a meaningful and sustainable quality improvement effort
depends on understanding the problem and its root causes. 
Such studies can be based on clinical record reviews, health center
register data, staff or patient interviews, service delivery observations.
9. Developing Solutions and Actions for Quality Improvement:
The problem-solving team should now be ready to develop and
evaluate potential solutions.

10. Implementing and Evaluating Quality Improvement Efforts:

The team must determine the necessary resources and time frame and
decide who will be responsible for implementation. It must also decide
whether implementation should begin with a pilot test in a limited area or
should be launched on a larger scale. The team should select indicators to
evaluate whether the solution was implemented correctly and whether it
resolved the problem it was designed to address. In-depth monitoring
should begin when the quality improvement plan is implemented.
Documentation:
Documentation is the written, legal
record of all pertinent interaction with
the client- assessing, diagnosing,
planning, implementing and evaluating.
Importance of documentation in psychiatric nursing:

 Documentation in psychiatric nursing is the important source of

information to meet legal and professional requirements.
 It is essential for good clinical communication. 
 Accurate and effective documentation ensures continuity of care. 
 Save time & prevent duplication or error in the patient care. 
 Support the multidisciplinary team to deliver great care.
Principles of documentation:
Factual
Accurate
Completeness
Current
Organized
Timing
 Methods of documentation:

Problem-Oriented Recording:

Problem-oriented recording, based on a list of problems, follows the

subjective, objective, assessment, plan, implementation, and evaluation
(SOAPIE) format. When used in nursing, the problems (nursing
diagnoses) are identified on a written plan of care, with appropriate
nursing interventions described for each. Documentation written in the
SOAPIE format.
Focus Charting:
Another type of documentation that reflects use of the nursing
process is Focus Charting.

Lampe (1985) suggested that a focus for documentation can be any

of the following:

 Nursing diagnosis
 Current client concern or behaviour
 Significant change in the client status or behaviour
 Significant event in the client's therapy.
The PIE Method
The PIE method, or more specifically, "APIE" (assessment,
problem, intervention, evaluation), is a systematic approach of
documenting to nursing process and nursing diagnosis. A
problem-oriented system, PIE charting uses accompanying flow
sheets that are individualized by each institution.
Electronic Documentation
Health information and data
Results management
Order entry and order management
Decision support
Electronic communication and connectivity
Patient support
Administrative processes
Reporting and population health management
CONTENT OF RECORDS:

1. Full name;

2. Home address;

3. Home telephone number

4. Date of birth;

5. Sex

6. Race or ethnic origin;

7. Next of kin;

8. Education;
9. Marital status;

10. Type and place of employment;

11. Date of initial contact or admission to the

facility

12. Legal status, including relevant legal

documents;

13. Other identifying data as indicated;

14. Date the information was gathered; and

15. Signature of the staff member gathering the

information.
The patient record shall contain information on
any unusual occurrences such as the following:

1. Treatment complications;

2. Accidents or injuries to the patient;

3. Morbidity;

4. Death of a patient; and

5. Procedures that place the patient at risk or

that cause unusual pain.
 PRESERVATION AND STORAGE
Written policies and procedures shall govern the compilation, storage, dissemination and
accessibility of patient records to assure that the facility fulfil its responsibility to safeguard
and protect the patient record against loss, unauthorized alteration, or disclosure of
information; to assure that each patient record contains all required information; The facility
shall provide facilities for the storage, processing and handling of patient records, including
suitably locked and secured rooms and files. When a facility stores patient data on magnetic
tape, computer files, or other types of automated information systems, adequate security
measures shall prevent unauthorized access to such data. A written policy shall govern the
disposal of patient records. Methods of disposal shall be designed to assure the
confidentiality of information in the records.
Conclusion:
Hospital planning is by general and building layout related
principles. Master planning, project planning and strategy
planning are carried out in the planning of hospital. Patient care
unit is a part of hospital design. It is an area in a hospital or any
health care settings where patients of similar needs are grouped
to facilitate health care delivery by healthcare professional,
including nurses.
Thank you