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WARD MANAGEMENT IN SELECTED HOSPITALS

Chapter · September 2009

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Citation: Sharma SK. Ward management in selected hospitals (Chapter-3). Nursing Care
Administration: A study of patients’ satisfaction in selected government and private hospitals at
Ludhiana [PhD Thesis]. Chandigarh: Punjab University; 2009.

CHAPTER-3

WARD MANAGEMENT IN SELECTED HOSPITALS

3.1 Introduction
In British English the term “ward” refers to an area in a hospital or other
healthcare delivery setting where patients with similar needs are grouped to facilitate
health care delivery by medically trained professionals. In United States ‘Ward’ is
also known as a ‘Nursing Unit’, which is used to describe a division of a hospital
shared by patients who need a similar kind of care.
Davis (1989) defines ward as a “Unit of the hospital where all amenities for
medical or surgical care as well as physical, social and psychological care are made
available to make the patients feel at home during their stay in the hospital from the
moment of admission till they are discharged”. In other words ‘it is a temporary home
for the patients who are admitted in the hospital’. The ward provides accommodation
for patients, who are prescribed admission in the hospital and the nurses provide
requisite but routine care.1
The wards form approximately one third of the whole hospital complex. The
most usual functions of the wards are, a) to render nursing care to all the admitted
patients, b) to provide necessary equipments, essential drugs and other stores required
for patient care in an organized manner in the ward. c) to serve as a temporary home
for the patient and hence it is designed to accommodate all the needs of the patients.
d) to provide opportunity for training medical, nursing and paramedical staff, besides
conducting research work.2
Basically ward management includes management of the ward structure
(anatomy) and functions (physiology). Structure or anatomy of the ward consists of
ward layout, supportive service area, ancillary area, and miscellaneous facilities of the
ward. Physiological process or functional component of the ward may include care
practices and management of ward environment.3
There is a close relationship between good ward management and good
nursing care. A well managed ward provides required facilities plus a trained,
satisfied and motivated staff to provide effective nursing care. In fact, ward
management and nursing care are complimentary and supplementary to each other
and as such cannot be separated. Therefore, efficient ward management is always

145
essential to provide quality nursing care. Ultimately good ward management leads to
overall satisfaction among care providers as well as care recipients.4

3.2. Functions of the Ward

The functions of a ward are better understood by looking at the three primary
components that comprise the ward, namely, the patient area, the nursing station and
the service area. The patient area consists of private rooms, semiprivate rooms and
multiple general wards. The said area is designed to be a safe and aesthetically
pleasing treatment area that is conducive for speedy recovery. It may contain space
required for equipments, staff and various other needs of the patient. The nursing
station provides workspace for nurses and other healthcare staff. It is located and
designed in such a way that the nurse may oversee maximum patient area and
directing people entering and leaving that ward and at the same time carry on
activities associated with the care and safety of patients. The functions of the work
area relates to handling material necessary for patient care, maintaining
communication and handling patient records, fulfillment of social and physical needs
of patients and the specific needs of the staff. Kunder (2004)5 mentioned that a ward
must results in the most economical operations, highest quality patient care, most
desirable patient comfort and environment, most efficient operation of the unit/ward,
greater degree of job satisfaction for nursing and medical staff and meeting the needs
of visitors.

3.3 Classification of Wards

The wards can be categorized in several ways since beds for inpatients can be
arranged in wards in a number of different ways due to varying reasons. They may be
grouped in the wards to form functional units such as acute, long stay, psychiatric,
maternity, medical or surgical. Alternatively, they may be grouped according to the
characteristics of the patients; generally age and gender or by the way in which it is
proposed that the patients will be treated. The allocation of beds according to
specialties or particular type of patients may be a component of one ward or to cover
several wards. The beds in a particular ward space may range from single bedrooms,
to rooms containing more than fifty beds. Basically wards are classified as;
a) General wards: where patients are admitted without any specific requirement.

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 b) Specific wards: where patients are admitted with the specific objectives either
by nature of disease or other specific reason e.g. Intensive Care Unit (ICU),
Intensive Cardiac Care Unit (ICCU), Pediatric ward, Isolation ward,
Emergency unit, Psychiatric ward, Geriatric ward, Cardiology ward,
Orthopedic ward, Skin ward, Burn ward, and Neurology ward etc.6

Wards in the selected hospitals under study were basically categorized in

general as well as special wards. General wards in CMC, ESI and Civil hospitals were
categorized on the basis of gender viz. male and female wards. However, in DMC
hospital, general wards were not categorized on the basis of gender but male and
female patients were placed in different cubicles of the same ward. It was found that
majority (69.3 percent)* of the patients preferred categorization of the wards
according to medical specialty as well as gender. Similar findings were also reported
by nurses, where 67.3 percent** of them were in favour of patients’ view point.
Bennis et al (1969)7 conducted a study on ward categorization in public and
private hospitals. The study found that wards were basically categorized as general
and special wards. In general wards, patients with general medical, surgical and
maternity care needs were placed and in special wards; patients with specific
healthcare needs were placed like psychiatry, intensive care, geriatric care etc. A good
majority of hospitals (>90 percent) categorized their wards on the basis of gender and
only few (<10 percent) hospitals placed male and female patients together in wards.

3.4 Location of the Wards

Location of the wards is very important factor in hospital management, some
of the basic facilities are preferably needed at ground floor making it an easy access
for patients seeking healthcare like emergency and trauma wards need to be located at
ground floor in close proximity with supportive facilities such as recovery room,
radiology department, laboratory facilities, blood bank, operation theater and central
sterile supply department. More stable patients can be placed at higher floors based on
their type of illness and subsequent care and other supportive services. It was further
added that similar type of wards can be grouped on a single floor with closely located

*
Which categorization of the wards do you (patients) prefer? a) Medical specialty b) Gender c) Both
**
Which categorization of the wards do you (nurses) prefer? a) Medical specialty b) Gender c) Both

147
supportive services (Holden, 2005).8 Location of the wards in selected hospitals may
be perused from Table 3.1.

Table 3.1: Location of wards in selected hospitals

PRIVATE HOSPITALS GOVERNMENT HOSPITALS
Floors
CMC DMC ESI Civil
Ground floor - Emergency - Emergency - Emergency - Emergency
- Trauma & ICU-II - Trauma & Emergency ICU - Trauma - Trauma
- Male Surgical - Dialysis - Labour room - ICU

First floor - Male Ortho - Surgical Ward-I, II, III & IV - Pediatrics - Female Medical
- Neurosurgery - Neurosurgery-64 - Maternity & - Female Surgical
- Labour room - Neurosurgery-65 Gynecology - Female Ortho
- Maternity & - Female surgical - Maternity &
Gynecology & Ortho Gynecology
- Nursery - Pediatrics

Second floor - Female Medical - Medical Ward-I,II,III & IV - Male Ortho - Male Medical
- Male Medical & ICU-I - Nephrology , Pediatrics - Male Surgical - Male Surgical
- Nephrology/dialysis - Maternity , Labour Room - TB Ward - Male Ortho
- Pediatrics - ICCU

Third floor - Cardiac - Gynecology, Psychiatric - Male Medical

- ICCU - Male & Female Ortho - Female Medical
- Cardiac Surgery - Urology & Nephrology
- Staff ward - Endocrinology , Chest & Oncology
- Dental - Gastroenterology, Burns & plastic

Fourth floor - Burns, Plastic Surgery - ICU Block

- Psychiatric
- Poor free ward

Computed from primary data

It was found that in CMC hospital, emergency, trauma wards, ICU-II and male
medical wards were located on ground floor. Male orthopedics, neurosurgery, labour
room, maternity, gynecology wards and nursery were located on second floor. Third
floor had cardiac ward, Intensive Cardiac Critical Unit (ICCU), cardiac surgery, staff
and dental ward. Burns, plastic, psychiatry and poor free wards were located on fourth
floor of hospital building.
In DMC hospital, emergency, trauma ward, emergency ICU and dialysis unit
were located on the ground floor. Medical ward-I, II, III & IV, nephrology, pediatrics,
maternity, labour room and ICCU were present on the second floor. Third floor
consisted of all super-specialty areas like gynecology, psychiatry, male and female
orthopedic wards, urology, nephrology, endocrinology, chest, oncology,

148
gastroenterology, burns and plastic surgery wards. Seven Intensive Care Units were
located on the fourth floor.
In ESI hospital, emergency, trauma and labour room were located on the
ground floor. Female surgical and orthopedics, pediatrics, maternity and gynecology
wards were located on the first floor. Male orthopedics, surgical and tuberculosis
wards were placed on the second floor. Male and female medical wards were located
on the top floor of the hospital. In Civil hospital, emergency, trauma and ICU were
present on the ground floor Female medical, surgical, orthopedic, pediatric, maternity
and gynecology wards were present on the first floor. Male medical, surgical and
male orthopedic wards were located on the top floor of the hospital building.
In addition, wards in selected private hospitals were located away from the
main road, outpatient department, or any other means of disturbance. Furthermore,
wards were located in close proximity with recovery room, radiology department,
laboratory facilities, blood bank, Operation Theater and central sterile supply
department. In Civil hospital, wards were located in close proximity with main road
and outpatient department. During informal discussion with nurses at Civil hospital it
was found that patients admitted in wards were experiencing lots of noise disturbance
because of close proximity with main road and out patient department. In ESI
hospital, wards were located away from main road and outpatient department, but
were not closely located to other supportive services such as recovery room, radiology
department, laboratory facilities, blood bank, Operation Theater and central sterile
supply department etc.
Brown (2006)9 mentioned that wards must be located away from main roads
and outpatient department to avoid disturbance, noise, and infection. However, it was
further suggested that the wards should be easily approachable to supportive services
(radiology, laboratory, blood bank, central sterile supply department and operation
theater etc.)
It was inferred from the data that in all the selected hospitals, emergency and
trauma wards were located on ground floor. However, placement of other wards was
not same in selected hospitals. In DMC and ESI hospital, similar type of clinical
specialty wards were grouped on single floor, however in CMC hospital it was
partially achieved. While in Civil hospital, wards were grouped on the basis of gender
on single floor. Wards of selected private hospitals were better placed than

149
government hospitals in reference to their location away from the main road and out
patient department and in close proximity to the supportive facilities.

3.5 Layout of the Ward

Figure 3.1 shows the relationship between core layout components of the
ward, which is necessary for satisfying the layout of a general ward. A good ward
layout ensures the visibility of majority of beds from nursing station, reduces the
walking distance of nurses between the beds and nursing station, provides adequate
privacy for patients, and reduces the risk of hospital acquired infections among
patients admitted in the ward.10

Fig. 3.1: Layout of a ward

Delivery Sanitary

Clean
Utility

Treatment
Room
Nursing
station Beds Day space

Dirty utility
disposal

Collection Sanitary

It was found that in CMC and Civil hospital a limited number of nurses
(average 22.5 percent) were satisfied with visibility of beds from nursing station as
may be seen in Table 3.2. However, it was found higher in DMC (65.0 percent) and
ESI hospital (60.0 percent). Majority of the nurses (80.0 percent) in selected hospitals
were not satisfied with open space available in wards for early ambulation of patients
and movement of staff. In addition, only 12.5 percent nurses were satisfied with
provision of privacy for patients in wards of selected hospitals.

150
 Majority of nurses (83.7 percent)* were not satisfied with placement of
supportive services (clean utility, dirty utility, material delivery, waste collection
system and procedure room) in wards of the hospitals as illustrated in Table 3.2,
which could be a major cause of higher hospital acquired infections in the wards.
Similarly, majority of nurses (85.0 percent) were also not satisfied with location of
sanitary facilities in wards. Nurses’ satisfaction with overall layout of the wards was
relatively better in DMC (25.0 percent) and ESI hospital (25.0 percent) as compared
with CMC (20.0 percent) and Civil hospital (15.0 percent).

Table 3.2: Nurses’ satisfaction# with different dimensions of ward layout

Hospitals Total
Features of Layout Private Government
N=80
CMC DMC ESI CIVIL
n=20 n=20 n=20 n=20
f (%)
f (%) f (%) f (%) f (%)
Visibility of beds from
06 (30.0) 13 (65.0) 12 (60.0) 03 (15.0) 43 (42.5)
nursing station

Open space in ward 05 (25.0) 03 (15.0) 05 (25.0) 03 (15.0) 16 (20.0)

Provision of privacy for

03 (15.0) 02 (10.0) 03 (15.0) 02 (10.0) 10 (12.5)
patients
Placement of
04 (20.0) 04 (20.0) 03 (15.0) 02 (10.0) 13 (16.3)
supportive services
Location of sanitary
03 (15.0) 03 (15.0) 04 (20.0) 02 (10.0) 12 (15.0)
facilities

Overall layout 04 (20.0) 05 (25.0) 05 (25.0) 03 (15.0) 17 (21.3)

#
Computed from primary data, Figures mentioned in table are of satisfied nurses

Benson (2005)11 also reported similar findings in a study, where it was found
that majority of wards (93 percent) were poor in architectural plans to meet the needs
of the patients, staff and visitors. The study further mentioned, that this basically
happened because of the non-involvement of operational level healthcare workers or
the patients in planning the layout of the hospital wards.

*
Are you (nurses) satisfied with following features of the layout of your ward?
 Visibility of beds from nursing station. a) Yes b) No
 Open space in ward a) Yes b) No
 Provision of privacy for patients a) Yes b) No
 Placement of the supportive services a) Yes b) No
 Location of the sanitary facility a) Yes b) No
 Overall layout a) Yes b) No

151
 Jean Barret (1998)12 mentioned that an ideal ward must ensure maximum
visibility of patients from nursing station, minimal walking distance between the beds
and nursing station, and patients are provided space, which ensures privacy, early
ambulation and prevents risk of hospital acquired infection.
As mentioned by the nurses about poor patients’ visibility from nursing
station, lack of privacy for patients, and poor placement of supportive services and
sanitary facilities in wards of selected hospitals, it was inferred that ward layout of
selected government and private hospitals was not according to the ideal ward layout
principles. Therefore, these wards failed to satisfy nurses with selected ward layout
features.

a) Size of the ward

The size of any ward or unit depends on variety of factors such as the size and
type of the hospital, the type of services provided by the hospital, the average length
of patient stay, the demands of the community, the number of single rooms, the type
of floor plan and the need for segregation on the basis of gender, medical services or
otherwise. It is also determined by the capacity of the nurses to carryout nursing care
of patients. Florence Nightingale recommended a 30-bedded ward and now the same
limit is more or less being followed. The modern trend is to have bigger ward of 40-
50 beds.13
It was found that in selected hospitals size of wards was not similar. About 50-
60 bedded wards were present in CMC and Civil hospital. While in DMC hospital,
wards were only 20-30 bedded and in ESI hospital wards were 30-40 bedded units. As
presented in Table 3.3, majority of nurses were not satisfied with size of the wards in
CMC (75 percent)* and Civil hospital (80 percent). However, more number of nurses
were satisfied with size of wards in DMC (70 percent) and ESI hospital (60 percent).

Table 3.3: Nurses’ satisfaction with size of wards

Hospitals Total
Satisfied with ward Private Government
size N=80
CMC DMC ESI CIVIL
n=20 n=20 n=20 n=20
f (%)
f (%) f (%) f (%) f (%)

Yes 05 (25.0) 14 (70.0) 12 (60.0) 04 (20.0) 35 (43.8)

No 15 (75.0) 06 (30.0) 08 (40.0) 16 (80.0) 45 (56.2)

Computed from primary data

*
Are you (nurses) satisfied with the number of beds placed in relation to the size of your ward? a) Yes b) No

152
 It was found that less than one fourth of the patients were satisfied with size of
wards in CMC and Civil hospital, where wards were large in size accommodating
about 50-60 patients in each ward. However, small size wards in DMC and ESI
hospital were more successful in satisfying admitted patients viz. 69.7 percent* and
63.0 percent respectively may be perused from Table 3.4.

Table 3.4: Patients’ satisfaction with size of wards

Hospitals Total
Satisfied with Private Government
ward size CMC DMC ESI CIVIL N=1200
n=300 n=300 n=300 n=300
f (%) f (%) f (%) f (%) f (%)

Yes 73 (24.3) 209 (69.7) 189 (63.0) 67 (22.3) 548 (45.7)

No 227 (75.7) 91 (30.3) 111 (37.0) 233 (77.7) 652 (54.3)

Computed from primary data

It was reported by Nagelkerk (2006)14 that hospital wards must be as small as

possible, ideally with maximum of 20-30 beds, which will facilitate better patient
supervision by nurses while working and minimize nurses walking distance between
patient’s beds and centralized nursing station. It was further added that smaller ward
size also minimizes the risk of cross infections among patients.
Empirical studies have begun to address the appropriate design of wards in
general and other components of ward configuration. However, one topic that has not
been thoroughly addressed is ward size. Shepley M (2002)15 mentioned that although
the average number of beds in a typical ward is somewhere between twenty-five and
thirty, ward size may range widely-from six beds in intensive care to as many as
forty-eight in a general wards. In addition, the overall physical dimensions of wards
are wide-ranging due to the impact of patient density (single, double-, or multiple-
rooms). The tendency to increase the area per patient results in a larger ward and
potentially, decreases staff efficiency. Even if two-bed rooms meet the social and
medical needs of some patients, these rooms may lack room assignment, flexibility
and infection control efficiency of single-bed rooms.

*
Are you (patients) satisfied with the number of beds placed in relation to the size of your ward? a) Yes b) No

153
 Ministry of Health and Family Welfare, Govt. of Kerala (2005)16 also
recommended that the basic consideration in placement of wards is to provide
sufficient nursing care, locating them according to the needs of treatment in respect of
medical discipline and checking cross infection. Wards shall be small dormitory with
10-15 beds.
It is a current trend to have a large sized ward to improve cost effectiveness
and to increase the profit in healthcare services. Large sized wards are cost effective
because same resources can be used for a large number of patients. Therefore, larger
size wards were preferred by management but healthcare professionals like to work in
small size wards. Similarly, patients do prefer the small size wards. These were the
two extreme opinions; however, it is recommended that wards should neither be too
large nor too small. Ideally a ward can be 25-30 bedded unit, which can easily cater
the basic requirements of patients, nurses and management.

b) Ward designs
The fundamental design of the 19th century ward layout was an open floor plan
with as many as thirty-six patient beds in one rectangular room or unit. In 1863,
Florence Nightingale described the design element of visibility as essential to nursing
efficacy, stressing the importance of positioning a nursing station in the ward to
ensure a view of the entire room both during daytime and at night (Nightingale,
1863).17 The design of the corridor ward with four to six beds in each room and one
central nursing station was introduced around 1920s to improve privacy (Hamilton,
1996).18 Similar corridor unit designs with multiple nursing stations can be found in
UK, planned according to the Nuffield Trust system (Pattison & Robertson, 1996).19
In a patient focused ideology of past decades within health care delivery, the
design of ward has revolved around the patient room and the immediate area
surrounding the patient (Verderber & Fine, 2000). The advancements in ward designs
of older facilities were according to Verderber and Fine (2000)20 gradual at best until
the Planetree model was founded in San Francisco in 1978. The Planetree model was
the first patient-centered care model inclusive of the physical environment. Its overall
aim is to maximize the time nurses spend caring for patients. This is achieved by
reframing the organizational health care philosophy, reorganizing work tasks and by
rearranging the physical environment to achieve more efficiency, thus transferring

154
more time to direct patient care. The purpose is to create more patient and family
centered health care units. One way of doing this is to keep patient’s supplies and
computer terminals in patient rooms so as to reduce the amount of time nurses spend
at the nursing station. Planetree suggests that architecture and design is vital to health
and healing (Schweitzer et al. 2004).21 According to Hendrich, A (2004)22 there are
three essential ward design measures needed to achieve efficient nursing care; 1)
bringing together all required facilities and services (including nursing stations) to
reduce nurses’ walking time 2) eliminating unnecessary communication and design
features which impede on maximum contact between nurse and patient and 3)
incorporating these principles effectively into the ward design. With the obvious
development towards more flexible hospital care, truly adaptable wards are gaining
momentum.
It does not necessarily make sense to classify wards by shape since the internal
configurations including the nursing station determines workflow and other work
behaviors as much as the geometric outline of the ward. However, there are certain
relevant design implications of the various ward types. A short introduction of three
main categories of ward design follows:
Linear Corridor Designs: The linear corridor ward design, also called “race track”
design, occurs as a single corridor or double corridor layout (Figure 3.2). Most
existing original floor plans typically have one nursing station in each unit. Most
corridor floor plans are organized around the central nursing station where charts,
orders, medications and supplies are concentrated. The nursing station functions as
the heart of the patient care activities and allows responsive access to all patient
rooms and good visibility to the patient rooms in close vicinity to the nursing station.
Negative aspects include long walking distances for nurses and restricted visual
control over patient rooms further away from the nursing station (Shepley, 2002).23 A
modified corridor design is called as courtyard design. The courtyard ward design
consists of corridors in square or rectangular configuration divided into completely
separated cubicles and surrounding a central courtyard area. This ward design is more
common in Europe. Invariably this design creates a need for additional nursing
stations, limits visibility further and increases walking distance. As nurses spend
much of their time walking up and down the halls, Hamilton (1993)24 concluded that

155
the secret of workability for nursing staff in the corridor unit is a combination of bed
numbers, nursing station numbers and nursing station placements.

Fig. 3.2: Double corridor ward design with decentralized nursing stations

Cluster Designs: The Unit 2000 symposium held in Huston (1990) was organized as
an attempt to generate ideas on the ideal ward configuration of the future and to
anticipate future trends in ward design. For the first time, cluster bed pods (Figure
3.3) were introduced in one case study, which aimed to accomplish a more human
scale ward. In the cluster design, patient rooms are organized around the nursing
station, dedicating one station as a main nursing location or entry reception station.
Compact clustered ward designs were not only aimed to reduce walking distances but
also to eliminate centrally located nursing stations, to place the provision of drugs,
closer to patients and to take full advantage of visibility. Patient support services were
decentralized with each pod consisting of six to twelve beds and one decentralized
nursing station with amenities for charting data, preparing medications etc.25

156
 Fig. 3.3: Cluster design with two decentralized nursing stations

Radial Designs: The radial ward designs (Figure 3.4) maximize visualization; patient
rooms are organized around nursing sub-stations within each unit. Nurses have an
unobstructed view of each patient room from each decentralized nursing station. This
design also accommodates fewer nurses and staff during night shift. Radial wards are
space consuming and tend to be smaller in bed numbers, which increases construction
and staffing costs. Nursing staff has expressed greater satisfaction with the radial
ward designs compared to single and double corridor designs (Trites et al., 1970)26
and in ICU units, nurses preferred the semicircular unit (MacDonald et al. 1981).27
Radial ward design cannot accommodate an adequate number of private rooms
without a tremendous waste of central core space (Hamilton, 1993).28 The trend
towards larger patient rooms cause restrictions on the radial design terms of the
remaining space for a nursing station and supplies. The development towards
increased number of single and larger patient rooms in the many countries like United
States has generated the use of alternative ward designs such as the triangular and
horseshoe shapes. According to some research this design is preferred by nurses
working with patients that required frequent observation and attention. Modified
radical design is known as horseshoe design. Horseshoe design is an incomplete circle

157
with other features of radical design to prevent wastage of space and to take benefits
of radical design.

Fig. 3.4: Radial ward design with one centralized nursing station

Early Indian rulers, considered the provision of institutional care to the sick as
their spiritual and temporal responsibility. The forerunners of the present hospitals can
be traced to the times of Buddha, followed by Ashoka. India could boast of a very
well organized hospital and medical care system even in the ancient times. In ancient
times, designs of wards in hospitals were not well defined, however, the basic
amenities were provided to patients including maintenance and sterilization of bed
linen with steam and fumigation and use of syringes and other medical appliances.
The most notable early hospitals were those build by king Ashoka (273-232
BC). These hospitals were built with the basic principle that patients must be kept in
comfortable environment and they have access of all basic amenities in suffering and
pain. However, designs of inpatient facilities were not specifically defined; several
patients were placed in rectangular rooms with availability of all basic amenities.
The modern system of medicine in India was introduced in the 17th century
with the arrival of European Christian missionary in South India. Thereafter, ward
designs were largely influenced by Florence Nightingale’s recommendations.29 In a
survey conducted by Triveni (2002)30 regarding existing ward design in public and
private hospitals, it was reported that 93.7 percent wards in public hospitals were of

158
corridor design, and rest of the wards were of modified corridor design (some changes
were made in basic corridor design). While in private hospitals 86.3 percent wards
were of corridor design and rest of the wards were of modified corridor design. It was
concluded that majority of the wards in public and private hospitals were of corridor
or modified corridor design.
Existing ward designs in selected hospitals and nurses’ perception about it
may be perused from Table 3.5.

Table 3.5: Existing ward designs and nurses’ perception about it in selected hospitals
Ward Positive comments Negative comments
Hospitals
design
- More number of patients - Less patient-nurse contact
managed with less nursing - Long walking distance for nurses
Double staff. - Poor visibility of patient beds from nursing
CMC
corridor - Cost effectiveness station
- Privacy for patients and - Nurses spend less time in direct patient care
nurses - Leads exhaustion among nurses
- Better visibility of patients - Lack of privacy at nursing station
Single - Less walking distance for - Nurses’ discussion at nursing station creates
DMC
corridor nurses noise disturbance for patients
- Good patient-nurse contact
- Better visibility of patients - Lack of privacy at nursing station
Single - less walking distance for - Nurses’ discussion at nursing station creates
ESI
corridor nurses noise disturbance for patients
- Good patient-nurse contact
- More number of patients - Less patient-nurse contact
Courtyard
managed with less nursing - Long walking distance for nurses
design
staff. - Poor visibility of patient beds from nursing
CIVIL (Modified
- Cost effectiveness station
Corridor
- Privacy for patients and - Nurses spend less time in direct patient care
design) nurses - Leads exhaustion among nurses
Computed from primary data

It was found that in CMC hospital, wards were built using double corridor
design. These double corridor design wards were large enough to accommodate 50-60
patients and patients were placed in four rows by leaving two corridors in between for
movements. Nursing station was placed at entrance of wards and other service
facilities were built on extreme ends of the wards. Single corridor design was used in

159
DMC and ESI hospital. These wards were having capacity to accommodate about 20-
40 patients and their beds were placed in two rows with one corridor in between.
Nursing station was placed in the center to have maximum visibility and thereby
decreasing the walking distance for nurses. In Civil hospital, wards were built using
courtyard ward design. This type of wards has capacity to accommodate 60-70
patients in single ward. In courtyard ward design, wards were further divided into
completely separated cubicles to accommodate 8-10 patients in each. Nursing station
was placed in middle of these completely separated cubicles. Other service areas were
built in side of the ward.
Nurses were asked about their perception for existing ward designs in their
respective hospitals.* In CMC and Civil hospital, nurses verbalized that double
corridor and courtyard design wards accommodate more number of patients and they
can be managed with fewer staff and facilities. Therefore, it proves to be more cost-
effective.
They further added that since nursing station is placed far from patients in
these designs; ensures less noise disturbance for patients and provides better privacy
for the patients and staff. However, nurses mentioned several negative aspects of
these designs such as less patient-nurse contact, long walking distance for nurses,
poor visibility of patients from nursing station. They further added that nurses spend
less time in direct patient care and waste their major time in walking between patients
and nursing station, which ultimately leads to exhaustion and decreased overall work
output of nurses.
During discussions, nurses in DMC and ESI hospital mentioned that small size
single corridor design wards accommodate small number of patients and provides
better visibility of patients from nursing station, less walking distance for nurses
between beds and nursing station and good level of patient-nurse contact. However,
they mentioned that such wards fail to provide privacy for patients and staff. They
further added that since nursing station was centrally located, it leads to noise
disturbance for the patients.

*
Please give your (nurses) comments with regard to the ward design(s) in your hospital?
a) Positive points…………………………………………………………………………………………
b) Negative points………………………………………………………………………………………..

160
 Fig. 3.5: Overview of wards in selected hospitals

Single corridor ward design at DMC hospital Courtyard ward design at Civil hospital

It may be inferred that none of the ward designs can be considered perfect or
without drawbacks. However, the overall aim of today’s ward design is to maximize
nursing efficiency, patient centered care and their satisfaction. In ward design, every
square meter of space must be efficiently used. An accepted compromise would
comprise a mix of three sub-components viz. patients’ privacy, high level of amenities
and ease of patients’ supervision by nursing staff . Another important factor was staff-
patient contact, which can be crudely measured by distance between the bed and
nursing station. To achieve these objectives, modified corridor designs can be
planned, which accommodate significant number of patients and have centralized as
well as mobile decentralized nursing stations.

c) Space requirements
Several national and international statuary bodies have provided
recommendations about space requirements in wards for different purposes. Syed
Amin Tabis (2003)31 in his text book ‘Hospital and Nursing Homes Planning,
Organization and Management’ mentioned about space requirements for different
purposes in a ward. It was mentioned that there should be seven feet distance between
bed center in non-teaching hospitals, eight feet distance between bed center in
teaching hospitals, one feet clearance between head end and wall, two feet clearance
between wall and side of bed and five feet space between two rows of beds. In
addition, it was mentioned that there must be minimum 70 to 90 sq. feet floor (about 7
sq. meters) area per bed in general wards.

161
 Ministry of Health and Family Welfare, Government of Kerala (2005)32 also
recommended that in planning a ward, the aim should be to minimize the work of the
nursing staff and to provide amenities to the patients within the Unit. The distances
between the bed areas to nursing station, treatment room or pantry etc. should be kept
to a minimum level.
The report also mentioned that the ward may be made of desired number of
beds and should be arranged with a minimum distance of 2.25 m between centre of
two beds and a clear 200 mm distance between the bed and the wall. In wards, the
width of doorways should not be less than 1.2 m. Isolation unit in the form of one
single bedded room per ward unit may be provided for certain specific cases requiring
isolation from other patients. An area of 14 meter square for such room to contain a
bed, locker, and easy chair for patient, a chair for the visitor and a built in cupboard
for storing clothes is recommended. Isolation unit should have separate toilet
facilities.
It was found that about 65-90 sq. feet floor space area per bed is recommended
by different organizations as discussed in this chapter. While, available per bed floor
space area in government and private hospitals, was as short as fifty percent (only 25 -
40 Sq. ft) in relation to the recommended space. Other available spaces, such as
distance between bed center, clearance of head end and wall, clearance between wall
and side, space between two rows of beds was also found to be as short as fifty
percent in relation to recommendations, which may be perused from Table 3.6. This
space shortage makes it difficult for nurses or doctors to work in congested wards. In
addition it increases the risk of hospital-acquired infections. Width of doorway was
recommended about 3 ft by Bombay Nursing Home Act (2006)33, while this space
was between 3-3.5 feet in private hospitals and in government hospitals it varied
between 3-4 feet, which was adequate as per the reported recommendations. Adequate
size of doorway facilitates, smooth movements of patients on wheel chairs and
stretchers as well material supplied to wards.

162
 Table 3.6: Space available for patient beds in wards of selected hospitals
MHFW PRIVATE GOVERNMENT
Recommended* HOSPITALS HOSPITALS
Variables
CMC DMC ESI CIVIL

Distance between bed center* in non-

7 NA NA 5-6 4-5
teaching hospitals (in feet)
Distance between bed center* in teaching 8 5-6 4-5 NA NA
hospitals (in feet)
Clearance between head end and wall (in
1 <½ <½ <¼ <¼
feet)
Clearance between wall and side of bed
2 <½ <½ <½ <½
(in feet)
Space between two rows of beds (in feet) 5 3-4 3-4 4-5 3-4
35 -
Space area per bed (in sq. feet) 70-90 30-35 35-40 23-35
40
Width of doors (ft) -- 3.5 3 4 3
Computed from primary data, *As mentioned in text book of Syed Amin Tabish (2003)

Table 3.7: NBHF recommendations for basic space requirements in wards

Description of area Minimum net area in m sq.
General ward facilities
Single room 14
Double room (not dividable) 21
Four person room 42
Sanitary unit (Wash basin, shower, toilets) 4
Sanitary facility with wheelchair accessible 5
Sluice in single room 2
Specific Units
ICUs: cubicle for one bed/ single room 18
Pediatrics: cubicle for incubator/ cot 9
Day care: cubicle for reclining chair, stretcher (in multiple
8
occupancy room)

Netherlands Board for Hospital Facilities (NBHF) also provided the building
guidelines for hospital nursing care. They were subsequently approved by their

*
Center of implies mid pint between two consecutive beds.

163
government in 17 December 2003. The guidelines of NBHF expressed no preference
for rooms for single or multiple occupancy (In children’ wards, however, a maximum
of 2 patients per room are permitted). The relevant recommendations of Netherlands
Board for Hospital Facilities (NBHF)34 for basic ward space requirements may be
perused from Table 3.7.
Bombay Nursing Home Act (2006)35 also provided recommendations about
space requirements in ward. This Act recommended that there must be minimum of
65 sq. feet floor area for each bed in wards. This Act also provided space requirement
recommendations for minimum distance between center of beds (6 ft), clearance
between bed and wall (60mm), width of doorways (3 ft), ward store (100 sq ft),
trolley bay (30 sq ft), nursing station (100 sq ft), resident doctor’s room (100 sq ft),
each toilet or bathroom (36 sq ft), pantry (80 sq ft) and day care space (100-120 sq ft).
Details are depicted in Table 3.8.

Table 3.8: Bombay Nursing Home Act, 2006 recommendations for space requirements
Description of area Minimum space requirements
Floor space per bed in ward accommodating not less than 4 65 sq. ft
patients
Distance between centers of two beds 6 ft
Clearance between bed and wall 60 mm
Width of doors in the wall 3 ft
Nursing station 100 sq. ft (with toilet)
Resident Medical Officer s room 100 sq. ft (with toilet)
Ward store 100 sq. ft
Trolley bay 30 sq. ft
Bath & toilet 36 sq. ft
Day care area 100-120 sq feet respectively
Pantry (NH more than 20 beds) 80 sq. ft

Majority of nurses (77.5 percent)* expressed inadequacy of space provided for

each patient in wards of selected hospitals. However, problem of inadequacy of space
was acute in DMC hospital (85.0 percent), followed by Civil hospital (80.0 percent),
CMC hospital (75.0 percent), while the problem was on lower side in ESI hospital
(70.0 percent) as depicted in Table 3.9.

*
There is adequate space available for each patient in the form of bed and its surrounding area in your (nurses)
ward. a) Yes b) No

164
 Table 3.9: Nurses’ opinion about adequacy of space available for each patient in ward
Hospitals Total
Space available for Private Government
each bed is adequate N=80
CMC DMC ESI CIVIL
n=20 n=20 n=20 n=20
f (%)
f (%) f (%) f (%) f (%)

Yes 05 (25.0) 03 (15.0) 06 (30.0) 04 (20.0) 18 (22.5)

No 15 (75.0) 17 (85.0) 14 (70.0) 16 (80.0) 62 (77.5)

Computed from primary data

During informal discussions with nurses, it was mentioned by one of the

nurses in Civil hospital that because of lack of adequate space and presence of more
number of patient’s relatives with each patient, it becomes difficult to work smoothly
in wards. Hence, it is suggested that placement of beds in wards should be such that
each bed should have adequate space to achieve patient’s privacy, comfort, and hassle
free working space for healthcare workers. In addition, adequate space per bed also
helps in prevention of cross infection among patients, which minimize the length of
patient’s hospital stay and ultimately, the cost of care.

3.6 Supportive Service Areas

Supportive area consists of ward pantry, store room, clean utility, treatment
room, dirty utility and sanitary facilities.

a) Ward pantry
Ward pantry is a specially designated area in ward, which is used for
temporary storage, distribution of meals and the preparation of beverages for patients.
The existence of ward pantry in different hospitals may be perused from Table 3.10.

Table 3.10: Ward pantry in wards of selected hospitals

PRIVATE HOSPITALS GOVERNMENT HOSPITALS
Variables
CMC DMC ESI CIVIL
Ward pantry Not available Not available Not available Not available
Heating Hot plate at Hot plate at Electric heater at Electric heater at
devices nursing station nursing station nursing station nursing station

Refrigerator One One One Not available

Computed from primary data

165
 It was observed that ward pantry was not present in any of the selected
hospitals. However, a hotplate or electric heater was lying near the nursing station in
the wards of selected hospitals. During discussions it was found that these heating
devices were mostly being used for preparing hot beverages (tea/ coffee) for the ward
staff. Patients or their attendants were not being given access to hot plates/ electric
heaters. Therefore, they were supposed to visit the market outside the hospital for
getting tea, hot water etc. for the patients. They further opined that this causes lots of
inconvenience especially to those patients who do not have attendants or the attendant
is a child, lady or an old person.
Refrigerator was available in few wards of selected private hospitals and ESI
hospital. While, this facility was not available in the wards of Civil hospital.
Refrigerators available in wards of selected private hospitals and ESI hospital were
used to store medicines, water for ward staff. This too was not accessible to the
patients. Bennett (2007)36 mentioned that ward pantry should be equipped with
refrigerator, hot case, water boiler and facilities for storing crockery and cutleries and
should have a large sink for washing various articles.
In majority of Indian hospitals diet is directly supplied by dietary department
to the patients. Wards were not having facility to prepare, store or deliver the food for
patients. Majority of the patients (90.2 percent)* overwhelmingly desired to have
pantry facility in the wards, so as to meet some of their basic necessities, instead of
rushing to the market for the same. The nurses however did not support this view
point. As many as 52.5 percent** respondents (nurses) were against it, which may be
perused from Table 3.11. They were of the view that this facility would not only
hamper their work but would create chaos in the ward.
Table 3.11: Nurses’ opinion about need of pantry in ward
Pantry is needed Hospitals Total
in ward Private Government
CMC DMC ESI CIVIL N=80
n=20 n=20 n=20 n=20
f (%) f (%) f (%) f (%) f (%)
Yes 11 (55.0) 08 (40.0) 07 (35.0) 12 (60.0) 38 (47.5)
No 09 (45.0) 12 (60.0) 13 (65.0) 08 (40.0) 42 (52.5)
Computed from primary data

*
Do you (patients) feel the need of pantry in your ward? a) Yes b) No
**
Do you (nurses) feel the need of pantry in your ward? a) Yes b) No

166
 Thus there are two extreme opinions, if pantry facility is provided it can cause
not only chaos in the ward but there is a probability of bringing more infection inside
the ward. Without panty the patients would be forced to visit market that would be
difficult and time consuming. It is especially difficult for certain set of attendants. It is
therefore, suggested that every ward may have one small area earmarked for pantry
facility, which can meet certain basic needs of the patients like provision of hot water,
facility to prepare hot beverages, provision of a refrigerator to store patient’s diets etc.
Some one from the staff can officially regulate the use of this facility, so as to avoid
chaos in the ward.

b) Ward store room

Ward store is a small area in the ward which is used to keep linen and bulk
supply of cleaning material, ward stationary etc. The ward store is also used to store
old patient’s records until they are sent to medical record section. Beside all these,
condemned old linen, equipments and other material is also kept in ward store room
until these are sent back to main store of hospital.
It was found that the store room facility did not exist in all the wards but it was
present in few wards (33.3 present) of the selected hospitals. It was further observed
that 4 out of 10 wards in CMC hospital, 6 out of 15 wards in DMC hospital and 4 out
of 11 wards in ESI hospital and only 1 out of 6 wards in Civil hospital had store room
facility as may be seen from Table 3.12.

Table 3.12: Ward store room facility in wards of selected hospitals

Hospitals
Variables Private Government Average

CMC DMC ESI CIVIL

12/36
Ward store 1/4 (40.0%) 6/15 (40.0%) 4/11 (36.4%) 1/6 (16.7%)
(33.3%)

Average size 30-40 sq. ft 35-50 sq ft 50-60 sq. ft 45-60 sq. ft. 40-53 sq. ft.

Upkeep Fair Fair Poor Very poor ------

Lockers for
Not available Not available Not available Not available ------
patients
Computed from primary data

167
 Thus, existence of store rooms in wards of government hospitals as compared
to private hospitals was very poor viz. only 26.6 percent. The size of the store rooms
was very small in wards of selected hospitals, on an average their size was 30-60 sq.
ft. However, ideal suggested size for this facility was 80-130 sq. ft area.37
Further, upkeep of store rooms was very poor. The store rooms in wards of
government hospitals were full of condemned material. Their condition in the private
hospitals was not much different; they were found to be overfilled with ward supply
and inventory. During informal discussions, the nursing staff mentioned that store
rooms were too small to accommodate ward supply, causing wastage of time in
searching or rearranging the needed material. An overwhelming number of nurses
(73.0)* were dissatisfied with existing storerooms in wards as depicted in Table 3.13.
However, the size of the store rooms in private hospitals was more organized as
compared to government hospitals. As such their storage capacity was also more.

Table 3.13: Nurses’ satisfaction with storeroom in ward

Hospitals Total
Satisfied with Private Government
storeroom N=37*
CMC DMC ESI CIVIL
n=08 n=16 N=09 n=04
f (%) f (%) f (%) f (%)
f (%)

Yes 02 (25.0) 05 (31.3) 02 (22.3) 01 (25.0) 10 (27..0)

No 06 (75.0) 11 (68.7) 06 (66.7) 03 (75.0) 27 (73.0)

Computed from primary data, * Some of nurses did not had storeroom facility in their wards

As a matter of fact, lockers for patients were not provided in the wards of the
selected hospitals; therefore, patients were forced to dump their personal belongings
on the bed or inside the bedside medicine locker, which gave unhygienic look to the
ward and served as a potential source of infection. It was found that majority of
patients (84.7 percent)* favour lockers in the store room. They were finding it more
convenient when their belongings were kept in the lockers. Majority of the nurses
(68.8 percent),** also suggested the need for lockers in the store room as this will help
to keep bedside lockers only for medicine purposes. Sakharkar (1998)38 too
*
Do you (nurses) have store room in your ward? a) Yes b) No,
If yes are you satisfied with existing facility? a) Yes b) No
*
Do you (patients) feel the need to have lockers in store room to keep your belongings? a) Yes b) No
**
Do you (nurses) feel the need to have lockers in store room to keep patient’s belongings? a) Yes b) No

168
mentioned that near the storage area, lockers can be provided to patients for storage of
their extra belongings, which were not needed in the daytime like bedding etc. This
facility can be easily provided in the store room.

c) Clean utility
Other than ward store room, a clean utility facility is also required in each
ward, which is used to store clean and sterile consumable items like intravenous sets
and solutions, sterile packs, syringes, needles, bandages, external lotions and
disinfectants, Central Sterile Supply Department (CSSD) articles, dressings, drugs and
to do clean work like setting up a trolley or treatment tray for minor procedures and so
on for the patients. At times this room is also used as a treatment room. Kelin Burton
et al (1989)39 suggested that clean utility must be at least 100-120 sq feet to cater the
basic needs of the ward effectively. The clean utility did not exist in the wards of
selected hospitals. However, clean storage was done in cupboards available at nursing
station.
Furthermore, nurses were asked about clean utility supply in wards of selected
hospitals and results are depicted in Table 3.14.

Table 3.14: Nurses' response about clean utility supply in wards

PRIVATE HOSPITALS GOVERNMENT HOSPITALS
Variables
CMC DMC ESI CIVIL
Purchased by patient Purchased by patient Supplied by hospital Supplied by hospital as
Drugs and fluid
from hospital from hospital free of cost well purchased by
supply pharmacy pharmacy patients from market
Purchased by patient Purchased by patient Supplied by hospital Supplied by hospital as
Disposable supply from hospital from hospital free of cost well purchased by
pharmacy pharmacy patients from market
Nursing care Few nursing care Few nursing care Only B.P monitoring Only thermometer &
articles available articles articles device B.P monitoring device

Source of sterile
CSSD CSSD Main OT Main OT
supply
% of nurses found
sterile supply 18 (90.0) 17 (85.0) 06 (30.0) 02 (10.0)
adequate*
Frequency of linen
Daily or as per need Daily or as per need Alternate day or if Once or twice in a week
change urgently required
% of nurses found
linen supply 14 (70.0) 15 (75.0) 05 (25.0) 01 (05.0)
adequate*
Computed from primary data, *N=20

169
 It was mentioned by nurses that drugs, intravenous fluids and disposable items
were purchased by the patients from hospital pharmacy in selected private hospitals.
In ESI hospital, this supply was provided totally free of cost by hospital. However, in
Civil hospital, this supply was taken care of by the hospital but was also purchased by
patients from market when it was not available from the hospital*.
The sterile supply in private hospitals was managed by Central Sterile Supply
Department (CSSD), while in government hospitals it was supplied by the main
Operation Theater. Majority of the nurses (87.5 percent)* in private hospitals were
satisfied with the adequacy of sterile supply to the wards. Contrary to it 80 percent
nurses from government hospitals highlighted the inadequacy of sterile supply to the
wards.
A good quantity of nursing care articles were available like articles for vital
signs monitoring, bed-bath, back-care, hair-care, nasogastric tube feeding, catheter
care etc. in the wards of selected private hospitals, while in government hospitals only
vital signs monitoring devices (thermometers, blood pressure monitoring equipment)
were available.**

Fig. 3.6: Pictures depicting state of linen supply in wards of selected hospitals

View of a private hospital View of a government hospital

*
The drugs, fluids and disposable items are provided by the hospital. a) Yes b) No
If no, from where do you procure these items?
a) Provided by charitable trusts b) Purchased from market c) Any other source, please specify:…………
*
Source of sterile supply in your ward. a) CSSD b) Main OT c) If any other source, please specify:, ……………………..
There is adequate supply of sterile items in your ward. a) Yes b) No
**
Please tick the articles available in your ward for providing nursing care (original questionnaire contains an exhaustive list of
articles). Please see annexure-IV)

170
 Regarding frequency of linen change in wards, it was found that linen were
changed everyday*** or when required in private hospitals. However, linen were
changed on alternate days in ESI hospital and once in a week in Civil hospital.
Majority of nurses (72.5 percent) were satisfied with the adequacy of linen supply to
the wards of private hospitals. However, in government hospitals majority of nurses
(85.0 percent) were dissatisfied with availability of linen in wards. Inadequacy of bed
linen is a common feature in Indian hospitals including PGIMER, Chandigarh. Kulvir
Kaur (2005)40 found that demand and supply of bed linen for admitted patients in
general wards was not satisfactory. It was found that supply of bed linen was as short
as fifty percent in most of the wards. The patients also expressed dissatisfaction* due
to not changing the bed sheet at a stretch for several days. It was an unusual practice
both for the ward and patients as is apparently clear from the Figure 3.6, wherein, it is
clearly visible that the patient in government hospital is sleeping without bed-sheet.
Whereas, 24 hours adequate supply of patient’s consumable items, linen and drugs
were essential as per Huston (2003)41 for providing effective nursing care.

d) Treatment room
Treatment or procedure room is used for carrying out various medical, surgical
or nursing procedures for patients. This place is basically used for special
examinations, minor dressings, lumbar puncture, intravenous injections etc. This
reduces the risk of cross infection. The patient and the care providing team receive
better facilities and privacy and other patients are not disturbed. The provision of a
treatment room depends upon the type of treatment and hospital policy. Usually there
is provision of emergency trolley with adequate equipments and drugs, dressing or
medicine trolley, suction facilities and oxygen supply system in the treatment room.
None of the wards of the selected government and private hospitals had
separate procedure/ treatment room; procedures were preformed at the bedside only.
Rawlison (1989)42 suggested that the treatment room should be arranged in such a
way so that it can be converted to another function if no longer required and it should
be located preferably near the nursing station and connected by means of a hatch to

***
How frequently linen is changed in your ward. Daily/ Alternate day / twice in a weekly/ once in week/ Any other,
specify:……..

There is adequate supply of linen in your (nurses) ward. a) Yes b) No
*
There is adequate linen supply in your (patients) ward a) Yes b) No

171
clean utility and disposal areas. The minimum space area suggested for this room was
150-170 sq feet.
Though the treatment room did not exist in these hospitals yet some of the
requisite facilities were available in the selected hospitals, as may be perused from
Table 3.15.

Table 3.15: Treatment room related facilities in wards of selected hospitals

PRIVATE HOSPITALS GOVERNMENT HOSPITALS
Variables
CMC DMC ESI CIVIL
Separate treatment Not available Not available Not available Not available

room
Available with Available with Emergency drugs Few emergency
most of the most of the were available, drugs were available,
Emergency trolley emergency emergency however however equipments
equipments & equipments & equipments were were not available
drugs drugs not available
Dressing/medication Two separate Two separate Single trolley Single trolley

trolley trolleys trolleys

- Wall mounted -Wall mounted - Only one - Only one portable

suction system suction system portable machine machine but non-
Suction facilities
- Portable suction - Portable functional
machine suction machine
- Central supply - Central supply - Only oxygen - Only oxygen
for every bed for every bed cylinders cylinders
Oxygen supply
- Oxygen - Oxygen
cylinders cylinders
Computed from primary data

For example, emergency trolley with adequate emergency equipments and

drugs were available in selected wards of private hospitals, whereas in government
hospitals, emergency trolley was not available, only few emergency drugs were
available in nursing sister’s possession.
Pratt et al (2005)43 mentioned that every ward or hospital unit must have a
well equipped emergency trolley with essential emergency drugs and instruments.
They stressed that emergency trolley was one of the most essential tools, since a
hospitalized patient may require an emergency life saving intervention at any time and
availability of well equipped emergency trolley may help in saving such victims. Life

172
threatening conditions give very minimal time to act and in absence of well equipped
emergency trolley one may fail to survive such emergency victims because
arrangement of emergency drugs and equipments may take longer time.
Administration of drugs and providing surgical dressings are the sterile
procedures and may be performed under sterile conditions with separate cleanable
trolleys or trays to prevent hospital acquired infections.44 Separate stainless steel
trolleys were present for medication and surgical dressings in wards of selected
private hospitals, whereas, in government hospitals, a single trolley was being used
for medication as well as surgical dressings. Steel trolleys can be cleaned and
disinfected very easily, therefore minimizing the chances of transmitting infections
from one patient to another. Similarly, separate trolley for surgical dressing and
medication prevents delay in procedures as well as reduces the chances of hospital
acquired infections.
Suctioning facilities are required for patients to provide artificial removal of
body secretions by applying a negative pressure through a wall mounted suction
apparatus or a portable suction system. It is routinely used to remove oral or
respiratory secretions in unconscious or postoperative patients. There may be one wall
mounted suction system for every patient and additional one portable suction machine
for every five patients in general wards.45 It was observed that in private hospitals,
there was only one wall mounted suction port for each patient and one portable
suction machine for each ward. Whereas in government hospitals, wall mounted
suction system was not available, there was only single portable suction machine
shared by several wards. During discussions it was found that in Civil hospital
portable suction machine was lying out of order since November 2007. Molly
(2007)46 suggested that wall mounted suction system must be preferred over portable
suction machine to prevent cross infection, since wall mounted suction system is used
for single patient and portable suction machine is used for several patients, therefore,
it should be used only in case of emergency with no alternative.
Oxygen is one of the most essential life saving drug, must be easily accessible
for patient in need. Oxygen can be supplied through either central wall supply or
through traditional methods by bedside oxygen cylinders. Irrespective of supply
system, adequate amount of oxygen must be supplied to inpatient care facilities to
meet the needs of patients.47 In private hospitals, central oxygen supply as well as
bedside oxygen cylinders were available. However, in government hospitals, only

173
bedside oxygen cylinders were available. In ESI hospital, oxygen cylinders were
available in most of the wards, while in Civil hospital at the time of observation spare
oxygen cylinders were not available in wards for emergency use. Nurses in the Civil
hospital mentioned that during emergency they get oxygen cylinders from the
emergency department.
It was found that in selected private hospitals more than half of the nurses
(67.5 percent)* were satisfied with existing treatment room related facilities as
illustrated in Table 3.16.

Table 3.16: Nurses’ satisfaction with treatment room related facilities in ward
Hospitals Total
Satisfied with Private Government
treatment room N=80
related facilities CMC DMC ESI CIVIL
n=20 n=20 n=20 n=20
f (%)
f (%) f (%) f (%) f (%)

Yes 14 (70.0) 13 (65.0) 05 (25.0) 01 (05.0) 33 (41.3)

No 06 (30.0) 07 (35.0) 15 (75.0) 19 (95.0) 47 (58.7)

Computed from primary data

During informal discussions it was learnt that the nurses were not satisfied
because of non-availability of adequate number of instruments/ equipments in
working condition like laryngoscope, ophthalmoscope, knee hammer and organization
of emergency trolley in private hospitals. While, in government hospitals majority of
nurses (average 85.0 percent) were dissatisfied with existing treatment room related
facilities in wards.
It was therefore inferred that none of the selected hospitals had separate
treatment room in wards. However, wards of selected private hospitals were better
equipped with treatment room related facilities like emergency trolley, dressing/
medication trolley, suction facilities, oxygen supply as compared to government
hospitals. It is suggested that wards must be equipped with emergency drugs,
emergency equipments/ instruments in proper working order.
Mechanical suctioning system and oxygen supply are life saving facilities;
they must be in optimum supply. Wall mounted suctioning system and oxygen supply

*
Are you (nurses) satisfied with treatment room related facilities in your ward? a) Yes b) No

174
must be preferred over portable system to prevent chances of cross infection and
accidental hazards. In addition, adequate number of separate medication and dressing
trolleys must be available in wards to avoid delay in work and prevent chances of
hospital acquired infections.

e) Dirty utility
Dirty utility is a small room (about 150-170 sq ft.) existing in various wards,
which is used for cleaning trays and trolleys used in treatment, storing dirty linens,
mobile linen stands, bins containing hospital waste, returning containers for Central
Sterile Supply Department, disposing liquids, washing and storing bedpans and
sputum mugs, storing and processing stool and urine samples.48 Dirty utility facility
did not exist in present either of the selected hospitals. A small room labeled as dirty
room existed in the Civil hospital but was used only for storing dirty linen till they
were sent for laundry.
Pattison and Robertson (1996)49 mentioned that adjoining to dirty utility, a
small room (40-60 sq feet) known as janitor’s closet room need to be provided for
washing articles used in nursing care like buckets, mugs etc., it also can be used to
keep bedpan washer. This facility was not present in wards of selected hospitals.
Waste bins are supposed to be kept in dirty utility. In the absence of dirty
utility waste segregation bins were kept in the open space. This was true for other
hospitals as research study conducted by Devinder Kaur (2003).50 The author was of
the view that storage of waste segregation bins in open ward in absence of dirty utility
may have serious hospital acquired infection implications.
Majority of nurses in government (77.5 percent)* and private hospitals (87.5
percent) expressed the need of dirty utility facility in wards as depicted in Table 3.17.
During discussions it was mentioned by nurses that in the absence of such a
facility in wards; dirty utility related material was stored in ward toilets, bathrooms or
in corners of wards, which might have a serious risk of hospital acquired infections
for the indoor patients. Some of the nurses in private hospitals, during discussions
mentioned that they did not find any space where they can clean and store nursing
care articles.

*
Do you (nurses) feel the need of dirty utility in your ward? a) Yes b) No.

175
 Table 3.17: Nurses’ opinion about need of dirty utility in ward

Need of dirty utility Hospitals Total

in ward Private Government
N=80
CMC DMC ESI CIVIL
n=20 n=20 n=20 n=20
f (%)
f (%) f (%) f (%) f (%)

Yes 18 (90.0) 17 (85.0) 16 (80.0) 15 9 (75.0) 66 (82.5)

No 02 (10.0) 03 (15.0) 04 (20.0) 05 (25.0) 14 (17.5)

Computed from primary data

It is suggested that each ward may have a dirty utility facility, so that dirty
utility related functions can be accomplished there itself. This will not only keep the
ward and its surrounding clean but will also reduce the risk of hospital acquired
infections among patients.

f) Sanitary facilities
Sanitary facilities include toilets, bathrooms and washing facilities for
patients. The exact number of toilets, bathrooms has to be determined in relation to
the nature of patients treated in the ward or other requirements of the ward; for
example, for infectious indoor patients, more such facilities are likely to be needed.
Special type of bathrooms form an essential part of treatment for certain specific
patients.
According to the instructions issued by the Ministry of Health and Family
welfare, Government of India:51
 One toilet should be provided for six patients, apart from one for each patient
in single room.
 One wash-basin should be provided for six patients,
 One bathroom should be provided for ten patients.

In this regard Bombay Nursing Home Act, (June 2006)52 has also given
certain recommendations, which may be perused from Table 3.18.

176
 Table 3.18: Sanitary facility recommendations by Bombay Nursing Home Act
(June 2006)
Sanitary facility Minimum recommended number
Bathrooms One per 8 beds
Toilets One per 8 beds
Washbasins One per 10 beds
Urinals One per 16 beds

i) Bathrooms
Bathroom is a room that may have different functions depending on the
cultural context. In the most literal sense, the word bathroom implies "a room for
bath". Because the traditional bathtubs have partly made way for modern showers,
including steam showers, the more general definition is "a room where one takes
bath". There can be just a shower, just a bathtub and often both plumbing fixtures are
combined in the bathtub.
Bathing is an important activity of daily living. Majority of the Indians are in
the habit of taking bath in the morning before the routine activities start. Helping a
patient to maintain personal hygiene is a fundamental aspect of nursing care but
bathing of disabled and elderly people can be difficult and time consuming.
Inadequate aids, equipments and facilities further compound the difficulty and the
process can become arduous for busy ward staff. Adequate and suitable washing and
bathing facilities can help to ensure that patients get bath in private and with dignity.53
In selected private hospitals, the number of bathrooms were as short as fifty
percent as per recommendations of apex healthcare regulatory organizations.
However, in government hospitals one bathroom was available for about 12-15
patients, which was quite close to recommendations of Government of India, which
provided at least one bathroom for each 10 beds.
Bathrooms in the government hospitals were approximately 20-25 sq. feet in
size with doorway width of 60 cm. While in private hospitals bathrooms were about
35-45 sq. ft in size with 60 cm doorway width. This small doorway did not allow the
entry of a wheelchair. As such the bathrooms in selected hospitals were of small size;
no extra space was provided for special patients needing assisted bath. Shendell-Falik
et al (2007)54 suggested at least 75 sq. ft space area for bathroom used for ambulant
patients and about 110-130 sq. ft floor space area for bathrooms used for assisted

177
bath. In addition, the width of the bathroom doorways may be at least 80 cm to allow
access for a wheelchair. Bathrooms of government hospitals were too narrow that
there was no space for attendant to help the patients, while in private hospitals
situation was relatively better in this regard as can be seen from Figure 3.7.

Fig. 3.7: Bathrooms in the wards of selected hospitals

View of bathroom in private hospital View of bathroom in government hospital

It was also found that there was no alarm call system in bathrooms and there
was no sign on the bathroom door indicating its use. In government hospitals, latches
to close the door of bathroom were missing. Water heating facility was present in
bathrooms of private hospitals; while, this facility was not available in the
government hospitals. Bathrooms in the wards were found unclean on subjective
inspection. However, in private hospitals they were relatively clean but wet, while in
government hospitals, they were very unclean, that a normal human being cannot
stand there for even a few seconds. Moreover, the bathrooms were stinking with urine
odor. In private hospitals, the standard practice was that a domestic staff cleaned the
bathroom once in every shift, while in government hospitals; some times it was not
even done once in a day as per the information provided by a ward nurse.
Majority of the patients (81.2 percent)* in government hospitals were not
happy with existing bathroom facility in their wards specifically they were critical
about cleanliness of these facilities. However, in private hospitals situation was
slightly better, where 46.5 percent patients were satisfied with these facilities. Health
Advisory Service survey55 of eight English hospitals in UK found that no patient was

*
Are you (patients) satisfied with bathrooms facilities available in your ward? a) Yes b) No

178
happy with the number of bathrooms or washbasins and most of them were critical of
standards of cleanliness. It was inferred that number of bathrooms were not adequate
in selected hospitals as well as size was too small to accommodate wheelchair users.
In addition, upkeep was not good to satisfy its users.

ii) Toilets
Toilet is a plumbing fixture and disposal system primarily intended for the
disposal of the bodily wastes: urine and fecal matter. Additionally, vomit and
menstrual waste is sometimes disposed off in toilets especially in western societies.
The word "toilet" can be used to refer to the fixture itself or to the room containing the
fixture, especially in British English. In Canadian English, the latter is
euphemistically called a washroom, and in American English, a restroom.56
It was found that in private hospitals one toilet was available for about 15-20
patients, while in government hospitals one toilet was provided to about 10-15
patients admitted in wards. The sign boards placed outside the toilets were missing
both in government and private hospitals. In addition, there was no alarm call system
installed in toilets for use during emergency. In government hospitals, door closers in
some of the bathroom’s door were missing. Toilets in wards of government hospitals
were as small as 10-20 sq ft. with doorway width of 60 cm. In private hospitals size of
toilets was 20-40 sq ft with doorway width of 60 cm. The toilets were too small in
size to accommodate a patient on wheelchair and doorway was so small that it was
not possible to take patient in the toilet on wheelchair.
Shendell-Falik and Feinson (2007)57 mentioned that toilet floors are
especially liable to contamination, so that patients should not place their belongings
on floor. Therefore, a hook and/or a shelf should be fitted to accommodate handbags;
walking sticks etc. But nothing of this kind was present in toilets of wards in
government and private hospitals. Ideally toilet doors must open outward and it
should be possible to release the latches from outside if necessary, while this kind of
design was not used in toilets of selected wards as it is evident from Figure 3.8.
However, in government hospitals walls of the toilets were not built till ceiling to
fulfill this objective.

179
 Fig. 3.8: Toilets in wards of selected hospitals

Toilet at private hospital Toilet at government hospital

Toilets should be able to flush efficiently and quietly. This is especially

important if they are near to the ward because the patients are likely to be disturbed by
noise, especially during night.58 However, flush in toilets were noisy in selected
hospitals, in addition, flush system of toilets in some wards of government hospitals
were even non-functional as can be seen in Figure 3.8. Toilets in wards of selected
hospitals were found very unhygienic and unclean. Toilets in government hospitals
were having very bad stinking smell. Exhaust fans can be used to throw bad smell out
of the toilets but toilets of selected hospitals were without any exhaust fan.
Majority of the patients were also not happy with toilet facility in government
(81.5 percent)* as well as private hospitals (53.5 percent). Specifically they were
critical about cleanliness of these facilities. Similar, findings were reported by Pratima
Rao (1991),59 Mahapatra P (2001),60 Bhattacharya A et al (2003)61 where they
reported patients’ strong dissatisfaction with maintenance and cleanliness of toilets.
Adequate number and size of clean toilets are necessary for the indoor
patients. These facilities may be located in close proximity to patient area, but poor

*
Are you (patients) satisfied with toilet facilities available in your ward? a) Yes b) No

180
cleanliness may cause problem of bad odor in the ward, which can be managed
through frequent cleaning of these facilities. It was suggested that toilets may be of
minimum 50-75 sq ft area with a doorway to accommodate patient on wheelchair.
Toilets may be cleaned at least 5- 6 times in a day to maintain optimum cleanliness.

iii) Washbasin
Wash basin or a sink is a bowl-shaped fixture that is used for washing hands
or small objects such as fruits, food dishes etc. In American plumbing parlance, a
bathroom sink is known as a lavatory. Basins or sinks generally have taps that supply
hot and cold water and may include a spray feature to be used for faster rinsing. They
also include a drain to remove used water; this drain may itself include a strainer
and/or shut-off device and an overflow-prevention device. Wash basin or sinks may
also have an integrated soap dispenser.62
Sufficient number of washbasins are required for efficient control of cross
infection in hospital wards. Bombay Nursing Home Act, June 2006 also
recommended at least one washbasin for ten patients in general hospital wards. In
CMC and DMC hospital, there was about one washbasin for 20-30 beds, In ESI
hospital, one washbasin was available for 30-40 patients. Furthermore, in civil
hospital there was only one washbasin for 50-60 patients. There was thus acute
shortage of washbasins in the selected hospitals. In addition, washbasins were too
small in government and private hospitals as to prevent splashes on floor. Splashes on
floor made the floor slippery thus causing threat to the patients to fall thereby leading
to other difficulties. Inadequate number of hand washing facilities for patients may
hamper the hand washing practices and increases the risk of infection.
Washbasins must have paper towel, so that chances of cross infection can be
minimized. Wet hand or drying the hands with cloth towel may increases the risk of
cross infection.63 In private hospitals, there were cloth towels and in government
hospitals even cloth towels were not available near wash basins. Wash basins must
have elbow operated taps, so that hands will not contaminate the tap. But washbasin
taps in government and private hospitals were hand operated only, which may be
perused from Table 3.9.

181
 Fig. 3.9: Hand washing facilities for patients in wards of selected hospitals

Washbasin at private hospital Washbasin at government hospital

Hospital sanitary facilities are used by multiple people and posses high risk of
infection, if cleanliness is ignored. Therefore, cleanliness is most significant issue of
each hospital, in-fact this is the first dimension of hygienic environment. Syed Amin
Tabis (2003)64 suggested cleaning of sanitary facilities regularly at least two to three
times in each shift with different chemical products as per hospital policy. He
suggested that aldehyde, per-oxygen and phenolic compounds can be used for
cleaning the sanitary facilities. In case of phenol, which is most commonly used; one
must use one per cent concentrated phenol solution (100 ml solution in 10 liters of
water) for cleaning toilets, bathrooms and washbasins. It was added, that if sanitary
facility is used by a patient with infectious diseases (like HIV/AIDS, Hepatitis-C,
Hepatitis-B etc), it must be cleaned with two percent hypochlorite solution. However,
it is evident from Figure 3.7 and 3.8 that sanitary facilities in government hospitals
were in a very bad shape as per cleanliness is concerned, which may have a serious
health risk for the patients as well visitors.
Similar view was expressed by patients, where overwhelming majority of
them (89.7 percent)* were critical about cleanliness of sanitary facilities in wards of
government hospitals. However, in private hospitals about 56.9 percent patients were
not satisfied with cleanliness of sanitary facilities.
It was inferred that number of sanitary facilities were not adequate in selected
hospitals. In addition, cleanliness was very poor in government hospitals. There

*
Are you (patients) satisfied with overall cleanliness of sanitary facilities in your ward? a) Yes b) No

182
should be at least one bathroom, toilet and washbasin for 8-10 patients and these
facilities may be cleaned 5-6 times to ensure optimum cleanliness to improve overall
patients’ satisfaction towards healthcare system.

3.7 Ward Environment

Creating a conducive ward environment is one of the essential inputs of ward
management to provide quality care to indoor patients. It mainly includes adequate
ventilation, temperature control, lighting, noise control, infection control and waste
segregation in ward.

a) Ventilation
Ventilation is the intentional movement of air from outside to the inside of a
building. Ventilation of building can be natural ventilation or mechanical forced
ventilation. Natural ventilation occurs when the air in a closed area is changed with
outdoor air without the use of mechanical systems, such as a fan. Most often natural
ventilation is assured through operable windows but it can also be achieved through
temperature and pressure differences between inside and outside area. Open windows
or vents are not a good choice for ventilating a basement or other below ground
structure. Allowing outside air into a cooler below ground space will cause problems
with humidity and condensation. Mechanical forced ventilation is an act of direct
pulling and pushing the air inside and outside a closed area by a mechanical device
like exhaust fan etc. Effectiveness of mechanical ventilation solely depends on
working condition of the machines used for ventilation.65
The government hospital wards were adequately ventilated through large
windows. Whereas, private hospitals wards were ventilated both through windows as
well as mechanical ventilation through exhaust fans. In private hospitals, wards were
relatively less naturally ventilated because of their location. Therefore, to ensure
adequacy of ventilation; natural ventilation was supplemented with mechanical
ventilation (exhaust fans). All type of respondents,*$ as may be perused from Table
3.19, expressed satisfaction with respect to adequacy of ventilation in their respective
wards.

*
There is adequate ventilation of air in your (nurses) ward. a) Yes b) No
$
There is adequate ventilation of air in your (patients) ward. a) Yes b) No

183
 Table 3.19: Ventilation and its perception among patients and nurses in wards
Private hospitals Government hospitals
Variables
CMC DMC ESI CIVIL
Natural (windows) Natural (windows)
Modes of Natural only Natural only
and mechanical and mechanical
ventilation (windows) (windows)
(exhaust fans) (exhaust fans)
% of Patients
found adequate 241 (80.3) 227 (75.7) 275 (91.6) 272 (90.7)
ventilation*
% of nurses
found adequate 15 (75.0) 14 (70.0) 17 (85.0) 16 (80.0)
#
ventilation
Computed from primary data, *N=20, #N=1200

A. Roderick Escombe et al (2007)66 in their study found that natural

ventilation provided 28 air changes per hour compared to 12 in negative pressure
rooms. The high ceilings and large windows of old buildings allowed 40 air changes
per hour. Rooms with open windows showed 6-fold greater absolute ventilation than
that calculated for mechanically ventilated rooms. In fact, poor maintenance of
ventilation machines meant that only half of the recommended air changes were
delivered. The model of infection risk suggested a 39 percent infection rate in 24
hours of exposure to open tuberculosis in negative pressure rooms and 97 percent in
closed unventilated rooms (13 infectious quanta per hour). In contrast, the rate with
natural ventilation was 33 percent in newer buildings and 11 percent in older
buildings.
The study concluded that artificial ventilation (ceiling, exhaust fans and air
circulators etc.) was noisy and air conditioning was very costly. If the hospital is
located away from dusty and noisy surrounding, natural ventilation is the most
desired.
McDonald et al (1998)67 mentioned that proper use of ventilation system, air
filters and adequate cleaning and maintenance can control the air borne infection
significantly. Based on study findings and literature discussions, it is suggested that
natural ventilation may be preferred as compared to mechanical ventilation.
Mechanical ventilation is costly and did not prove to be more effective than natural
ventilation. However, hospital built in cities with small space have less provision of

184
natural ventilation, therefore while planning hospital buildings, all possible attempts
should be made to keep the wards naturally ventilated.

b) Temperature control
The ward needs to be maintained at an even temperature, which provides
comfort to the patients and staff. A temperature of 650 F (about 170 C) is usually
considered suitable. Some form of central heating or cooling is required to maintain a
uniform temperature throughout the ward. A centralized positive pressure air
conditioning of hospital inpatient area helps to maintain the even temperature during
summers which increases the patient’s comfort as well as reduces the hospital
acquired infection rate. During winter, this may be achieved through radiators or the
room heaters/ blowers.68
The study findings revealed that during summer temperature of wards ranged
between 30-350C in wards of private hospitals, while it ranged between 32-370C in
government hospitals. During winters, the temperature of wards ranged between 09-
120C, in private hospitals and between 07-090C in government hospitals. This
signifies that during summer, temperature in wards of selected hospitals was close to
double of optimum level temperature. Similarly in winter situation of temperature
control was not much good in wards. It was further observed that none of selected
hospitals had air conditioning or centralized heating facility in general wards.
However, there was one fan for two to three beds and one air cooler for 5-7 beds in
wards of private hospitals. While, in government hospitals only one fan was available
for three to four beds and no other cooling facility was available. Wards of private
hospitals were equipped with heating facilities, where one blower or heater was
available for 3-7 beds. However, in government hospitals no such heating facility was
available. Details of the temperature and temperature control facilities in wards of
selected hospitals may be perused from Table 3.20.

185
 Table 3.20: Temperature control in wards of selected hospitals
Private hospitals Government hospitals
Variables
CMC DMC ESI CIVIL
Ward temperature
(during day time)
- Summer 30- 340 C 31- 350 C 32- 360 C 33- 370 C
- Winter 09-110C 10-120C 07-080C 07-090C
1 fan for 2-3 beds 1 fan for 2-3 beds 1 fan for 3-4
1 fan for 3-4
Cooling facilities 1 air cooler for 6-7 1 air cooler for 5-6 beds
beds
beds beds
1 blower or wall 1 wall heater for 3- No facility No facility
Heating facilities
heater for 6-7 beds 4 beds
Computed from primary data

Highlighting the importance of keeping hospital wards at an even temperature

S K Joglekar (2002)69 mentioned, this provides comfort to patients as well as staff
members. It was very difficult for staff to work in chilling winter and scorching
summer and quality of care accordingly gets affected.
It may therefore be stated that the situation of temperature control in wards of
private hospitals was relatively better as compared to government hospitals. These
findings were further supported by nurses, where in government hospitals only 12.5
percent* nurses were satisfied with temperature control in wards. While, in private
hospitals situation was slightly better where 42.5 percent nurses were satisfied with
temperature control in wards as illustrated in Table 3.21.

Table 3.21: Nurses’ satisfaction with temperature control in ward

Hospitals Total
Satisfied with Private Government
temperature control N=80
CMC DMC ESI CIVIL
n=20 n=20 n=20 n=20
f (%)
f (%) f (%) f (%) f (%)

Yes 09 (45.0) 08 (40.0) 3 (15.0) 02 (10.0) 22 (27.5)

No 11 (55.0) 12 (60.0) 17 (85.0) 18 (90.0) 58 (72.5)

Computed from primary data

*
Are you (nurse) satisfied with temperature control in your ward? a) Yes b) No

186
 During informal discussions with nurses in government hospitals, it was
mentioned by one of the senior nurses that during peak summer and extreme winter it
was very difficult to work in wards with large variations in temperature. They added
that our wards even did not have sufficient supply of hospital blankets for patients to
keep them warm in winter and most of the patients have to bring their own warm
clothes, which may be a source of infection transferred from home to hospital wards
or vice versa. Nurses in private hospital verbalized that because of poor temperature
control in wards during winter nurses have to wear lots of warm cloths, and during
summer they experience nonstop intolerable sweating, which ultimately reduces work
output.
Supporting the cause of controlled temperature in hospital wards Waring
(2007)70 mentioned that even ward temperature not only help in providing comfort to
patients and working staff in the wards but it is also essential for the control of
infection. It is therefore suggested that there may be better facilities to keep ward
temperature at even level to enhance the comfort of staff, which ultimately improve
the work output and keep hospital acquired infections under check. Ultimately, it
helps in improving patients’ comfort and satisfaction.

c) Lighting
Normal lighting facilities in hospitals wards were essential for ward staff to
accomplish routine tasks. Poor lighting facility may cause errors and accidents, which
may have serious consequences. Busch-Vishniac et al (2005)71 also documented that
poor lighting conditions in wards may be a contributing factor for medical errors.
Lighting facilities in wards of selected hospitals may be perused from Table 3.22.

Table 3.22: Lighting facilities in wards of selected hospitals

Private hospitals Government hospitals
CMC DMC ESI CIVIL
- Wall white tubes - Wall white tubes - Wall white tubes - Wall white tubes
- Generator backup - Generator backup - No generator backup - No generator backup
- Emergency lights/ - Emergency lights/ - No emergency lights/ - No emergency lights/
torches torches torches torches

- No dim light for night - No dim light for night - No dim light for night - No dim light for night
use use use use
Computed from primary data

187
 High level wall mounted white tubes were used for lighting in the wards.
Ceiling illuminations are believed to distribute light equivocal in all directions and
prevent eye-strain/ glares but this type of lighting system was not used in wards of
selected hospitals. Clancy et al (2006)72 mentioned that in wards lights should be such
that prevents eye-strain, or glare. It was further added that dim light facility is desired
for night to enhance sleep among patients. However, this facility was also not
available in wards of selected hospitals.
Generator backup during power cuts was available in selected private hospitals
but this facility was not available in government hospitals. In addition, emergency
lights were available in wards of private hospitals to use during power failure,
whereas this facility was also not available in wards of government hospitals. Busch-
Vishniac et al (2005)73 also documented that in staircases, corridors and hospital
wards there must be provision of power backup in events of power failure. Generators
may be used for this purpose or storage batteries can be utilized. Emergency lights
must be provided in wards to manage an emergency situation of power failure and
non-availability of power backup through generators or batteries for short time.
It was found that majority of patients (60.1 percent)* were not satisfied with
lighting facility in wards of selected hospitals. However, more number of patients
were satisfied with lighting facility in private hospitals (56.2 percent) as compared to
government hospitals (23.7 percent) as presented in Table 3.23.

Table 3.23: Patients’ satisfaction with lighting facility in ward

Hospitals Total
Satisfied with Private Government
lighting facility in N=1200
ward CMC DMC ESI CIVIL
n=300 n=300 n=300 n=300
f (%)
f (%) f (%) f (%) f (%)

Yes 158 (52.7) 179 (59.7) 69 (23.0) 73 (24.3) 479 (39.9)

No 142 (47.3) 123 (41.0) 231 (77.0) 227 (75.7) 721 (60.1)

Computed from primary data

In government hospitals during discussions patients mentioned that absence of

power backup during power cuts and dim lights for night use were their main factors

*
Are you (patients) satisfied with lighting facilities in your ward? a) Yes b) No

188
of dissatisfaction. However, in private hospitals patients were dissatisfied due lack of
dim light facility in wards. Similar views were expressed by nurses;* the same may be
perused from Table 3.24.

Table 3.24: Nurses’ satisfaction with lighting facility in ward

Hospitals Total
Satisfied with lighting Private Government
facility N=80
CMC DMC ESI CIVIL
n=20 n=20 n=20 n=20
f (%)
f (%) f (%) f (%) f (%)

Yes 16 (80.0) 17 (85.0) 05 (25.0) 02 (10.0) 40 (50.0)

No 04 (20.0) 03 (15.0) 15 (75.0) 18 (90.0) 40 (50.0)

Computed from primary data

It is suggested that ceiling illumination may be preferred over wall mounted

tubes since ceiling illumination help to prevent eye-strain and glares. Each ward may
have provision of emergency lights, dim lights, and power backup through generator
or batteries.

d) Noise control
Noise is often defined as an ‘unwanted sound’, but this definition is subjective
because of the fact that one man’s sound may be another man’s noise. Perhaps a better
definition of noise is ‘wrong sound, at the wrong place. In hospital wards noise may
affect patients and staff in many ways.74 Elevated level of noise may cause hearing
impairment, cardiovascular problems, emotional stress and instability among staff,
sleep disturbance among patients, and it also interferes in speech communication.
High level of noise in hospital wards not only cause negative effect on health of the
healthcare workers and patients but also make healthcare workers prone to cause
medical errors due to negative effect of noise on their cognitive task performance
(Flynn et al, 2005).75
Busch-Vishniac et al (2005)76 found that reduced noise level in wards (using
sound-absorbing versus sound-reflecting ceiling tiles) cause several positive outcomes

*
Are you (nurses) satisfied with lighting facilities in your ward? a) Yes b) No

189
among staff members including improved speech intelligibility, reduced perceived
work demands, and lessened perceived pressure and strain.
Noise level in hospital wards can be measured with decibelo-meter. In study it
was measured and found that noise level in wards of private hospitals was 68-76 dB
during daytime and 35-42 dB during night time. Whereas, noise level in wards of
government hospitals was found to be 76-84 dB during daytime and 40-48 dB during
night time as may be seen from Table 3.25. As per World Health Organization
guidelines (1996)77 up to 45 decibel (dB) noise is accepted during the day and less
than 35 decibel (dB) in night in hospital wards.

Table 3.25: Noise level in wards of selected hospitals

PRIVATE HOSPITALS GOVERNMENT HOSPITALS
Variables
CMC DMC ESI CIVIL
Day time 68-72dB Day time 70-76 dB Day time 76-80 dB Day time 80-84 dB
Noise level
Night time 35-40 dB Night time 32-42 dB Night time 40-46 dB Night time 40-48 dB

Use of noise Not placed in any Not placed in any Not placed in any Not placed in any
warning signs ward ward ward ward

% of satisfied
nurses with noise 07 (35.0) 06 (30.0) 05 (25.0) 05 (25.0)
level in ward*

Nurses’ perceived - Plenty of visitors - Plenty of visitors

- lack of privacy - lack of privacy
- lack of privacy - lack of privacy
causes for high - lack of adequate - lack of adequate
- lack of adequate - lack of adequate
level of noise ward space ward space
ward space ward space
Computed from primary data, * N = 20

It was found that majority of nurses (71.25 percent)* were not satisfied with
noise level in wards of selected hospitals. However, nurses in private hospitals had
relatively better feeling of comfort with noise level in wards as compared to nurses in
government hospitals. Nurses added that lack of privacy and inadequate ward space
were the few main causes responsible for higher level of noise in wards of selected
private hospitals. In government hospitals, nurses mentioned that plenty of visitors,
location of wards close to the main road, lack of privacy and in adequate space in

*
Are you (nurses) satisfied with noise level in your ward? a) Yes b) No
If no, specify the causes of poor noise control: ……………..................................................................

190
wards were the major causes of higher level of noise in wards. Swansburg and
Swansburg (2002)78 found that in wards noise is usually caused by visitors, equipment
alarms, movement of equipments and loud conversation by staff and patient’s
relatives.
In hospital wards noise level may be controlled by several ways, however,
placement of noise warning signs have proved to be very popular for use in hospital
wards, reminding people to be quiet in the usual locations such as nursing station,
corridors close to wards, ward entrances and exits etc. These signs are to remind not
just the visitors but also the staff and patients to keep their noise levels down. The
mere existence of the noise warning sign in an obvious location is often enough to
remind people about the area's sensitivity to noise.79 But this type of facility was not
available in wards of selected hospitals.

e) Infection control
Infection control in hospitals has always been a burning issue. Hospital
acquired infection may delay the recovery of patients, which ultimately increases their
stay in hospital, more work for healthcare workers and an increase in cost of care.80
Pennsylvania Health Care Containment Council, (2005) in of its studies found and
reported that average hospital payment for a patient without hospital acquired
infection was $ 8078, compared to $ 60678 for patients who had hospital acquired
infection.
Infection in hospitals can be mainly transferred to patients either by healthcare
workers or ward environment. Healthcare workers have to care for several patients as
well as handle so many equipments and instruments used for patients. Therefore,
infection control in hospital wards has two major issues hand-washing facilities and
practices and environmental disinfection.
Hand washing is considered as gold standard for infection control in
healthcare settings. Hand washing facilities affect the hand washing behavior among
healthcare professionals. Hoston et al (1997)81 mentioned that availability of more
number of hand washing facilities in close proximity to care setting tremendously
increase the hand washing practices among healthcare professionals.
It was found that a single hand-washing facility was available in the wards of
selected hospitals as can be perused from Table 3.26 and Figure 3.10. Cohen et al
(2003)82 examined the relationship between availability of hand-washing facilities

191
(accessibility, number of sinks and dispensers for hand washing) and prevalence of
hospital acquired infections. Results shown that number of hand-washing facilities
and prevalence of hospital acquired infections were inversely proportional to each
other.
It was further observed that these hand-washing facilities were equipped with
bar soap in private hospitals, while bar soap was not available in government
hospitals. However, National AIDS Control Organization (2006)83 mentioned in its
manual for control of hospital associated infections that liquid soap suspensors are
better than soap bar because with multiple hand-washing; these bar get infected and
further spread the infection.

Table 3.26: Hand washing facilities for healthcare providers in wards of selected
hospitals
Private hospitals Government hospitals
Facilities
CMC DMC ESI CIVIL
Number of hand One in each One in each
One in each ward One in each ward
washing facilities ward ward

Substance used for Bar soap on each Bar soap on each Bar soap on most Bar soap on few
hand washing facility facility of the facilities facilities
Cloth towel on Cloth towel on
most of the some facilities at Hospital linen No hand drying
Hand drying
facilities at some some places were used for facility was
facility
places hospital hospital linen drying hands present
linen were used were used
Present in some Present in some
Alcohol hand rub No such facility No such facility
wards wards
Computed from primary data

In private hospitals, after hand-washing hands were dried with cloth towels,
however, in some wards it was done with hospital linen. While, in government
hospitals either hands were drayed with hospital linen or otherwise there was no
facility to dry hands. NACO (2006)84 mentioned that preferably paper towels must be
used to dry hands because cloth towel becomes wet and may harbour microorganisms,
which may be spread further. But paper towel facility was not available in wards of
selected government or private hospitals. Alcohol solution is one of the best
recommended solutions for disinfection of hand. This facility was available in some

192
of the wards of selected private hospitals, but it was not available in wards of
government hospitals.

Fig. 3.10: Hand washing facilities for health care providers in wards

View of hand washing facility in private hospital View of hand washing facility in govt. hospital

More than half of the nurses (58.8 percent)* were not satisfied with hand
washing facilities available in wards of selected hospitals as illustrated in Table 3.27.
However, in government hospitals more number of the nurses (75.0 percent) were
dissatisfied with existing hand washing facilities as compared to private hospitals
(42.5 percent). During discussions it was found that in private hospitals, number of
hand washing facilities were the main cause of dissatisfaction among nurses, while
nurses in government hospitals were not only dissatisfied due to less number of hand-
washing facilities but also because of the non-availability of hand washing soap and
hand drying materials.

Table 3.27: Nurses’ satisfaction with hand washing facilities in ward

Satisfied with hand Hospitals Total
washing available in Private Government
ward N=80
CMC DMC ESI CIVIL
n=20 n=20 n=20 n=20
f (%)
f (%) f (%) f (%) f (%)
Yes 11 (55.0) 12 (60.0) 06 (30.0) 04 (20.0) 33 (41.3)

No 09 (45.0) 08 (40.0) 14 (70.0) 16 (80.0) 47 (58.8)

Computed from primary data

*
Are you (nurses) satisfied with existing hand washing facilities in your ward? a) Yes b) No
if no, please specify the reasons:……………………………………………………………………

193
 It was found that in private hospitals floor mopping was done at least two
times in each shift, while in ESI it was done once in each shift and in Civil hospital it
was done only once in a day. Terminal disinfection (Cleaning bed, locker and
patient’s area thoroughly after discharge) was practiced in wards of private hospitals
with either undisassociated hypochlorous acid tablets or bacillocid solution, but
terminal disinfection was not practiced in wards of government hospitals as can be
seen from Table 3.28.

Table 3.28: Environmental disinfection practices in wards of selected hospitals

Disinfection Private hospitals Government hospitals
practices CMC DMC ESI CIVIL

2 times in each shift 2 times in each shift Once in a every shift Once in a day with
Mopping of floor
with Phenol with Phenol with phenol phenol

After discharge of
patient with After discharge of
Terminal
undisassociated patient with
disinfection No such practice No such practice
hypochlorous acid Bacillocid
tablets
With undisassociated
Surface
hypochlorous acid
disinfection With 70% alcohol With soap and water With plain water
tablets or 70% alcohol
Never done as per
Periodic Once in a year with No record of ward Never done as per
head nurse
fumigation Formaldehyde fumigation head nurse knowledge
knowledge
Subjective overall
Good Good Poor Very poor
ward cleanliness
Computed from primary data

Working surfaces like nursing station, medical trolley etc. were cleaned by
either undisassociated hypochlorous acid tablets or 70 percent alcohol in private
hospitals but this was done with either soap and water or only plain water in
government hospitals. Periodic fumigation is necessary for disinfection of wards.
Periodic fumigation was done every year in CMC hospital. However, in other three
selected hospitals, this was never done in more than least five years as per records or
knowledge of ward in-charge nurses.
On subjective observation wards of private hospitals were found clean but
wards in government hospitals were either poor or very poor in cleanliness. Similar

194
findings were reported by nurses working in wards of government hospitals, where
majority of them (80.5 percent)* were not satisfied with overall cleanliness of wards.
While, in private hospitals 59.5 percent of the nurses were satisfied with cleanliness
of the wards. During discussion nearly similar view points** were expressed by
patients from wards of selected hospitals.

f) Waste segregation
Hospital is such an institutions, which is frequently visited by people from
every society without any distinction of age, sex, race and religion. This is over and
above the normal inhabitants of hospital i.e. patients and staff. All of them produce
wastes, which is increasing in its amount and type due to advances in scientific
knowledge and is creating its impact. The hospital waste, in addition to the risk for
patients and personnel who handle these wastes poses a threat to public health and
environment.85
Ministry of Environment & Forest, Government of India (2001),86 notified the
type of containers and their colour codes for segregation and storage of different
categories of hospital waste as appended in Table 3.29.

Table 3.29: Colour coding, container needs and waste segregation category
Colour code Waste category

Yellow Human tissues, organs and body parts, animal tissues and body parts, waste generation from
the animal houses, microbiology cultures, stocks and vaccines, human and animal cell
Yellow cultures, waste generated from production of biological, solid contaminated waste like cotton,
dressings, plaster cast, linens, beddings and other such material contaminated with blood or
body fluids.
In case, incineration is not available for certain type of waste mentioned above for the yellow
bag (microbiology/ biotechnology waste, contaminated solid disposable waste (e.g. syringes,
Red
IV sets, urobags, blood bags, gloves, catheters etc). All these items can be sent to a landfill
site only after autoclaving/ microwaving or chemical disinfections.
This container used for unused sharps. Glass bottles, vials, ampoules, and metallic sharps.
Blue
These items can only be sent to landfill after shredding, mutilation and chemical disinfection.
These bags are used for discharging drugs; food and paper waste and send to the municipal
Black landfill.

*
Are you (nurses) satisfied with overall cleanliness of the ward? a) Yes b) No
**
Are you (patients) satisfied with overall cleanliness of the ward? a) Yes b) No

195
 The waste segregation practices in wards of selected may be perused from
Table 3.30.

Table 3.30: Waste segregation practices in wards of selected hospitals

Private hospitals Government hospitals
CMC DMC ESI CIVIL
Waste segregation
Follow above Follow above Used three colour Used two clour coded
recommended protocol recommended protocol coded bins bin
(Red, yellow, blue & (Red, yellow, blue & (Green, yellow & (Red, white and blue )
black) green) blue)

Needle cutter
1-2 in each ward 1-2 in each ward One in each ward Only in few wards
Use of puncture proof containers
Not available Not available Not available Not available
Use of 1% hypochlorite solution to treat infected waste
Used as per need Used as per need Not used Not used
Computed from primary data

It was found that private hospitals were following the protocol recommended
by the Government of India for waste segregation. While, in government hospitals
recommended protocol was not followed and they used incomplete colour coding
system like in ESI hospital green, yellow and blue colour coded containers were used,
and in Civil hospital red, white and blue colour coded containers were used for
segregation of hospital waste in wards. In addition, in Civil hospital colour coded
bags were not used in colour coded containers but waste is directly segregated in
containers. Needle cutters were available in wards of selected hospitals but puncture
proof containers for collection of sharp hospital waste were missing in wards of
selected hospitals. In private hospitals, one percent hypochlorite solution was used to
treat infected waste in wards but this practice was not followed in wards of selected
government hospitals.

196
 Fig. 3.11: Colour coded containers in wards for waste segregation

View of colour coded in ward of DMCH View of colour coded bin in Civil hospital

Furthermore, nurses’ knowledge was assessed for biomedical waste

segregation as presented in Table 3.31; it was found that only 15 percent nurses* were
having good level of knowledge, while 36.2 percent and 48.8 percent of them were
having average and poor knowledge of biomedical waste segregation respectively.
However, a much better of knowledge of waste segregation was found among nurses
in private hospitals (22.5 percent) as compared to government hospitals (07.5
percent).
In addition, during informal discussions a ward incharge nurse verbalized that
waste segregation practices were not very well followed because poor knowledge of
healthcare workers. It was further mentioned by her about a recent incidence of needle
stick injury to one ward staff because a needle was thrown by some one in paper
waste bin and while collecting the waste; staff had got needle stick injury. Similar
findings are reported by J.J. Nobel (1995),87 where it was mentioned that almost 85
percent sharps injuries were accidental due to improper disposal of these items.
Aggarwal et al (1998)88 stated that although sharps comprise of a relatively small
portion of the hazardous waste generated in hospital, they have maximum propensity
and potential for causing needle stick injuries and hence can cause infection.
Therefore these require maximum precautions. Sain Fisher (2007)89 reported poor
waste management practices and added that an organization adopting good waste
management practices not only improve standard of care but it also saves money.

*
Refer annexure-VI for detailed schedule.

197
Table 3.31: Knowledge of waste segregation among healthcare workers in ward
Level of knowledge Hospitals Total
Private Government
CMC DMC ESI CIVIL N=80
n=20 n=20 n=20 n=20
f (%) f (%) f (%) f (%) f (%)
Good 04 (20.0) 05 (25.0) 02 (10.0) 01 (05.0) 12 (15.0)
Average 11 (55.0) 08 (40.0) 04 (20.0) 06 (30.0) 29 (36.2)
Poor 05 (25.0) 07 (35.0) 14 (70.0) 13 (65.0) 39 (48.8)
Computed from primary data

It was inferred that waste segregation practices were not uniform in wards of
selected hospitals; private hospitals followed the waste segregation guidelines but
containers used were not of uniform size as can be seen in Figure 3.11. Majority of
nurses had poor to average knowledge of waste segregation. Improper hospital waste
segregation is very health hazardous for healthcare workers as well as it poses a health
risk for general public as well. Therefore, it is suggested that there should be regular
training and motivation of staff for proper hospital waste segregation.

3.8 Ancillary Area

Ancillary area of a ward may include day space, visitors’ waiting area,
patient’s relatives’ stay facility and multipurpose room.

a) Day space
According to the modern medical science concept patients who underwent
some form of surgery are encouraged to move out of the bed at earliest possible time.
This requires a safe place near their ward to move around. It may be a small adjoining
room; a place congenial for sitting, walking and relaxing since it allows patients a
change in environment. This is also known as concept of early ambulation; early
ambulation not only helps in the early recovery but also facilitates early vacancy of
the bed. However, none of the selected hospital had day space facility for the patients
in wards, where patients can move in day time and an early ambulation can be
achieved. Patients were found moving in ward corridor for ambulation in recovery
phase. According to a manual of Trained Nurses Association of India (2000)90
mentioned that the day space should be built in 15 percent of total ward area or 180 sq
feet per ward, such a room may have TV/ radio facility beside the reading material

198
like newspaper, magazine etc. Majority of nurses (72.5 percent)* expressed the need
to have day space in wards of selected hospitals. Similarly majority of patients (83.2
percent) also expressed the need of day space in wards.

Table 3.32: Ancillary area in wards of selected hospitals

Private hospitals Government hospitals
Ancillary area
CMC DMC ESI CIVIL

Day Space Not available Not available Not available Not available

Sarai Sarai No facility, stay in No facility, stay in

Patients’ relatives accommodate accommodate open space or open space or
stay facility
about 20 people about 30 people corridors corridors
Visitors waiting
Not available Not available Not available Not available
area
Multipurpose
Not available Not available Not available Not available
Room
Computed from primary data

b) Visitors’ waiting area

Visitors waiting area allows patient’s relatives to wait and relax before
meeting with patient admitted in wards. It was observed that in selected hospitals
visitors’ waiting area was not available. Patients’ relatives were found waiting in
corridors. Majority of the nurses (91.3 percent)* felt the need of visitors waiting area.
Similar opinion was provided by patients, where 83.7 percent** of them felt the need
of visitors waiting area. During discussions, nurses mentioned that in absence of
visitors’ waiting area either patients’ relatives sit in corridors or they try to be with
patients in wards that create chaos in ward.

c) Stay facility for patients’ relatives

This accommodation is used for relatives, allowing them to relax, be
comfortable and sleep overnight. In India there is concept of family support during
hospitalization, it is always observed that every patient is accompanied by one or
more relatives, there is always need of a facility where relatives can take rest and
perform their daily rituals, otherwise they are tend to fall sick.91 It is evident from

*
Do you (nurses) feel the need of day space in your ward? a) Yes b) No

Do you (patients) feel the need of day space in your ward? a) Yes b) No
*
Do you (nurses) feel the need of visitors’ waiting in near your ward? a) Yes b) No
**
Do you (patients) feel the need of visitors’ waiting in near your ward? a) Yes b) No

199
Table 3.32 that private hospitals, were having small facilities to accommodate 20-30
patient relatives in the form of a ‘sarai’. While in government hospitals, there was no
such facility. Patient’s relatives were seen taking food, relaxing, resting and sleeping
within the corridors or in the open space under trees. Overwhelming majority (89.7
percent) of the patients expressed the need of stay facility for patients’ relatives.
Similarly 80 percent nurses also felt the need for such facilities.

d) Multipurpose room
The main purpose of multipurpose room is to organize formal and informal
teaching sessions by medical and nursing staff; clinical demonstrations involving a
patient in bed or wheelchair.92 However, multipurpose room was not available in
wards of selected hospitals. Majority of nurses (71.3 percent)* opined that there
should be a multipurpose room in wards.

Table 3.33: Nurses’ opinion about need of ancillary area in ward

Hospitals Total
Private Government
Ancillary area* N=80
CMC DMC ESI CIVIL
n=20 n=20 n=20 n=20
f (%)
f (%) f (%) f (%) f (%)
Day Space 16 (80.0) 17 (85.0) 13 (65.0) 12 (60.0) 58 (72.5)

Patients’ relatives
18 (90.0) 17 (85.0) 15 (75.0) 14 (70.0) 64 (80.0)
stay facility
Visitors waiting area 19 (95.0) 18 (90.0) 19 (95.0) 17 (85.0) 73 (91.3)

Multipurpose Room 17 (85.0) 16 (80.0) 13 (65.0) 11 (55.0) 57 (71.3)

*Figures mentioned are of nurses who agreed with need of selected ancillary facilities in ward
Computed from primary data

It was inferred that ancillary was totally missing in selected hospitals.

Therefore, it is suggested that there may be at least one day space, patients’ relative
stay facility, visitors waiting area and a small multipurpose room for training of
medical/ nursing staff and students.
3.9 Miscellaneous Facilities


Do you (patients) feel the need of stay facility for patient’s relatives in your hospital? a) Yes b) No

Do you (nurses) feel the need of stay facility for patient’s relatives in your hospital? a) Yes b) No
*
Do you feel the need of a multipurpose room in your ward for training of medical/ nursing staff/ students?
a) Yes b) No

200
 Miscellaneous facilities of a ward may include basic amenities for patients in
ward, wheelchairs, recreational facilities and drinking water facilities.
a) Basic amenities
Hospital wards are said to be a temporary home for the patients. Therefore,
patients need several basic amenities for their comfortable stay in hospital.
Availability of basic amenities in wards of selected hospitals is depicted in Table
3.34.
Table 3.34: Basic amenities in wards of selected hospitals
Private hospitals Government hospitals
Basic amenities
CMC DMC ESI CIVIL
One bed for each One bed for each
Few beds were
patient inbuilt patient inbuilt One bed for each
Beds occupied by two
facility of head end facility of head patient
patients
elevator end elevator
Comfort devices Inbuilt facility in Inbuilt facility in
Not available Not available
for patients beds beds
Medicine & utility 1 for every Average 1:1.5 (not
1 for every patient 1 for every patient
locker for patients patient for every patient
Standpipe and hose Standpipe and
system and 2-3 hose system and 2- 1-2 Hand held 1-2 Hand held fire
Fire control
hand held fire 3 hand held fire fire extinguishers extinguishers in
facilities
extinguishers in extinguishers in in each ward each ward
each ward each ward
Flies or mosquito
No facility No facility No facility No facility
control facilities
Computed from primary data

Modern type of beds with inbuilt head end elevator was available for each
patient in wards of selected private hospitals. In ESI and Civil hospital, old traditional
hospital beds were available for each patient. It was also observed in Civil hospital
that at times a single bed was used by two patients. A good number of patients (60.7
percent)* were satisfied with beds in private hospitals but in government hospitals
majority of them (77.7 percent) were dissatisfied. Similar view was expressed by
nurses,** which may be perused from Table 3.35.

*
Are you (patients) satisfied with beds provided to you in your wards? a) Yes b) No
**
Are you (nurses) satisfied with beds provided for patients in your wards? a) Yes b) No

201
 Sick patients may need support to sit on bed, therefore, they may require back
rests. In private hospitals, each patient had this facility since beds were having inbuilt
head end elevators. Whereas, in government hospitals, beds were neither having head
elevation facility not the back rests were available. Furthermore, in private hospitals,
various comfort devices such as sandbags, extra pillows, air rings etc were available
in wards, while, in government hospitals these facilities were not available. A
majority of patients (77 percent)* were dissatisfied with availability of comfort
devices in government hospitals, while in private hospitals situation was better (40
percent). Majority of nurses (82.5 percent)** in private hospitals were satisfied with
available comfort devices for patients, while in government hospitals majority of them
(87.5 percent) were dissatisfied.
Medicine/ utility lockers are usually kept at bed side to store patients’
medicines, water, feed etc. This facility was availed by each patient in private
hospitals and ESI hospital. Whereas, every patient in Civil hospital could not get this
facility. Majority of patients (76.8 percent) were not satisfied with this facility in
government hospitals, while in private hospitals 45.3 percent of them were satisfied.
Majority of nurses (92.5 percent) were satisfied with availability of medicine/ utility
lockers for patients in private hospitals, while in government hospitals only half of
them were satisfied (average 55 percent).

Table 3.35: Nurses’ satisfaction with basic amenities available in ward N= 80

Private hospitals Government hospitals
Basic
CMC DMC ESI CIVIL
amenities* n=20 n=20 n=20 n=20
f (%) f (%) f (%) f (%)
Beds 17 (85.0) 18 (90.0) 15 (75.0) 11 (55.0)

Comfort devices
16 (80.0) 17 (85.0) 03 (15.0) 02 (10.0)
for patients
Medicine & utility
18 (90.0) 19 (95.0) 16 (80.0) 06 (30.0)
locker for patients
Fire control
13 (65.0) 12 (60.0) 11 (55.0) 10 (50.0)
facilities
Computed from primary data, *Figures mentioned are of satisfied nurses for different amenities

*
Are you (patients) satisfied with the comfort devices provided to you in your wards? a) Yes b) No
**
Are you (nurses) satisfied with the comfort devices provided for patients in your wards? a) Yes b) No

Are you (patients) satisfied with medicine/ utility lockers provided to you in your wards? a) Yes b) No

Are you (nurses) satisfied with medicine/ utility lockers provided for patients in your wards? a) Yes b)No

202
 One of the most essential safety measures in a hospital is the fire control
facility. The suppression of fire is achieved either manually or by automated
extinguishing system. The most commonly used device for suppression of fire in large
buildings is the water sprinklers system. The standpipe and water hose system are
used to provide quick and convenient water stream. The handheld extinguishers are
mainly used for small areas.93
In private hospitals, manual standpipe with water hose system and hand held
extinguishers were present. Whereas in government hospitals there was only 1-2 hand
held fire extinguishers. Water sprinkling system was not available in government
hospitals. Fire fighting system needs regular maintenance, which is done by
standardized agencies by taking annual maintenance charges, but in government
hospitals no record of maintenance was found. About slightly more than half (average
57.5 percent)*of the nurses were satisfied with fire control facilities available in
selected hospitals. However, situation was relatively better in private hospitals
(average 62.5 percent) as compared to government hospitals (average 52.5 percent).
It was thus, inferred that in government hospitals wards were poorly equipped
with basic amenities as compared to private hospitals. Therefore, it is suggested that
hospital authorities must ensure that wards are equipped with basic amenities so that
patients feel comfortable during their stay in hospitals wards.
b) Wheelchairs
Wheelchairs are used for patients with varying level of incapabilities from
ambulant to accident or illness related disabilities. Wheelchairs are used for
transportation of patients from one place to another in hospitals. Inadequate
wheelchair or other transportation facilities may delay the patient’s transfer activity
and a poor quality of facility may have a health hazard for patients like fall or
neurovascular injuries. It was found that in private hospitals, 1 to 2 wheelchairs were
available in every ward, whereas in government hospitals, ESI hospital had
wheelchairs available in few wards only and in Civil hospital wheelchairs were not
available in wards but used from emergency department as and when need arose.
A comparative data regarding availability of wheelchairs may be perused from
Table 3.36.

*
Are you (nurses) satisfied with fire control facilities in your hospital? a) Yes b)No

203
 Table 3.36: Wheelchairs in wards of selected hospitals
Private hospitals Government hospitals
Variables
CMC DMC ESI CIVIL
Number of 1-2 wheelchair/ 1-2 wheelchair/ Available in few Not available in
wheelchairs/ ward ward ward wards wards

Type of wheel
Cushioned type Cushioned type Rigid metallic type Rigid metallic one
chairs
Not available Not available Not available
Wheelchair bay -NA-
Stored in corridors Stored in corridors Stored in corridors
Computed from primary data

In private hospitals, majority of nurses (75.0 percent)* verbalized the adequacy

of wheelchairs. While, majority of nurses (87.5 percent) in government hospitals
highlighted the inadequacy of wheelchairs in wards as illustrated in Table 3.37.

Table 3.37: Nurses’ opinion about adequacy of wheelchairs in ward

Hospitals Total
Adequate Private Government
wheelchairs in ward N=80
CMC DMC ESI CIVIL
n=20 n=20 n=20 n=20
f (%)
f (%) f (%) f (%) f (%)

Yes 16 (80.0) 15 (70.0) 04 (20.0) 01 (05.0) 36 (45.0)

No 04 (20.0) 05 (25.0) 16 (80.0) 19 (95.0) 44 (55.0)

Computed from primary data

In private hospitals, wheelchairs were with comfortable cushioned backrest,

hand-rest and lock facility, while in government hospitals wheelchairs were old
metallic type without cushioned backrest, hand-rest and lock facility. It was found that
none of wards in selected hospitals had wheelchair bay facility to store wheelchairs in
wards. Wheelchairs were found to be stored in corridor, which were obstructing the
smooth movement of people in corridor. During discussions nurses mentioned that
they had witnessed on several occasions patients falling from the wheelchairs due to
defective wheelchair or wheelchair hitting the attendants sitting in corridors. Nurses

*
There are adequate number of wheelchairs in your (nurses) ward for patient’s transportation. a) Yes b) No

204
in government hospitals too mentioned acute shortage and poor working condition of
wheelchairs in wards of government hospitals.
Institute of Medicine (2001)94 documented that at least one wheelchair
must be available for every 15-20 patients in ward/hospital. It was further stressed that
wheelchairs must be comfortable, about 0.48 m high above floor with hand rest and
lock facility. However, in selected hospitals, there was shortage of wheelchairs as per
these recommendations. Same was felt by nurses in selected government and private
hospitals. There might be adequate amount of wheelchairs in good working condition
to facilitate smooth and comfortable transportation of patient without wastage of time.

c) Recreational facilities
Wards are the temporary home for the indoor patients. An environment
identical to home can facilitate the recovery process of patients. Evidently, there is a
need to ensure a congenial environment comprising certain recreational facilities for
the patients. Kaissi, (2006)95 while supporting this view point stated in general wards,
patients remain stable and they feel the need of recreational facilities. Similar view
expressed by Rao (2002)96 observed that recreational facilities not only prevent
boredom among patients but also helps in minimizing pain feelings and facilitates
early recovery. Newspapers, magazines, radio, television and various indoor games
are the good examples of the recreational facilities in hospitals
It was found that in CMC hospital only few wards were equipped with single
T.V., rest of the selected hospitals did not provide any recreational facility to the
admitted patients.
Majority of patients (72.6 percent)* expressed the strong need of recreational
facilities in the wards of selected hospitals, which may be perused from Table 3.38.
During discussions it was mentioned by one elderly patient that there should be at
least provision of spiritual music in morning and evening time. He believed that this
could help patients to cope effectively with disease and hospitalization related stress.

*
Do you (patients) feel the need of recreational facilities in a hospital ward? a) Yes b) No

205
 Table 3.38: Patients’ opinion about need of recreational facilities in ward
Recreational Hospitals Total
facilities are needed Private Government
in ward N=1200
CMC DMC ESI CIVIL
n=300 n=300 n=300 n=300
f (%)
f (%) f (%) f (%) f (%)

Yes 223 (74.3) 221 (73.7) 210 (70.0) 217 (72.3) 871 (72.6)

No 77 (25.7) 79 (26.3) 90 (30.0) 83 (27.7) 329 (27.4)

Computed from primary data

The nurses however, expressed divergent view. Majority of them (75.0

percent)* felt that recreational facilities were not feasible in hospital wards, because it
might disturb other unstable patients. They were of the view that recreational facilities
like television or music system was either feasible in single rooms or there might be
provision of day space where stable patients can come and view television, listen
music, read newspapers/ magazines or play indoor games. On the other hand 27.4
percent nurses expressed the need and necessity of recreational facilities in wards. An
audio tape at a low pitch can divert the attention of the patients. It can help in
providing a soothing effect on the mental and physical conditions of patients, opined
some of the nurses.
It is suggested that the facility of day space in general wards where stable
patients can have access to recreational facilities or wherever feasible, bed side music
outlets with headphone facility may be provided. Low volume instrumental music can
be played in morning or evenings for some time, which probably may increase nurses’
work output and play a major role in patients’ overall satisfaction with healthcare
system.

d) Drinking water facility

It was found that the private hospitals were having water coolers with
purifying filters, but it was restricted to only few wards. Interestingly, whereas no
such facilities existed in government hospitals. As a matter of fact unsafe drinking
water was available to the patients from ward bathrooms taps. A study of municipal
general hospital shown that in most of the wards, patients were receiving unsafe

*
Do you (nurses) feel the need of recreational facilities in a hospital ward? a) Yes b) No

206
drinking water from sources which were not cleaned, kept open and not chlorinated
since several months.97
Majority of patients (88.0 percent)* verbalized inadequacy of drinking water
supply in wards of private hospitals, while in government hospitals significant good
number of respondents (63.5 percent) expressed adequacy of drinking water. Similar,
views were reported by nurses** as illustrated in Table 3.39.

Table 3.39: Opinion about adequacy of drinking water supply in ward

Hospitals
Respond Water Private Government Total
ents supply
was CMC DMC ESI CIVIL
n=300 n=300 n=300 n=300
f (%)
adequate
f (%) f (%) f (%) f (%)

Patients Yes 39 (13.0) 32 (10.7) 208 (69.3) 173 (57.7) 452 (37.7)

N=1200 No 261 (87.0) 268 (89.3) 92 (30.7) 127 (42.3) 748 (62.3)

Nurses Yes 03 (15.0) 06 (30.0) 13 (65.0) 12 (60.0) 34 (42.5)

N=80 No 17 (85.0) 14 (70.0) 07 (35.0) 08 (40.0) 46 (57.5)

Computed from primary data

It may be inferred that there was safe but inadequate supply of drinking water
in wards of private hospitals, while in government hospitals drinking water supply
was adequate but in Civil hospital drinking water supply was not safe and potable.
Supply of adequate and safe potable water is one of the essential requirements for
every person in a civilized society. Thus necessary arrangements of adequate, safe and
potable drinking water for patients and staff may be made. Unsafe drinking water may
prove fatal for patients as well people accompanying them.

3.10 Organization of Nursing Care

A machine can not run without man, similarly a ward is incomplete without a
nurse, since ultimate goal of a ward is to provide quality care to indoor patients.
Henderson (1966) defines that ‘nurse is a person to assist the individual, sick or well

*
Supply of drinking water is adequate and safe in your (patients) ward. a) Yes b) No
**
Supply of drinking water is adequate and safe in your (Nurses) ward. a) Yes b) No

207
in the performance of those activities contributing to health or its recovery that he/she
would perform unaided if he/she had the necessary strength, will or knowledge.’
These unique functions of nurse are called as nursing. Therefore, later in 1973
International Council of Nurses (ICU) adopted this definition for word nursing.98
Nursing care can be organized in several ways like case method, functional
method and team method. Nursing care can not be provided by a single person in
ward, it requires a team, which may comprise ward incharge nurse, staff nurses,
housekeeping staff, clerks, ward aids and sweepers etc. This team needs a place to sit,
observe and monitor the patients in wards in the form of nursing station and as nurses
are human being s they also need a place to sit and relax in between the work.99
Undocumented work is considered equal to not performed. Therefore, nurses
need to document care provided to patients. Hence, here onwards this chapter
discussed about nursing care providing team, their functions, organizing the patient
care, nursing station, nurses’ rest room and nursing care documentation.

a) Nursing care team

The ward team includes all members of the staff, who are working under the
leadership of ward sister. Some members of the team provide the nursing care
required by the patients, others perform non-nursing services, which are equally
significant and necessary. It is important that nurses are used effectively for
performing the nursing duties so that their skills are used for the work for which their
training especially prepares them. Therefore, in current scenario different new types
of personnel are included in ward team to perform non-nursing duties, for example
ward housekeepers and wards clerks. It is the ward sister’s responsibility as a ward
administrator to ensure that each member of the team has an opportunity to use her
special aptitudes and skills to the fullest extend. It follows that the ward sister must
not only be capable of assessing the personal qualities and potential of each individual
in the ward team but also be aware of the functions and responsibilities of each
member of the team.100
The resources play an important role in achieving the desired goal. The
resources include man, money and material. The quality and number of personnel
available for accomplishment of a task play an important role in an organization.
Sufficient manpower is essential to provide quality care to a group of patients.

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Staffing is of deep concern to the ward sister in the hospital ward to provide standard
patient care in order to carry out all the functions allocated to the nursing personnel.
Staffing of any set-up is concerned with three factors; quality, quantity and utilization
of personnel, keeping the structure and the process in mind.101 The general staffing
norms for wards are suggested as following by Indian Nursing Council (INC, 1985)
and Bombay Nursing Home Act, June 2007.
Indian Nursing Council recommended nursing staff requirement for wards as
depicted in Table 3.40. It was recommended that there should be one ward sister for
25 beds and one staff nurse for 3 beds for teaching hospitals and one staff nurse for 5
beds in non-teaching hospitals.

Table 3.40: Indian Nursing Council recommendations for ward nursing staff
Category of staff Staff: bed ratio
Ward Sister 1:25 beds+30% leave reserve
Staff Nurses 1:3 (or 1:9 for each shift) in teaching hospitals + 30% leave
reserve

Bombay Nursing Home Act, 2006 has provided recommendations of ward

staff in a general hospital, which is presented in Table 3.41. It was recommended that
there should be one resident Medical Officer for 10 beds, one registered nurse for five
beds, one general duty assistant for three beds and one sweeper for five beds round
the clock.

Table 3.41: Bombay Nursing Home Act June 2006 recommendation for ward staff
Category of staff Staff: bed ratio round the clock
Resident Medical Officer 1 for every 10 beds
Registered Nurse 1 for every 5 beds
General duty assistant 1 for every 3 beds
Sweeper 1 for every 5 beds

There is another set of norms in practice for number of ward staff

requirements based on the nature of illness of patients. These norms are helpful in
implementing progressive patient care concept in hospitals as presented in Table 3.42.

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 Table 3.42: Staff nurse patient ratio based on nature of illness in wards
Nature of Illness Direct nursing Nurse-patient ratio
hours required
Critically-ill patients needing intensive care 8-10 hours 1:1
Moderately-ill patients needing intermediate care 3-5 hours 1:3 (teaching hospital)
1:5 (Non-teaching “ )
Mildly-ill patients needing self care (Ambulatory) 1-2 hours 1:6 (Teaching hospital)
1:10 (non-teaching “ )
Chronically-ill patients requiring skill prolonged 30 minutes to 1 1:12 (teaching hospital)
medical & nursing care hour 1:18 (Non-teaching “)
Source: academy of hospital administration, Diploma in hospital and health management Course Paper-II, 11th edition, 2000.

The existing ward staff in hospitals was as shown in Table 3.43. Ward nursing
care team was headed by a ward sister in each ward of private hospitals. However, in
government hospitals some of the ward sisters managed more than one ward. Ward
sister patient ratio was close to the recommendations in private hospitals, while in
government hospitals shortage was more than fifty percent.

Table 3.43: Nursing care team in wards of selected hospitals

Category of staff Private hospitals Government hospitals
CMC DMC ESI CIVIL
Ward Sister 1:29 1:23 1:68 1:65
Staff Nurses 1:6 1:9 1:30 1:14
ANMs/ ward 01-2 01 Nil Nil
Nurse Teacher/ward 01 01 NA NA
Student Nurses/ ward 4-5 3-4 NA NA
Clerks/ ward 01 Nil Nil Nil
Ward aids* 1:20 1:15 1:30 1:35
Sweepers* 1:40 1:20 1:40 1:60
Computed from primary data
* Ratio is calculated for each shift without 30% staff for leaves reserve.

On an average there was about one nurse for six patients in CMC hospitals, in
DMC hospital one nurse cared about nine patients during each shift in general wards,
while in government hospitals nurse patient ratio was very poor viz. 1:14 and 1:30 in
Civil and ESI hospital respectively. Clerical staff was only available in CMC hospital,
other three selected hospital did not have clerical staff in wards. In private hospitals,

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one ward aid cared about 15 to 20 patients, while in government hospitals one ward
aid cared for more number of patients (30-35). Similar situation existed for sweepers,
where in private hospitals average one sweeper was available for each ward, whereas
in government hospitals one sweeper was shared by several wards. Shortage of ward
aid and sweepers was alarming in government as well as in private hospitals, where
this category staff was even less than one fourth of the recommendations.
It was thus inferred that there was acute shortage of nursing staff in the wards
of government hospitals. However, ancillary staff (ward aids and sweepers) was short
in both the government as well as the private hospitals.

b) Functions of the ward sister102

Direct Patient Care
 Ensure proper admission and discharge process of the patients.
 Make patient care assignment based on the patients’ needs and availability of
nursing personnel.
 Provide the direct care to the patients as and when required.
 See that total health needs of patients are met.
 Ensure safety, comfort and good personal hygiene of her/ his patients.
 Assist in planning and administration of the therapeutic diet to her patients.
 See that proper observation records of the patients are made and necessary
information imparted to the concerned authorities.
 Take nursing rounds with nursing staff and students.
 Make rounds with doctors. Assist him in diagnosis and treatment of the
patients.
 Implement doctors’ instructions concerning to patient treatment.
 Assist patient and his/her relatives to adjust in the hospital and its routine.
 Co-ordinate patient care with other departments.
Supervision and Administration:
 Ensure safe and clean environment of the ward.
 Make duty and work assignments.
 Indent ward store and keep necessary records.
 Do regular inventory checking of her/his ward.
 Make list for condemnation of articles and submit it to all concerned.

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  Assist in making ward requirements.
 Establish and reinforce ward standards prescribed in the procedures and
manuals of the ward and the hospital policies that are in force.
 Act as liaison officer between ward staff and hospital administration.
 Maintain good public relations in her/his ward.
 See that ward statistics are regularly submitted.
 Maintain discipline among the ward workers, e.g., staff nurses, students and
domestic staff.
 Deal appropriately with any adverse situation that has occurred in the ward
and report to the concerned authorities.
 Report about any medico legal cases in the ward.
 Write and submit confidential reports of the staff.
 See that students get desired learning experience in the ward.
Educational Functions:
 Organize orientation programs for new staff.
 Organize formal and informal ward teachings, conducts bedside clinics and
demonstrations.
 Conduct ward conferences / meetings.
 Give incidental teaching to patient relatives, staff nurses, students and
domestic staff.
 Guide in formulation of Nursing Care Studies, and Nursing Care Plans etc.
 Evaluate the students’ performance and submit reports to school authorities.
 Help in medical and nursing research.
 Encourage staff development programs in ward.

c) Functions of the staff nurses103

Related to patient care:

 Evaluate in detail every day the care requirement of each patient assigned:
o Prepare a plan of care according to nursing needs and program of therapy
as prescribed by medical team.
o Communicate the plan to co-workers and delegate duties according to their
qualification and ability.

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 o Apply knowledge, skill and judgment to provide hygienic comfort and
optimum health for each patient. Perform necessary procedures and
treatment appropriately and with proficiency.
o Prioritize workload to attend critical patients and essential duties first
responsible for dispensing medication and ensuring treatment is done
correctly and at prescribed time.
o Co-ordinate nursing care functions with other team members to enhance
efficiency and patient comfort.
o Maintain and ensure an accurate and legible record of observations,
measurements, procedures, medications, treatments, positive and negative
reactions, patients’ progress and any other significant information.
o Discuss with ward Sister any concerns to seek advice and exchange ideas
and information to provide the best possible nursing care.
o Receive reports on patients and ward activity from previous shift and give
accurate and complete reports to successive shift.
o Inform ward Sister/Master immediately of any unusual events or concerns
during the shift.
 Demonstrate knowledge of purposes, principles and precautions associated
with drugs, therapeutic methods and diagnostic lists.
 Share responsibility with Ward Sister/ other nursing administrators to provide
quality and appropriate nursing care.
 Observe or supervise activities of auxiliary nursing staff, student nurses and
non-professional workers to ensure that accurate safety techniques (methods)
are performed and utilized.
 Recognize and utilize the resources available in the institution, supplies,
equipments, personnel and diagnostic tools. Communicate needs to specialized
departments, dietary, physiotherapy, fellowship etc.
 Ensure emergency cart is readily accessible, contains, required emergency
equipments and supplies as designed by emergency care advisory committee,
is fully stocked at all times and is checked regularly by using a check list to
verify assessment.
 Promote optimal and economical use of supplies, equipments and utilities.

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  Perform, enforce and instruct co-workers regarding the importance of strict
infection control practices.
 Recognize and promote the value of keeping the patient and family informed
of medical conditions, treatment, prognosis and methods by which they can
participate effectively in therapy and rehabilitation.
 Provide physical, spiritual and emotional support to patient and family during
time of crises and/or bereavement.
 Recognize and present relevant health teaching sessions to patients and
relatives.
 Participate in ward rounds with medical team, discuss nursing observations
and concerns and be a patient advocate.
 Assist physician with treatment and procedure, check chart daily for new
orders and changes in treatment plans, and ensure implementation.
 Direct daily routine of ward/department.
o Send requisitions and specimens.
o Receive reports and supplies.
o Maintain admission, discharge and death registers.
o Ensure admission and discharge procedures are followed.
o Inform Medical team immediately of every sudden change in patient’s
status.
o Maintain ward environment conducive for patients comfort and better care
outcome.
 Respond promptly and appropriately to complaints made by patients, relatives
and doctors regarding nursing care.
 Practice and reinforce confidentiality of sensitive information at all times.
Relating to Personnel:
 Attend departmental and staff meetings and participate in committees as
required.
 Be receptive to new ideas and concepts, contribute opinions and share
concerns.
 Support and encourage membership of nursing organizations.
 Observe and evaluate the work performance of subordinate staff.
 Assist with orientation of nursing staff and students.

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  Encourage and participate in intra-departmental activities to boost morals.
 Prepare self for schedule performance evaluation by interoperation, seeking
advice and reflecting future aspirations.
Relating to Education:
 Support the bearing process and offer prompt and timely advice or interactions
to nursing students as they gain clinical experience.
 Participate in educational and in-service programs whenever possible.

d) Methods of patient care assignment

Patient care assignment can be defined as “It is the way by which care of
patients is assigned to the nurses”. It is also termed as patient assignment to nurses.
There are three methods of patient assignments for nurses, namely patient method,
functional method and team method.104
Patient method or case method of care is the oldest method of organizing
patient care. In this method, nurses assume total responsibility for meeting all the
needs of assigned patients during their duty. It involves the assignment of one or more
patients to a nurse for a specific period of time, such as shift. Complete care,
including treatment, medication administration and nursing care is the assigned
nurse’s responsibility.
In functional method of patient assignment, a nurse is assigned to complete
specific tasks rather than total care of a specific patient. For example, carry out only a
specific task like blood pressure monitoring or administering medication etc. for each
patient. In this method of organizing the nursing care head nurse has complete
responsibility of care.
Team Nursing or modular nursing is based on a philosophy in which group of
professional and non-professional personnel work together, The team identify, plan,
implement, and evaluate comprehensive client-centered care. The key concept is a
group that works together towards a common goal, providing qualitative
comprehensive nursing care. In team nursing, ancillary personnel collaborate in
providing care to a group of patients under the direction of a professional nurse.
Actually the team nursing involves decentralization of a nursing unit to be headed by
a professional. The unit is divided into teams. Each team comprises of team leader,
team members and patients. Comprehensive care of the client is the responsibility of
the entire team, but it is led by the team leader who must be a registered nurse.105

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 It was found that in government hospitals functional assignment method was
used, where each nurse carried out a specific task for every patient. However, in
private hospitals case method was used, where a single nurse carried out the total
nursing care for assigned patients. Team method of patient care was not used in
selected wards of government or private hospitals.
It was found that majority of nurses (72.5 percent) * were satisfied with
existing method of patient care assignment (case assignment method) in wards of
private hospitals. Whereas, in government hospitals only 37.5 percent nurses were
satisfied with existing method of the patient care assignment (functional method) as
depicted in Table 3.44.

Table 3.44: Nurses’ satisfaction with existing methods of patient care assignment
Satisfied with Hospitals Total
existing patient Private Government
assignment method N=80
CMC DMC ESI CIVIL
n=20 n=20 n=20 n=20
f (%)
f (%) f (%) f (%) f (%)
Yes 14 (70.0) 15 (75.0) 07 (35.0) 08 (40.0) 44 (55.0)

No 06 (30.0) 05 (25.0) 13 (65.0) 12 (60.0) 36 (45.0)

Computed from primary data

During discussions, it was mentioned by nurses in private hospitals that in

case method, total responsibility of care for assigned patients, lies with one nurse only
and she was held responsible for her performance. Nurses in government hospitals
mentioned that they too preferred the case assignment method, but poor nurse patient
ratio make them to use only functional method. Significant number of patients (53.8
percent)** were also in favour to receive nursing care by case assignment method.
During informal group discussions, it was mentioned by patients that they feel more
comfortable when cared by a single nurse, since they know to whom should contact in
their needs. They further added that when cared by multiple nurses, they feel confused
and certain unassigned functions remain unattended.

*
Are you (nurses) satisfied with existing patient care assignment method in your ward? a) Yes b)
No
**
By which method you (patients) would like to receive the nursing care.
a) Case method b) functional method c) Team method d) Any method e) Uncertain

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 Similar findings were reported by Gingerich (2007)106 in his study. It was
reported that 76.1 percent patients were satisfied with single nurse care approach,
whereas 22.7 percents were satisfied with team method of the patient care assignment.
However, only 1.2 percent patients were satisfied with functional method of the
patient care assignment. Hence, it was suggested that ward sister must assign the
nursing care of patients to nurses based on case method or patient method to enhance
nurses’ and patients’ satisfaction with care.

e) Nursing station
The nursing station is as old as the hospitals itself. Historical influences and
technological advancements may have changed the location of the nursing stations in
the ward but not its existence. ‘A nursing station is a room or area used by nurses and
other healthcare staff, for delivering nursing care services. It is the primary
workstation that is assigned to a specific ward and normally equipped with a
cupboard, drug cupboard, sink, chairs, table, telephone, call system signs and records.
In other words a nursing station can be defined as a specific area or room used by
nurses to receive and provide patient related information, store patients records,
essential medicines and care inventories. It is basically used as a center point to plan
and deliver nursing care activities for patients admitted in a ward.107 The main
functions of nursing station are; nursing, administrative and clerical control point for
the ward, storage of patient records, issuing and receiving point for all information, it
may include medicine storage and a beverage point.
Nursing station was existing in all selected hospitals. It was found that in
CMC hospital about 36-40 sq ft area was allocated for nursing stations and in DMC
hospital it was about 42 to 50 sq ft. While in ESI and Civil hospital nursing station
was built in 120 sq. ft. and 80 sq ft. area respectively as illustrated in Figure 3.12. In
addition, area allocated for nursing station in wards of private hospitals was not same
in each ward, while this was found same in wards of government hospitals.
Furthermore, in none of the wards of selected hospitals nursing stations were provided
with attached toilet facility. Nursing Home Act (2006)108 recommended about 100 sq.
ft. area for nursing station with attached toilet. Hence, it is inferred that space
available for nursing station in selected government hospitals was close to adequate
and it was found as much as fifty percent short in private hospital.

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 The location of the nursing station is very important from the point of view of
providing adequate and timely care to the patients. Rowland (1984)109 suggested that
the location of nursing station should be such that maximum number of patients
remain under direct observation of the nurses and walking distance for nurses should
be kept as short as possible. It was further added that maximum distance of nursing
station to farthest bed should not be more than 65 feet.

Fig. 3.12: View of nursing station in wards of selected hospitals

Nursing station in private hospital Nursing station in government hospital

In CMC and Civil hospital, wards were too large with central nursing station
design. Therefore, distance of farthest bed from nursing station was about 80 to 120
ft., while in DMC and ESI hospital; wards were small in size with centralized nursing
station. Therefore, distance of farthest bed from nursing station was only 30 to 50 ft.
Basically nursing station designs can be classified in two major categories;
namely centralized or decentralized nursing station designs. In centralized nursing
station design, a single nursing station is used by nurses or other members for
providing healthcare services for patients admitted in a particular ward. In
decentralized nursing station design, there are multiple nursing stations located very
close to patient area, which is used by nurses and other members to deliver healthcare
services to patients admitted in the respective wards. A centralized nursing station
was available in wards of selected hospitals, which may be perused form Table 3.45.

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 Table 3.45: Nursing station in wards of selected hospitals
Private hospitals Government hospitals
Variables
CMC DMC ESI CIVIL

Design Central design Central design Central design Central design

Total area 36-40 sq. ft. 42-50 sq. ft. 120 sq. ft. 80 sq. ft.

Attached
Not available Not available Not available Not available
Toilet facility
Distance from
80-100 sq. ft. 30-40 ft. 40-50 ft. 100-120 sq. ft
farthest bed
Computed from primary data

Centralized and decentralized nursing stations have own benefits and

drawbacks. Malkin (1992)110 mentioned that in the centralized nursing station design,
patients and staff enjoy better privacy, since nursing station often can provide ample
space for nurses to discuss confidential issues of patient care and private consultation.
In addition, patients do not feel nurses always on their heads. Centralized nursing
station design place nurses away from patient area; therefore, they need to walk long
distance for providing direct nursing care. Moreover, it also compromises the direct
observation of patients from the nursing station.
The decentralized nursing station is planned to keep the nurses closer to their
patients, where nurses interact more closely with patients. Fisher, S (2003)111
conducted a comparative study on time utilization by nurses in providing nursing care
by using centralized and decentralized nursing station. They studied nurses walking
pattern with a video camera and found that with centralized nursing station a large
part of time was spent by nurses in walking, searching and gathering supplies and
information. The research also demonstrated that decentralized nursing stations
reduced staff walking and increased patient care time especially when supply spaces
also were decentralized and placed near the nursing station. These studies seem to
suggest that bringing staff and supplies physically and visually closer to the patients
helps in reducing the time spent on walking. It was argued by Agnetta Morelli
(2007)112 that although decentralized nursing stations usually improve visibility and
reduces nurses walking time, however, nurses have reported feeling more isolated
from their colleagues and loosing a sense of team connection.

219
 It was found that majority of nurses (70.0 percent)* in selected hospitals were
not satisfied with nursing station provided for them may be perused from Table 3.46.
Furthermore, in CMC and Civil hospital about one fourth of nurses were satisfied
with nursing station facility of their ward. While more number of nurses were
satisfied with nursing station facility in wards of ESI (40.0 percent) and DMC hospital
(30.0 percent). This could be because there are small size wards with central design
nursing station in DMC and ESI hospital, where nurses had less walking distance
between beds and nursing station and better visibility of patient’s beds from nursing
station.

Table 3.46: Nurses’ satisfaction with nursing station in ward

Hospitals Total
Satisfied with nursing Private Government
station N=80
CMC DMC ESI CIVIL
n=20 n=20 n=20 n=20
f (%)
f (%) f (%) f (%) f (%)

Yes 05 (25.0) 06 (30.0) 08 (40.0) 05 (25.0) 24 (30.0)

No 15 (75.0) 14 (70.0) 12 (60.0) 15 (75.0) 56 (70.0)

Computed from primary data

Furthermore, it was found that the main causes of nurses’ dissatisfaction* in

CMC and Civil hospital were nurses’ perceived long walking distance between beds
and nursing station, poor direct patient observation from nursing station. While in
DMC and ESI hospital the main causes of nurses’ dissatisfaction were lack of privacy
for nurses, lack of storage facility at nursing station. Lack of attached toilet was
complaint of all the nurses in four selected hospitals. In addition, in government
hospitals, nurses also mentioned about lack of communication facilities at nursing
station, which also served as cause of their dissatisfaction with nursing station of their
ward may be perused from Table 3.47.

*
Are you (nurses) satisfied with nursing station available in your ward? a) Yes b) No
*
If no, please give the reason of your dissatisfaction with nursing station: ………………………………………

220
 Table 3.47: Reason for nurses’ dissatisfaction with nursing station in ward
Private hospitals Government hospitals
Variables
CMC DMC ESI CIVIL
Area Small Small Adequate Adequate

Walking distance Long ---- ------ Long

Direct patients observation Poor Good Good Poor
Toilets facility Absent Absent Absent Absent
Privacy Poor Poor Poor Good
Storage facility Adequate Inadequate Inadequate Inadequate
Communication facility Yes Yes No No

All selected hospitals used centralized nursing station design in wards. Large
wards with centralized nursing design had long walking distance between beds and
nursing station, which leads to reduced nurse’s time for direct patient care and
exhaustion among nurses that ultimately causes decreased work output. Therefore, it
is suggested that large wards with centralized nursing design might be supplemented
with portable nursing stations to reduce nurses walking distance, enhance patients’
direct visibility and increasing nurse’s time for direct patient care. Kosnik et al
(2007)113 also supported this idea, where he mentioned that single centralized nursing
station can work well in small size wards but large wards must be supplemented with
portable nursing stations to enhance nurses comfort and time of direct patient care.

f) Nurses’ rest room

Owing to their arduous and hard nature of job, nurses need to have a place in
ward, where they can take short break during their working period. Constant standing
and working with patients can lead to exhaustion among nurses, which reduces their
work efficiency as well can bring deleterious effect on their own health. As such a
cubical or small room is provided in hospitals for the nurses. The rest room facilitates
the nurses to take breaks in between their work as per institutional policy. Nurses can
use this facility to have their tea, lunch, dinner or snacks in between the working
period.114
It was found that overwhelming majority of nurses (87.5 percent) * expressed
the need of nurses’ restroom in hospital wards. More number of nurses expressed the

*
Nurses’ rest room is needed with wards? a) Yes b) No

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need of restrooms in government hospitals (92.5 percent) as compared to private
hospitals (82.5 percent).
It was observed that nurses’ rest room facility was present in the private
hospitals but was restricted to few wards viz. six out of 19 wards (31.6 percent) were
having the rest room. While, this facility was not available for nurses in government
hospitals.
However, nurses’ rest room available in private hospitals, was too small to
accommodate nursing staff, hardly one chair and cot was available. There was toiletry
facility within the nurses’ rest room but its upkeep was poor. It was also found that
rest room lacked some of the basic facilities such as hotplate/ microwave for warming
their food in winter, or refrigerator to store food stuff or drinks in summer. In
addition, nurses were also deprived of recreational facility in their rest rooms. It was
found that in private hospitals, 70 percent** nurses were dissatisfied with existing
facilities of nurse’s rest room as illustrated in Table 3.48.
The main reasons*** of their dissatisfaction were very small area, poorly
equipped and poor cleanliness of sanitary facility. During discussions, nurses in
government hospitals, mentioned that in the absence of rest room nursing station itself
was used for eating and taking rest. Putsep (1979)115 suggested that nurses’ rest room
is one of the mandatory facility in wards, which must be furnished with chairs, tables,
sofas, rest devices, refrigerator, heating devices and recreational facilities like
television, music system and magazines. It was further, mentioned that nurse’s rest
room can be shared between two or more wards.

Table 3.48: Nurses’ satisfaction with nurses’ restroom in ward

Hospitals Total
Satisfied with nurses’ Private Government
rest room N=10*
CMC DMC
ESI CIVIL
n=6 n=4
f (%) f (%)
f (%)

Yes 02 (33.3) 01 (20.0) Facility 03 (30.0)

Facility was
was not
not available
No 04 (66.7) 03 (75.0) available 07 (70.0)
Computed from primary data, *Only few wards in private hospital had nurses’ restroom

**
Do you (nurses) have nurses’ restroom with your ward? a) Yes b) No,
If yes, are you satisfied with existing facility? a) Yes b) No
***
If no, please mention the main reasons:……………………………………………………………………

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 Continuous working without break brings exhaustion and exasperation among
nurses, which reduces work efficiency, innovation and may increase chances of
errors. This may even lead to frustration and job dissatisfaction among these
professionals. In nursing care practices, nurses deals with human beings, where
chances of errors can not be afforded. Therefore, it is suggested that nurses must be
provided with a rest room in between two to more wards, where they can have short
breaks during working period to restore their energy level and further raising their
threshold of being tired.

g) Nursing care documentation

Record refers to anything that is written or printed and relied on, a document
of proof for authorized person.116 Effective record keeping reflects the quality of care
and provides evidence of each healthcare team member’s accountability in giving
care. Records and reports are maintained to provide an accurate, current,
comprehensive and concise form of information concerning the condition and care of
patient.117 In routine clinical practice nurses maintain various types of records and
reports.
The United Kingdom Council of Care118 observed:
“The quality of recordkeeping is also a reflection of the standard of
your professional practice. Good record keeping is a mark of a
skilled practitioner, while careless or incomplete recording often
highlights wider problem with individual’s practice”. The patient’s
clinical record is the most important administrative record for which
the head nurse/ ward incharge nurse is responsible. It has legal,
scientific and educational value and should be accurate, neat and
legible.”
Reports are of prime importance for the good ward management as well as
effective functioning of a hospital. Many reports are oral and are concerned chiefly
with the immediate functioning of the ward such as reports between nurses and
reports to doctors and supervisors. Reports are written when they may be needed for
legal purposes, when they are to serve as a source of reference or are to be used by
several people. Written report includes day, evening, night reports and those relating
to accidents and unusual conditions that may reflect the quality of the care, which the
patient has received. The reports are of different types viz. interdepartmental reports,

223
interagency reports, special reports on usual conditions in the patient, reports on
mistakes and accidents (incident report), reports of complaints etc.119
Undocumented work is considered equal to not performed. To maintain
continuity of care and to protect the nurses from legal liability, nurse’s records are
very essential. Details of the records and reports maintained in wards may be perused
3.49.

Table 3.49: Records and reports maintained in wards of selected hospitals

Private hospitals Government hospitals

CMC DMC ESI CIVIL

Patient’s clinical record Admission register Patient’s clinical record Patient’s clinical register
Ward staff attendance Discharge register Diet register Diet register
register Patient’s censuses Dhobi register Dhobi register
Ward staff leaves record Staff attendance register Investigation register Rounds register
Anecdotal record Diagnostic test file Round register Death register
Store and maintenance Nurse’s notes Patient’s census Investigation register
record Complaint book Indent and stock register
Inventory record, Movement Report register Census register
register , Patient’s census Serious patient’s report
Indent register , Duty roster
Notice file, Pharmacy record
Medicine register
Patient assignment register
Nurse’s notes
Computed from primary data

It was observed that in private hospitals nurses maintained few records of

nursing care, which included nurse’s notes, patient assignment records, vital signs
records, medication records, however still these hospitals were lagging behind from
modern nursing care related records and reports like nursing process, process
recording, nursing care progress records etc. On other hand in government hospitals
none of nursing records were maintained except vital signs records. Furthermore these
might have high degree of legal consequences, in case a consumer files a complaint.
About 200 records and reports randomly selected and audited* for their
completeness, appropriateness, organization, legibility and storage from wards of
selected hospitals as illustrated in Table 3.50

*
Please refer annexure-VII for details of audit proforma.

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Table 3.50: Quality of records and reports maintained in wards of selected hospital
N = 200
Variables Percentage of documents
Government Private Total
hospitals hospitals (200)
Completeness
33 47 80 (40.0)

Appropriateness
(Entries in appropriate space) 29 42 71 (35.5)
Organization of entries
- Logical order was followed 72 87 159 (79.5)
- Entries in straight line 41 54 95 (47.5)
- Properly spaced entries 27 38 65 (32.5)
Legibility
- Legible ink used 79 82 161 (80.5)
- Understandable handwriting 74 84 158 (79.0)
- No cutting 54 65 119 (59.5)
- No overwriting 37 49 86 (43.0)
Storage (Compilation)
- Intact storage 93 98 191 (95.5)
- Compiled documents 87 90 177 (88.5)
- No folds 23 45 68 (34.0)
- No stains 89 98 187 (93.5)
Computed from primary data

It was found that only 40 percent documents were complete in their required
entries, rest documents were left incomplete. In addition, only 35.5 percent were
completed by writing in appropriate space. For organization of entries, in 79.5 percent
documents logical order was followed, in 47.5 percent documents entries were in
straight line and only 32.5 percent documents had properly spaced entries. In
assessment of legibility, it was found that in 80.5 percent documents legible ink was
used, 79.0 percent documents had understandable hand writing. Cutting and
overwriting was not found in 59.5 and 43.0 percent documents respectively. In
storage category it was found that 95.5 percent documents were stored intact, 88.5
percent of them were found compiled and in 93.5 percent documents no stain was
found. However, only 34.0 percent documents were found without folds.
Furthermore, it was found that, maintenance of documents was better in wards of
private hospitals as compared to government hospitals.
Several research studies revealed shortcoming in maintenance of records and
reports by nurses. Leana and Jonne (2004)120 conducted a survey on the quality of
nursing care records and reports in several districts of South Africa in which a total of
137 records were audited. It was revealed that the quality of the nursing records was
generally very poor. Elioart (1994)121 audited 116 nursing records and found that the

225
nursing assessment recording generally got the highest scoring (61 percent). The main
weakness in the vast majority of wards was related to signing, dating and timing of
records. Sinha et al (1989)122 analyzed charting at St. Boniface Hospital, Canada. The
main problems identified were poor narrative style of charting, low quality monitoring
results and care plans that were frequently empty and not attached to permanent chart.
Hence, it was inferred that wards of government hospitals were very poor in
maintenance of nursing records and reports as compared to private hospitals.
Furthermore, quality of records and reports maintenance was also poor in selected
hospitals. Therefore, it is suggested that nurses must have regular in-service education
regarding records and reports maintenance in wards and there might be a regular audit
of ward records to check the quality, which helps the nurses to improve the
documentation in wards.

Major Observations
 Classification of wards: Wards were mainly categorized in general as well as
special wards in selected hospitals. General wards in CMC, ESI and Civil
hospitals were categorized on the basis of gender and medical specialty viz.
male medical and female surgical wards etc., while in DMC hospital, wards
were classified on the basis of medical specialty and male, female patients were
placed in same ward. Majority of the patients and nurses preferred classification
of the wards according to medical specialty as well as gender.
 Location of wards: Emergency/trauma wards were located on ground floor in
selected hospitals, rest of the wards lacked uniformity in location. In private
hospitals wards were located away from noise sources and were in close
proximity with the supportive services, while wards of government hospitals
were lacking in these positive features.
 Ward layout: Wards were large in size to accommodate 50-60 patients in CMC
and Civil hospital, while in DMC and ESI hospital wards were small in size to
accommodate 20-40 patients. Patients and nurses preferred small size wards.
Wards of CMC hospital were built with double corridor design. Single corridor
design wards were available in DMC and ESI hospital, while in Civil hospital,
courtyard design was used to built the wards. None of the ward design was
found perfect by nurses. Space available per bed in selected hospitals was as
short as fifty percent. Majority of nurses were not satisfied with available space

226
 for each bed in selected hospitals. Majority of nurses were not satisfied with
overall layout of the wards in selected hospitals.
 Ward Pantry: Ward pantry was not available in wards of selected hospitals.
However, a hotplate or electric heater was available near the nursing station, but
these heating devices were mostly used for preparing hot beverages (tea/ coffee)
for ward staff. Majority of the patients desired to have pantry facility in the
wards; however the nurses did not support this view point.
 Ward store room: Store rooms were available in only few wards of selected
hospitals and they were very small in size to accommodate ward inventory.
Ward store rooms in government hospitals were poorly organized and found
filled with condemn material. Majority of nurses were not satisfied with existing
store room facilities in wards. Lockers are needed for patients to keep their
belongings, but this facility was not available in store room of the selected
hospitals. In addition, good number of nurses felt need of lockers for patients,
because patients were storing their belongings at bedside, which was giving
poor aesthetic look to ward. However, majority of patients had divergent
opinion and wanted to keep their belongings at their bedside only.
 Clean utility: There was no clean utility in wards of selected hospitals.
However, clean storage was done in cupboards available at nursing station.
Majority of nurses verbalized adequacy of clean utility supply in wards of
private hospitals but in government hospitals majority of nurses were finding
clean utility supply inadequate in wards. Linen supply was significantly short in
wards of government hospitals, while in private hospitals it was found
satisfactory. Interestingly wards of government hospitals were totally deficit
with nursing care articles, whereas in private hospitals few nursing care articles
were available in wards. Drugs and disposable supply was provided free of cost
in ESI hospital, in Civil hospital, it was supplied by hospital as well as
purchased by patients from market in non-availability. However, in private
hospitals drugs and disposable items were purchased by patients from hospital
pharmacy. Interestingly, patients in private as well as government hospitals were
willing to get these supplies from hospitals because they were scared of getting
poor quality from market.

227
 Treatment room: Separate treatment/ procedure room was not found in wards of
selected hospitals. Minor procedures were performed at bedside only. In
addition, emergency trolley, dressing and medication trolley, suction facility and
oxygen supply was found satisfactory in wards of private hospitals but wards of
government hospitals were not well equipped with these facilities. Inadequacy
of these facilities would compromise the quality of care. Majority of nurses were
satisfied with treatment room related facilities in wards of private hospitals but
in government hospitals, it was opposite, where majority of them were not
satisfied with treatment room related facilities in their wards.
 Dirty utility: Separate dirty utility facility was not available in wards of selected
hospitals. However, in Civil hospital, a small room labeled as dirty room was
available but was only used for storing dirty linen till they were sent for laundry.
Dirty utility material was stored in corners of the wards close to sanitary
facilities. This was considered as major risk of hospital acquired infections.
Overwhelming majority of nurses expressed the need for dirty utility in wards of
selected hospitals.
 Sanitary facilities: The number of sanitary facilities in wards of selected
hospitals were even less than half of the recommendations. Cleanliness of these
facilities was very poor in government hospitals, while in private hospitals it
was found satisfactory. Majority of patients were critical about cleanliness of
sanitary facilities in wards of government hospitals. However, in private
hospitals situation was slightly better, where about fifty percent of patients were
found dissatisfied with cleanliness of sanitary facility. Size of bathrooms and
toilets was very small to accommodate a dependent patient and helping person;
the doorways of bathrooms and toilets were too narrow to accommodate patients
on wheelchair. Alarm call systems were not available in these sanitary facilities
and in government hospitals latches were not available on doors of bathrooms
and toilets. In addition, basic amenities were lacking in these facilities of
selected hospitals like hot water supply, buckets, mugs, tissue paper, dustbins,
racks etc. Sufficient number of washbasins are required for efficient control of
cross infection in hospital wards. Bombay Nursing Home Act, (June 2006)
recommended at least one washbasin for ten patients in general hospital ward.
Shortage of washbasins was found as high as more than fifty percent in wards of

228
 selected hospitals. Size of washbasins was small, hand operable taps were
present and paper towels were not available to dry hands.
 Ventilation: Wards were ventilated naturally with large windows in government
hospitals. However, in private hospitals wards were ventilated through windows
as well as exhaust fans. Majority of nurses experienced adequate ventilation in
wards of selected hospitals, which was slightly more with naturally ventilated
wards as compared to mechanically ventilated wards. Naturally ventilated wards
were considered better than mechanical ventilation because they had better air
exchange and help in patient comfort as well as infection control in wards.
 Temperature control: Air conditioning facility was not available in wards of
selected hospitals. However, fans were available in wards to comfort patients
during summers. In private hospitals, few air coolers were available in wards but
wards of government hospitals were lacking with this facility. Furthermore,
blowers or room heaters were present in wards of private hospitals to make the
patient feel warm during winter. However, these facilities were not available in
wards of selected government hospitals. Majority of nurses were not satisfied
with temperature control in wards of selected hospitals, while satisfaction was
slightly better in private hospitals as compared to government hospitals.
Hospital wards must be kept at an even temperature, which provides the comfort
to the patients and staff, otherwise it is very difficult for staff to work in chilling
winter or scorching heat and quality of care can be affected.
 Lighting: Wards of private hospitals were lighted with wall mounted white
tubes with backup of generator and emergency lights during power failures. In
government hospitals also wall mounted white tubes were used for lighting the
wards but generator backup or emergency lights were not available for use
during power failures. Furthermore, none of the wards in selected hospitals had
provision of dim lights to be used during night to facilitate sleep among patients.
There may be provision of dim lights in wards that can be used during night to
facilitate sound and undisturbed sleep among patients. Majority of patients and
nurses were not satisfied with lighting facilities of wards in government
hospitals. However, in private hospitals majority of nurses were satisfied with
lighting facilities in wards but only fifty percent patients were satisfied because
of absence of dim light for use at night.

229
 Noise Control: Poor noise control was found in wards of selected hospitals.
Noise level during day time or night time was found double of WHO
recommendations. Majority of nurses were not satisfied with noise level in
wards of selected hospitals. Furthermore, it was perceived by them that major
factors of high level noise in wards of private hospitals were lack of privacy and
inadequate ward space. Whereas, in government hospitals, plenty of visitors,
improper location of wards and inadequate ward space were the main perceived
factors responsible for high level of noise. Noise warning sign devices were not
available in wards of selected hospitals.
 Infection control practices: Inadequate hand washing facilities were observed
in wards of selected hospitals. Bar soaps were used for hand-washing and cloth
towels or hospital linen were used for drying the hands, which were against the
latest empirical evidences of hand-washing practices. To perform dry hand-
washing alcohol rub is used, which was available in wards of private hospitals,
but not in government hospitals. Majority of nurses were not satisfied with
existing hand washing facilities in wards of government hospitals, while in
private hospitals slightly more than half of the nurses were satisfied with
existing hand washing facilities in wards. Floor mopping, terminal disinfection
and surface disinfection practices were found satisfactory in wards of private
hospitals but in government hospitals terminal disinfection was not performed,
surface disinfection and floor mopping was done with soap and/or plain water
only. Periodic fumigation practices were found only in CMC hospital. However,
other three selected hospitals did not have record of such practices during last
five years. Overall cleanliness of wards in private hospitals was satisfactory on
subjective observation but in government hospitals cleanliness was in poor state.
 Waste segregation: Hospital waste segregation was done according to
Government of India recommendations in wards of private hospitals. However,
government hospitals used their own colour coding for hospital waste
segregation. Needle cutters were available in wards of selected hospitals, but
puncture proof containers were not available. Infected waste was disinfected
with one percent hypochlorite solution in wards of private hospitals but this
practice was not followed in government hospitals. Furthermore, healthcare
professionals had poor knowledge of biomedical waste segregation (good

230
 knowledge: 15 percent, average knowledge: 36.2 percent and poor knowledge:
48.8 percent) in wards of selected hospitals.
 Ancillary area: Day space, visitors waiting area and multipurpose rooms were
not available in wards of selected hospitals. Patient relatives stay facility was
available in selected private hospitals to accommodate about 20-30 patient’s
relatives, while this facility was not available in government hospitals.
Therefore, patient’s relatives were using corridors or open space for this
purpose. Majority of nurses expressed the need to have day space, patient’s
relative stay facility; visitor’s waiting area and multipurpose room in selected
hospitals.
 Basic amenities: Adequate number of beds, medicine and utility lockers were
available for patients in wards of private hospitals and ESI hospital. However in
Civil hospital, these facilities were not available for each patient. Standpipe and
hose system as well as portable fire extinguishers were available in wards of
private hospitals, while in government hospitals, only portable fire extinguishers
were available but there was no record about their regular maintenance and
functioning status. Interestingly, flies or mosquito control facilities were not
available in wards of selected hospitals. Majority of nurses were satisfied with
existing basic amenities in wards of private hospitals, but situation in
government hospitals was just opposite.
 Wheelchairs: On an average about one to two wheelchairs were available in
each ward of private hospitals and ESI hospital. Majority nurses found them
adequate for patients. However, in Civil hospital wheelchairs were not available
in wards but used from emergency department during need and therefore
patients waited for longer period to get transfer from wards. In addition,
majority of nurses also found wheelchairs inadequate in Civil hospital.
Cushioned and comfortable wheelchairs were available in wards of private
hospitals but in government hospitals rigid metallic type wheelchairs were
available. Wheelchair bays were not available in wards of selected hospitals;
wheelchairs were kept in corridor, which hindered the smooth movement of
people in corridor.
 Recreational facilities: Wards of selected hospitals, there was scarcity of
recreational facilities, except a television in few wards of CMC hospital.

231
 Majority of patients expressed the need of recreational facilities in ward of
selected hospitals, while nurses were not in favor to have recreational facilities
in wards but suggested to have a day space equipped with recreational facilities.
 Drinking water facility: There was provision of safe and potable drinking water
supply in wards of private hospitals and ESI hospital. However, in private
hospitals drinking water supply was inadequate. While in wards of Civil
hospital, safe and potable drinking water was not available for patients, they
were taking their drinking water from ward bathrooms.
 Nursing care team: There was on an average about one nurse for six patients in
CMC hospitals, in DMC hospital one nurse cared for about nine patients during
each shift in general wards, while in government hospitals nurse patients ratio
was very poor viz. 1:14 and 1:30 in Civil and ESI hospital respectively. Clerical
staff was only available in CMC hospital, other three selected hospital did not
have clerical staff in wards. In private hospitals, one ward aid was caring about
15 to 20 patients, while in government hospitals one ward aid cared for more
number of patients (30-35). Similar situation existed for sweepers, where in
private hospitals average one sweeper was available for each ward, whereas in
government hospitals one sweeper was shared by several wards. Shortage of
ward aid and sweepers was alarming in government as well as in private
hospitals, where this category staff was even less than one fourth of the
recommendations.
 Methods of patient care assignment: In private hospitals, patient care was
assigned by case assignment method, while in government hospitals functional
assignment method was used for the patient care. Case assignment method was
preferred by nurses as well as patients. However, due to shortage of nurses in
government hospitals, nurses felt compulsion to use functional assignment
method.
 Nursing station: Centralized nursing station design was available in wards of
selected hospitals. Designated floor area for nursing stations was found adequate
in government hospitals, whereas in private hospitals nursing stations were
placed in small area (only 36-50 sq ft). Toilet facility for nurses, close to nursing
station was not provided in wards of selected hospitals. Distance of farthest bed
from nursing station was more in wards of CMC and Civil hospital because

232
 wards were large in size, while it was adequate in wards of DMC and ESI
hospital, because wards were small in size. Because of large size ward with
centralized nursing station in CMC and Civil hospital, nurses experienced long
walking distance between beds and nursing station and poor direct observation
of patients. Whereas in DMC and ESI hospital, wards were small in size with
centralized nursing station, therefore nurses did not experience above said
problems but they were critical about privacy and storage facilities at nursing
station. Majority of nurses were not satisfied with existing nursing stations in
wards of selected hospitals.
 Nurses’ rest room: This facility was available in only few wards of selected
private hospitals. However, these facilities were lacking in basic amenities and
upkeep was very poor. Therefore, these facilities failed to satisfy its users. While
in government hospitals, nurses’ rest rooms were not available in wards and
nursing stations were used for this purpose. Overwhelming, majority of nurses
expressed the need to have nurses’ rest room facility in wards.
 Nursing care documentation: Nursing documentation was very poor in wards
of government hospitals, where except vital signs no nursing care record was
maintained by nurses. However, they maintained other several ward related
records. In wards of private hospitals, nursing care documentation practices
were relatively better, where nurses mentioned some of the nursing care records
like nurse’s notes, patient assignment record, vital signs record, medication
record etc. Interestingly in selected hospitals about 60 percent records were
incomplete, 65 percent were lacking in appropriateness, about fifty percent
records had poor organization of entries, similar number of records had cutting
and overwriting. However, private hospitals were better in maintaining the
quality of records as compared to government hospitals.

Inferences drawn
 Classification and location of the wards was not uniform in selected hospitals.
 The existing designs and layout of the wards were not perfect to satisfy the
needs of nurses and patients.
 Supportive service areas like ward pantry, ward stores, clean utility, dirty utility
and treatment room were not available in most of the wards in selected

233
 hospitals. However, clean utility and treatment room related facilities were
better managed in private hospitals.
 Basic amenities like bed, bed side storage locker, comfort devices and bed linen
were not provided to every patient in government hospitals.
 Sanitary facilities were in pathetic condition in selected hospitals as per their
number, organization and cleanliness is concerned.
 Ventilation was satisfactory in selected hospitals but temperature and noise
control was poor.
 Lighting facilities, infection control and waste segregation practices were better
in private hospitals as compared to government hospitals.
 Ancillary area like day space, visitor’s waiting area, multipurpose room were
not present in wards of the selected hospitals. However, stay facility for
patients’ relatives was also not available in government hospitals.
 Drinking water supply and recreational facilities were not given significant
importance in wards of the selected hospitals.
 Nursing care was poorly organized in wards of the government hospitals as
compared to the private hospitals.

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